Test 4

The nurse is assessing a client who has borderline personality disorder. Which of the following would be a priority? A. nutrition patterns B. personal hygiene practices C. physical functioning D. somatic complaints

A

Dementia Nursing Interventions

-provide safe environment -assist with ADLs -use simple, direct statements -maintain health, hygiene, rest -routine activities

Which statements from a patient indicate an understanding of behaviors that often disrupt sleep? (Select all that apply.) 1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 3. "A short nap late in the evening will lead to a more restful night of sleep." 4. "A glass of wine before bed will help me relax and sleep through the night." 5. "I will try to develop a regular evening exercise program."

1. Answer: 1, 2, 5. The noise of television can be disruptive and adds stimulation that is disruptive to sleep. Caffeine should not be consumed late in the day because it can cause wakefulness at bedtime. A regular exercise program completed in the morning is part of sleep-hygiene practices. Exercise should not be done right before bed because it can disrupt sleep

A 10-year-old child with Tourette's disorder is receiving haloperidol as part of his treatment plan. When assessing the child at a follow up visit, which statement by the child would lead the nurse to suspect that he is experiencing a side effect of the drug? A) ​Sometimes I feel like I'm so sleepy.​ B) ​I'm eating about the same amount as before.​ C) ​My muscles seem pretty flexible lately.​ D) ​I think I'm much more alert with this drug.​

A

A client has been admitted to the psychiatric unit with a diagnosis of narcolepsy. Which client statement would the nurse interpret as reflecting this condition? A) Sometimes when Im falling asleep, I see and hear things that my wife doesnt. B) I often have brief periods of intense excitement when going to sleep, and my legs wont hold still. C) I lie there and worry all night, and it keeps me awake. I just cant relax. D) I think my sleep pattern is messed up because I took sleeping pills when I was younger.

A

A client with insomnia is prescribed zolpidem. When describing the action of this medication to the client, the nurse would incorporate information related to the medications effect on which of the following? A) GABA B) Serotonin C) Dopamine D) Norepinephrine

A

A group of nursing students is reviewing information about factors affecting the pattern and quality of sleep. The students demonstrate a need for additional review when they identify which of the following? A) Sleep patterns are relatively constant across the lifespan. B) Women report more problems with sleep than men. C) Working night shifts and sleeping during the day can affect sleep. D) Environmental influences on sleep can be internal or external.

A

A nurse is interviewing a client and suspects that the client may have narcissistic personality disorder. which client statement would help support the nurses suspicions? A. i have a very important position in life; everyone I know wants to be like me B. My wife is poisoning my food so she can get rid of me and marry her boss C. I like to work alone because then I can let my thoughts wander D. im always the life of the party, making new friends all the time

A

A psychiatric​mental health nurse working in the community is planning an educational program for fifth and sixth grade teachers. Which of the following would the nurse include? A) Discussion of strategies the teachers can use to counteract the role media plays in encouraging eating disorders B) Emphasis on the need for teachers to focus their prevention efforts on female students C) Stressing of the need to allow students to eat without undue attention or supervision to prevent inadvertently influencing eating patterns D) Clarification that peer pressure is not typically problematic in children who are in the fifth and sixth grades

A

A student nurse is preparing a nursing care plan for a client who has insomnia and is experiencing sleep deprivation. Which nursing diagnosis would the nurse most likely identify as reflecting a priority care issue? A) Risk for Injury B) Ineffective Coping C) Deficient Knowledge D) Anxiety

A

After teaching the parents of a child diagnosed with ADHD about the disorder and its treatment, the nurse determines that the teaching has been effective when the parents state which of the following? A) ​We need to remember that our son is not a bad kid; he just has difficulty with impulse control and attention.​ B) ​We need to be careful so he doesn't develop a substance abuse problem as he grows older.​ C) ​We should stop the medication after 2 months to see how effective it is in really controlling his symptoms.​ D) ​We should set up regular routines for him but not worry if he violates the limits once in a while.​

A

After teaching the parents of a child diagnosed with ADHD about the disorder and its treatment, the nurse determines that the teaching has been effective when the parents state which of the following? A) We need to remember that our son is not a bad kid; he just has difficulty with impulse control and attention.​ B) ​We need to be careful so he doesn't develop a substance abuse problem as he grows older.​ C) We should stop the medication after 2 months to see how effective it is in really controlling his symptoms.​ D) ​We should set up regular routines for him but not worry if he violates the limits once in a while.​

A

The nurse is assessing a client who is diagnosed with borderline personality disorder. which client statement indicates the client is at risk for self-injurious behavior? a. i have felt so down lately. I dont enjoy doing anything anymore b. i do what i do because others tell me to do so c. when i feel extremely anxious, it is like my mind goes somewhere else d. it is almost as if as soon as i think of doing something, I immediately do it

A

The nurse is caring for a client diagnosed with BPD. the nurse has instructed the client about using the communication triad. The nurse determine that the client has understood this technique when he states which of the following? A. I should start by stating my feelings as an "I" statement B. maybe i should start by describing the situation that has me upset C. I should first tell the other person what I'd like to be different about the situation D. I should begin by telling the other person what has triggered my emotion

A

The nurse is caring for a client with schizoid personality trait. when developing the plan of care for the client which of the following would the nurse most likely include A. social skills training B. anger management training C. relaxation techniques D. coping skills training

A

The nurse is preparing to assess a client with paranoid personality trait. The nurse integrates knowledge of this condition, anticipating that the clients affect and behavior will most likely be which of the following? A. angry and hostile B. flirtatious and seductive C. fearful and anxious D. friendly and open

A

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others

A

Which nursing statement reflects a common characteristic of a client diagnosed with paranoid personality disorder? A. "This client consistently criticizes care and has difficulty getting along with others." B. "This client is shy and fades into the background." C. "This client expects special treatment and setting limits will be necessary." D. "This client is expressive during group and is very pleased with self."

A

While caring for a client with anorexia nervosa, the nurse anticipates that the client would have difficulty making which of the following comments? A) ​I'm mad at you because you won't let me go on a pass unless I gain weight!​ B) ​I need to have everything in its place and perfect.​ C) ​If I gain a pound, I'll just keep gaining weight.​ D) ​​I am very involved in preparing my food and counting calories.​

A

a women with borderline personality disorder has been admitted to the inpatient unit because she has been engaging in wrist cutting. the clients sister is visiting and the sister asks the nurse to explain why her sister sometimes does this to herself. which response would be most appropriate ? A. sometimes the self injurious behavior is undertaken to relieve stress B. self injurious behavior often calms and sedates people with this diagnosis C. sometimes they do it to avoid onslaught of delusional thinking D. the self mutilation often slows the mood swings your sister experiences

A

the nurse is reviewing the medical record of a client diagnosed with antisocial personality disorder. the nurse notes that the client has had numerous episodes involving irritability, aggressiveness, and impulsivity and has exhibited callousness towards others. based on this information, which nursing diagnosis would the nurse most likely identify as priority? A. risk for other directed violence B. risk for self injury C. risk for suicide D. risk for self directed violence

A

The nurse is caring for a client diagnosed with delirium who has been brought for treatment by his son. While taking the client's history, which question would be most appropriate for the nurse to ask the client's son? A)"Has your father taken any medications recently?" B)"Are you aware of your father falling or injuring his head in any way?" C)"Has your father had a recent stroke?" D)"Has your father experienced any major losses recently?"

A) "Has your father taken any medications recently?"

A nurse is assessing a client diagnosed with avoidant personality disorder. Which of the following would the nurse most likely expect to find? Select all that apply. A. Shyness B. Feelings of inadequacy C. Feelings of superiority D. Perfectionism E. Detail orientated

A B

A 12-year-old child is brought to the mental health clinic by his parents because of a court-ordered evaluation. When assessing the child, which of the following would lead the nurse to suspect that the child has a conduct disorder? Select all that apply. A) Destruction of neighbor's car on two separate occasions B) Arrests for petty larceny several times C) Repetitive disobedience of parents D) Blaming of others for problems E) Evidence of overt lying

A B E

A client is brought into the emergency department because of complaints from the neighbors that the client was acting strangely. The nurse assess the client and suspects schizotypical personality disorder based on assessment of which of the following? Select all that apply A. Magical beliefs B. Hallucinations C. Paranoia D. Avoidance of eye contact E. Meticulous dress

A C D

A nursing instructor is describing the prevalence of obstructive sleep apnea (OSA) as being greater in individuals with mental health disorders. Which disorders would the instructor include as being associated with OSA? Select all that apply. A) Depression B) Borderline personality disorder C) Schizophrenia D) Posttraumatic stress disorder E) Anxiety

A D E

After teaching a class about circadian rhythm disorders, a nursing instructor determines that the teaching was successful when the class identifies which of the following as a subtype? Select all that apply. A) Delayed sleep phase B) Nightmare C) Sleep terror D) Jet lag E) Shift work

A D E

A client is admitted to the hospital with dementia related to Parkinson's disease. The client is being treated for a fractured tibia from a recent fall. The nurse should assess the client's history for use of which type of medication? A) Anticholinergics B) Dopamine agonists C) Anxiolytics D) Benzodiazepines

A) Anticholinergics

A group of nursing students is reviewing information about delirium and dementia. The students demonstrate a need for additional review when they identify which of the following as characteristics of dementia? A) Fluctuating changes within a 24-hour period B) Possible hallucinations C) Normal psychomotor activity D) Globally impaired cognition

A) Fluctuating changes within a 24-hour period

A client with Alzheimer's disease is admitted to the acute care facility for treatment of an infection. Assessment reveals that the client is anxious. When developing the client's plan of care, which of the following would be least appropriate to include? A) Frequently provide reality orientation. B) Simplify the client's routines. C) Limit the number of choices to be made. D) Establish predictable routines.

A) Frequently provide reality orientation.

A daughter brings her mother, who has Alzheimer's disease, to the clinic. The client has been taking a cholinesterase inhibitor medication for 1 month. When assessing the client, the nurse would be alert for the possibility of which side effect? A) Gastrointestinal distress B) Mild headache C)Muscle tics D) Blurred vision

A) Gastrointestinal distress

A client is brought to the emergency department by his wife. The wife states that over the past few hours, the client has become disoriented and confused. "He didn't know where he was and didn't seem to recognize me or be able to carry on a coherent conversation." The nurse suspects delirium. When reviewing the client's medication history with the wife, use of which of the following would alert the nurse to a potential cause? Select all that apply. A) Propranolol B) Acetaminophen C) Diphenhydramine D) Verapamil E) Quinidine

A) Propranolol C) Diphenhydramine E) Quinidine

While the nurse is caring for a hospitalized client in the advanced stages of Alzheimer's disease, the client begins to have a catastrophic reaction to feeding himself. Which of the following should the nurse do first? A) Remain calm and reassuring. B) Restrain the client temporarily. C) Draw the curtains to darken the room. D) Offer to feed the client.

A) Remain calm and reassuring.

After teaching a group of nursing students about Alzheimer's disease and appropriate nursing care, the instructor determines that the teaching was successful when the students identify which of the following as the foundation for providing care to the client and family? A) Therapeutic relationship B) Medication therapy C) Injury prevention D) Functional independence

A) Therapeutic relationship

As part of a follow-up home visit to an 80-year-old client who has had surgery, the nurse discusses the client's risk for delirium with his family members. Which of the following would the nurse include as placing the client at increased risk? Select all that apply. A)Urinary tract infection B)Hypertension C)Acute stress D)Bone fractures E)Dehydration F)Electrolyte balance

A)Urinary tract infection C)Acute stress D)Bone fractures E)Dehydration

a group of nursing students is reviewing possible risk factors for development of borderline personality disorder. the students demonstrate understanding of the information when they identify which of the following as a risk factor? select all that apply A. childhood sexual abuse B. parental loss C. substance abuse D. family history E. genetics

A,B

a nurse is reading a journal about the various theories associated with the development of antisocial personality disorder. the article mentions difficult temperament as a possible theory. the nurse demonstrates understanding of this concept when identifying which of the following as a key behavior associated with a difficult temperament. select all that apply A. aggression B. inattention C. hyperactivity D. impulsivity E. depression F. paranoia

A,B,C,D

a nurse is developing a plan of care for a client diagnosed with an antisocial personality disorder who has been admitted to the inpatient psychiatric unit. which of the following would the nurse most likely include. select all that apply A. developing a therapeutic relationship B. bargaining about unit rules C. holding the client responsible for behavior D. discouraging the client from discussing thoughts E. using a firm, lecture like approach for teaching

A,C

A nursing instructor is preparing a class discussion on personality disorders and characteristics. Which term would the instructor include to differentiate personality disorders from normal personality? select all that apply A. inflexible B. short term C. pervasive D. unstable over time E. distressing

A,C,D,E

A nursing instructor is preparing a teaching plan for a class of nursing students about antisocial personality disorder. which of the following would the nurse include as a term often used to describe the behaviors associated with this condition. select all that apply A. psychopath B. manipulator C. criminality D. sociopath E.psychotic

A,D

A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.

A. Schedule structured daily routines.

A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. Taking multiple medications may lead to adverse interactions or toxicity. B. Age-related cognitive changes may lead to alterations in mental status. C. Lack of rigorous exercise may lead to decreased cerebral blood flow. D. Decreased social interaction may lead to profound isolation and psychosis.

A. Taking multiple medications may lead to adverse interactions or toxicity.

A nursing instructor is teaching about donepezil (Aricept). A student asks, How does this work? Will this cure Alzheimers disease (AD)? Which is the appropriate instructor reply? A. This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. B. This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease. C. This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. D. This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.

A. This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD.

A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this client's diagnosis? A. The client will name own body parts as separate from others by day 5. B. The client will establish a means of communicating personal needs by discharge. C. The client will initiate social interactions with caregivers by day 4. D. The client will not harm self or others by discharge.

ANS: A An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes? A. Provide external limits on client behavior. B. Foster discussions of rationales for behavioral change. C. Implement interventions consistently by only one staff member. D. Encourage the client to involve self in care.

ANS: A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff.

Which characteristics should a nurse recognize as being exhibited by individuals diagnosed with any personality disorders? A. These clients accept and are comfortable with their altered behaviors. B. These clients understand that their altered behaviors result from anxiety. C. These clients seek treatment to avoid interpersonal discomfort. D. These clients avoid relationships due to past negative experiences.

ANS: A Clients who are diagnosed with personality disorders accept and are comfortable with their altered behaviors. Personalities that develop in a disordered pattern remain somewhat unstable and unpredictable throughout the lifetime.

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

ANS: A The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to society norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains

ANS: A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction such as manipulation and splitting.

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

An adolescent client who was diagnosed with conduct disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. How should the nurse apply knowledge of conduct disorder to this client's situation? A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely. D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: A The nurse should apply knowledge of conduct disorder to determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. "Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone." B. "Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, while clients diagnosed with avoidant personality disorder do not." C. "Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant." D. "Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, while clients diagnosed with avoidant personality disorder remain based in reality."

ANS: A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's disorder? A. Antipsychotic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor medications

ANS: A The nurse should recognize that antipsychotic medications are effective in the treatment of Tourette's disorder. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Risperidone (Risperdal) has been shown to reduce symptoms by 21% to 61%. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not." C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not." D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."

ANS: A The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food followed by purging.

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? A. The pharmacological action of Ritalin causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: A The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? A. "This child's behavior must be evaluated according to developmental norms." B. "This child has symptoms of attention deficit hyperactivity disorder." C. "This child has symptoms of the early stages of autistic disorder." D. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

ANS: A The student's evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

ANS: A, B The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

Which of the following risk factors noted during a family history assessment should a nurse associate with the potential development of intellectual disability? Select all that apply. A. A family history of Tay-Sachs disease B. Childhood meningococcal infection C. Deprivation of nurturance and social contact D. History of maternal multiple motor and verbal tics E. A diagnosis of maternal major depressive disorder

ANS: A, B, C The nurse should associate a family history of Tay-Sachs disease, childhood meningococcal infections, and deprivation of nurturance and social contact as risk factors that would predispose a child to intellectual disability. Major predisposing factors of intellectual disability include: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, environmental influences, and other mental disorders. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.) A. The client will relate one empathetic statement toward another client in group by day 2. B. The client will identify one personal limitation by day 1. C. The client will acknowledge one strength that another client possesses by day 2. D. The client will list four personal strengths by day 3. E. The client will list two lifetime achievements by discharge.

ANS: A, B, C The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. An exaggerated sense of self-worth, a lack of empathy, and exploitation of others are characteristics of narcissistic personality disorder.

A nurse is caring for a group of clients within the DSM-IV-TR cluster B category of personality disorders. Which factors should the nurse consider when planning client care? (Select all that apply.) A. These clients have personality traits that are deeply ingrained and difficult to modify. B. These clients need medications to treat the underlying physiological pathology. C. These clients use manipulation, making the implementation of treatment problematic. D. These clients have poor impulse control that hinders compliance with a plan of care. E. These clients commonly have secondary diagnoses of substance abuse and depression.

ANS: A, C, D, E The nurse should consider that individuals diagnosed with cluster B-type personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

Which of the following interventions should a nurse anticipate implementing when planning care for children diagnosed with attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. Behavior modification B. Antianxiety medications C. Competitive group sports D. Group therapy E. Family therapy

ANS: A, D, E The nurse should anticipate that behavior modification, group therapy, and family therapy may be implemented in the management of ADHD in children. These interventions are often used in conjunction with psychopharmacology to reduce impulsive and hyperactive behaviors and to increase attention span. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu C. A client diagnosed with conduct disorder who is demanding special attention from staff D. A client diagnosed with attention deficit disorder who has a history of self-mutilation

ANS: B A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

ANS: B A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

ANS: B Based on Maslow's hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

ANS: B By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

A client diagnosed with cluster C traits sits alone and ignores other's attempts to converse. When ask to join a group the client states, "No thanks." In this situation, which should the nurse assign as an initial nursing diagnosis? A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues

ANS: B Clients diagnosed with cluster "C" traits are described as anxious and fearful. The DSM-IV-TR divides cluster "C" personality disorders into three categories: avoidant, dependent, and obsessive-compulsive. Anxiety and fear contribute to social isolation.

While improving, a client demands to have a phone installed in the intensive care unit (ICU) room. When a nurse states, "This is not allowed. It is a unit rule." The client angrily demands to see the doctor. Which approach should the nurse use in this situation? A. Provide an explanation for the necessity of the unit rule. B. Assist the client to discuss anger and frustrations. C. Call the physician and relay the request. D. Arrange for a phone to be installed in the client's unit room.

ANS: B Clients who demand special privileges may be diagnosed with narcissistic personality disorder. The best approach in this situation is for the nurse to identify the function that anger, frustration, and rage serve for the client. The verbalization of feelings may help the client to gain insight into his or her behavior.

A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works? A. "Ritalin's sedation side effect assists children by decreasing their energy level." B. "How Ritalin works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD." C. "Ritalin helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapse." D. "Ritalin decreases hyperactivity by increasing serotonin levels."

ANS: B It is unknown how Ritalin works, but even though it is a stimulant, it does decrease hyperactivity in individuals diagnosed with ADHD. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis.

ANS: B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis.

A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of "suffering" in silence. Which underlying cause of this client's personality disorder should a nurse recognize? A. "Nurturance was provided from many sources, and independent behaviors were encouraged." B. "Nurturance was provided exclusively from one source, and independent behaviors were discouraged." C. "Nurturance was provided exclusively from one source, and independent behaviors were encouraged." D. "Nurturance was provided from many sources, and independent behaviors were discouraged."

ANS: B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate intellectual disability? A. Meeting all of the client's self-care needs to avoid injury B. Providing simple directions and praising client's independent self-care efforts C. Avoiding interference with the client's self-care efforts in order to promote autonomy D. Encouraging family to meet the client's self-care needs to promote bonding

ANS: B Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate intellectual disability. Individuals with moderate intellectual disability can perform some activities independently and may be capable of academic skill to a second-grade level. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

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

ANS: B The appropriate nursing diagnosis associated with this degree of intellectual disability is altered social interaction R/T nonadherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual disability and may also experience some limitations in speech communications. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. "You are very disrespectful. You need to learn to control yourself." B. "I understand that you are angry, but this behavior will not be tolerated." C. "What behaviors could you modify to improve this situation?" D. "What anti-personality-disorder medications have helped you in the past?"

ANS: B The appropriate nursing statement is to reflect the client's feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the diagnosis of a personality disorder.

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. "Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling." B. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." C. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection." D. "They pay particular attention to details which can frustrate the development of relationships."

ANS: B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.

Using a behavioral approach, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues.

ANS: B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? A. "Researchers really don't know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." B. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." C. "Research has shown that the mother appears to play a greater role in the development of this disorder than the father." D. "Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?"

ANS: B The most appropriate reply by the nurse is to explain to the parent that autism spectrum disorder is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism spectrum disorder occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Family intervention and support are important in your child's recovery." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

ANS: B The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder.

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.

A client diagnosed with BPD tells the nurse that she frequently spaces out. Which response by the nurse would be most appropriate? A. do you feel stressed most of the time? B. does this frighten you when it happens? C. Whats happening around you when this occurs? D. do you feel as if you are out of your body?

C

Which finding would be most likely in a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The child's mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The child's mother and father have an inconsistent parenting style.

ANS: B The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child diagnosed with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A child has been recently diagnosed with mild intellectual disability (ID). What information about this diagnosis should the nurse include when teaching the child's mother? A. Children with mild ID need constant supervision. B. Children with mild ID develop academic skills up to a sixth-grade level. C. Children with mild ID appear different from their peers. D. Children with mild ID have significant sensory-motor impairment.

ANS: B The nurse should inform the child's mother that children with mild ID develop academic skills up to a sixth-grade level. Individuals with mild ID are capable of independent living, capable of developing social skills, and have normal psychomotor skills. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents? A. If one dose of Ritalin is missed, double the next dose. B. Administer Ritalin to the child after breakfast. C. Administer Ritalin to the child just prior to bedtime. D. A side effect of Ritalin is decreased ability to learn.

ANS: B The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which nursing intervention should be prioritized when caring for a child diagnosed with intellectual disability? A. Encourage the parents to always prioritize the needs of the child. B. Modify the child's environment to promote independence and encourage impulse control. C. Delay extensive diagnostic studies until the child is developmentally mature. D. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

ANS: B The nurse should prioritize modifying the child's environment to promote independence and encourage impulse control. This intervention is related to the nursing diagnosis self-care deficit. Positive reinforcement can serve to increase self-esteem and encourage repetition of behaviors. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A preschool child is admitted to a psychiatric unit with a diagnosis of autism spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? A. Encourage and reward peer contact. B. Provide consistent caregivers. C. Provide a variety of safe daily activities. D. Maintain close physical contact throughout the day.

ANS: B The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autism spectrum disorder. Children diagnosed with autism spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders? A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life

ANS: B The nurse should reinforce positive actions to encourage repetition of desired behaviors when caring for children diagnosed with a disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesman to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership.

ANS: B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

A nurse is assessing a client diagnosed with Alzheimer's disease. As part of the assessment, the nurse asks the client to identify common objects. The nurse is assessing for which of the following? A) Aphasia B) Apraxia C) Agnosia D) Executive functioning

C) Agnosia

The nurse should recognize which of the following findings contribute to a client's development of attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. The client's father was a smoker. B. The client was born 7 weeks premature. C. The client is lactose intolerant. D. The client has a sibling diagnosed with ADHD. E. The client has been diagnosed with dyslexia.

ANS: B, D The nurse should identify that premature birth and having a sibling diagnosed with ADHD would predispose a client to the development of ADHD. Research indicates evidence of genetic influences in the etiology of ADHD. Studies also indicate that environmental influences such as lead exposure and diet can be linked with the development of ADHD. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Physiological Integrity

A child diagnosed with attention deficit-hyperactivity disorder (ADHD) is having difficulty completing homework assignments. What information should the nurse include when teaching the parents about task performance improvement? A. The parents should isolate the child when completing homework to improve focus. B. The parents should withhold privileges if homework is not completed within a 2-hour period. C. The parents should divide the homework task into smaller steps and provide an activity break. D. The parents should administer an extra dose of methylphenidate (Ritalin) prior to homework

ANS: C By dividing the homework task into smaller steps, the child can remain more focused within a limited about of time. Physical activity can release pent-up energy that would distract from task completion. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this client's symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

ANS: C Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this client's fainting to the loss of alkaline stool due to laxative abuse which would lead to a relative metabolic acidotic condition.

A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? A. Place client in restraints until the aggression subsides. B. Sedate the client with neuroleptic medications. C. Hold client's head steady and apply a helmet. D. Distract the client with a variety of games and puzzles.

ANS: C The most appropriate intervention for head banging is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence, that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the client's paranoid perceptions.

ANS: C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

A client diagnosed with antisocial personality disorder comes to a nurses' station at 11:00 p.m. requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. "Go ahead and use the phone. I know this pending divorce is stressful." B. "You know better than to break the rules. I'm surprised at you." C. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow." D. "The decision to divorce should not be considered until you have had a good night's sleep."

ANS: C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? A. The client will communicate all needs verbally by discharge. B. The client will participate with peers in a team sport by day 4. C. The client will establish trust with at least one caregiver by day 5. D. The client will perform most self-care tasks independently.

ANS: C The most realistic client outcome for a child diagnosed with autism spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

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

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder

ANS: C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.

A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mother's concern? A. "The physician will probably switch from Ritalin to a central nervous system stimulant." B. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." C. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." D. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

ANS: C The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate (Ritalin) is a central nervous system stimulant in which tolerance can develop rapidly. Physical and psychological dependence can also occur. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment

ANS: C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

ANS: C The nurse should identify that behavior modification therapy will be used because it provides the client with control over behavioral choices. Clients diagnosed with anorexia nervosa are often allowed to contract privileges based on weight gain. The client maintains control over eating and exercise.

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

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

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

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing which is followed by inappropriate compensatory behaviors.

Looking at a slightly bleeding paper cut, the client screams, "Somebody help me, quick! I'm bleeding. Call 911!" A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

ANS: C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive.

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Sibutramine (Meridia) OR C. Lorcaserin ( Belviq) D. Pemoline (Cylert)

ANS: C The nurse should teach the client that sibutramine (Meridia) is an anorexiant medication prescribed for morbidly obese clients. The mechanism of action in the control of appetite appears to occur by inhibiting the neutotransmitters serotonin and norepinephrine. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

Which client statement would demonstrate a common characteristic of Cluster B personality disorder? A. "I wish someone would make that decision for me." B. "I built this building by using materials from outer space." C. "I'm afraid to go to group because it is crowded with people." D. "I didn't have the money for the ring, so I just took it."

ANS: D Antisocial personality disorder is included in the Cluster "B" personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

ANS: C The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites

ANS: C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.

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

ANS: C The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behaviors and to intervene before violence occurs. This intervention serves to keep the client and others safe. This is the priority nursing concern. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

ANS: C The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, measurable, and also include a time frame.

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100 mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 mL

ANS: C Twenty mg of Prozac multiplied by three results in the calculated 60 mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the rationale for scheduling group therapy at this time? A. To shift the clients' focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

ANS: C When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

ANS: D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

A client exhibits dependency on staff and peers and expresses fear of abandonment. Using Mahler's theory of object relations, which should the nurse expect to note in this client's childhood? A. Lack of fulfillment of basic needs by parental figures B. Absence of the client's maternal figure during symbiosis C. Difficulty establishing trust with the maternal figure D. Inconsistency by the maternal figure during individuation

ANS: D During phase 3 (5 to 36 months) of Margaret Mahler's individuation theory, there should be a strengthening of the ego and an acceptance of "self" with independent ego boundaries. Inconsistency by the maternal figure during individuation may in later years result in feelings of helplessness when the client is alone because of exaggerated fears of being unable to care for self.

A nursing instructor is teaching about pharmacological treatments for attention deficit-hyperactivity disorder (ADHD). Which information about atomoxetine (Strattera) should be included in the lesson plan? A. Strattera, unlike methylphenidate (Ritalin), is a central nervous system depressant. B. When taking Strattera, a client should eliminate all red food coloring from the diet. C. Strattera will be a life-long intervention for clients diagnosed with this disorder. D. Strattera, unlike methylphenidate (Ritalin), is a selective norepinephrine reuptake inhibitor.

ANS: D Strattera is a selective norepinephrine reuptake inhibitor. Ritalin is classified as a stimulant. The exact mechanism by which these drugs produce a therapeutic effect in ADHD is unknown. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and whispers, "The night nurse is evil. You have to stay." B. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me." C. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here." D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

ANS: D The client who states, "I cut myself because you are leaving me" reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.

Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual disability? A. The client can perform some self-care activities independently. B. The client has advanced speech development. C. Other than possible coordination problems, the client's psychomotor skills are not affected. D. The client communicates wants and needs by "acting out" behaviors.

ANS: D The nurse should identify that a client diagnosed with severe intellectual disability may communicate wants and needs by "acting out" behaviors. Severe intellectual disability indicates an IQ between 20 and 34. Individuals diagnosed with severe intellectual disability require complete supervision and have minimal verbal skills and poor psychomotor development. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual disability (ID). Which student statement indicates that further instruction is needed? A. "These clients can work in a sheltered workshop setting." B. "These clients can perform some personal care activities." C. "These clients may have difficulties relating to peers." D. "These clients can successfully complete elementary school."

ANS: D The nursing student needs further instruction about moderate mental retardation because individuals diagnosed with moderate ID are capable of academic skill up to only a second-grade level. Moderate ID reflects an IQ range of 35 to 49. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance

An 8-year-old client diagnosed with attention deficit-hyperactivity disorder (ADHD) was admitted 5 days ago for management of temper tantrums. What would be a priority nursing intervention during the termination phase of the nurse-client relationship? A. Set a contract with the client to limit acting-out behaviors while hospitalized. B. Teach the importance of taking fluoxetine (Prozac) consistently, even when feeling better. C. Discuss behaviors that are and are not acceptable on the unit. D. Ask the client to demonstrate learned coping skills without direction from the nurse.

ANS: D The priority nursing intervention during the termination phase of the nurse-client relationship should include encouraging the client to demonstrate the coping skills learning during the working phase of the nurse-client relationship. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder? A. "Skaters need to be thin to improve their daily performance." B. "All the skaters on the team are following an approved 1,200-calorie diet." C. "When I lose skating competitions, I also lose my appetite." D. "I am angry at my mother. I can only get her approval when I win competitions."

ANS: D This client statement reflects the underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family member's development of anorexia nervosa.

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. "I do not use any laxatives or diuretics to lose weight." B. "I am losing lots of hair. It's coming out in handfuls." C. "I know that I am thin, but I refuse to be fat!" D. "I don't know why people are worried. I need to lose this weight."

ANS: D When the client states, "I don't know why people are worried. I need to lose this weight," the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

In providing education for a patient taking melatonin as a sleeping aid, which statements indicate understanding of the teaching? (Select all that apply.) 1. "I should use melatonin for a short period of time." 2. "The usual does is 0.3 to 3 mg per night." 3. "Melatonin is not regulated by the U.S. FDA." 4. "Melatonin may cause me to have night sweats." 5. "I will take melatonin right before I get in bed."

Answer: 1, 2, 3. Melatonin should not be used long-term; however, short-term use of melatonin is considered safe with mild side effects of nausea, headache, and dizziness. The normal dose of melatonin is 0.3 to 3 mg taken about 2 hours before bedtime. Melatonin is considered a supplement and is not regulated by the FDA.

Mrs. Wilson is a 70-year-old patient who visits the medical clinic for a routine visit. Which nursing interventions would you recommend for this patient? (Select all that apply.) 1. Limit fluids 2 to 4 hours before sleep 2. Ensure that room is completely dark 3. Ensure room temperature is comfortably cool 4. Provide warm covers 5. Encourage walking an hour before going to bed

Answer: 1, 3, 4. Limiting fluids reduces the incidence of nocturia. Keeping the bedroom temperature at a cooler, comfortable temperature is conducive to sleep. Older adults sometimes require extra blankets or covers to achieve a comfortable sleeping temperature

A nurse is completing a sleep history for a patient being assessed for obstructive sleep apnea (OSA). Which symptoms does the nurse expect the patient to report? (Select all that apply.) 1. Nocturia 2. Frightening dreamlike experiences 3. Snoring 4. Fatigue 5. Increased sex drive

Answer: 1, 3, 4. Patients with OSA may experience excessive daytime sleepiness; frequent awakening during the night secondary to increasing hypoxia, which causes the patient to wake up to breathe, snoring, and nocturia. Other symptoms of OSA include fatigue, irritability, depression, difficulty concentrating, and decreased sex drive

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply.) 1. Give patients a cup of coffee 1 hour before bedtime 2. Plan vital signs to be taken before patients are asleep 3. Turn television on 15 minutes before bedtime 4. Have patients follow at-home bedtime schedule 5. Close the door to patients' rooms at bedtime

Answer: 2, 4, 5. Taking vital signs before sleep onset prevents disruption of sleep and improves sleep duration and quality. Bedtime routines relax patients in preparation for sleep. Patients in the hospital should follow their at-home bedtime routine. Closing the door to the patient room decreases noise that can disrupt sleep

The nurse is teaching a patient about the sleep cycle. Which statement is true regarding REM sleep? 1. REM sleep is the deepest stage of sleep. 2. Individuals in REM sleep often experience vivid dreams. 3. During REM sleep the individual is easily aroused by noise. 4. The REM sleep stage lasts only a few minutes.

Answer: 2. Vivid, full-color dreaming occurs during REM sleep

Which condition in the patient's history most likely contributes to the diagnosis of OSA? 1. Hyperthyroidism 2. Gastric reflux 3. Obesity 4. Anorexia

Answer: 3. Obesity is a major factor in OSA. Body weight (in particular, body mass index) has been shown to be the strongest risk factor for developing OSA

Which statement made by the patient indicates an understanding of sleep-hygiene practices? 1. "I drink a cup of warm milk in the evening about 30 minutes before bedtime." 2. "If I exercise right before bedtime I will be tired and fall asleep faster." 3. "I know that it is best for me to go to bed when I feel tired." 4. "Long term use of hypnotics will cure my insomnia."

Answer: 3. The best time to go to bed is when a person feels tired. Drinking a warm beverage such as milk in the evening can help promote sleep but can cause nocturia if taken just before a person goes to bed. Exercise should occur at least 2 hours before bedtime. Long term use of hypnotics can cause insomnia.

When educating a new mother on normal infant sleep patterns, which statement made by the mother indicates a need for further teaching? 1. "My baby will develop a regular nighttime sleep pattern by the 3 to 4 months." 2. "My baby will not likely wake up in early morning hours." 3. "I should expect my baby to nap several times during the day." 4. "My baby will sleep about 7 to 8 hours a night."

Answer: 4. Infants typically sleep about 9 to 11 hours per night, not 7 to 8 hours. Sleep time of 7 to 8 hours is a typical adult sleep time.

When developing a nursing care plan, which intervention is most appropriate for a patient experiencing narcolepsy? 1. Develop a weight reduction plan 2. Instruct patient to take an over-the-counter sleep aid 3. Complete a health history 4. Plan 20-minute naps during the day

Answer: 4. Short daytime naps of no more than 20 minutes help to reduce feelings of sleepiness for persons with narcolepsy. Other interventions that are helpful are maintaining a regular nighttime sleep schedule, eating light meals, deep breathing, and chewing gum

A child diagnosed with autism is hospitalized in an inpatient mental health unit. When developing the plan of care for this child, which of the following would the nurse most likely include? A) Ensuring that a variety of caregivers are available for the child B) Providing a consistent, structured environment with predictable routines C) Allowing the child frequent visits off the unit to provide stimulation D) Sending the child to the ​time out" area if the child repeats phrases continually

B

A child diagnosed with autism is hospitalized in an inpatient mental health unit. When developing the plan of care for this child, which of the following would the nurse most likely include? A) Ensuring that a variety of caregivers are available for the child Test Bank - Psychiatric Nursing: Contemporary Practice (6th Edition by Boyd) 136 B) Providing a consistent, structured environment with predictable routines C) Allowing the child frequent visits off the unit to provide stimulation D) Sending the child to the ​time out" area if the child repeats phrases continually

B

A client with BPD tells the nurse, Im afraid to get on the train because well probably get into a wreck. Which response by the nurse would be most appropriate? A. Have you had a bad experience riding a train? B. what are the chances of that actually happening C. now you know that wont happen D. have you thought about going by automobile

B

A group of nurses is reviewing medications used to treat attention deficit hyperactivity disorder. The students demonstrate understanding of the information when they identify methylphenidate as which of the following? A) Selective serotonin reuptake inhibitor B) Psychostimulant C) Noradrenergic reuptake inhibitor D) Alpha agonist

B

A group of nursing students is reviewing information about antisocial personality disorder. the students demonstrate understanding of the disorder when they state which of the following? A. the disorder occurs more frequently in women B. the individual must be 18 y/o C. the disorder is found primarily in asian individuals D. alcohol abuse disorder rarely accompanies this disorder

B

A nurse is assessing a client with BPD. Which question would be most appropriate to assess the clients level of impulsivity? A. what things bother you and make you feel happy B. have you ever felt sorry after acting as you did in the spur of the moment? C. how do you view other people around you? D. have you ever felt like you were separated from your body?

B

A nurse is assessing an 8-year-old girl with a mood disorder. Which of the following would the nurse most likely expect to assess? A) Statement from the child that she feels sad B) Behavioral problems C) Recurrent obsessions D) Ritualistic behavior

B

A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which of the following would the nurse expect to implement in conjunction with pharmacologic therapy? A) Behavioral therapy B) Cognitive behavioral therapy C) Interpersonal therapy D) Family therapy

B

A nurse is developing a teaching plan for a client with impulse control disorder. The nurse is planing to explain the emotional aspects associated with the behavior as part of the plan. which of the following would the nurse describe as occurring first before the individual commits the act? A. remorse B. Tension C. regret D. pleasure

B

A nurse is performing an admission assessment for an adolescent girl with an eating disorder who is being admitted to the psychiatric unit. Which statement would the nurse interpret as most likely supporting the client's diagnosis? A) ​My father was always very thin.​ B) ​I've never really liked myself.​ C) ​I have a lot of confidence in myself.​ D) ​I feel really close to my parents and my brother.​

B

A nurse is preparing a presentation on sleep disorders for a community group. Which of the following would the nurse include when explaining the differences between narcolepsy and obstructive sleep apnea syndrome? A) Symptoms of both disorders are essentially the same, so it is difficult to differentiate between the two disorders. B) People with narcolepsy awaken from a nap feeling rested and replenished, but those with obstructive sleep apnea do not. C) People with obstructive sleep apnea syndrome can experience temporary paralysis with naps. D) Naps are not recommended for clients with narcolepsy because of their association with severe loss of muscle tone.

B

A nurse is providing parent training for parents of a child diagnosed with a disruptive behavior disorder involving the use of time out. When describing how to implement this, which of the following would the nurse identify as the first step? A) Having the child recount the reason for the time out B) Clearly identifying what is required for the child C) Informing the child what will happen because of the behavior D) Placing the child in a designated area removed from others

B

A nurse is reading an article about a young girl who developed GI symptoms from a hair ball because of a ritual she engaged in. the girl would pull her hair over several hours to relieve tension and anxiety and then eat the hair. the nurse most likely is reading an article about which of the following ? A. kleptomania B. trichotillomania C. pyromania D. intermittent explosive disorder

B

A nurse is working with a client diagnosed with insomnia. When developing a teaching plan for the client, which sleep promotion intervention would the nurse implement first? A) Encouraging the client to consider stopping smoking B) Instructing the client to keep regular bedtimes and rising times C) Encouraging the client to take frequent naps D) Administering prescribed sleep medications

B

A nurse is working with a psychiatric client who was admitted to the inpatient facility and is being discharged. The client asks the nurse what he should do when he goes home to promote getting adequate sleep. Which response by the nurse would be most appropriate? A) Go to bed at the same time every night and watch a television show that relaxes you. B) Save your bedroom for sleeping; that means no work and no TV in the bedroom. C) Why dont you ask your psychiatrist for a prescription for a sleeping pill? D) Make sure to keep the bedroom warm and toasty.

B

A nurse is working with the family of a client who has been diagnosed with antisocial personality disorder. which of the following would be most important for the nurse to focus on when teaching the family about this disorder? A. anger management B. boundary setting C. medication therapy D. self responsibility

B

The history of a child newly diagnosed with ADHD reveals that the child is experiencing sleeping difficulties. Which agent would the nurse most likely use? A) Methylphenidate B) Atomoxetine C) Bupropion D) Clonidine

B

The nurse is assessing the sleep patterns of a 70-year-old female client with a mental disorder. Based on the knowledge of circadian rhythms and the influence of age, which of the following would the nurse anticipate that the client would report about her sleep pattern? A) When I was younger, I didnt notice any differences in how I felt in the morning or evening. B) Now it seems like I am sleepier at night and more alert in the morning. C) When I worked days, Id always have trouble feeling sleepy in the morning. D) When I was younger, the amount of sleep I got didnt seem to matter.

B

The nurse is counseling a parent whose child has a communication disorder. Which of the following would the nurse emphasize when teaching the parent about this disorder? A) Providing the child with nonverbal activities B) Initiating conversations with the child frequently C) Stopping the child's conversation if stuttering begins D) Asking the physician for medication to improve the child's speech

B

The nurse is giving a presentation comparing and contrasting autism disorder and Asperger syndrome. Which of the following would the nurse include as differentiating Asperger syndrome from autism disorder? A) ​Children typically do not engage in stereotypic behavior.​ B) ​They display age-appropriate intelligence.​ C) ​The children often reverse pronouns when speaking.​ D) ​They appear aloof and indifferent to others.​

B

The nurse is initiating a group for adolescent girls diagnosed with anorexia nervosa. Many of the clients in the group are irritable and resent having to attend. One of them comments, ​This is a stupid waste of time!​ Which of the response by the nurse would be most appropriate? A) ​If you feel that way, then you can just leave.​ B) ​You sound irritated; tell me about what is bothering you.​ C) ​You were assigned to this group by your therapist, so you must participate.​ D) ​Sit down and be quiet; your peers would appreciate some peace and quiet.​

B

The nurse is preparing to initiate a behavioral treatment program for a child with encopresis. Which of the following would the nurse most likely implement first? A) Administration of mineral oil B) Bowel cleansing C) Low-fiber diet D) Toilet sitting after each meal

B

A client with BPD has difficulty maintaining boundaries of the professional relationship. which of the following would be most effective for the nurse to do? select all that apply A. punish the client with seclusion for violating established boundaries B. respond to the clients arrogance in a neutral, non confrontational manner C. discuss the purpose of the limits in the therapeutic relationship D. state the parameters of limits and boundaries clearly E. ensure that any established limits are maintained consistently

B,C,D,E

The parents of a child with ADHD bring the child for a follow-up visit. During the visit, they tell the nurse that the child receives his first dose of methylphenidate (Ritalin) at about 7:30 AM every morning before leaving for school. The teacher and school nurse have noticed a return in the child's overactivity and distractibility just before lunch. The child's second dose is scheduled for about 12 noon. Which of the following might the nurse suggest as a possible solution to control the child's symptoms a bit more effectively? A) Giving the second dose at 1 PM or later. B) Switching to a longer acting preparation. C) Splitting the early morning dose in half. D) Switching to another class of medication.

B

a nurse is assisting a client with bpd in how to manage transient psychotic episodes that involve auditory hallucinations. the teaching is planned for times when the client is free of these symptoms. which of the following would the nurse instruct the client to do first? A. use skills to tolerate painful feelings B. practice deep abdominal breathing C. identify early internal cues of distress D. refer to cards listing potential symptoms

B

A nurse is working with a client who is a compulsive gambler. Which of the following would the nurse emphasize as crucial for relapse prevention? Select all that apply A) Medication therapy B) Family involvement C) Identification of triggers D) Anger management E) Milieu management

B C

A nursing instructor is describing depressive and negativistic personality traits to a group of nursing students. The instructor determines that the teaching was successful when the students identify which of the following as characteristic of negativistic personality traits? Select all that apply. A) Anhedonia B) Hostility C) Pessimism D) Oppositionality E) Guilt

B D E

A nursing instructor is preparing a presentation on the etiology of Alzheimer's disease. When discussing the role of neurotransmitters in the course of the disease, which of the following would the instructor most likely emphasize? A) Serotonin B) Acetylcholine C) Dopamine D) Norepinephrine

B) Acetylcholine

When assessing a client with dementia, the nurse identifies that the client is experiencing hallucinations. Based on the nurse's understanding of this disorder, which type of hallucination would the nurse expect as most common? A) Auditory B) Visual C) Gustatory D) Olfactory

B) Visual

A nurse is engaged in role playing with a client with BPD to assist the client in learning how to communicate effectively. Which of the following would the nurse encourage the client to use. select all that apply A. me statements B. validating perceptions with others C. paraphrasing before responding D. listening passively E. compromising

B,C,E

Which of the following would the nurse do when providing care to a patient with delirium? A. Keep the environment brightly lit B. Carefully supervise the patient C. Withhold fluids D. Apply restraints

B. Carefully supervise the patient

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients diagnosed with amnesic disorders? A. Neurocognitive disorders involve disorientation that develops suddenly, whereas amnestic disorders develop more slowly. B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not. C. Neurocognitive disorders include the symptom of confabulation, whereas amnestic disorders do not. D. Both neurocognitive disorders and profound amnesia typically share the symptom of disorientation to place, time, and self.

B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not.

A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this clients assessment data, which diagnosis would the nurse expect the physician to assign? A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimers disease

B. Vascular neurocognitive disorder

A client with a mental disorder is being discharged from the inpatient unit. During the clients stay in the hospital, the client eventually was able to get an adequate nights sleep even though the client had experienced chronic insomnia over the years. The clients spouse asks the nurse what the family can do in the clients home environment to promote healthy sleep. Which response by the nurse would be most appropriate? A) It is basically up to your husband to focus on promoting his own sleep. B) You might consider a glass of wine about 30 minutes before he is ready to go to bed. C) Remember to keep stimulating activities at a minimum before he goes to bed. D) Give him a spicy snack with a warm cup of tea at night before bedtime.

C

A group of nursing students is reviewing information about schizoid personality trait. The students demonstrate understanding of information when they identify which disorder as the most common comorbid disorder? A depression B. substance abuse C. avoidant personality disorder D. anxiety

C

A nurse is giving a presentation to a community group about sleep and its relationship to health. In explaining the relationship between REM sleep and body temperature, which statement by the nurse would be most appropriate? A) There is no observable relationship between REM sleep and body temperature. B) With higher levels of REM sleep, we also experience higher body temperatures. C) Our REM sleep and body temperature cycles are inversely related. D) The extent of our experience of REM sleep is directly proportional to a rise in body temperature

C

A nurse is observing a client diagnosed with BPD on the inpatient unit. Which of the following would the nurse most likely note? A. actively participating in several different groups B. openly verbalizing feelings C. participating in relationships in which the client has control D. adhering to the personal boundaries of others

C

A nurse is obtaining information about a clients sleep patterns and asks him about the total amount of sleep time compared with the amount of time spent in bed. The nurse is assessing which of the following? A) Sleep latency B) Sleep architecture C) Sleep efficiency D) Sleepwake cycle

C

A nurse is reviewing the plan of care for a client with anorexia nervosa and notes a behavioral plan for increasing weight. The nurse correlates this intervention with which nursing diagnosis? a) Disturbed Body Image B) anxiety C) Imbalanced Nutrition: Less Than Body Requirements D) Ineffective Coping

C

A nurse would expect a client diagnosed with schizotypal personality disorder to exhibit which characteristic? A. The client keeps to self and has few, if any relationships. B. The client has many brief but intense relationships. C. The client experiences incorrect interpretations of external events. D. The client exhibits lack of tender feelings toward others.

C

The nurse has explained the biologic theories of causation to a client diagnosed with BPD and his family. the nurse determines the client and the family have understood the instructions when they state which of the following? A. the disorder may be caused by increased serotonin activity B. the disorder is caused by decreased dopamine activity in my brain C. a frontal lobe dysfunction may be causing this condition D. A decrease in hormonal substances increases the risk for this illness

C

The nurse is caring for a 3½-year-old child with autism who has been hospitalized. The child rocks continuously without any danger present to the child's safety. Which intervention by the nurse would be most appropriate? A) Continue to monitor the child's behaviors. B) Hold the child until the child stops rocking. C) Ignore the child's rocking behavior. D) Place the child in a ​time out​ area until the rocking stops.

C

The nurse is counseling a family whose 4-year-old child has mild mental retardation. The nurse is working with the family on realistic long-term goals. Which of the following would be most appropriate? A) Locating suitable residential placement for the child B) Finding a foster home for the child C) Achieving independent functioning of the child as an adult D) Preventing the onset of psychiatric disorders in the child

C

The nurse is counseling a family whose child has autism. When describing this condition, which of the following would the nurse most likely include? A) Connection to ineffective parental practices B) Detection after the child enters school C) Onset before child is 2.5 years old D) Girls are more frequently affected than boys

C

The nurse is planning to explain the purpose of the behavioral therapy technique of self-monitoring to a client with bulimia nervosa. The nurse would emphasize keeping a diary to record which of the following? A) Feelings of hunger B) Efforts at distraction C) Environmental stimuli D) Rigid rules about eating

C

The sleep history of a client experiencing sleep problems reveals that the client ingests a significant amount of caffeine each day. When reviewing the effect of caffeine on sleep with the client, which of the following would the nurse incorporate into the discussion as a caffeine effect? A) Decreased sleep latency B) Increased total sleep time C) Decreased REM sleep D) Increased slow-wave sleep

C

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

C

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed.

C

a nurse is providing care to a client with antisocial personality disorder. as a part of the plan of care, the client is to participate in a problem solving group. the nurse understands that this intervention is effective based on which rationale? A. it requires the client to develop attachments B. it sets up specific boundaries for the client C. it helps reinforce self responsibility D. it avoid confrontation about dysfunctional patterns

C

A nurse tells a client that the nursing staff will state alternating weekend shifts. Which response should a nurse identify as characteristics of clients diagnosed with obsessive-compulsive personality disorder? A. You really don't have to go by that schedule. I'd just stay home sick B. There has got to be a hidden agenda behind this schedule change C. Who do you think you are? I expect to interact with the same nurse every Saturday D. You can't make these kinds of changes! Isn't there a rule that governs this deceison?

D

The nurse makes a home visit to a family caring for a client with Alzheimer's disease. The client's wife tells the nurse that she hasn't been out of the house for more than 2 weeks because her sister has been unable to help her care for the client. Which nursing diagnosis would the nurse identify as the priority? A) Ineffective Family Coping related to care of a client with Alzheimer's disease B) Risk for Activity Intolerance related to Alzheimer's disease C) Caregiver Role Strain related to social isolation D) Powerlessness related to seclusion and long-term care of client

C) Caregiver Role Strain related to social isolation

A nurse is talking with the husband of a female client diagnosed with Alzheimer's disease. During the conversation, the husband tells the nurse that "she often begins to scream and curse for no apparent reason". The nurse interprets this as which of the following? A) Hypersexuality B) Disinhibition C) Hypervocalization D) Apathy

C) Hypervocalization

While reviewing the medical record of a client with moderate dementia of the Alzheimer type, the nurse notes that the client has been receiving memantine. The nurse identifies this drug as which type? A) Atypical antipsychotic B) Cholinesterase inhibitor C) NMDA receptor antagonist D) Benzodiazepine

C) NMDA receptor antagonist

The nurse is assessing a client who has received a tentative diagnosis of delirium. The nurse is explaining to the family about the major cause of the client's condition. Which statement by the nurse would be most appropriate? A)"Basically, this diagnosis is based on the client's inability to talk normally." B)"Your report of gradually developing confusion over time was the basis for the diagnosis." C)"His diagnosis is primarily based on the rapid onset of his change in consciousness." D)"The client's exposure to an infectious agent led us to determine the diagnosis."

C)"His diagnosis is primarily based on the rapid onset of his change in consciousness."

An adolescent client is seen in the emergency department with symptoms of dementia, tremors, and ataxia. The client had been sniffing glue with a friend. The nurse suspects the client's symptoms were caused by poisoning with which of the following? A)Mercury B)Lead C)Toluene D)Arsenic

C)Toluene

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)? A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity

C. Altered task performance

A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the clients behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

C. Assess environmental triggers and potential unmet needs.

At what time during a 24-hour period should a nurse expect clients with Alzheimers disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications

C. At twilight

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition? A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism

C. Neurocognitive disorder

After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimers disease. What should cause the nurse to question this diagnosis? A. Neurocognitive disorder does not typically occur in African American clients. B. The symptoms presented are more indicative of Parkinsonism. C. Neurocognitive disorder does not develop suddenly. D. There has been no T3 or T4 level evaluation ordered.

C. Neurocognitive disorder does not develop suddenly.

A client is in the late stage of Alzheimers disease. To address the clients symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.

C. Promote dignity by providing comfort, safety, and self-care measures.

A client diagnosed with neurocognitive disorder due to Alzheimers disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis? A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance

C. Risk for injury

As a part of clients treatment plan for BPD, the client is engaged in dialectical behavior therapy. As a part of therapy, the client is learning how to control and change behavior response to events. the nurse identifies the client as learning which type of skills? A. emotion regulation skills B. mindfullness skills C. distress tolerance skills D. self-management skills

D

During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. "I really don't have a problem. My family is inflexible, and every relative is out to get me." B. "I am so excited about working with you. Have you noticed my new nail polish: 'Ruby Red Roses'?" C. "I spend all my time tending my bees. I know a whole lot of information about bees." D. "I am getting a message from the beyond that we have been involved with each other in a previous life."

D

A client with bulimia nervosa is being treated at an outpatient clinic and is prescribed a selective serotonin reuptake inhibitor (SSRI). Which of the following would the nurse include when teaching the client about the prescribed medication? A) Closely monitor your fluid intake while taking this medication. B) Stop taking this medication if it causes weight gain. C) Expect menstrual irregularities, particularly if they've occurred previously. D) Report any weight changes that occur during the first few weeks this medication is taken.

D

A client with insomnia is taught to avoid watching television, eating, and doing work in the bedroom. Which technique is being used? A) Sleep restriction B) Relaxation training C) Cognitive behavior therapy D) Stimulus control

D

A female client who is receiving counseling at a community health center has complained about being unable to sleep at each of the last three weekly sessions. The nurse interviews the family members to determine the effect of the clients problem on them. Which response would the nurse most likely expect to hear? A) It really hasnt seemed to be a problem for us. B) Theres been little change in how she gets along with other family members. C) The not sleeping has really had a positive effect on her and us. D) Its been exhausting living with her these past few weeks.

D

A group of nursing students is reviewing information about disruptive behavior disorders. The students demonstrate understanding of the topic when they identify which of the following as an externalizing disorder? A) Anxiety Test Bank - Psychiatric Nursing: Contemporary Practice (6th Edition by Boyd) 137 B) Depression C) Schizophrenia D) Conduct disorder

D

A group of nursing students is reviewing the various agents used to treat insomnia. The students demonstrate an understanding of the information when they identify which agent as a melatonin receptor agonist? A) Trazodone B) Estazolam C) Mirtazapine D) Ramelteon

D

A nurse is interviewing a client diagnosed with bulimia nervosa about her family and her relationship with her mother. Which statement by the client would the nurse least likely associate with bulimia nervosa? A) ​My mother is my confidante for everything.​ B) My mother's happiness depends on me.​ C) My family basically has very few rules.​ D) ​My mother and I are close but not joined at the hip.​

D

The mother of a child with Asperger disorder tells the nurse that her child has few playmates. She states, ​He has such poor social skills with other children, and he strongly rejects any change in his routine by throwing a tantrum.​ Based on this information, the nurse identifies which nursing diagnosis as the priority? A) Self-Care Deficits related to repeated tantrums B) Risk for Injury related to Asperger disorder C) Ineffective Family Coping related to having a child with Asperger disorder D) Risk for Social Isolation related to poor social skills of the child

D

The nurse is caring for a family with a 3-year-old child who has autism disorders. When developing the teaching plan for the parents, which of the following would the nurse most likely include? A) The child is at higher risk for seizure disorders as well. B) The child's IQ will typically be higher than that of other children. C) Dyslexia also may be a comorbid condition. D) A structured physical environment is an important aspect.

D

The nurse is discussing sleep enhancing strategies with a client who is experiencing insomnia. Which of the following would be most appropriate for the nurse to suggest? A) Eat right before you go to bed as long as it is something rich that will make you sleepy. B) Try exercising a bit right before your bedtime so you will feel tired and sleepy. C) Drinking a warm cup of tea right before bedtime will help to relax you. D) Establish a regular time for going to bed and getting up in the morning.

D

The nurse is preparing to discharge a client who has been hospitalized with anorexia nervosa. Which of the following would the nurse include in the teaching plan? A) Knowing the calorie content of numerous foods B) Learning strategies to control impulses C) Describing physiologic consequences of anorexia nervosa D) Setting realistic goals

D

The nurse plans to confront a client about secondary gains related to extreme dependency on spouse. Which nursing statement would be most appropriate? A. "Do you believe dependency issues have been a lifelong concern for you?" B. "Have you noticed any anxiety during times when your husband makes decisions." C. "What do you know about individuals who depend on others for direction?" D. "How have the specifics of your relationship with your spouse benefited you?"

D

The school nurse is caring for a 7-year-old child who has demonstrated a significantly lower-than- average score for mental age on standardized tests in reading. However, the child's IQ scores were within the average range. The nurse interprets this information as suggesting which of the following? A) Communication disorder B) Attention deficit hyperactivity disorder C) Asperger syndrome D) Dyslexia

D

nurse is assessing a child who is suspected of having attention deficit hyperactivity disorder. Which of the following would the nurse identify as reflecting impulsiveness in the child? A) Inability to wait his turn B) Restlessness C) Difficulty completing a task D) Risk-taking behavior

D

An older adult client is brought to the emergency department after ingesting an unknown substance. The client, who appears to have dementia, has tremors, ataxia of the upper and lower extremities, depression, and confusion. The nurse suspects ingestion of which of the following? A)Lead B)Aluminum C)Manganese D)Mercury

D)Mercury

A son brings his mother to the clinic for an evaluation. The son's mother has moderate Alzheimer's disease without delirium. The nurse assesses the client for which of the following as the priority? A) Hearing deficits B) Mania C) Strange verbalizations D) Catastrophic reactions

D) Catastrophic reactions

A nurse is providing care to a client with Alzheimer's disease who is exhibiting suspiciousness and delusional thinking. Which of the following would be most important for the nurse to do with this client? A) Tell the client that he is experiencing delusions. B) Confront the client about his distorted thinking. C) Correct the client's interpretation of the situation. D) Determine the trigger for the distorted thinking.

D) Determine the trigger for the distorted thinking.

A client diagnosed with neurocognitive disorder due to Alzheimers disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the clients room with name and number D. Assist with bathing and toileting

D. Assist with bathing and toileting

A client diagnosed with neurocognitive disorder due to Alzheimers disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

D. Late stage

An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft)

D. Sertraline (Zoloft)

A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the clients safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.

D. The client smokes one pack of cigarettes per day.

Medications for Neurocognitive disorders

Delirium: Avoid Benzos Alzheimers: Cholinesterase inhibitors Donepezil (Aricept), Galantamine (Razadyne) delay the decline in cognitive functioning but do not improve cognitive function after it has declined. Start as soon as diagnosis made. N-Methyl-D-Aspartic Acid Antagonists Memantine (Nameda) Blocks toxic effects of excess glutamate and regulates glutamate activation

A client with bulimia nervosa is scheduled for a visit to the clinic. When assessing this client, which of the following would the nurse expect to find? A) impulsivity B) panic C) hyperactivity D) delusions

a

A group of nursing students is reviewing the similarities and differences between bulimia nervosa and binge-eating disorder. The students demonstrate understanding when they identify which characteristics as specific to binge-eating disorder? Select all that apply. A) Clients typically are obese. B) Clients refrain from purging behaviors. C) Binge-eating periods are shorter. D) Clients engage in overexercising. E) Feelings of guilt do not occur after binging.

a, b

A nurse is preparing a presentation for a local middle school health class about eating disorders as a means for prevention and early detection. Which of the following would the nurse incorporate into the presentation as being common to both anorexia nervosa and bulimia nervosa? Select all that apply. A) Body dissatisfaction B) Feelings of control C) Obsessiveness D) Boundary problems E) Sexuality fears F) Cognitive distortions

a, c, f

A nursing instructor is reviewing the various theories related to anorexia nervosa. Which of the following would the instructor include when describing theories related to the biologic domain? Select all that apply. A) Genetic vulnerability B) Separation​individuation C) Role pressures D) Dieting leading to starvation E) Pursuit of thinness F) Decreased serotonin activity

a, d, f

Which of the following interventions is most appropriate in helping a client with early-stage dementia complete activities of daily living (ADLs)? a. Allow enough time for the client to complete ADLs as independently as possible. b. Provide the client with a written list of all the steps needed to complete ADLs. c. Plan to provide step-by-step prompting to complete the ADLs. d. Tell the client to finish ADLs before breakfast or the nursing assistant will do them

a. Allow enough time for the client to complete ADLs as independently as possible.

A client with dementia has been admitted to a long-term care facility. Which of the following nursing interventions will help the client to maintain optimal cognitive function? a. Discuss pictures of children and grandchildren with the client. b. Do word games or crossword puzzles with the client. c. Provide the client with a written list of daily activities. d. Watch and discuss the evening news with the client.

a. Discuss pictures of children and grandchildren with the client.

The nurse is caring for several hospitalized clients with anorexia nervosa. The nurse would be especially alert for which of the following if noted in the clients' histories? A) paranoia B) primary insomnia C) depression D) aggression

c

An adolescent is brought to the emergency department by her parents because they were concerned about their daughter's appearance. The client appears emaciated and pale. The parents tell the nurse that the client has been diagnosed with anorexia nervosa. A history and physical examination and laboratory testing are completed. Which of the following would lead the nurse to suspect that the client will be admitted to the hospital? Select all that apply. A) Blood pressure of 110/60 mm Hg B) Elevated serum potassium level C) Decreased serum magnesium level D) Heart rate of 40 beats/min E) Statements of being ​hopeless​

c, d, e

Which of the following statements by the caregiver of a client newly diagnosed with dementia requires further intervention by the nurse? a. "I will remind Mother of things she has forgotten." b. "I will keep Mother busy with favorite activities as long as she can participate." c. "I will try to find new and different things to do every day." d. "I will encourage Mother to talk about her friends and family."

c. "I will try to find new and different things to do every day."

While talking with a client with an eating disorder, the client states, ​I've gained 2 pounds, so soon I'll be over 100 pounds.​ The nurse interprets this as which of the following? A) magnification B) selective abstraction C) overgeneralization D) dichotomous thinking

d