Townsend Review Questions Ch 21-26

A client is hospitalized on the psychiatric unit with a history and current diagnosis of bulimia nervosa. Which symptoms would be congruent with this client's diagnosis? a. Binging, purging, obesity, hyperkalemia b. Binging, purging, normal weight, hypokalemia c. Binging, laxative abuse, amenorrhea, severe weight loss d, Binging, purging, severe weight loss, hyperkalemia

b. Binging, purging, normal weight, hypokalemia

A school nurse notices suspicious bruises and scars on a child's body. The nurse suspects that the child is being physically abused. Which action by the nurse is a priority at this point? a. As a health-care worker, report the suspicion to child protective services. b. Check the child again in a week and see if there are any new bruises. c. Meet with the child's parents and ask them how the child got the bruises. d. Initiate paperwork to have the child placed in foster care.

a. As a health-care worker, report the suspicion to child protective services.

According to researchers, which is a common theme in the health history of the client with BPD? a. Autism b. Attention deficit-hyperactivity disorder c. Positive and fulfilling interpersonal relationships d. Early childhood trauma

d. Early childhood trauma

An 80-year-old client says to the nurse, "I'm all alone now. My husband is gone. My best friend is gone. My daughter is busy with her work and family. I might as well just go, too." Which is the best response by the nurse? a. "Are you having thoughts of wanting to hurt yourself or take your own life?" b. "You have lots to live for, but we need to talk to your daughter about her priorities." c. "It's hard getting old." d. "Tell me about your family."

a. "Are you having thoughts of wanting to hurt yourself or take your own life?"

The physician has ordered trazodone 150 mg to be taken at bedtime for a 75- year- old widow with co- occurring insomnia and a history of depression. Which statement about this medication is a priority for the home health nurse to make in teaching the client about trazodone?! a. "You may feel dizzy when you stand up, so go slowly when you get up from sitting or lying down." b. "Make sure you let me know if you're getting adequate sleep. Trazodone sometimes interferes with sleep." c. "Don't get out of bed unless someone is available to assist you." d. "This medication takes around four to six weeks before you will notice any therapeutic effect."

a. "You may feel dizzy when you stand up, so go slowly when you get up from sitting or lying down."

In a group exercise class, Mr. B., a 79-year-old man with major depression, becomes tired and short of breath very quickly. This symptom is most likely due to which cause? a. Age-related changes in the cardiovascular system b. Anxiety c. The effects of pathological depression d. Medication the physician has prescribed for depression

a. Age-related changes to the cardiovascular system

The community mental health nurse is assessing a homeless woman who left her husband and "had nowhere else to go." She was referred to the clinic from the homeless shelter for an evaluation to rule out depression. Which priority action should the nurse include in the initial assessment? (Select all that apply.) a. Ask about trauma history. b. Assess risk for suicide. c. Assess her comfort level with the accommodations at the homeless shelter. d. Explore her financial resources.

a. Ask about trauma history b. Assess risk for suicide

A SANE nurse's primary role when intervening with a victim of violence is to: a. Conduct a sexual assault examination and preserve evidence b. Conduct a mini mental status examination c. Refer the client to a police officer d. Determine whether the client is lying about the events

a. Conduct a sexual assault examination and preserve evidence.

The Maudsley approach to treatment of adolescents with anorexia nervosa advances which fundamental concept? a. Family should be actively involved in each phase of treatment. b. Parents should be prohibited from involvement in helping their child eat more because there are often control issues. c. Adolescents need to work on developing healthy self-identities before they can begin to gain weight. d. Individual psychotherapy is the most effective treatment for adolescents with anorexia nervosa.

a. Family should be actively involved in each phase of treatment

A client on the psychiatric unit has a diagnosis of antisocial personality disorder. Which characteristic is consistent with this diagnosis? a. Lack of guilt for wrongdoing b. Insight into own behavior c. Ability to learn from past experiences d. Compliance with authority

a. Lack of guilt for wrongdoing

A male client, age 79, is admitted to the psychiatric unit for depression. He has lost weight and become socially isolated. His wife died 5 years ago, and his son tells the nurse, "He did very well when Mom died. He didn't even cry." Which is the priority nursing diagnosis? a. Maladaptive grieving b. Imbalanced nutrition: less than body requirements c. Social isolation d. Risk for injury

a. Maladaptive grieving

Which statement about oppositional behavior in children is true? a. Oppositional behavior in a child over 2 years of age is diagnostic of ODD. b. Oppositional behavior at various stages of development is normal and healthy. c. Oppositional behavior is genetic. d. Oppositional behavior is characterized by limited and repetitive rituals.

a. Oppositional behavior in a child over 2 years of age is diagnostic of ODD.

Which behavioral pattern is characteristic of individuals with narcissistic personality disorder? a. Overly self-centered and exploitative of others b. Suspicious and mistrustful of others c. Rule conscious and disapproving of change d. Anxious and socially isolated

a. Overly self-centered and exploitative of others

10. A client presents in the emergency department with complaints of suicidal ideation. The following data is collected by the nurse. Which assessment findings suggest that bulimia nervosa might be a health problem? (Select all that apply.) a. Parotid glands appear enlarged. b. Teeth have a "moth eaten" pattern of tooth decay. c. Client reports taking laxatives daily. d. Client's weight is within the expected range.

a. Parotid glands appear enlarged. b. Teeth have a "moth eaten" pattern of tooth decay. c. Client reports taking laxatives daily. d. Client's weight is within the expected range.

Which issue has been identified as contributing to the increase in the population of those who are homeless? (Select all that apply.) a. Poverty b. Lack of affordable health care a. Substance abuse c. Severe and persistent mental illness d. Growth in the number of family members living together

a. Poverty b. Lack of affordable health care c. Substance abuse d. Severe and persistent mental illness

A client diagnosed with BPD manipulates the staff in an effort to fulfill their own desires. All of the following may be examples of manipulative behaviors except: a. Refusal to stay in room alone, stating, "It's so lonely." b. Asking the nurse for cigarettes after 30 minutes, knowing that the assigned nurse has explained the client must wait 1 hour. c. Stating to the nurse, "I really like having you for my nurse. You're the best one around here." d. Making superficial cuts to their arms after discussing discharge plans with physician.

a. Refusal to stay in room alone, stating, "It's so lonely."

Which nursing diagnosis would be considered the priority in planning care for a child with a severe ASD? a. Risk for self-mutilation evidenced by banging head against wall b. Impaired social interaction evidenced by unresponsiveness to people c. Impaired verbal communication evidenced by absence of verbal expression d. Disturbed personal identity evidenced by inability to differentiate self from others

a. Risk for self-mutilation evidenced by banging head against wall

Which represents a nursing intervention at the tertiary level of prevention? a. Serving as case manager for a mentally ill homeless client b. Leading a support group for newly retired men c. Teaching prepared childbirth classes d. Caring for a depressed widow in the hospital

a. Serving as a case manager for a mentally ill homeless client.

Which represents a nursing intervention at the primary level of prevention? a. Teaching a class in parent effectiveness training b. Leading a group of adolescents in drug rehabilitation c. Referring a married couple for sex therapy d. Leading a support group for battered women

a. Teaching a class in parent effectiveness training.

The nurse is caring for a client who has been hospitalized with anorexia nervosa and is severely malnourished. The client refuses to eat. What is the most appropriate response by the nurse? a. "You know that if you don't eat, you will die." b. "If you continue to refuse to take food orally, you will be fed through a nasogastric tube." c. "You might as well leave if you are not going to follow your therapy regimen." d. "You don't have to eat if you don't want to. It is your choice."

b. "If you continue to refuse to take food orally, you will be fed through a nasogastric tube."

A female client arrives at the emergency department and tells the nurse her husband inflicted the cuts to her face that required sutures. She says, "I didn't want to come. I'm really okay. He only does this when he has too much to drink. I just shouldn't have yelled at him." The best response by the nurse is: a. "How often does he drink too much?" b. "It is not your fault. You did the right thing by coming here." c. "How many times has he done this to you?" d. "He is not a good husband. You have to leave him before he kills you."

b. "It is not your fault. You did the right thing by coming here."

A client has sought help for their concern that they are binge eating, and the client believes it has "gotten out of control." The client asks the nurse what can be done to help him. Which is the most accurate response? a. "There are no recognized treatments for bine eating disorder." b. "Some medications and psychological treatments that have demonstrated effectiveness in reducing binge eating behaviors." c. "The primary problem is obesity. I can help you set up a calorie-restricted diet." d. "Medications can help with weight loss, but there are no medications effective for reducing binge eating."

b. "Some medications and psychological treatments have demonstrated effectiveness in reducing binge eating behaviors."

A college-age female client is brought to the emergency department by their roommate after she confided that she was raped by her date who invited her to a frat party. The client says to the nurse, "It's all my fault. I shouldn't have gone to a party where I knew there was going to be alcohol." Which of these is the best response by the nurse? a. "Yes, you're right. You put yourself in a very vulnerable position when you allowed him to get you drunk." b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack." c. "There's no sense looking back now. Just look forward, and make sure you don't put yourself in the same situation again." d. "You'll just have to see that he is arrested so he won't do this to anyone else."

b. "You are not to blame for his behavior. You obviously made some right decisions, because you survived the attack."

Which behavioral pattern is characteristic of individuals with schizoid personality disorder? a. Belittling themselves and their abilities b. A lifelong pattern of social withdrawal a. Suspiciousness and mistrust of others d. Overreacting inappropriately to minor stimuli

b. A lifelong patters of social withdrawal

Which drug class is most commonly used for management of the child with ADHD? a. CNS depressants (e.g., diazepam [Valium]) b. CNS stimulants (e.g., methylphenidate [Ritalin]) c. Anticonvulsants (e.g., phenytoin [Dilantin]) d. Major tranquilizers (e.g., haloperidol [Haldol])

b. CNS stimulants (e.g., methylphenidate [Ritalin])

A nurse on the psychiatric unit documents that the client is using "splitting" behaviors with staff. This should be interpreted to mean that the client is exhibiting what behavior? a. Trying to keep the staff away from other clients b. Characterizing staff members as either all good or all bad c. Having brief psychotic episodes d. Manifesting two or more distinct subpersonalities when communicating with staff

b. Characterizing staff members as either all good or all bad

Which of the following medications is used to treat Tourette's disorder? a. Methylphenidate (Ritalin) b. Haloperidol (Haldol) c. Imipramine (Tofranil) d. Phenytoin (Dilantin)

b. Haloperidol (Haldol)

A 14-year-old client has just been admitted to the psychiatric unit for anorexia nervosa. They are emaciated and refuses to eat. What is the primary nursing diagnosis for this client? a. Complicated grieving b. Imbalanced nutrition: Less than body requirements c. Interrupted family processes d. Anxiety (severe)

b. Imbalanced nutrition: Less than body requirements

A 75-year-old male client, who is taking a selective serotonin reuptake inhibitor (SSRI) for depression, reports to the nurse that he recently began having erectile dysfunction. Which is the most appropriate action by the nurse? a. Set clear boundaries that this is not an appropriate topic to discuss with the nurse. b. Instruct the client that this is a potential side effect of his medication and ask whether he would prefer to explore other treatment options. c. Educate the client that this is a normal age-related change and cannot be treated. d. Reinforce that this is a common symptom of depression and should subside after 4 to 6 weeks of antidepressant treatment.

b. Instruct the client that this is a potential side effect of his medication and ask whether he would prefer to explore other treatment options.

A female child, age 5, is sent to the school nurse's office with an upset stomach. She has vomited and soiled her blouse. When the nurse removes her blouse, she notices that the child has numerous bruises on her arms and torso in various stages of healing. She also notices some small scars, and her abdomen protrudes on her small, thin frame. From the objective physical assessment, the nurse should screen further for: a. Physical and sexual abuse b. Physical abuse and neglect c. Emotional neglect d. Sexual and emotional abuse

b. Physical abuse and neglect

Which factor is most associated with mental health in older adults? a. Pureed foods and warm beverages b. Physical activity and socialization c. Moderate alcohol and lower calorie intake d. Living alone and adhering to antidepressant medications

b. Physical activity and socialization

A client with ODD has been admitted to a residential treatment setting and tells the nurse, "I don't want to be here and you're not in charge of me." Which intervention by the nurse is a priority? a. Instruct the client that they will have to follow the rules, or they will be put in seclusion. b. Provide information about the structured activities and behavioral expectations in the treatment program. c. Give positive feedback to the client for their assertive communication. d. Ask the client whether they would rather go to jail.

b. Provide information about the structured activities and behavioral expectations in the treatment program.

A young man who has just undergone a sexual assault is brought into the emergency department by a friend. What is the priority nursing intervention? a. Help him to bathe and clean himself up. b. Provide physical and emotional support during evidence collection. c. Provide him with a written list of community resources for survivors of rape. d. Discuss the importance of a follow-up visit to evaluate for sexually transmitted diseases.

b. Provide physical and emotional support during evidence collection.

Which represents a nursing intervention at the secondary level of prevention? a. Teaching a class about menopause to middle- aged women b. Providing support in the emergency department to a rape victim c. Leading a grief support group for widows and widowers d. Making monthly visits to the home of a client with schizophrenia to ensure medication compliance

b. Providing support in the emergency department to a rape victim.

A male client with antisocial personality disorder was found on the bed in a female client's room. When instructed to leave the room, the client states, "I'm sick of you telling me what I can and can't do. If I want to carry on a relationship with one of these ladies, it's my right. I'll do exactly as I please!" Which action by the nurse is a priority at this point? a. Reassure the client that he will have plenty of opportunities with women after he is discharged. b. Reinforce the rules of the treatment program that all clients are expected to follow. c. Escort the client to a seclusion room. d. Establish a trusting relationship by telling the client that an exception will be made just this once.

b. Reinforce the rules of the treatment program that all clients are expected to follow.

To help a child with mild to moderate intellectual developmental disorder develop satisfying relationships with others, which nursing intervention is most appropriate? a. Interpret the child's behavior for others. b. Set limits on behavior that is socially inappropriate. c. Allow the child to behave spontaneously without the concept of right or wrong. d. Discourage relationships because the child is not capable of forming social relationships.

b. Set limits on behavior that is socially inappropriate.

A child with ADHD has a nursing diagnosis of impaired social interaction. Which nursing interventions are appropriate for this child? (Select all that apply.) a. Socially isolate the child when interactions with others are inappropriate. b. Set limits with consequences on inappropriate behaviors. c. Provide rewards for appropriate behaviors. d. Provide group situations for the child.

b. Set limits with consequences on inappropriate behaviors. c. Provide rewards for appropriate behaviors. d. Provide group situations for the child.

A 78- year- old widow who lives alone has been diagnosed with depression. Which criterion would qualify this client for home health visits? a. The client doesn't like to drive on busy roads. b. The client is physically too weak to travel without risk of injury. c. The client refuses to seek assistance as suggested by their physician, "because I don't have a psychiatric problem." ad. The client says they would rather have home visits than go to the physician's office.

b. The client is too physically weak to travel without risk of injury

A hospitalized client with bulimia nervosa has stopped vomiting in the hospital and tells the nurse they are afraid they're going to gain weight. Which is the most appropriate response by the nurse? a. "Don't worry. The dietician will ensure that you don't get too many calories in your diet." b. "Don't worry about your weight. We are going to work on other problems while you are in the hospital." c. "I understand that you are concerned about your weight, and we will talk about the importance of good nutrition; but for now, I want you to tell me about your recent invitation to join the National Honor Society. That's quite an accomplishment." d. "You are not fat, and the staff will ensure that you do not gain weight while you are in the hospital, because we know that is important to you."

c. "I understand that you are concerned about your weight, and we will talk about the importance of good nutrition; but for now, I want you to tell me about your recent invitation to join the National Honor Society. That's quite an accomplishment."

During the admission assessment for a 72-year-old male client the nurse notices an open sore on his arm. When she questions him about it, he says, "I scraped it on the fence two weeks ago. It's smaller than it was." Which of the following is the best interpretation of this finding? a. Lower testosterone levels in older adult men results in injury-prone skin. b. Confusion is common in older adults, so the client probably doesn't remember how long ago he sustained the injury. c. A diminished inflammatory response in older adults increases healing time. d. The supply of blood vessels to the skin increases with age and delays healing time.

c. A diminished inflammatory response in older adults increases healing time.

A client with BPD reports to the nurse that they are having abdominal pain and is requesting pain medication. Which action by the nurse is a priority? a. Explore alternative pain management strategies b. Confront the client about their manipulation to try to get drugs c. Assess the client's pain in more detail d. Set limits on the client's attempts to cling to the nurse

c. Assess the client's pain in more detail

The child with autism spectrum disorder often has difficulty with trust. With this in mind, which nursing action would be most appropriate? a. Encourage all staff to hold the child as often as possible, conveying trust through touch. b. Assign a different staff member each day so the child will learn that everyone can be trusted. c. Assign the same staff person as often as possible to promote feelings of security and trust. d. Avoid eye contact because it is extremely uncomfortable for the child and may even discourage trust.

c. Assign the same staff person as often as possible to promote feelings of security and trust.

What physical manifestations would you expect to assess in a client with anorexia nervosa? a. Tachycardia, hypertension, hyperthermia b. Bradycardia, hypertension, hyperthermia c. Bradycardia, hypotension, hypothermia d. Tachycardia, hypotension, hypothermia

c. Bradycardia, hypotension, hypothermia

A homeless person has just come to live in a shelter. The shelter nurse is assigned to their care. Which is a priority intervention on the part of the nurse? a. Referring them to a social worker b. Developing a plan of care c. Conducting a behavioral and needs assessment d. Helping them apply for Social Security benefits

c. Conducting a behavioral and needs assessment

An older male client with depression says to the nurse, "I don't want to go to that crafts class. I'm too old to learn anything." Which of these is the most appropriate action by the nurse at this point? a. Tell the client that groups are mandatory and escort him by the hand. b. Pat the client on the shoulder and tell him "We all feel that way sometimes." c. Educate the client that people don't typically lose the ability to learn as they age and encourage him to express his thoughts and feelings associated with aging. d. Assess the client for suicide risk and warning signs.

c. Educate the client that people don't typically lose the ability to learn as they age and encourage him to express his thoughts and feelings associated with aging.

The nursing history and assessment of an adolescent with a conduct disorder might reveal all behaviors except: a. Manipulation of others for fulfillment of own desires b. Chronic violation of rules c. Feelings of guilt associated with the exploitation of others d. Inability to form close peer relationships

c. Feelings of guilt associated with the exploitation of others

Which medication has been used with some success in clients with bulimia nervosa? a. Lorcaserin (Belviq) b. Diazepam (Valium) c. Fluoxetine (Prozac) d. Carbamazepine (Tegretol)

c. Fluoxetine (Prozac)

A psychiatric home health nurse has received an order to begin regular visits to a client diagnosed with depression. Which potential problems is a priority to evaluate during the first home visit? a. Maladaptive grieving b. Social isolation c. Risk for injury d. Sleep pattern disturbance

c. Risk for injury

Some obese individuals take amphetamines to suppress appetite and help them lose weight. Which is an adverse effect associated with use of amphetamines that makes this practice undesirable? a. Bradycardia b. Amenorrhea c. Tolerance d. Convulsions

c. Tolerance

Trauma-informed care is foundational to all interventions with a victim of violence for which of the following reasons? a. It is a legal requirement in all 50 states. b. Trauma victims are unaware they have been traumatized until they are so informed. c. Victims of violence are at high risk for retraumatization. d. The client has a right to know what will happen to the perpetrator.

c. Victims of violence are at high risk for retraumatization.

The home health nurse is assessing an 87- year- old man who states, "I've lived long enough and there's just nothing left for me." Which is the best response on the part of the nurse? a. "Of course there is; why would you say such a thing?" b. "You seem so sad. I'm going to do my best to cheer you up." c. "Let's talk about why you are feeling this way." d. "Are you having any thoughts of suicide?"

d. "Are you having thoughts of suicide?"

A woman who has a long history of being battered by her husband is staying at the woman's shelter. She has received emotional support from staff and peers and has been made aware of the alternatives open to her. Nevertheless, she decides to return to her home and marriage. The best response by the nurse to the woman's decision is: a. "I just can't believe you have decided to go back to that horrible man." b. "I'm just afraid he will kill you or the children when you go back." c. "What makes you think things have changed with him?" d. "I hope you have made the right decision. Call this number if you need help."

d. "I hope you have made the right decision. Call this number if you need help."

A client diagnosed with antisocial personality disorder approaches the nurse and says "You're so cute, are you married?" Which is the most appropriate response by the nurse? a. "I'm married but that's none of your business." b. "Let's talk about your love life instead." c. "Thank-you so much for the compliment but I'm married." d. "Our relationship is strictly professional. It's not appropriate for us to have that kind of discussion."

d. "Our relationship is strictly professional. It's not appropriate for us to have that kind of discussion."

A male client, age 79, is admitted to the psychiatric unit for depression. He has lost weight and has become socially isolated. His wife died 5 years ago, and his son tells the nurse, "He did very well when Mom died. He didn't even cry." Which is the priority nursing intervention? a. Take blood pressure once each shift. b. Ensure that the client attends group activities. c. Encourage the client to eat all of the food on his food tray. d. Encourage the client to talk about his wife's death.

d. Encourage the client to talk about his wife's death

The developmental task of transcendence suggests that mental health in older adulthood is contingent upon: a. Being able to ignore the stigmas associated with being old b. Developing the ability to be alone c. Transcending physical limitations imposed by age-related changes in the body d. Having a sense of meaning in life and a sense of satisfaction

d. Having a sense of meaning in life and a sense of satisfaction

Certain family dynamics are believed to predispose adolescents to the development of conduct disorder. Which pattern is thought to be a contributing factor? a. Parents who are overprotective b. Parents who have high expectations for their children c. Parents who consistently set limits on their children's behavior d. Parents who are alcohol dependent

d. Parents who are alcohol dependent

The nurse is providing education to a support group for survivors of rape. Which of the following items is evidence-based information to include in this teaching? a. Rapists typically drink alcohol and are not in control of their actions. b. Rape is usually an event that occurs between two people who are sexually frustrated. c. Men who are born into poverty are predisposed to becoming rapists after puberty. d. Rape is an expression of power and dominance by means of sexual aggression and violence.

d. Rape is an expression of power and dominance by means of sexual aggression and violence.

A client with a diagnosis of BPD often exhibits alternating clinging and distancing behaviors. Which is the most appropriate nursing intervention for the client with this type of behavior? a. Encourage the client to establish trust in one staff person with whom all therapeutic interaction should take place. b. Secure a verbal contract from the client to discontinue these behaviors. c. Withdraw attention if these behaviors continue. d. Rotate staff members who work with the client so that the client will learn to relate to more than one person.

d. Rotate staff members who work with the client so that the client will learn to relate to more than one person.

What is the most appropriate way to communicate with an older client who is deaf in their right ear? a. Speak loudly into their left ear. b. Speak to the client from a position on their left side. c. Speak face-to-face in a high-pitched voice. d. Speak face-to-face in a low-pitched voice.

d. Speak face-to-face in a low-pitched voice.

A school nurse notices bruises and scars on a 5-year-old child's body, but the child refuses to say how they received them. Which of the following is an evidence-based approach for further assessment by the nurse? a. Have the child evaluated by the school psychologist. b. Tell the child they may select a "treat" from the treat box (e.g., sucker, balloon, junk jewelry) if they answer the nurse's questions. c. Explain to the child that if they answer the questions, they may stay in the nurse's office and not have to go back to class. d. Use a "family" of dolls to role-play the child's family with them.

d. Use a "family" of dolls to role-play the child's family with them.