Concepts Exam 3 Part 2

A patient tells the nurse, "My doctor prescribed paroxetine for my depression. I assume I'll have side effects like I had when I was taking imipramine." The nurse's reply should be based on the knowledge that paroxetine is a(n) a. selective norepinephrine reuptake inhibitor. b. tricyclic antidepressant. c. monoamine oxidase (MAO) inhibitor. d. SSRI.

D Paroxetine is an SSRI and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

A patient begins therapy with a phenothiazine medication. What teaching should the nurse provide related to the drug's strong dopaminergic effect? a. Chew sugarless gum. b. Increase dietary fiber. c. Arise slowly from bed. d. Report changes in muscle movement.

D Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Movement disorders and motor abnormalities (extrapyramidal side effects), such as parkinsonism, akinesia, akathisia, dyskinesia, and tardive dyskinesia, are likely to occur early in the course of treatment. They are often heralded by sensations of muscle stiffness. Early intervention with antiparkinsonism medication can increase the patient's comfort and prevent dystonic reactions. The distracters are related to anticholinergic effects.

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

D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patient's physiological integrity. The other body systems are not initially involved in the refeeding syndrome. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-14, 54 (Table 18-1) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hour. A potassium level of 3.4 mEq/L is within the normal range. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-7, 28, 68 (Box 18-2) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

Which medication is FDA approved for treatment of anxiety in children? A. Lorazepam (benzodiazepine) B. Fluoxetine (selective serotonin reuptake inhibitor) C. Clomipramine (tricyclic antidepressant) D. None of the above

D. None of the above There are no medications with FDA approval for children with anxiety disorders; however, medications approved for other age groups are often prescribed. None of the other options are FDA approved to treat anxiety in children (see the previous sentence).

The nurse caring for a client experiencing a panic attack anticipates that the psychiatrist would order a stat dose of: A. standard antipsychotic medication. B. tricyclic antidepressant medication. C. anticholinergic medication. D. a short-acting benzodiazepine medication.

D. a short-acting benzodiazepine medication. A short-acting benzodiazepine is the only type of medication listed that would lessen the client's symptoms of anxiety within a few minutes. Anticholinergics do not lower anxiety; tricyclic antidepressants have very little antianxiety effect and have a slow onset of action; and a standard antipsychotic medication will lower anxiety but has a slower onset of action and the potential for more side effects.

Working to help the client view an occurrence in a more positive light is called: A. flooding. B. desensitization. C. response prevention. D. cognitive restructuring.

D. cognitive restructuring. The purpose of cognitive restructuring is to change the individual's negative view of an event or a situation to a view that remains consistent with the facts but that is more positive.

The primary purpose of performing a physical examination before beginning treatment for any anxiety disorder is to: A. protect the nurse legally. B. establish the nursing diagnoses of priority. C. obtain information about the client's psychosocial background. D. determine whether the anxiety is primary or secondary in origin.

D. determine whether the anxiety is primary or secondary in origin. The symptoms of anxiety can be caused by a number of physical disorders or are said to be caused by an underlying physical disorder. The treatment for secondary anxiety is treatment of the underlying cause.

A symptom commonly associated with panic attacks is: A. obsessions. B. apathy. C. fever. D. fear of impending doom.

D. fear of impending doom. The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur.

The major distinction between fear and anxiety is that fear: A. is a universal experience; anxiety is neurotic. B. enables constructive action; anxiety is dysfunctional. C. is a psychological experience; anxiety is a physiological experience. D. is a response to a specific danger; anxiety is a response to an unknown danger.

D. is a response to a specific danger; anxiety is a response to an unknown danger. Fear is a response to an objective danger; anxiety is a response to a subjective danger.

You are providing teaching to Lana, a preoperative patient just before surgery. She is becoming more and more anxious as you talk. She begins to complain of dizziness and heart pounding, and she is trembling. She seems confused. Your best response is to: A. reinforce the preoperative teaching by restating it slowly. B. have Lana read the teaching materials instead of verbal instruction. C. have a family member read the preoperative materials to Lana. D. not attempt any teaching at this time.

D. not attempt any teaching at this time. Patients experiencing severe anxiety, as the symptoms suggest, are unable to learn or solve problems. The other options would not be effective because you are still attempting to teach someone who has a severe level of anxiety.

Delusionary thinking is a characteristic of: A. chronic anxiety. B. acute anxiety. C. severe anxiety. D. panic level anxiety.

D. panic level anxiety. Panic level anxiety is the most extreme level and results in markedly disturbed thinking.

A client is running from chair to chair in the solarium. He is wide-eyed and keeps repeating, "They are coming! They are coming!" He neither follows staff direction nor responds to verbal efforts to calm him. The level of anxiety can be assessed as: A. mild. B. moderate. C. severe. D. panic.

D. panic. Panic-level anxiety results in markedly disorganized, disturbed behavior, including confusion, shouting, and hallucinating. Individuals may be unable to follow directions and may need external limits to ensure safety.

2. The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. open a window to let fresh air into the room. B. use nasal strips to assist with breathing. C. sleep in a side-lying position. D. use pillows to prop yourself up while sleeping.

D. use pillows to prop yourself up while sleeping. Correct Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat. Awarded 1.0 points out of 1.0 possible points.

Which population group has the highest rate of infection with chlamydia? a. Older adults b. midlife adults c. young teens d. young adults

D. young adults

382. The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Restrict fluid intake 2. Position for comfort 3. Avoid strain on painful joints 4. Apply nasal oxygen at 2 L/min 5. Provide a high-calorie, high-protein diet 6. Give meperidine (Demerol) 25 mg intravenously every 4 hours for pain

1 Restrict fluid intake 6 Give meperidine (Demerol) 25 mg intravenously every 4 hours for pain Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the RBC; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine (Demerol) is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

383. The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. 1. Easy bruising occurs 2. Gum bleeding occurs 3. It is a hereditary bleeding disorder 4. Treatment and care are similar to that for hemophilia 5. It is characterized by extremely high creatinine levels 6. The disorder causes platelets to adhere to damaged endothelium

1, 2, 3, 4, 6 von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.

The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1. palpating the abdomen for a mass 2. assessing the urine for the presence of hematuria 3. monitoring the temperature for the presence of fever 4. monitoring the blood pressure for the presence of hypertension

1. palpating the abdomen for a mass

The nurse is monitoring a 3 yo child for signs and symptoms of increased intracranial pressure after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. vomiting 2. bulging anterior fontanel 3. increasing head circumference 4. complaints of a frontal headache

1. vomiting

376. The nursing student is presenting a clinical conference and discusses the cause of beta-thalassemia. The nursing student informs that a child at greatest risk of developing this disorder is which one? 1. A child of Mexican descent 2. A child of Mediterranean descent 3. A child whose intake of iron is extremely poor 4. A breast-fed child of a mother with chronic anemia

2 Beta-thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with beta-thalassemia major), This disorder is found primarily in individuals of Mediterranean descent.

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1. place the child in a supine position 2. notify the HCP 3. place the child in Trendelenburg position 4. increase the flow rate of the intravenous fluids

2. notify the HCP

The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately? 1. reinforce the dressing 2. notify the HCP 3. document the findings and continue to monitor 4. circle the area of drainage and continue to monitor

2. notify the HCP

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1. maintain the child in a semi-private room 2. reduce exposure to environmental organisms 3. use strict aseptic technique for all procedures 4. ensure that anyone entering the child's room wears a mask 5. apply firm pressure to a needle-stick area for at least 10 minutes

2. reduce exposure to environmental organisms 3. use strict aseptic technique for all procedures 4. ensure that anyone entering the child's room wears a mask

375. The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child? 1. Soccer 2. Basketball 3. Swimming 4. Field hockey

3 Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets with other sports. The safe activity for them is swimming.

379. A 10 y/o child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? 1. Injection of factor X 2. Intravenous infusion of iron 3. Intravenous infusion of factor VIII 4. Intramuscular injection of iron using the Z-track method

3 Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disprder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A.

381. Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? 1. Elevated hemoglobin level 2. Decreased reticulocyte count 3. Elevated red blood cell count 4. Red blood cells that are microcytic and hypochromic

4 In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBCs. The results of a complete blood cell count in children with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

377. A child with beta-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed? 1. Fragmin 2. Meropenem (Merrem) 3. Metoprolol (Toprol-XL) 4. Deferoxamine (Desferal)

4 Beta-thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with beta-thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. to prevent organ damage from too much iron, chelation therapy with either Exhade of deferoxamine (Desferal) may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Fragmin is an anticoagulant used as prophylaxis for postop DV. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension

378. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instructions? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

4 Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical/emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 1/2 to 2 times the daily requirement to prevent dehydration.

Client Needs: Psychosocial Integrity 17. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

A

Client Needs: Psychosocial Integrity 4. An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training c. Desensitization techniques b. Relaxation training classes d. Use of complementary therapy

A

The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses c. Night blindness d. Reflux disease

A

The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? a. "The sinoatrial node stimulates the heart to beat in a normal rhythm." b. "The sinoatrial node protects the heart from atherosclerotic changes." c. "The sinoatrial node provides the heart with oxygenated blood." d. "The sinoatrial node protects the heart from infection."

A

The nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the a. parasympathetic nervous system. b. sympathetic nervous system. c. reticular activating system. d. medulla oblongata.

A Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When anticholinergic drugs inhibit acetylcholine action, blurred vision, dry mouth, constipation, and urinary retention commonly occur.

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

A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 18-30 (Case Study and Nursing Care Plan) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

An obese patient has a diagnosis of schizophrenia. Medications that block which receptors would contribute to further weight gain? a. H1 b. 5 HT2 c. Acetylcholine d. GABA

A H1 receptor blockade results in weight gain, which is undesirable for an obese patient. Blocking of the other receptors would have little or no effect on the patient's weight.

12. A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

A In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent's role. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-12, 13, 27 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

The nurse administers a medication that potentiates the action of ã-aminobutyric acid (GABA). Which effect would be expected? a.Reduced anxiety b.Improved memory c.More organized thinking d.Fewer sensory perceptual alterations

A Increased levels of GABA reduce anxiety. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

26. The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a patient diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? a. The patient's history of poly-substance abuse b. The patient's preference for homeopathic remedies c. The patient's family history of autoimmune disorders d. The patient's comorbid diagnosis of a learning disability

A Lisdexamfetamine dimesylate is designed to suppress the appetite and presents a risk for abuse. The patient with a history of substance abuse is at risk to abuse this medication as well. The patient's preference for homeopathic remedies is a consideration, but the history of substance abuse has a higher priority. Lisdexamfetamine dimesylate is commonly used to treat attention deficit hyperactivity disorder rather than learning disabilities. A history of autoimmune disorders in the family is irrelevant. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 18-37, 65 (Table 18-7) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving a. lithium. b. clozapine. c. fluoxetine. d. venlafaxine.

A Lithium is a salt and known to alter fluid and electrolyte balance, producing polyuria, edema, and other symptoms of imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block. Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.

A drug causes muscarinic receptor blockade. The nurse will assess the patient for a. dry mouth. b. gynecomastia. c. pseudoparkinsonism. d. orthostatic hypotension.

A Muscarinic receptor blockade includes atropine-like side effects, such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with á1 antagonism.

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

A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36 C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 18-7, 28, 68, (Box 18-2) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

27. A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? a. The child frequently eats newspapers and magazines. b. The child refuses to eat peanut butter and jelly sandwiches. c. The child often rechews and reswallows foods at mealtimes. d. The parents feed the child clay because of concerns about anemia.

A Pica refers to eating nonfood items after maturing past toddlerhood. Some cultures practice eating nonfood items; however, this factor is a cultural preference rather than a disorder. Refusing to eat peanut butter and jelly sandwiches is an example of a simple food preference in a child. Rumination refers to regurgitation with rechewing, reswallowing, or spitting. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 18-43, 44, 74 (Box 18-6) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE

20. Physical assessment of a patient diagnosed with bulimia often reveals a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.

A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 18-26, 55 (Table 18-2), 71 (Box 18-5) | Page 18-30 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3. Select the nurse's best action. a. Report the results to the health care provider immediately. b. Administer the next dose as prescribed. c. Give aspirin and force fluids. d. Repeat the laboratory test.

A These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider, and the drug should be withheld. The health care provider may repeat the test, but in the meantime, the drug should be withheld.

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

A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-14, 54 (Table 18-1) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

A patient's sibling says, "My brother has a mental illness, but the doctor ordered a functional magnetic resonance image (fMRI) test. That test is too expensive and will just increase the hospital bill." Select the nurse's best responses. (Select all that apply.) a. "Sometimes there are physical causes for psychiatric symptoms. This test will help us understand whether that is the situation." b. "Some mental illnesses are evident on fMRIs. This test will give information to help us plan the best care for your brother." c. "This test will indicate whether your brother has been taking his psychotropic medications as prescribed." d. "It sounds like you do not truly believe your brother had a mental illness." e. "It would be better for you to discuss your concerns with the health care provider."

A, B The correct responses provide information to the sibling. Modern imaging techniques are important tools in assessing molecular changes in mental disease and marking the receptor sites of drug action, which can help in treatment planning. Psychiatric symptoms can be caused by anatomical or physiologic abnormalities. There is no evidence of denial in the sibling's comment. The nurse can answer this question rather than referring it to the physician/health care provider. An fMRI does not demonstrate adherence to the medication regime.

Client Needs: Psychosocial Integrity 3. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

A, B, C

Which instructions are most important for the nurse to include in the healthcare teaching for a client who is diagnosed with gonorrheal infections? (Select all that apply. One, some, or all options may be correct.) a. Sexual partners should be examined, cultured, and treated with appropriate regimens. b. Most treatment failures result from reinfections from untreated partners. c. Complications are consequences of reinfection. d. Gonorrhea infection can be spread by using public toilets. e. HCPs are legally responsible for reporting to the local health department.

A, B, C, D, F

Infection with chlamydia trachomatis is of particular concern for which of the following reasons? (Select all that apply. One, some, or all options may be correct.) a. The infection is often asymptomatic, especially among females. b. Chlamydia is the most prevalence sexually transmitted infection worldwide. c. There is no effective treatment for the infection. d. Untreated infection can lead to endometriosis and pelvic peritonitis.

A, B, D

An individual is experiencing problems with memory. Which of these structures are most likely to be involved in this deficit? (Select all that apply.) a. Amygdala b. Hippocampus c. Occipital lobe d. Temporal lobe e. Basal ganglia

A, B, D The frontal and temporal lobes of the cerebrum play a key role in the storage and processing of memories. The amygdala and hippocampus also play roles in memory. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement, as well as some thoughts and emotions.

Which of the following are components of a comprehensive sexual education program?(Select all that apply. One, some, or all options may be correct.) a. Abstinence. b. Sexually transmitted diseases/infections. c. Religious views about sexuality. d. Pregnancy prevention. e. Healthy communication and healthy relationships.

A, B, D, E

The nurse has received new orders by electronic medical record (EMR) in response to the recent laboratory results. One of the orders is for intravenous potassium chloride 20 mEq/100 mL over one hour. Which drug implications are important for the nurse to consider before giving it? (Select all that apply. One, some, or all options may be correct.) a. The intravenous site should be monitored closely for infiltration. b. Giving the infusion too rapidly can cause fatal hyperkalemia. c. It should be injected directly and slowly by intravenous push. d. The intravenous infusion is best given through a central line. e. The intravenous potassium can be given by gravity infusion. f. Administering the intravenous medication can burn a peripheral vein.

A, B, E, F

The client is instructed to return for a follow-up examination if symptoms persist after treatment. The nurse explains to the client that recent research shows that strains of gonorrhea bacteria have emerged that are resistant to penicillin, tetracycline, ciprofloxacin, and cefixime. Which instructions are the most important for the nurse to provide to the client prior to discharge? (Select all that apply. One, some, or all options may be correct.) a. Direct the client to take medication to her sexual partner. b. Advise the client to take the antibiotic until symptoms subside. c. Counsel the client about reinfection from a new or untreated partner. d. Emphasize compliance with completion of the antibiotic regimen. e. Recommend abstinence from sexual intercourse until treatment completion.

A, C, D, E, F

Client Needs: Psychosocial Integrity 2. A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

A, C, D, F

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

A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 18-12, 13, 54 (Table 18-1), 58 (Table 18-3), 68 (Box 18-2) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A nurse prepares to administer a second-generation antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring for adverse effects will be most important if the patient has which co-morbid health problems? (Select all that apply.) a. Parkinson's disease b. Grave's disease c. Hyperlipidemia d. Osteoarthritis e. Diabetes

A, C, E Antipsychotic medications may produce weight gain, which would complicate care of a patient with diabetes, and increase serum triglycerides, which would complicate care of a patient with hyperlipidemia. Parkinson's disease involves changes in transmission of dopamine and acetylcholine, so these drugs would also complicate care of this patient. Osteoarthritis and Grave's disease should have no synergistic effect with this medication.

Client Needs: Psychosocial Integrity 4. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

A, D, E

Data about infection with chlamydia trachomatis are obtained by the health department in order to do which of the following? (Select all that apply. One, some, or all options may be correct.) a. Report to the Centers for Disease Control and Prevention (CDC). b. Follow up with individuals after they have received treatment. c. Notify others who may have contracted the infectious disease. d. Identify trends in the incidence of communicable diseases. e. Plan and implement prevention and disease control programs.

A, D, E

A client who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." A helpful response for the nurse to make would be: A. "What things have you done in the past that helped you feel more comfortable?" B. "Let's try to focus on that adorable little granddaughter of yours." C. "Why don't you sit down over there and work on that jigsaw puzzle?" D. "Try not to think about the feelings and sensations you're experiencing."

A. "What things have you done in the past that helped you feel more comfortable?" Because the client is not able to think through the problem and arrive at an action that would lower anxiety, the nurse can assist by asking what has worked in the past. Often what has been helpful in the past can be used again.

3. A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? A. "Your father may be having mini-strokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion."

A. "Your father may be having mini-strokes; I will notify his physician." Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified. Awarded 1.0 points out of 1.0 possible points.

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? A. An elevation of the total white cell count indicates generalized inflammation. B. Eosinophil count will assist to identify the presence of a respiratory infection. C. White cell count will differentiate types of respiratory bacteria. D. Level of neutrophils provides guidelines to monitor a chronic infection.

A. An elevation of the total white cell count indicates generalized inflammation. Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A. Chronic lung disease with increased carbon dioxide retention B. Acute anxiety, hyperventilation, and decreased carbon dioxide retention C. Decreased cardiac output with increased serum lactic acid production D. Gastric drainage with increased removal of gastric acid

A. Chronic lung disease with increased carbon dioxide retention Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

A possible outcome criterion for a client diagnosed with anxiety disorder is: A. Client demonstrates effective coping strategies. B. Client reports reduced hallucinations. C. Client reports feelings of tension and fatigue. D. Client demonstrates persistent avoidance behaviors.

A. Client demonstrates effective coping strategies. Option A is the only desirable outcome listed.

Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? A. Hemoglobin level of 8.0 B. Bronchoconstriction and mucus C. Peripheral arterial disease D. Decreased thoracic expansion

A. Hemoglobin level of 8.0 Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) A. Neurologic system B. Endocrine system C. Pulmonary system D. Immune system E. Cardiovascular system F. Hepatic system

A. Neurologic system C. Pulmonary system E. Cardiovascular system The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? A. Peripheral arterial disease of the lower extremities B. Chronic obstructive pulmonary disease (COPD) C. Chronic asthma D. Severe anemia secondary to chemotherapy

A. Peripheral arterial disease of the lower extremities Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? Select all that apply. A. Poor eye contact B. Increased fever C. Appetite changes D. Increased white blood cell count E. Slowed speech

A. Poor eye contact C. Appetite changes E. Slowed speech

Generally, ego defense mechanisms: A. often involve some degree of self-deception. B. are rarely used by mentally healthy people. C. seldom make the person more comfortable. D. are usually effective in resolving conflicts.

A. often involve some degree of self-deception. Most ego defense mechanisms, with the exception of the mature defenses, alter the individual's perception of reality to produce varying degrees of self-deception.

Inability to leave one's home because of avoidance of severe anxiety suggests the anxiety disorder of: A. panic attacks with agoraphobia. B. obsessive-compulsive disorder. C. posttraumatic stress response. D. generalized anxiety disorder.

A. panic attacks with agoraphobia. Panic disorder with agoraphobia is characterized by recurrent panic attacks combined with agoraphobia. Agoraphobia involves intense, excessive anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred.

A potential problem for a client diagnosed with severe obsessive-compulsive disorder is: A. sleep disturbance. B. excessive socialization. C. command hallucinations. D. altered state of consciousness.

A. sleep disturbance. Clients who must engage in compulsive rituals for anxiety relief are rarely afforded relief for any prolonged period. The high anxiety level and need to perform the ritual may interfere with sleep.

A cultural characteristic that may be observed in a teenage, female Hispanic client in times of stress is to: A. suddenly tremble severely. B. exhibit stoic behavior. C. report both nausea and vomiting. D. laugh inappropriately.

A. suddenly tremble severely. Ataque de nervios (attack of the nerves) is a culture-bound syndrome that is seen in undereducated, disadvantaged females of Hispanic ethnicity.

A client is experiencing a panic attack. The nurse can be most therapeutic by: A. telling the client to take slow, deep breaths. B. verbalizing mild disapproval of the anxious behavior. C. asking the client what he means when he says "I am dying." D. offering an explanation about why the symptoms are occurring

A. telling the client to take slow, deep breaths. Slow diaphragmatic breathing can induce relaxation and reduce symptoms of anxiety. Often the nurse has to tell the client to "breathe with me" and keep the client focused on the task. The slower breathing also reduces the threat of hypercapnia with its attendant symptoms.

A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? a. "I will tell myself that I am a good person when things don't go well at work." b. "My medications will make my problems go away." c. "My family will help take care of my children while I am in the hospital." d. "This therapy will improve my response to neurotransmitter impulses."

ANS: A

As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a. Assess for depression and ask directly about suicide thoughts. b. Ask the care provider to prescribe blood lab work to assess for depression. c. Focus on the presenting problems and refer the patient for a mental health evaluation. d. Interview the patient's family to identify their concerns about the patient's behaviors.

ANS: A

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

ANS: A A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment

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

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 214 (Box 12-5) | Page 221 TOP: Nursing Process: Implementation

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

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

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

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

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

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

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

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

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

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

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

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

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

21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

ANS: A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.

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

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option; yet, important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 210-211 | Page 215 (Box 12-6) | Page 222 (Case study and Nursing Care Plan 12-1) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

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

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

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

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

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

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

14. A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

ANS: A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

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

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 (Table 12-1) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

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

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

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

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

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

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

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 201-202 | Page 204-205 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

ANS: A Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A patient approaches the nurse in the clinic waiting room and says, "I want to talk to you about a sexual matter." The nurse can best facilitate the discussion by: a. saying, "Let's go my office." b. responding, "I want to help. Go ahead; I'm listening." c. telling the patient, "Let's schedule another appointment." d. offering to sit in a corner of the waiting room with the patient.

ANS: A A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. The distracters block communication.

A man says, "I enjoy watching women when I am out in public. I like to go to places where I can observe women crossing their legs in hopes of seeing something good." Which statement about this behavior is most accurate? a. It is a sexual disorder. The behavior is socially atypical. It could disrupt relationships and could be insulting to others. b. It is not a sexual disorder. These events occur in public, where those he observes do not have a reasonable expectation of privacy. c. It is not a sexual disorder. Because it occurs in public areas, this behavior does not hurt others or involve intrusion into the personal space of those observed. d. An action is or is not a sexual disorder depending on applicable local laws, so whether this meets the definition of a sexual disorder depends on the location.

ANS: A A sexual disorder is defined as an activity that is socially atypical, has the potential to disrupt significant relationships, and may result in insult or injury to others. The behavior described constitutes a sexual disorder (voyeurism). Although laws vary, an act does not have to be illegal to constitute a sexual disorder. The fact that the behavior occurs in a public setting could have a bearing on whether it is illegal, but not on whether it is considered to be a sexual disorder.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with boys who are athletic d. Intense urges to watch his parents have sex

ANS: A An individual with gender dysphoria feels at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender dysphoria.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? a. "My employer should have paid for a health club membership for me." b. "My family will see me through this. It won't be easy, but I will never be alone." c. "My heart attack was no fun, but it showed me up the importance of a good diet and more exercise." d. "I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily."

ANS: A Blaming someone else and rationalizing one's failure to exercise are not adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one's situation are seen as more effective strategies. The distracters demonstrate effective coping associated with a serious medical condition. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 326-327 | Page 331 | Page 334-335 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which season would be most associated with increased periods of wakefulness in the general population? a. Summer b. Winter c. Spring d. Fall

ANS: A Circadian drive is associated with physiology. Light is the main exogenous factor that drives wakefulness. Days are longest in summer. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 367 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patient's sexual practices? a. "Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?" b. "Sexual health can reflect a number of medical problems, so I'd like to ask if you have any sexual problems you think we should know about." c. "It's your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please?" d. "I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment."

ANS: A Explaining that sexual practices vary helps reduce patient anxiety about the topic by normalizing the full range of sexual practices so that whatever his situation, the patient can feel comfortable sharing it. "It's your business of course..." implies the nurse does not have a valid reason to seek the information and in effect suggests that the patient perhaps should not answer the question. "It might be helpful..." makes the information seem less valid or important for the nurse to pursue and, again, could discourage the patient from responding fully. Asking if the patient has any sexual problems that staff should know about is not unprofessional, but it is a very broad question that may increase a patient's uncertainty about what the nurse wants to hear, thus increasing his anxiety. Defining or giving an example of "sexual problem" would make this inquiry more effective.

7. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.

ANS: A Having a night light on for the patient can help orient them to their surroundings. Having the flickering light and sound from a television will not help a confused patient remain calm or oriented. Restraining a patient will increase their agitation and actually increase their risk of injury if they try to get out of bed. Sleeping medications often increase confusion in cognitively impaired patients.

A patient reports, "The medicine prescribed to help me get to sleep worked well for about a month, but I don't have any more of those pills, and now my insomnia is worse than ever. I had nightmares the last 2 nights." Which type of medication did the health care provider most likely prescribe? a. Hypnotic b. Tricyclic antidepressant c. Conventional antipsychotic d. Central nervous system stimulant

ANS: A Hypnotics can worsen existing sleep disturbances when they induce drug-dependency insomnia. Once the drug is discontinued, the individual may have rebound insomnia and nightmares. CNS stimulants worsen insomnia while they are in use. Tricyclic antidepressants and atypical antipsychotics may help insomnia but would not be used for initial therapy. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 375-376 (Table 19-2) TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, "I am using contraceptives." c. says, "I feel full after eating a small meal." d. reports problems with dry mouth and constipation.

ANS: A Lorcaserin is designed to make people feel full after eating smaller meals by activating a serotonin 2c receptor in the brain and blocking appetite signals. According to the FDA, this drug should be stopped if a patient does not have 5% weight loss after 12 weeks of use. If the patient now weighs 196 pounds, the medication has not been effective. The distracters indicate patient learning was effective and expected side effects of this medication.

8. An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion? a. Pain medication received earlier in the night b. The death of the patient's spouse 2 years ago c. The patient's history of diabetes d. The age of the patient

ANS: A Medications such as narcotics, hypertensives, sleeping meds, and others can cause disorientation and symptoms of delirium. The death of a spouse is more likely to cause depression than disorientation. A history of diabetes alone does not cause disorientation. Normal aging alone does not cause disorientation, although it is a risk factor.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

Which person would be most likely to experience sleep fragmentation? a. An obese adult b. A toddler who attends day care c. A person diagnosed with mild osteoarthritis d. An adolescent diagnosed with anorexia nervosa

ANS: A Obese adults experience more disruption of sleep stages, resulting in fragmentation. Obesity is the leading factor for obstructive sleep apnea, which causes sleep fragmentation. These changes are also associated with illness and some medications. The changes are evident on a hypnogram. An adolescent with anorexia nervosa would have a low body weight and therefore decreased risk for sleep fragmentation. Persons with arthritis have pain that may sometimes interrupt sleep, but it would not have as high risk as would obesity. Toddlers do not generally experience sleep fragmentation. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 369 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

*An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult: a. consistently avoids schools and shops at malls only during school hours.* b. indicates sexual drive and enjoyment from sex have decreased. c. reports an active and satisfying sex life with an adult partner. d. volunteers to become a scout troop leader.

ANS: A One strategy for avoiding acting on inappropriate urges is to avoid environments and circumstances that evoke those urges; for a pedophile this would include avoiding all situations that would likely result in contact with children. Pedophilic disorder is persistent; elimination of fantasies about children would be unrealistic. A person who volunteers to lead a scout troop is placing himself/herself around children. A diminished sex drive or a healthy sex life with an appropriate partner does not necessarily reduce the desire for sexual contact with children.

An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, "I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough." Which nursing diagnosis applies? a. Deficient knowledge related to faulty perception of health status b. Disturbed self-concept related to required lifestyle changes c. Disturbed body image related to treatment side effects d. Sexual dysfunction related to self-esteem disturbance

ANS: A Patients who have had a myocardial infarction often believe sexual intercourse will cause another heart attack. The patient has completed the rehabilitation, but education is needed regarding sexual activity. These patients should receive information about when sexual activity may begin, positions that conserve energy, and so forth. The scenario does not suggest self-concept or body image disturbance.

A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

ANS: A Patients with conversion (functional neurological) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed "la belle indifférence." There is also a specific, identifiable cause for the development of the symptoms; in this instance, the death of a parent would precipitate stress. The distracters relate to sexual dysfunction and illness anxiety disorder. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-326 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A patient experiencing primary insomnia asks the nurse, "I take a nap during the day. Doesn't that make up for a lost night's sleep?" Select the nurse's best reply. a. "Circadian drives give daytime naps a structure different from nighttime sleep." b. "The body clock operates on a 24-hour cycle, making nap effectiveness unpredictable." c. "It is a matter of habit and expectation. We expect to be more refreshed from a night's sleep." d. "Sleep restores homeostasis but works more efficiently when aided by melatonin secreted at night."

ANS: A Regular sleep cycles occur with nighttime sleep, with progression through two distinct physiological states: four stages of non-rapid eye movement and a period of REM sleep. Naps often contain different amounts of REM sleep, thus changing the physiology of sleep as well as the psychological and behavioral effects of sleep. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 373 (Box 19-1) | Page 375-376 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse provides health education for an adult experiencing sleep deprivation. Which instruction has the highest priority? a. "It's important to limit your driving to short periods. Sleep deprivation increases your risks for serious accidents." b. "Sleep deprivation is usually self-limiting. See your health care provider if it lasts more than a year." c. "Turn the radio on with a soft volume as you prepare for bed each evening. It will help you relax." d. "Three glasses of wine each evening help many patients who suffer from sleep deprivation."

ANS: A Safety is the highest priority for this patient. Sleep deprivation causes psychomotor deficits. Driver drowsiness and fatigue lead to many automobile injuries and fatalities. Alcohol compounds problems associated with sleep deprivation. Sleep deprivation should be evaluated and treated; a 1-year delay is too long. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 365-366 | Page 371 | Page 373-374 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder? a. "What are you unable to do now but were previously able to do?" b. "How many doctors have you seen in the last year?" c. "Who do you talk to when you're upset?" d. "Did you experience abuse as a child?"

ANS: A Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The patient's dependency needs may be evident through losses of abilities. When secondary gains are prominent, the patient is more resistant to giving up the symptom. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 329 | Page 331 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

A nurse is performing an assessment for a 59-year-old man who has hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? a. Sexual dysfunction may result from use of prescription medications for management of hypertension. b. Such questions are an indirect way of learning about the patient's medication adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.

ANS: A Some of the drugs used to treat hypertension can interfere with normal sexual functioning and lead to sexual disorders. Hypertension itself can lead to acquired erectile dysfunction. It would not be appropriate or necessary to use such inquiries as a lead-in to other sexual health topics. Sexual dysfunction, while stressful, does not cause hypertension.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

During history-taking, a patient tells the nurse that he is addicted to alprazolam (Xanax) and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. The nurse suspects which disorder? a. Stress reaction b. DTs c. Overdose d. Relapse

ANS: A Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

1. A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective Coping related to hospitalization c. Denial related to hospitalization d. High Risk for Insomnia related to hospitalization

ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient's data do not support Defensive Coping, Ineffective Denial, or Risk-Prone Health Behavior as problems for this patient.

A parent who is very concerned about a 3-year-old son says, "He likes to play with girls' toys. Do you think he is homosexual or mentally ill?" Which response by the nurse most professionally describes the current understanding of gender identity? a. "A child's interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood." b. "It's difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult." c. "The research is incomplete, but many boys play with girls' toys and turn out normal as adults." d. "I am sure that whatever happens, he will be a loving son, and you will be a proud parent."

ANS: A The parent's inquiry is really two questions: (1) whether the child's behavior suggests an increased risk of developing mental illness and (2) what the child's future sexual preference will be. The psychiatric disorder that most directly addresses gender preferences and cross-gender activities is gender identity disorder. Pointing out that cross-gender activities are not necessarily related to gender identity and not likely to be carried into adulthood is supported by current research. Saying the child will grow up to be "normal" implies that to be homosexual is to be abnormal, which reflects a cultural perspective that most professionals would believe to be inappropriate to share in a professional setting. Research provides information about the relationship between cross-gender interests in childhood and adulthood, so a comment that "research is incomplete" is not entirely accurate. Stating that the child is a wonderful boy the father will be proud of, whatever happens, evades the parent's question and suggests that parental bonds should not be affected by gender issues. The nurse has a professional obligation to maintain an objective, therapeutic relationship.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient's needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic? a. "I'm wondering if you are feeling anxious about your illness and being left alone." b. "The staff are concerned that you are not satisfied with the care you are receiving." c. "Let's talk about why you use your call light so frequently. It is a problem." d. "You frustrate the staff by calling them so often. Why are you doing that?"

ANS: A This patient is experiencing anxiety associated with a serious medical condition. Verbalization is an effective outlet for anxiety. "I'm wondering if you are anxious..." focuses on the emotions underlying the behavior rather than the behavior itself. This opening conveys the nurse's willingness to listen to the patient's feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. The other options focus on the behavior or its impact on nursing and do not help the patient with her emotional needs. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 326-327 | Page 331-334 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A man who regularly experiences premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner." Select the nurse's most therapeutic response. a. "I sense you are feeling frustrated and upset." b. "Tell me more about feeling like a failure." c. "You are too hard on yourself." d. "What do you mean by awful?"

ANS: A Using reflection and empathy promotes trust and conveys concern to the patient. The distracters do not offer empathy, probe, and offer premature reassurance.

A patient says, "I have trouble falling asleep at night and might lie awake until 3 or 4 AM before falling sleep." Which medication would the nurse expect a health care provider to prescribe for this patient? a. zolpidem (Ambien) b. flurazepam (Dalmane) c. risperidone (Risperdal) d. methylphenidate (Ritalin)

ANS: A Zolpidem is a short-acting hypnotic that will help the patient initiate sleep and awaken without untoward symptoms of drowsiness. Methylphenidate is a central nervous system stimulant. Flurazepam is a long-acting hypnotic that will produce hangover drowsiness during the next day. Risperidone is an antipsychotic and not likely to be useful in this scenario. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 375-376 (Table 19-2) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 209-210 (Table 12-3) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

Which presentations suggest the possibility of a factitious disorder, self-directed type? Select all that apply. a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries c. Going from one doctor to another seeking the desired response d. Claims illness to obtain financial benefit or other incentive e. Difficulty describing symptoms

ANS: A, B Persons with factitious disorders, self-directed type, typically have a history of multiple hospitalizations and medical workups, with negative findings from workups. Sometimes they have even had multiple surgeries seeking the origin of the physical complaints. If they do not receive the desired response from a hospitalization, they may elope or accuse staff of incompetence. Such persons usually seek treatment through a consistent health care provider rather than doctor-shopping, are not motivated by financial gain or other external incentives, and present symptoms in a very detailed, plausible manner indicating considerable understanding of the disorder or presentation they are mimicking. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 337-338 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

ANS: A, B, C, D Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder.

1. The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.) a. Cancer b. Chronic obstructive pulmonary disease c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism

ANS: A, B, D, E, F Cancer, COPD, dysrhythmias, encephalitis, and hyperthyroidism are all associated with anxiety. Hypothyroidism is not associated with anxiety.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend's apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

1. The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes. e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.

ANS: A, B, E Primary prevention attempts to prevent injury. Not using chemical substances, wearing a helmet, and wearing a seat belt are all measures to prevent injury to the brain, which protects cognitive function. An MMSE and CAM are secondary prevention, or screening tools performed once symptoms are present. Correcting acid-base imbalances from underlying disease processes is a tertiary prevention level, aimed at minimizing complications for disease already present.

A night shift worker reports, "I'm having trouble getting to sleep after a night's work. I have a hearty breakfast with coffee, read the paper, do my exercises, and then go to bed. However, I just lie awake until it is nearly time to get up to be with my family for dinner." What changes should the nurse suggest? Select all that apply. a. Drink juice with breakfast rather than coffee. b. Exercise after awakening rather than before. c. Turn on the television when going to bed. d. Do not read the paper. e. Eat a light breakfast.

ANS: A, B, E Sleep can be disrupted by caffeine, a central nervous system stimulant, exercise performed just before trying to sleep, and eating a heavy meal before retiring. Reading the newspaper is not likely to be so stimulating that it disrupts the patient's ability to sleep. Television will be disruptive to sleep. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 369 | Page 375 (Box 19-2) TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? Select all that apply. a. Female b. Reports frequent syncope c. Rates pain as "1" on a scale of "10" d. First diagnosed with psoriasis at age 12 e. Reports insomnia often results from back pain

ANS: A, B, E There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-326 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

A nurse assesses a patient diagnosed with pedophilic disorder. Which findings are most likely? Select all that apply. a. Childhood history of attention deficit hyperactivity disorder (ADHD) b. A poorly managed endocrine disorder c. History of brain injury d. Cognitive distortions e. Grandiosity

ANS: A, C, D Attention deficit hyperactivity disorder (ADHD) in childhood, substance abuse, phobic disorders, and major depression/dysthymia are strongly associated with paraphilic disorders. Errors in thought make it seem acceptable for deviant and destructive sexual behaviors to occur. Patients who have experienced head trauma with damage to the frontal lobe of the brain may display symptoms of promiscuity, poor judgment, inability to recognize triggers that set off sexual desires, and poor impulse control. Endocrine problems are not associated with pedophilic disorder. Self-confidence is lacking; therefore, grandiosity would not be expected.

A nurse's neighbor says, "I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?" The nurse should respond by noting that some serious medical conditions may be complicated by emotional stress, including: (select all that apply) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.

ANS: A, C, D, E A number of diseases can be worsened or brought to awareness by intense emotional stress. Immune disorders can be complicated associated with detrimental effects of stress on the immune system. Others can be brought about indirectly, such as cardiovascular disease due to acute or chronic hypertension. Hip fractures are not in this group. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 326-327 (Table 17-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

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

The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram (Antabuse) when the nurse reads in the health record that the patient is also which of the following? (Select all that apply.) a. On blood thinners b. Taking diphenhydramine (Benadryl) tablets c. Ingesting alcohol d. On penicillin e. Using mouthwash

ANS: A, C, E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use e. January birth date f. Physical abuse by the father

ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation

ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.

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

ANS: A, E Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiological well-being. The other topics are also important but are not priority topics. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 204 | Page 211-212 | Page 215 (Box 12-6) | Page 224 TOP: Nursing Process: Planning/Outcomes Identification MSC: Client Needs: Health Promotion and Maintenance

A patient diagnosed with a somatic symptom disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

ANS: A, E The patient's verbalization is consistent with spiritual distress. The patient's description of being unable to provide for and burdening the family indicates ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 329-333 (Table 17-3) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? a. There are no special preparations needed before this treatment. b. Common side effects include headache and short-term memory loss. c. One treatment will be needed to cure the depression. d. This treatment will leave you unconscious for several hours.

ANS: B

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion.

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

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

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

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

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

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

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

ANS: B Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 206-207 | Page 212-213 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

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

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 206 (Table 12-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

ANS: B Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 218-219 (Table 12-5) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

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

ANS: B Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

12. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

ANS: B Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques. See relationship to audience response question.

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

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

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

ANS: B Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

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

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

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

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

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

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 209-210 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity

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

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 | Page 213-215 (Box 12-4)

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

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

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as: a. denial. b. splitting c. defensive. d. reaction formation.

ANS: B Splitting involves loving a person, then hating the person because the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness. See relationship to audience response question.

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

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

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

ANS: B The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 207 | Page 212-213 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

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

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

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: a. affable, generous. b. perfectionist, inflexible c. suspicious, holds grudges. d. dramatic speech, impulsive.

ANS: B The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD. See relationship to audience response question.

30. A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain, but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

ANS: B The patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurse's understanding of the patient's distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the patient.

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

ANS: B The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 205-206 (Table 12-1) | Page 213-215 (Box 12-4)

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

ANS: B The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 210 (Table 12-3) | Page 213 (Box 12-4)

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

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

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

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

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

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction c. disturbed personal identity. d. diversional activity deficit.

ANS: B Without exception, individuals with personality disorders have problems with social interaction with others, hence, the diagnosis of "impaired social interaction." For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to patients with personality disorders; each might apply to selected clinical diagnoses, but not to others.

Which comment is most likely from a patient with chronic sleep deprivation? a. "I turn on the television every night to get to sleep. I set the timer so it goes off in 30 minutes." b. "I have diarrhea frequently and not much energy, so I stay at home most of the time." c. "I only sleep about 7 hours a night, but I know I should sleep 8 or 9 hours." d. "When my alarm clock goes off every morning, it seems like I am dreaming."

ANS: B A discrepancy between hours of sleep obtained and hours required leads to sleep deprivation. Adults with less than 6 hours of sleep per night often suffer from chronic sleep deprivation. Common complaints include poor general health, physical and mental distress, limitations in ADLs, depressive or anxious symptoms, and pain. One distracter indicates a problem with sleep hygiene [television]. The remaining distracters do not indicate a problem. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 365-366 | Page 373 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

A person says, "I often feel like I have been dreaming just before I awake in the morning." Which rationale correctly explains the comment? a. Sleep architecture changes during the sleep period, resulting in increased slow-wave sleep at the end of the cycle. b. Cycles of rapid eye movement sleep increase in the second half of sleep and occupy longer periods. c. Dreams occur more frequently when a person is experiencing unresolved conflicts or depression. d. Dream content relates directly to developmental tasks. The person is likely feeling autonomous.

ANS: B Cycles of rapid eye movement sleep increase in the second half of sleep and occupy longer periods, up to 1 hour. Dreaming occurs during REM sleep. The question relates to sleep architecture rather than dream content. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 366-367 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. The nurse suspects a. alcohol-induced psychosis. b. delirium tremens (DTs). c. neurologic injury related to a fall. d. posttraumatic stress reaction.

ANS: B During the 6 to 96 hours after last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

A patient needs diagnostic evaluation of sleep problems. Which test will evaluate the patient for possible sleep-related problems? a. Skull x-rays b. Electroencephalogram (EEG) c. Positron emission tomography (PET) d. Single-photon emission computed tomography (SPECT)

ANS: B Electroencephalogram (EEG) measures NREM and REM sleep. The distracters represent ways to diagnose structural and metabolic problems. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 366 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

The nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is essential to include? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight

ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

4. The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

ANS: B High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships are known to affect a person's coping effectiveness negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

A person is prescribed lorazepam (Ativan) 2 mg po bid prn for anxiety. When the person takes this medication, which change in sleep is anticipated? The patient will: a. have fewer dreams. b. have less slow-wave sleep. c. experience extended sleep latency. d. enter sleep through rapid eye movement (REM) sleep.

ANS: B Lorazepam is a benzodiazepine, which reduces slow-wave sleep. REM sleep would likely increase. Persons with narcolepsy often enter sleep through REM. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 367 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

3. The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. "How do you feel about what happened to you as a child?" b. "How do you feel about what is going on right now?" c. "Remember a time when you were calm." d. "Tap your hands until the feeling goes away."

ANS: B Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

A patient reports, "Nearly every night I awaken feeling frightened after a bad dream. The dream usually involves being hunted by people trying to hurt me. It usually happens between 4 and 5 AM." The nurse assesses this disorder as most consistent with criteria for which problem? a. Sleep deprivation b. Nightmare disorder c. Night terror disorder d. REM sleep behavior disorder

ANS: B Nightmares are long, frightening dreams from which people awaken in a frightened state. They occur during REM sleep late in the night. Night terror disorder occurs as arousal in the first third of the night during non-REM sleep and is accompanied by feelings of panic. REM sleep behavior disorder involves acting out a violent dream during REM sleep. Nightmare disorder may lead to sleep deprivation. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 369 | Page 373 (Box 19-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a. An infant who is being fed reconstituted powdered formula b. A toddler living in an older home that is being remodeled c. A preschooler who attends a play group 3 days a week d. A school-age child who rides a school bus 5 days a week

ANS: B Older homes frequently have lead-based paint; paint chips generated by remodeling put toddlers, who often put foreign objects in their mouths, at risk for exposure to lead which is a known toxic substance that can affect cognitive function. Powdered formulas, attendance at play groups, or riding on a school bus are not known to impair cognitive development.

A woman tells the nurse, "My partner is frustrated with me. I don't have any natural lubrication when we have sex." What type of sexual disorder is evident? a. Genito-Pelvic Pain/Penetration Disorder b. Female Sexual Interest/Arousal Disorder c. Hypoactive Sexual Desire Disorder d. Female Orgasmic Disorder

ANS: B One feature of female sexual interest/arousal disorder relates to inability to maintain physiologic requirements for intercourse. For women, this includes problems with lubrication and swelling. The patient's description does not meet criteria for diagnoses in the distracters.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a.Voluntary control of symptoms b. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains

ANS: B Patients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their concerns and display more obsessive attention to detail, whereas the patient with conversion (functional neurological) disorder often exhibits less concern with the symptom they are presenting than would be expected. Neither disorder involves voluntary control of the symptoms. Results of diagnostic testing for both would be negative (i.e., no physiological basis would be found for the symptoms). Secondary gains can occur in both disorders but are not necessary to either. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-327 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results were normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Conversion (functional neurological) disorder b. Illness anxiety disorder (hypochondriasis) c. Somatic symptom disorder d. Factitious disorder

ANS: B Patients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease. These fears persist despite medical evaluations and interfere with daily functioning. There are no complaints of pain. There is no evidence of factitious or conversion disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325-326 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably: a.readily seek psychiatric counseling. b.be resistant to accepting psychiatric help. c. attend psychotherapy sessions without encouragement. d.be eager to discover the true reasons for physical symptoms

ANS: B Patients with somatic symptom disorders go from one health care provider to another trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling offered, these patients reject both. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest? a. Determine the nature and extent of the coach's sexual disorder. b. Assess the coach's potential for suicide or other self-harm. c. Assess the coach's self-perception of problem and needs. d. Determine whether other children were harmed.

ANS: B Pedophiles and other persons with paraphilic disorders can be at increased risk of self-harm associated with the guilt, shame, and anger they feel about their behavior and its effect on their families, victims, and victims' families. They also face considerable losses, such as the end of their careers or the loss of freedom to imprisonment. Thus, safety is the priority issue for assessment. Determining the nature and extent of the patient's disorder and related patient perceptions would be appropriate but not the highest priority for assessment. Investigating whether other victims exist is a matter for law enforcement rather than health care personnel. See relationship to audience response question.

A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? a.The patient is suppressing accurate feelings regarding the problem. b.The patient's anxiety is relieved through the physical symptom. c.The patient's optic nerve transmission has been impaired. d.The patient will not disclose genuine fears.

ANS: B Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. While some MRI studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation, there is no actual alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously). See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325-326 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

patient says, "I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive reframing? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your belief." b. "Let's see if there are any other possible explanations for your vomiting." c. "You seem so worried. Let's talk about how you're feeling." d. "We need to talk about something else."

ANS: B Questioning the evidence is a cognitive reframing technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 331-334 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? a. Defensive coping b. Sexual dysfunction c. Ineffective sexuality pattern d. Disturbed sensory perception, tactile

ANS: B Sexual dysfunction is the most appropriate nursing diagnosis for a patient who is experiencing a problem affecting one or more phases of arousal. This is the primary problem reported by this patient. Ineffective sexuality pattern, since it is due to sexual dysfunction, is secondary to the absence of orgasms. The patient has not indicated she does not become aroused, just that she cannot achieve orgasm. Disturbed sensory perception may be part of the etiology, but the problem is sexual dysfunction. There is no evidence of defensive coping.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

A home care nurse assesses a very demanding patient with chronic obstructive pulmonary disease (COPD). Afterward, the nurse talks with the spouse who has provided this patient's care for 6 years. The spouse says, "I don't need much sleep anymore. I might need to help him during the night." Select the nurse's most therapeutic response. a. "It sounds like you are very devoted to your spouse." b. "I noticed you fell asleep while I was assessing your spouse. I'm concerned about you." c. "Your spouse is lucky to have you to provide care rather than being placed in a nursing home." d. "If you keep going like this, your health will be impaired also. Then who will take care of both of you?"

ANS: B Sleep deprivation can cause accidents. The correct answer makes an observation, gives important information about safety, and communicates care and compassion for the spouse. The distracters do not invite further dialogue with the spouse. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 365-366 | Page 373 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

A nurse counsels a patient on ways to determine the person's total sleep requirement. Which instruction would produce the most accurate results? a. "For 1 full week, record what you remember about your dream content and related feelings as soon as you wake up. Bring the record to your next appointment." b. "While off work for 1 week, go to bed at your usual time and wake up without an alarm. Record how many hours you sleep and then average the findings." c. "For 2 full weeks, record how much time you sleep each night and rate your daytime alertness on a scale of 1 to 10. Calculate your average alertness score." d. "All adults need 7 or 8 hours of sleep to function properly. Let's design ways to help you reach that goal."

ANS: B Sleep requirements are most accurately determined by going to bed at the usual time and waking up without an alarm for several nights, ideally on vacation. The average of these findings indicates the estimated requirements. Two distracters relate to dream content and daytime alertness. Some adults are long sleepers or short sleepers with different requirements for sleep from the general population. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 368 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

To prevent Wernicke's encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a. Benzodiazepine b. Thiamine and B complex IV c. Vitamins C and D3 d. Klonopin

ANS: B The B vitamins will prevent or reverse Wernicke's if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

A new staff nurse tells the clinical nurse specialist, "I am unsure about my role when patients bring up sexual problems." The clinical nurse specialist should give clarification by saying, "All nurses: a. qualify as sexual counselors. Nurses have knowledge about the biopsychosocial aspects of sexuality throughout the life cycle." b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths." c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality." d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples."

ANS: B The basic education of nurses provides information sufficient to qualify the generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy requires additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors. Additional education is necessary. A registered nurse may provide basic information about sexual function, but complex questions may require referral.

A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. The nurse's best response to this behavior is to a. ignore his remarks. b. express doubt that there are spiders on the wall. c. ask the client if he also sees spiders in the day room. d. tell the client there are no spiders and he should stop worrying about it.

ANS: B The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

A nurse cares for these four patients. Which patient has the highest risk for problems with sleep physiology? a. Retiree who volunteers twice a week at Habitat for Humanity b. Corporate accountant who travels frequently c. Parent with three teenagers d. Lawn care worker

ANS: B The corporate accountant is likely to work long hours and have significant stress associated with work demands. Compounded by travel, these factors are likely to precipitate unstable sleep patterns and inadequate sleep time. The retiree and lawn care worker engage in physical activity during the day, which will promote natural fatigue and sleep. The parent's sleep is unlikely to be disturbed; teenagers sleep through the night. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 365 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed self after explaining arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self. d.address needs of other patients in the dining room, then feed this patient.

ANS: B The patient is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 335-336 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A patient with blindness related to conversion (functional neurological) disorder says, "All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don't find me as interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

ANS: B The patient mentions that the symptoms make people more interested. This indicates that the patient feels uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in the scenario. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-326 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. assume roles and functions of other family members. b. demonstrate performance of former roles and tasks. c. focus energy on problems occurring in the family. d. rely on family members to meet personal needs.

ANS: B The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-326 | Page 338 (Nursing Care Plan 17-1) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

A woman consults the nurse practitioner because she has not achieved orgasm for 2 years, despite having been sexually active. This is an example of: a. Paraphilic Disorder. b. Female Orgasmic Disorder. c. Genito-Pelvic Pain/Penetration Disorder. d. Female Sexual Interest/Arousal Disorder.

ANS: B The persistent inhibition of orgasm is a form of sexual dysfunction called female orgasmic disorder. Genito-pelvic pain/penetration disorder applies to painful intercourse. The patient has not indicated that her interest in sexual activity is diminished, so female sexual interest/arousal disorder does not apply. Paraphilic disorder is not applicable.

A man who reports frequently experiencing premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner. Can you help me?" Select the nurse's best response. a. "Have you discussed this problem with your partner?" b. "I can refer you to a practitioner who can help you with this problem." c. "Have you asked your health care provider for prescription medication?" d. "There are several techniques described in this pamphlet that might be helpful."

ANS: B The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurse's role

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

A nurse who works night shift says, "I am exhausted most of the time. I sleep through my alarm. Sometimes my brain does not seem to work right. I am worried that I might make a practice error." Which question should the nursing supervisor ask first? a. "What stress are you experiencing in your life?" b. "How much sleep do you get in a 24-hour period?" c. "Would it help if you do some exercises just before going to bed?" d. "Have you considered using a hypnotic medication to help you sleep?"

ANS: B Total sleep hours should be ascertained before seeking to correct a sleep disorder. In this case, the patient describes sleep deprivation symptoms rather than a sleep disorder. The correct response is the only option that addresses total sleep hours. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 373-374 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat underlying depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions

ANS: B Various types of antidepressants may be helpful in somatic disorders directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood, but fatigue, pain perception, GI distress, and other somatic symptoms. Patients may benefit from short-term use of anti-anxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 335-336 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

Which neurotransmitters are most responsible for wakefulness? Select all that apply. a. Gamma-aminobutyric acid (GABA) b. Norepinephrine c. Acetylcholine d. Dopamine e. Galanin

ANS: B, C, D Gamma-aminobutyric acid (GABA) and galanin are sleep-promoting neurotransmitters. PTS: 1 DIF: Cognitive Level: Remember (Knowledge) REF: Page 367-368 TOP: Nursing Process: N/A MSC: Client Needs: Health Promotion and Maintenance

A new patient at the sleep disorders clinic tells the nurse, "I have not slept well in a year, so I never feel good. I do not expect things will ever improve or be any different." Interventions the nurse should consider include: (select all that apply) a. suggesting use of alcohol as a sedative. b. providing instruction in relaxation techniques. c. counseling the patient to address cognitive distortions. d. health teaching regarding factors that influence sleep. e. teaching fatigue-producing activities to become overtired. f. encouraging long daytime naps to compensate for sleep deprivation.

ANS: B, C, D Interventions that could be helpful include teaching relaxation techniques, such as meditation or progressive relaxation, to relieve the tension that sometimes prevents initiation of sleep. Reviewing factors that influence sleep can assist the patient to diagnose and remove barriers to sleep. Cognitive therapy could be helpful in combating the hopelessness verbalized by the patient. Alcohol consumption actually disrupts sleep. Becoming overtired may be a barrier to nighttime sleep. Naps may help replace lost sleep, but lengthy daytime sleep will prevent the patient from sleeping well at night. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 375-377 (Box 19-2) TOP: Nursing Process: Planning/Outcomes Identification MSC: Client Needs: Psychosocial Integrity

Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups

ANS: B, C, E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

2. The nurse wishes to use guided imagery to help an anxious patient relax. Which comment would be appropriate to include in the guided imagery script? (Select all that apply.) a. "Imagine others treating you the way they should, the way you want to be treated..." b. "With each breath, you are feeling calmer, more relaxed, almost as if you are floating..." c. "You are alone on a beach; the sun is warm; and you hear only the sound of the surf..." d. "You have taken control; nothing can hurt you now; everything is going your way..." e. "You have grown calm; your mind is still; there is nothing to disturb your well-being..." f. "You will feel better as work calms down, as your boss becomes more understanding..."

ANS: B, C, E The intent of guided imagery for managing stress is to lead the patient to envision images that are calming and health enhancing. Statements that involve the patient calming progressively with breathing, feeling increasingly relaxed, being in a calm and pleasant location, being away from stressors, and having a peaceful and calm mind are therapeutic and should be included in the script. However, words that raise stressful images or memories or that involve unrealistic expectations or elements beyond the patient's control (e.g., that others will treat the patient as he desires, that everything is going the patient's way, that bosses are understanding) interfere with relaxation and/or do not promote effective coping. These attempts are not health promoting and should not be included in the script.

A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder by proxy is suspected. Which nursing interventions are appropriate? Select all that apply. a. Increase private visiting time for the parents to improve bonding. b. Keep careful, detailed records of visitation and untoward events. c. Place mittens on the child to reduce access to ports and incisions. d. Encourage family members to visit in groups of two or three. e. Interact with the patient frequently during visiting hours.

ANS: B, D, E Factitious disorder by proxy is a rare condition wherein a person intentionally causes or perpetuates the illness of a loved one (e.g., by periodically contaminating IV solutions with fecal material). When this disorder is suspected, the child's life could be at risk. Depending on the evidence supporting this suspicion, interventions could range from minimizing unsupervised visitation to blocking visitation altogether. Frequently checking on the child during visitation and minimizing unobserved access to the child (by encouraging small group visits) reduces the opportunity to take harmful action and increases the collection of data that can help determine whether this disorder is at the root of the child's illness. Detailed tracking of visitation and untoward events helps identify any patterns there might be between select visitors and the course of the child's illness. Increasing private visitation provides more opportunity for harm. Educating visitors about aseptic techniques would not be of help if the infections are intentional, and preventing inadvertent contamination by the child himself would not affect factitious disorder by proxy. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 337-338 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? a. "I will call your care provider. Perhaps you need a different medication." b. "Don't worry. You can try taking it at a different time of day to help it work better." c. "It usually takes a few weeks for you to notice improvement from this medication." d. "Your life is much better now. You will feel better soon."

ANS: C

A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a. Serum blood levels must be regularly monitored to assess for toxicity. b. To prevent side effects, the medication should be administered as an intramuscular injection. c. Eating foods such as blue cheese or red wine will cause side effects. d. This medication class may only be used safely for a few days at a time.

ANS: C

10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patient's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

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

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

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

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

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

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

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

ANS: C Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident.

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

ANS: C Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 207 | Page 209-210 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome c. Pseudoparkinsonism b. Hepatocellular effects d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 215-216 (Table 12-4) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

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

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 206-207 | Page 212-213 (Box 12-3) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

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

27. A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

ANS: C The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.

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

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

2. The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a. The patient prescribed an antibiotic for a urinary tract infection. b. The patient prescribed a cholinesterase inhibitor for early Alzheimer's disease. c. The patient prescribed a beta-blocker for hypertension. d. The patient prescribed a bisphosphonate for osteoporosis.

ANS: C Anti-hypertensives such as the beta-blockers can cause adverse changes in cognition. While an infection can affect cognition, antibiotics do not generally cause cognitive changes. The cholinesterase inhibitors are prescribed to slow the progression in cognitive decline for patients diagnosed with Alzheimer's disease. Bisphosphonates are used for osteoporosis and are not generally a risk for altered cognition.

6. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response? a. "Hormone therapy will reverse the condition." b. "Vitamin C and zinc will reverse the condition." c. "There is no treatment that reverses dementia." d. "Dementia can be reversed with diet, exercise, and medications."

ANS: C Currently there is no proven treatment that has been shown to reverse dementia, although some treatments can slow the progression of the illness. Hormone therapy, vitamin therapy, diet, and exercise are all important for overall health but do not reverse the progression of dementia.

A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. marginally successful. b. minimally successful. c. partially successful. d. totally achieved.

ANS: C Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 333 | Page 337 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center

ANS: C Encopresis refers to unsuccessful bowel control. Bowel control is expected by age 5, so frequent involuntary defecation is associated with this diagnosis. Smearing feces is behavioral. Enuresis refers to the voiding of urine during the day (diurnal) or at night (nocturnal).

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? a. Homosexual b. Ritualistic behaviors c. Seeks access to children d. Self-confident professional

ANS: C Persons with pedophilic disorder usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilic disorder.

A nurse provides health education for an adult with sleep deprivation. It is most important for the nurse to encourage caution when the patient engages in: a. using a vacuum cleaner. b. cooking a meal. c. driving a car. d. bathing.

ANS: C Safety is the highest priority for this patient. Sleep deprivation causes psychomotor deficits. Driver drowsiness and fatigue lead to many automobile injuries and fatalities. The distracters are less likely to be associated with serious injury. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 365-366 | Page 371 | Page 373-374 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

A patient diagnosed with a somatic symptom disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. mood. b. cognitive style. c. secondary gains. d.identity and memory.

ANS: C Secondary gains should be assessed. The patient's dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient's diagnosis has been established. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 331-333 (Table 17-3) | Page 335 (Table 17-4) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A patient's medical record documents sexual masochism. This patient derives sexual pleasure: a. from inanimate objects. b. by inflicting pain on a partner. c. when sexually humiliated by a partner. d. from touching a non-consenting person.

ANS: C Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.

To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority: a. explain the pathophysiology of symptoms. b. help these patients suppress feelings of anger. c. shift focus from somatic symptoms to feelings. d.investigate each physical symptom as it is reported

ANS: C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome would be that the patient would express feelings, including anger if it is present. Once physical symptoms are investigated, they do not need to be reinvestigated each time the patient reports them. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 333-335 (Table 17-4) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A patient says, "It takes me about 15 minutes to go to sleep each night." This comment describes: a. delta sleep. b. parasomnia. c. sleep latency. d. rapid eye movement sleep.

ANS: C Sleep latency refers to the amount of time it takes a person to fall asleep. The distracters represent other phases of the sleep cycle. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 366 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively? a. Flooding b. Response prevention c. Relaxation techniques d.Systematic desensitization

ANS: C Somatic symptom disorders are commonly associated with complicated reactions to stress. These reactions are accompanied by muscle tension and pain. Relaxation can diminish the patient's perceptions of pain and reduce muscle tension. The distracters are modalities useful in treating selected anxiety disorders. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 334-335 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

4. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. "Don't worry; the patient should be fine once they are in a familiar environment." b. "I can make a referral for a home health aide to assist with the patient." c. "Once the dehydration is corrected, the patient's confusion should improve." d. "I can show you how to care for the patient once you return home."

ANS: C The confusion caused by an underlying medical condition is a temporary condition that can be corrected once the underlying condition is treated, in this case once the patient is rehydrated. It is not necessary to teach home care or make a referral to home health because it is not expected that the patient will be confused at discharge. Telling the daughter that there is nothing to worry about diminishes her concern and may decrease her trust in the nurse.

The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the main priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

ANS: C The main priority is the patient's safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal

The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient states which of the following? a. "I go to meetings once a day and still drink." b. "My family and friends have been avoiding me lately." c. "I don't have a problem with alcohol. I can quit anytime I want to." d. "I know it will be hard to quit, but I am willing to try."

ANS: C The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with DTs and determines that the communication was nontherapeutic. What should the nurse's next priority be? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating in self-help groups. c. Notify provider to obtain order for oxazepam (Serax) and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychologic consult.

ANS: C The patient will need to be treated for the psychosis prior to conducting the motivational interview, because the patient can become violent and nonreceptive to the interventions. Oxazepam and vitamin B are the two therapies that work for DTs.

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

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

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

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.) a. Risk for caregiver strain b. Impaired verbal communication c. Risk for injury d. Imbalanced nutrition, less than body requirements e. Ineffective coping f. Sleep deprivation

ANS: C, D, F

A patient newly diagnosed with depression states, "I have had other people in my family say that they have depression. Is this an inherited problem?" What is the nurse's best response? a. "There are a lot of mood disorders that are caused by many different causes. Inheriting these disorders is not likely." b. "Current research is focusing on fluid and electrolyte disorders as a cause for mood disorders." c. "All of your family members raised in the same area have probably learned to respond to problems in the same way." d. "Members of the same family may have the same biological predisposition to experiencing mood disorders."

ANS: D

A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? a. 0 to 0.5 mEq/L b. 0.6 to 0.9 mEq/L c. 1.0 to 1.4 mEq/L d. 1.5 or higher mEq/L

ANS: D

A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? a. The medication dose needs to be decreased. b. Treatment is successful, and medication can be stopped. c. The patient is ready to return to work. d. Specific assessment for suicide plan must be evaluated.

ANS: D

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

ANS: D Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 215-219 (Table 12-5) TOP: Nursing Process: Planning

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

ANS: D Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.

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

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

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

ANS: D Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 211-215 (Box 12-6) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

ANS: D Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder. (The educator may reformat this question as multiple response.)

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

ANS: D Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 207-209 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

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

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

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

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

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

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

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

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

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

ANS: D Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.

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

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 213-215 (Box 12-6) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement

ANS: D The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

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

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

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

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

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

ANS: D The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 204 | Page 212-213 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

ANS: D The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient's laughter) and then elicit the patient's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 206-207 | Page 212-213 (Box 12-3)

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

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

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

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

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

ANS: D The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

18. For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

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

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205 | Page 213-214 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 211 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a.are generally chronic. b. have a physiological basis. c. can be voluntarily controlled. d. provide relief from health anxiety.

ANS: D At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide secondary gain, patients frequently fiercely cling to the symptoms. The symptoms tend to be chronic, but that does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325-326 | Page 338 (Nursing Care Plan 17-1) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should: a. develop an understanding of human sexual response. b. assess the patient's sexual functioning and needs. c. acquire knowledge of the patient's sexual roles. d. clarify own personal values about sexuality.

ANS: D Before one can be helpful to patients with sexual dysfunctions or disorders, the nurse must be aware of his or her own feelings and values about sex and sexuality. Nurses must keep their personal beliefs separate from their patient care in order to remain objective, professional, and effective. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. The other options are indicated as well, but self-awareness must precede them to provide the best care.

A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, "My chest is tight, and my heart misses beats. I'm often absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Somatic symptom disorder c. Antisocial personality disorder d. Illness anxiety disorder (hypochondriasis)

ANS: D Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-326 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

6. A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. The most appropriate question the nurse should ask the patient's friend is a. "Does he take amphetamines or uppers?" b. "Has he ever used LSD?" c. "Have you two been out of the country in the last 2 days?" d. "Is he using any opioids such as heroin?"

ANS: D The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated

What is an essential difference between somatic symptom disorders and factitious disorders? a. Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic. b. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress. c. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound. d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.

ANS: D The key is the only fully accurate statement. Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound. Factitious disorders are under voluntary control. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325-326 | Page 337-338 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient: a.sees a relationship between symptoms and interpersonal conflicts. b. has little difficulty communicating emotional needs to others. c. rarely derives personal benefit from the symptoms. d. has altered comfort and activity needs.

ANS: D The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic symptom disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325-326 | Page 338 (Nursing Care Plan 17-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

A 76-year-old man tells the nurse at the sleep disorder clinic, "I awaken almost nightly in the midst of violent dreams in which I am defending myself against multiple attackers. Then I realize I have been hitting and kicking my wife. She has bruises." Which health problem is most likely? a. Sleep Paralysis b. Night Terror Disorder c. Sleep-Related Bruxism d. Rapid Eye Movement (REM) Sleep Behavior Disorder

ANS: D The scenario describes REM sleep behavior disorder in which the patient engages in violent and complex behaviors during REM sleep as though acting out his dreams. Older men have a higher incidence of this problem. Sleep paralysis refers to the sudden inability to perform voluntary movement at either sleep onset or awakening from sleep. Bruxism refers to grinding teeth during stage 2 sleep. Night terror disorder occurs as arousal in the first third of the night during non-REM sleep, accompanied by feelings of panic. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 369-370 | Page 373 (Box 19-1) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A man with hypospadias tells the nurse, "Intercourse with my new bride is painful." Which term applies to the patient's complaint? a. Delayed ejaculation b. Erectile dysfunction c. Premature ejaculation d. Genito-pelvic pain/penetration disorder

ANS: D This sexual pain is genito-pelvic pain/penetration disorder and may occur in men or women. The individual feels pain in the genitals during intercourse. Erectile or ejaculation problems are not evident. See relationship to audience response question.

The nurse is caring for a 32-year-old woman diagnosed with schizophrenia. The woman tells the nurse, "The news on TV last night was all about me." This is an example of what kind of thought content? a. Thought insertion b. Thought broadcasting c. Magical thinking d. Ideas of reference

ANS: D Thought insertion is a belief that others are placing thoughts in one's mind. Thought broadcasting is a belief that others can read one's thoughts. Magical thinking is a belief that one's thoughts can make an event happen. Ideas of reference refers to a person's belief that external events, like the evening news, have a direct personal reference to oneself.

*A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, "Without the red teddies, I am not interested in sex." The nurse can assess this as consistent with:* a. exhibitionism. b. voyeurism. c. frotteurism. d. fetishism.

ANS: D To be sexually satisfied, a person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality. Frotteurism involves deriving sexual pleasure from rubbing against others surreptitiously. Exhibitionism is the intentional display of the genitalia in a public place. Voyeurism refers to viewing others in intimate situations.

The male manager of a health club placed a hidden video camera in the women's locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is: a. homosexuality. b. exhibitionism. c. pedophilia. d. voyeurism.

ANS: D Voyeurism is achieving sexual pleasure through the viewing of others in intimate situations, such as undressing, bathing, or having sexual relations. A homosexual individual would be interested in watching members of the same sex, and homosexuality is not typically associated with voyeurism. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with children.

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

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

Client Needs: Physiological Integrity 10. A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

B

Client Needs: Physiological Integrity 29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

B

Client Needs: Physiological Integrity 13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

B

Client Needs: Physiological Integrity 14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

B

Client Needs: Physiological Integrity 23. During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a. Affect depressed; mood flat c. Affect labile; mood euphoric b. Affect flat; mood depressed d. Affect and mood are incongruent.

B

Client Needs: Psychosocial Integrity 5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

B

Client Needs: Psychosocial Integrity 21. A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness c. Stress overload b. Risk for suicide d. Spiritual distress

B

Client Needs: Psychosocial Integrity 3. A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." c. "I like the shirt you are wearing." b. "You're wearing a new shirt." d. "You must be feeling better today."

B

Client Needs: Psychosocial Integrity 7. A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: a. dysthymia. c. euphoria. b. anhedonia. d. anergia.

B

The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? a. "Central perfusion is monitored only by the physician." b. "Central perfusion involves the entire body." c. "Central perfusion is decreased with hypertension." d. "Central perfusion is toxic to the cardiac system."

B

The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications

B

A patient with a long history of hypertension and diabetes now develops confusion. The health care provider wants to make a differential diagnosis between Alzheimer's disease and multiple infarcts. Which diagnostic procedure should the nurse expect to prepare the patient for first? a. Skull x-rays b. CT scan c. PET d. Single photon emission computed tomography (SPECT)

B A CT scan shows the presence or absence of structural changes, including cortical atrophy, ventricular enlargement, and areas of infarct, information that would be helpful to the health care provider. PET and SPECT show brain activity rather than structure and may occur later. See relationship to audience response question.

8. A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-19 (Case Study and Nursing Care Plan), 58 (Table 18-3) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Which instruction has priority when teaching a patient about clozapine? a. "Avoid unprotected sex." b. "Report sore throat and fever immediately." c. "Reduce foods high in polyunsaturated fats." d. "Use over-the-counter preparations for rashes."

B Clozapine therapy may produce agranulocytosis... therefore, signs of infection should be immediately reported to the health care provider. In addition, the patient should have white blood cell levels measured weekly. The other options are not relevant to clozapine.

By which mechanism do SSRI medications improve depression? a. Destroying increased amounts of serotonin b. Making more serotonin available at the synaptic gap c. Increasing production of acetylcholine and dopamine d. Blocking muscarinic and á1 norepinephrine receptors

B Depression is thought to be related to lowered availability of the neurotransmitter serotonin. SSRIs act by blocking reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. SSRIs prevent destruction of serotonin. SSRIs have little or no effect on acetylcholine and dopamine production. SSRIs do not produce muscarinic or á1 norepinephrine blockade.

The therapeutic action of neurotransmitter inhibitors that block reuptake cause a. decreased concentration of the blocked neurotransmitter in the central nervous system. b. increased concentration of the blocked neurotransmitter in the synaptic gap. c. destruction of receptor sites specific to the blocked neurotransmitter. d. limbic system stimulation.

B If the reuptake of a substance is inhibited, it accumulates in the synaptic gap, and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

A nurse would anticipate that treatment for a patient with memory difficulties might include medications designed to a. inhibit GABA. b. prevent destruction of acetylcholine. c. reduce serotonin metabolism. d. increase dopamine activity.

B Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA affects anxiety rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson's disease rather than improving memory.

A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. Which drug action causes these symptoms to develop? a. Anticholinergic effects b. Dopamine-blocking effects c. Endocrine-stimulating effects d. Ability to stimulate spinal nerves

B Medication that blocks dopamine often produces disturbances of movement, such as akathisia, because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

The nurse prepares to assess a patient diagnosed with major depressive disorder for disturbances in circadian rhythms. Which question should the nurse ask this patient? a. "Have you ever seen or heard things that others do not?" b. "What are your worst and best times of the day?" c. "How would you describe your thinking?" d. "Do you think your memory is failing?"

B Mood changes throughout the day may be related to circadian rhythm disturbances. Questions about sleep pattern are also relevant tocircadian rhythms.

A fearful patient has an increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter? a. GABA b. Norepinephrine c. Acetylcholine d. Histamine

B Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight." GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

11. An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.

B One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-29, 30 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

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

B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 18-8, 12 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A nurse caring for a patient taking a SSRI will develop outcome criteria related to a. coherent thought processes. b. improvement in depression. c. reduced levels of motor activity. d. decreased extrapyramidal symptoms.

B SSRIs affect mood, relieving depression in many cases. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

A drug blocks the attachment of norepinephrine to a1 receptors. The patient may experience a. hypertensive crisis. b. orthostatic hypotension. c. severe appetite disturbance. d. an increase in psychotic symptoms.

B Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of a1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Teach patients ways of minimizing this phenomenon.

A patient has disorganized thinking associated with schizophrenia. Neuroimaging would likely show dysfunction in which part of the brain? a. Hippocampus b. Frontal lobe c. Cerebellum d. Brainstem

B The frontal lobe is responsible for intellectual functioning. The hippocampus is involved in emotions and learning. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

Consider these medications: carbamazepine, lamotrigine, gabapentin. Which medication below also belongs to this group? a. Galantamine b. Valproate c. Buspirone d. Tacrine

B The medications listed in the stem are mood stabilizers, anticonvulsant types. Valproate (Depakote) is also a member of this group. The distracters are drugs for treatment of Alzheimer's disease and anxiety.

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

B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relates to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-14, 54 (Table 18-1) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

The parent of an adolescent diagnosed with schizophrenia asks the nurse, "My child's doctor ordered a PET. What kind of test is that?" Select the nurse's best reply. a. "This test uses a magnetic field and gamma waves to identify problem areas in the brain. Does your teenager have any metal implants?" b. "PET means positron-emission tomography. It is a special type of scan that shows blood flow and activity in the brain." c. "A PET scan passes an electrical current through the brain and shows brain-wave activity. It can help diagnose seizures." d. "It's a special x-ray that shows structures of the brain and whether there has ever been a brain injury."

B The parent is seeking information about PET scans. It is important to use terms the parent can understand, so the nurse should identify what the initials mean. The correct response is the only option that provides information relevant to PET scans. The distracters describe magnetic resonance image (MRI), computed tomography (CT) scans, and EEG. See relationship to audience response question.

A patient diagnosed with bipolar disorder displays aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group? a. Psychostimulants b. Mood stabilizers c. Anticholinergics d. Antidepressants

B The symptoms describe mania, which is effectively treated by mood stabilizers, such as lithium, and selected anticonvulsants (carbamazepine, valproic acid, and lamotrigine). Drugs from the other classifications listed are not effective in the treatment of mania.

A professional football player is seen in the emergency department after losing consciousness from an illegal block. Prior to discharge, the nurse assists the patient to schedule an outpatient computed tomography (CT) scan for the next day. Which strategy should the nurse use to ensure the patient remembers the appointment? a. Write the appointment day, time, and location on a piece of paper and give it to the player. b. Log the appointment day, time, and location into the player's cell phone calendar feature. c. Ask the health care provider to admit the patient to the hospital overnight. d. Verbally inform the patient of the appointment day, time, and location.

B This player may have suffered repeated head injuries with damage to the hippocampus. The hippocampus has significant role in maintaining memory. Logging the appointment into the player's cell phone calendar will remind him of the appointment the next day. Paper will be lost, and the patient is unlikely to remember verbal instruction. Hospitalization is unnecessary.

In collaboration with the nurse, the attending healthcare provider (HCP) has consulted several specialists for a conference to plan the client's care. The nurse is also preparing to initiate a follow up discussion about treatment options with the client after the meeting. Which consultants will be most helpful during this meeting? (Select all that apply. One, some, or all options may be correct.) a. occupational therapy b. hematologist c. psychologist/psychiatrist d. gastroenterologist e. internist f. speech therapy

B, C, D, E

Questions the nurse could ask that would be nonjudgmental when obtaining information about a patient's use of complementary and herbal remedies include (Select all that apply) a. "You don't regularly take herbal remedies, do you?" b. "What herbal medicines have you used to relieve your symptoms?" c. "What over-the-counter medicines, vitamins, and nutritional supplements do you use?" d. "What differences in your symptoms do you notice when you take herbal supplements?" e. "Have you experienced problems from using herbal and prescription drugs at the same time?"

B, C, D, E The correct responses are neutral in tone and do not express bias for or against the use of complementary or herbal medicines. The distracter, worded in a negative way, makes the nurse's bias evident.

The client asks the nurse why it is necessary to have additional testing when she already took the prescribed antibiotic to cure the disease. Which responses by the nurse are likely to be the most helpful in explaining the need for further testing? (Select all that apply. One, some, or all options may be correct.) a. Complications need to be identified and treated, but they cannot be cured. b. Delay in initial treatment increased the risk for complications. c. Gonorrhea symptoms can be asymptomatic in women, which delays treatment. d. Further testing will ensure the bacteria are not resistant to treatments. e. Additional diagnostic tests will identify any existing complications.

B, C, E

The nurse performs a focused assessment. Which systems should the nurse evaluate? (Select all that apply. One, some, or all options may be correct.) a. neurological system b. cardiovascular system c. respiratory system d. integumentary system e. gastrointestinal system

B, C, E

Which potentially fatal complication(s) can occur? (Select all that apply. One, some, or all options may be correct.) a. Vaso-occlusive crisis. b. cerebral vascular accident c. priapism d. hypertensive crisis e. heart failure

B, E

An important question to ask during the assessment of a client diagnosed with anxiety disorder is: A. "How often do you hear voices?" B. "Have you ever considered suicide?" C. "How long has your memory been bad?" D. "Do your thoughts always seem jumbled?"

B. "Have you ever considered suicide?" The presence of anxiety may cause an individual to consider suicide as a means of finding comfort and peace. Suicide assessment is appropriate for any client with higher levels of anxiety.

What can be said about the comorbidity of anxiety disorders? A. Anxiety disorders generally exist alone. B. A second anxiety disorder may coexist with the first. C. Anxiety disorders virtually never coexist with mood disorders. D. Substance abuse disorders rarely coexist with anxiety disorders.

B. A second anxiety disorder may coexist with the first. In many instances, when one anxiety disorder is present, a second one coexists. Clinicians and researchers have clearly shown that anxiety disorders frequently co-occur with other psychiatric problems. Major depression often co-occurs and produces a greater impairment with poorer response to treatment.

Jerry is a 72-year-old patient with Parkinson's disease and anxiety. He is living by himself and has had several falls lately. His provider orders lorazepam, 1 mg PO bid, for anxiety. You question this order because: A. Jerry may become addicted faster than younger patients. B. Jerry is at risk for falls. C. Jerry has a history of nonadherence with medications. D. Jerry should be treated with cognitive therapies rather than medication because of his advanced age.

B. Jerry is at risk for falls. An important nursing intervention is to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. In a patient who has a history of falls, lorazepam would be contraindicated because it may cause sedation and ataxia leading to more falls. There is no evidence to suggest that elderly patients become addicted faster than younger patients. A history of nonadherence would not lead to you to question this drug order. Medication and other therapies are used congruently with all age levels.

Which therapeutic intervention can the nurse implement personally to help a client diagnosed with a mild anxiety disorder regain control? A. Flooding B. Modeling C. Thought stopping D. Systematic desensitization

B. Modeling Modeling calm behavior in the face of anxiety or unafraid behavior in the presence of a feared stimulus are interventions that can be independently used. The other options require agreement of the treatment team.

4. A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness.

B. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness. Awarded 1.0 points out of 1.0 possible points.

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? A. Anxiety B. Seasonal affective disorder C. Medication side effects D. Antisocial personality

B. Seasonal affective disorder

A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Modified prevention

B. Secondary prevention

An obsession is defined as: A. thinking of an action and immediately taking the action. B. a recurrent, persistent thought or impulse. C. an intense irrational fear of an object or situation. D. a recurrent behavior performed in the same manner.

B. a recurrent, persistent thought or impulse. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind.

The nurse anticipates that the nursing history of a client diagnosed with obsessive compulsive disorder (OCD) will reveal: A. a history of childhood trauma. B. a sibling with the disorder. C. an eating disorder. D. a phobia as well.

B. a sibling with the disorder. Research shows that first-degree biological relatives of those with OCD have a higher frequency of the disorder than exists in the general population.

Stella brings her mother, Dorothy, to the mental health outpatient clinic. Dorothy has a history of anxiety. Stella and Dorothy both give information for the assessment interview. Stella states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." You suspect: A. panic disorder. B. adult separation anxiety disorder. C. agoraphobia. D. social anxiety disorder.

B. adult separation anxiety disorder. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other. There may also be fear that something horrible will happen to the other person. Adult separation anxiety disorder may begin in childhood or adulthood. The scenario doesn't describe panic disorder. Agoraphobia is characterized by intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others.

The defense mechanisms that can only be used in healthy ways include: A. suppression and humor. B. altruism and sublimation. C. idealization and splitting. D. reaction formation and denial.

B. altruism and sublimation. Altruism and sublimation are known as mature defenses. They cannot be used in unhealthy ways. Altruism results in resolving emotional conflicts by meeting the needs of others, and sublimation substitutes socially acceptable activity for unacceptable impulses.

The initial nursing action for a newly admitted anxious client is to: A. assess the client's use of defense mechanisms. B. assess the client's level of anxiety. C. limit environmental stimuli. D. provide antianxiety medication.

B. assess the client's level of anxiety. The priority nursing action is the assessment of the client's anxiety level.

It can be said that the onset of most anxiety disorders occurs: A. before the age of 20 years. B. before the age of 40 years. C. after the age of 40 years. D. scattered throughout the life span.

B. before the age of 40 years. Epidemiology reports indicate that the onset of most anxiety disorders occurs before age 40 years.

A client is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the client reports: A. that his symptoms started right after he was robbed at gunpoint. B. being so worried he hasn't been able to work for the last 12 months. C. that eating in public makes him extremely uncomfortable. D. repeatedly verbalizing his prayers helps him feel relaxed.

B. being so worried he hasn't been able to work for the last 12 months. GAD is characterized by symptomatology that lasts 6 months or longer.

A man continues to speak of his wife as though she were still alive, 3 years after her death. This behavior suggests the use of: A. altruism. B. denial. C. undoing. D. suppression.

B. denial. Denial involves escaping unpleasant reality by ignoring its existence.

Selective inattention is first noted when experiencing anxiety that is: A. mild. B. moderate. C. severe. D. panic.

B. moderate. When moderate anxiety is present, the individual's perceptual field is reduced and the client is not able to see the entire picture of events.

A teenager changes study habits to earn better grades after initially failing a test. This behavioral change is likely a result of: A. a rude awakening. B. normal anxiety. C. trait anxiety. D. altruism.

B. normal anxiety. Normal anxiety is a healthy life force needed to carry out the tasks of living and striving toward goals. It prompts constructive actions.

A 20-year-old was sexually molested at age 10, but he can no longer remember the incident. The ego defense mechanism in use is: A. projection. B. repression. C. displacement. D. reaction formation.

B. repression. Repression is a defense mechanism that excludes unwanted or unpleasant experiences, emotions, or ideas from conscious awareness.

A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? a. "Hypertension happens to everyone sooner or later. Don't be concerned about it." b. "Hypertension can happen from eating a poor diet, so change what you are eating." c. "Hypertension can happen from arterial changes that block the blood flow." d. "Hypertension happens when people do not exercise, so you should walk every day."

C

Client Needs: Health Promotion and Maintenance 25. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

C

Client Needs: Physiological Integrity 16. Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness c. Situational low self-esteem b. Defensive coping d. Disturbed personal identity

C

Client Needs: Psychosocial Integrity 27. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

C

Client Needs: Psychosocial Integrity 12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

C

Client Needs: Psychosocial Integrity 18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

C

Client Needs: Psychosocial Integrity 8. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

C

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

C Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-12, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

19. A nurse conducting group therapy on the eating-disorder unit schedules the sessions immediately after meals for the primary purpose of a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.

C Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-15, 30, 71 (Box 18-5) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

16. A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 18-30 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

A nurse can anticipate anticholinergic side effects are likely when a patient takes a. lithium. b. buspirone. c. imipramine. d. risperidone.

C Imipramine (Tofranil) is a tricyclic antidepressant with strong anticholinergic properties, resulting in dry mouth, blurred vision, constipation, and urinary retention.

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

C Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 18-67 (Box 18-1) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A nurse instructs a patient taking a drug that inhibits MAO to avoid certain foods and drugs because of the risk of a. cardiac dysrhythmia. b. hypotensive shock. c. hypertensive crisis. d. hypoglycemia.

C Patients taking MAO-inhibiting drugs must be on a low tyramine diet to prevent hypertensive crisis. In the presence of MAO inhibitors, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A nurse cares for a group of patients receiving various medications, including haloperidol, carbamazepine, trazodone, and phenalgine. The nurse will order a special diet for the patient who takes a. carbamazepine. b. haloperidol. c. phenelzine. d. trazodone

C Patients taking phenelzine, an MAO inhibitor, must be on a low tyramine diet to prevent hypertensive crisis. There are no specific dietary precautions associated with the distracters.

A patient is hospitalized for severe major depressive disorder. Of the medications listed below, the nurse can expect to provide the patient with teaching about a. chlordiazepoxide. b. clozapine. c. sertraline. d. tacrine.

C Sertraline (Zoloft) is an selective serotonin reuptake inhibitor (SSRI). This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimer's disease.

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

C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 18-12, 54 (Table 18-1) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-19 (Case Study and Nursing Care Plan), 71 (Box 18-5) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? A. "I will call your care provider. Perhaps you need a different medication." B. "Don't worry. We can try taking it at a different time of day to help it work better." C. "It usually takes a few weeks for you to notice improvement from this medication." D. "Your life is much better now. You will feel better soon."

C. "It usually takes a few weeks for you to notice improvement from this medication."

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? A. Blood glucose of 350 mg/dL B. Anticoagulant therapy for 10 days C. Hemoglobin of 8.5 g/dL D. Heart rate of 100 beats/min and blood pressure of 100/60

C. Hemoglobin of 8.5 g/dL Correct The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

The plan of care for a client who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? A. Having the client repeatedly touch "dirty" objects B. Not allowing the client to seek reassurance from staff C. Not allowing the client to wash hands after touching a "dirty" object D. Telling the client that he or she must relax whenever tension mounts

C. Not allowing the client to wash hands after touching a "dirty" object Response prevention is a technique by which the client is prevented from engaging in the compulsive ritual. A form of behavior therapy, response prevention is never undertaken without physician approval.

Lana is out of surgery and on the medical-surgical unit for recovery. You visit her the day after her surgical procedure. While you are in the room, Lana becomes visibly anxious and short of breath, and she states, "I feel so anxious! Something is wrong!" Your best action is to: A. reassure Lana that she is experiencing normal anxiety and do deep breathing exercises with her. B. use the call light to inquire whether Lana has any prn anxiety medication. C. call for help and assess Lana's vital signs. D. tell Lana you will stay with her until the anxiety subsides.

C. call for help and assess Lana's vital signs. In anxiety caused by a medical condition, the individual's symptoms of anxiety are a direct physiological result of a medical condition, such as hyperthyroidism, pulmonary embolism, or cardiac dysrhythmias. In this case Lana is postoperative and could be experiencing a pulmonary embolism, as evidenced by the shortness of breath and anxiety. She needs immediate evaluation for any serious medical condition. The other options would all be appropriate after it has been determined that no serious medical condition is causing the anxiety.

A Gulf War veteran is entering treatment for post-traumatic stress disorder. An important facet of assessment is to: A. ascertain how long ago the trauma occurred. B. find out if the client uses acting-out behavior. C. determine use of chemical substances for anxiety relief. D. establish whether the client has chronic hypertension related to high anxiety.

C. determine use of chemical substances for anxiety relief. Substance abuse often coexists with post-traumatic stress disorder. It is often the client's way of self-medicating to gain relief of symptoms.

Panic attacks in Latin American individuals often involve: A. repetitive involuntary actions. B. blushing. C. fear of dying. D. offensive verbalizations.

C. fear of dying. Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness or tingling, as well as fear of dying.

If a client's record mentions that the client habitually relies on rationalization, the nurse might expect the client to: A. make jokes to relieve tension. B. miss appointments. C. justify illogical ideas and feelings. D. behave in ways that are the opposite of his or her feelings.

C. justify illogical ideas and feelings. Rationalization involves justifying illogical or unreasonable ideas or feelings by developing logical explanations that satisfy the teller and the listener.

A young adult applying for a position is mildly tense but eager to begin the interview. This can be assessed as showing: A. denial. B. compensation. C. normal anxiety. D. selective inattention.

C. normal anxiety. Normal anxiety is a healthy life force needed to carry out the tasks of living and striving toward goals. It prompts constructive actions.

A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor is demonstrating: A. projection. B. rationalization. C. reaction formation. D. undoing.

C. reaction formation. Reaction formation keeps unacceptable feelings or behaviors out of awareness by developing the opposite behavior or emotion.

A client frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the client's level of anxiety as: A. mild. B. moderate. C. severe. D. panic.

C. severe. Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart.

When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should: A. question the physician's order because the dose is excessive. B. explain the long-term nature of benzodiazepine therapy. C. teach the client to limit caffeine intake. D. tell the client to expect mild insomnia.

C. teach the client to limit caffeine intake. Caffeine is an antagonist of antianxiety medication.

an underlying symptom of Peptic ulcer disease is

Peptic ulcer disease is associated with pain and intestinal discomfort.

1. Which nursing response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar and her support system? Select all that apply. a. "Remember that alcohol and caffeine can trigger a relapse of your symptoms." b. "Due to the risk of a manic episode, antidepressant therapy is never used with bipolar disorder. c. "It's critical to let your healthcare provider know immediately if you aren't sleeping well." d. "Is your family prepared to be actively involved in helping manage this disorder?" e. "The symptoms tend to come and go and so you need to be able to recognize the early signs."

a. "Remember that alcohol and caffeine can trigger a relapse of your symptoms." c. "It's critical to let your healthcare provider know immediately if you aren't sleeping well." d. "Is your family prepared to be actively involved in helping manage this disorder?" e. "The symptoms tend to come and go and so you need to be able to recognize the early signs."

1. A young adult says, I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I dont remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them. Which disorders should the nurse suspect based on this history? Select all that apply. a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

a. Acute stress disorder b. Depersonalization disorder d. Posttraumatic stress disorder Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patients presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

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

a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from ones body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are lost to the patient (blackouts). See relationship to audience response question.

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

a. Alcohol use disorder b. Major depressive disorder d. Polydipsia e. Metabolic syndrome

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

a. Always afraid another student will steal her belongings.

Gonorrhea infection can coexist with other infections. As a result of the client testing positive for gonorrhea, the nurse should prepare her for which treatments? a. Antimicrobial treatment of gonorrhea and chlamydia. b. Antiviral treatment of human papillomavirus and syphilis. c. Antimicrobial treatment of gonorrhea and syphilis. d. Antiviral treatment of trichomonas and chlamydia.

a. Antimicrobial treatment of gonorrhea and chlamydia.

One student reports that they have several open and painful sores in their genital area. Which priority action should the nurse take? a. Assist the student to obtain an appointment with a reproductive healthcare provider. b. Ask the student if they have been having unprotected sex. c. Discuss the treatment of viral sexually transmitted diseases. d. Counsel about the risk for pregnancy/paternity.

a. Assist the student to obtain an appointment with a reproductive healthcare provider.

The healthcare provider (HCP) has also prescribed a single dose of intravenous (IV) magnesium sulfate 2 mg in 100 mL of 5% dextrose in water over one hour to be given now. The nurse is preparing to give the prescribed intravenous (IV) magnesium. Which laboratory values should the nurse monitor cautiously before starting the medication? a. Blood urea nitrogen (BUN) and serum creatinine levels. b. White blood cell (WBC) and red blood cell counts (RBC). c. Activated partial thromboplastin time (aPTT). d. Hemoglobin (Hb), hematocrit (Hct), and platelet count.

a. Blood urea nitrogen (BUN) and serum creatinine levels.

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

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

The nurse notices that the client has no central line and only has one peripheral intravenous catheter in the left forearm. Which intervention is the best way to give the ordered potassium? a. Consult with a pharmacist about giving it slowly over two hours. b. Administer the intravenous potassium as it was ordered. c. Call the healthcare provider and request a new order. d. Inject lidocaine into the intravenous bag and give as prescribed.

a. Consult with a pharmacist about giving it slowly over two hours.

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

a. Drug actions and interactions Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patients drug regime, but interactions are more likely the problem. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 433-434 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

a. Family history of mental illness d. Father with history of alcohol abuse e. History of an abusive relationship with one parent Parents who are abusive, rejecting, or overly controlling cause a child to suffer detrimental effects. Other stressors associated with impulse control disorders can include major disruptions such as placement in foster care, severe marital discord, or a separation of parents. Substance abuse by a parent is common. Acne and allergies are not aspects of the history that relate to the behavior. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 403-405 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

a. Family therapy Family therapy focuses on problematic family relationships and interactions. The patient has identified problems within the family. Play therapy is more appropriate for younger patients. Art therapy and bibliotherapy would not focus specifically on the identified problem.

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

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

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

a. I cannot recall why Im living in this town. The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder. See relationship to audience response question.

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

a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 433 | Page 439 (Table 23-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

The student meets again with the nurse and confirms the HSV diagnosis. The student is angry with her boyfriend because he told her that he had only been with one other girl in the past and that he did not have any sexually transmitted diseases. The student wants to know if her boyfriend could be telling the truth when he stated he does not have HSV. How should the nurse respond? a. Individuals can be infected with HSV and not have any symptoms. b. Anyone who is infected with HSV should have noticeable symptoms. c. Your boyfriend has most likely had more than one sexual partner. d. It sounds as if your boyfriend is not trustworthy.

a. Individuals can be infected with HSV and not have any symptoms.

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

a. Label the bathroom door. The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 443 (Table 23-4) | Page 447 (Table 23-7) | Page 449 (Table 23-9) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

5. Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select all that apply. a. Monitor the patient's vital signs frequently. b. Keep the patient distracted with group-oriented activities. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient.

a. Monitor the patient's vital signs frequently. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient.

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

a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior. Oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. The distracters identify findings associated with conduct disorder, anxiety disorder, and Tourettes syndrome. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 401-402 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which of the following is an example of incidence of communicable disease? a. New diagnoses of gonorrhea in the community. b. Number of individuals in the county with hepatitis C. c. Sexual partners exposed to an individual infected with HIV. d. Individuals with chlamydia who test positive when re-tested.

a. New diagnoses of gonorrhea in the community.

13. Parents of an adolescent diagnosed with a conduct disorder say, We dont know how to respond when our child breaks the rules in our house. Is there any treatment that might help us? Which therapy is likely to be helpful for these parents? a. Parent-child interaction therapy (PCIT) b. Behavior modification therapy c. Multi-systemic therapy (MST) d. Pharmacotherapy

a. Parent-child interaction therapy (PCIT) In parent-child interaction therapy (PCIT), the therapist sits behind one-way mirrors and coaches parents through an ear audio device while they interact with their children. The therapist can suggest strategies that reinforce positive behavior in the adolescent. The goal is to improve parenting strategies and thereby reduce problematic behavior. Behavior modification therapy may help the adolescent, but the parents are seeking help for themselves. Multi-systemic therapy is much broader and does not target the parents need. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 409 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 436 (Box 23-1) | Page 445 (Box 23-3) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

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

a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patients name and name of the item. e. If the patient resists dressing, use distraction and try again after a short interval. Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patients name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 443 (Table 23-4) | Page 447 (Table 23-7) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

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

a. Reexperiencing Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

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

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patients sensorium is clouded. The other diagnoses may be concerns, but are lower priorities. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 435 | Page 442-443 | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment

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

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

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

a. Second-generation antipsychotic Medications for conduct disorder are directed at problematic behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms. Second-generation antipsychotics are likely to be prescribed. Beta-blocking medications may help to calm individuals with intermittent explosive disorder by slowing the heart rate and reducing blood pressure. Calcium channel blockers reduce blood pressure but are not used for persons with impulse control problems. An anti-anxiety medication will not assist with impulse control. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 407-408 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. The adolescent and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The adolescent will continue to experience anger and frustration. The adolescent and parents must continue with family therapy to work on boundary and communication issues. It is not necessary to separate the adolescent from the family to work on these issues. Separation is detrimental to the healing process. While it is helpful for the adolescent to identify peers who are a positive influence, its more important for behavior to be managed for an adolescent diagnosed with a conduct disorder.

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

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

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

a. Using the patients glasses and hearing aids Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 434-436 (Box 23-1) | Page 445 (Box 23-3) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

The nurse asks the client how he is feeling. He reports that he does not have time for this hospitalization. The nurse notes that he seems annoyed. He coughs as he tries to sit up. He turns on the television, focuses on a news station, and ignores the nurse. a. a focused assessment b. a comprehensive assessment c. an emergency assessment d. a psychosocial assessment

a. a focused assessment

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

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

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

a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside. These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

The nurse receives shift report and proceeds to the client's room, bringing equipment to measure his vital signs. Which vital sign should concern the nurse the most? a. blood pressure is 142/80 mmHG b. respiration rate of 24 breaths/min c. heart rate of 98 beats/min d. pulse ox of 94%

a. blood pressure is 142/80 mmHG

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

a. conveying empathy and acknowledging the childs distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. e. staying with the child until the anxiety decreases. The childs symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the childs distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

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

a. delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimers disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 432 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

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

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

a. engage the parasympathetic nervous system. In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

Which action is most important for the nurse to perform before calling the healthcare provider (HCP) to report the lab values? a. initiate telemetry b. complete an SBAR form c. Give PO potassium chloride d. notify the unit manager

a. initiate telemetry

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

a. remain safe in the environment. Risk for injury is the nurses priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 435 | Page 442 | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Safe, Effective Care Environment

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

a. returning to premorbid levels of function. The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 435 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity

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

a. risk for self-harm. Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

During the follow up meeting, the student asks the nurse, "Is it possible to transmit the infection when I do not have any symptoms?" How should the nurse respond? a. "The greatest risk for transmitting infection is when there are no visible lesions or symptoms." b. "It is possible to transmit the virus when no visible lesions or symptoms are present." c. "If you don't have a recurrence after the first year, you decrease the chance of transmitting the virus to others." d. "You do not need to worry about transmitting the virus if you use condoms during vaginal sex."

b. "It is possible to transmit the virus when no visible lesions or symptoms are present."

What is the best response by the nurse? a. "I will get the HCP to explain why the vaccines are needed." b. "She is susceptible to infections. These vaccinations may help prevent a crisis." c. "These vaccines are required for all children younger than 10 years of age." d. "I know you don't like to see her hurt, but she must have these vaccines."

b. "She is susceptible to infections. These vaccinations may help prevent a crisis."

How should the nurse respond? a. "This disease is an inherited autosomal recessive disease and your daughter inherited the gene responsible for causing the disease." b. "Your daughter has the disease because she inherited the gene from one of her parents, who is a carrier." c. "She must have had a bad reaction to a transfusion as a child." d. "She was exposed to a virus while her caregiver was pregnant."

b. "Your daughter has the disease because she inherited the gene from one of her parents, who is a carrier."

Which action should the ED nurse implement first? a. Request arterial blood gasses stat. b. Administer oxygen via nasal cannula. c. Send the client for an x-ray of her knees and elbows. d. Prepare to administer analgesics as prescribed.

b. Administer oxygen via nasal cannula.

6. Substance abuse is often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that: a. Anxiety may be present. b. Alcohol ingestion is a form of self-medication. c. The patient is lacking a sufficient number of neurotransmitters. d. The patient is using alcohol because she is depressed.

b. Alcohol ingestion is a form of self-medication.

12. Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntingtons disease c. Parkinsons disease b. Alzheimers disease d. Vascular dementia

b. Alzheimers disease All of the options relate to dementias however, the pathophysiological phenomena described apply to Alzheimers disease. Parkinsons disease is associated with dopamine dysregulation. Huntingtons disease is genetic. Vascular dementia is the consequence of circulatory changes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 437-438 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

9. Tatiana has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizziness

b. Ataxia, severe hypotension, large volume of dilute urine

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

b. Bullying d. Autism spectrum disorder e. Intellectual development disorder Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. Its important for the nurse to use current terminology.

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

b. Careful observation and supervision Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patients safety. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 436 (Box 23-1) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

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

b. Confabulation Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patients response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

b. Dementia The listed health problems are all forms of dementia. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 437 | Page 451 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

b. Educate all members of the family about risks associated with cyberbullying. c. Talk with the parents about parental controls on the childrens communication devices. d. Encourage the family to schedule daily time together without communication devices. Education and awareness-based approaches have a chance of effectively reducing harmful online behavior, including risks associated with cyberbullying. Parental controls on the childrens devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the familys network password and an invasion of privacy to inspect sites family members have visited.

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

b. Encourage the victimized child to share feelings about the experience. The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the childs complaints and validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored it will only get worse.

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

b. Engage the patient in a physical activity such as exercise. Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.

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

b. Establish firm limits Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teens thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, ignoring, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.]

Which intervention should be included in the care plan? a. Assess pain by using a numerical pain scale. b. Explain how to use a patient controlled analgesic pump. c. Apply cold compresses periodically to painful joints. d. Administer acetaminophen as needed (PRN) as needed for pain.

b. Explain how to use a patient controlled analgesic pump.

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

b. Explain that the physical symptoms are related to the psychological state. Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the bodys responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

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

b. Flashback Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

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

b. Flashbacks Cortisol is a hormone released in response to stress. Severe dissociation or mindflight occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

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

b. Focus interaction on familiar topics. Reorientation may seem like arguing to a patient with cognitive deficit and increases the patients anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 445 (Box 23-3) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. After the sudden death of his wife, a man says, I cant live without her she was my whole life. Select the nurses most therapeutic reply. a. Each day will get a little better. b. Her death is a terrible loss for you. c. Its important to recognize that she is no longer suffering. d. Your friends will help you cope with this change in your life.

b. Her death is a terrible loss for you. Adjustment disorders may be associated with grief. A statement that validates a bereaved persons loss is more helpful than false reassurances and clichs. It signifies understanding.

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

b. I saw my best friend get killed by a roadside bomb. I dont understand why it wasnt me. The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

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

b. Impaired memory Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 439 (Table 23-2) | Page 442-443 (Table 23-5) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity 14. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day. a. Assist the patient to perform simple tasks by giving step-by-step directions. Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 447 (Table 23-7) TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

4. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially? a. Reinforce that the level is considered therapeutic. b. Instruct the patient to hold the next dose of medication and contact the prescriber. c. Have the patient go to the hospital emergency room immediately. d. Alert the patient to the possibility of seizures and appropriate precautions.

b. Instruct the patient to hold the next dose of medication and contact the prescriber.

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

b. ODD tests limits and disobeys authority figures. e. CD often violates the rights of others. Persons diagnosed with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas persons with conduct disorder frequently behave in ways that do violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are seen in persons with autism spectrum disorders. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 401-403 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

b. Oxygen saturation level is 98%. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

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

b. Place locks at the tops of doors. Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patients sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patients safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 449 (Table 23-9) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

12. An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurses initial action to defuse the situation? a. Say to the child, Tell me how youre feeling right now. b. Take the child swimming at the programs pool. c. Establish a behavioral contract with the child. d. Administer an anxiolytic medication.

b. Take the child swimming at the programs pool. Redirecting the expression of feelings into nondestructive, age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to measures that are more restrictive. A shouting child will not likely engage in a discussion about feelings. A behavioral contract could be considered later, but first the situation must be defused. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 407-408 (Box 21-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

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

b. The confusion will probably get better as we treat the infection. Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 433-434 | Page 439 (Table 23-2) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

The nurse explains to the client that medications will be administered to obtain which expected outcome? a. The first treatment is one in a series of treatments that will cure the infection. b. Uncomplicated gonorrhea is cured with a single dose of antibiotic therapy. c. The infection cannot be cured completely, but medication will reduce the pain. d. Antiviral medication will cure the infection faster and minimize pain in one dose.

b. Uncomplicated gonorrhea is cured with a single dose of antibiotic therapy.

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

b. Use short, simple sentences and keep the environment calm and protective. Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patients time should not be loaded with demanding or stimulating activities.

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

b. a therapeutic alliance is the first step in a nurses therapeutic use of self. d. acceptance and trust convey feelings of security for the adolescent. Trust is frequently an issue because the adolescent may never have had a trusting relationship with an adult. Trust promotes feelings of security and is the basis of the nurses therapeutic use of self. Adolescents value peer relationships over those related to authority. Rewards for appropriate behavior are the main component of behavior modification programs.

Which action should the nurse implement? a. notify the hcp immediately b. explain the blood in the urine is expected c. request a stat hemoglobin level d. request a stat sterile urine specimen

b. explain the blood in the urine is expected

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

b. oppositional defiant disorder. Oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Loading a virus is a vindictive behavior in retribution for a poor grade. Persons with conduct disorder are aggressive against people and animals; destroy property; are deceitful; violate rules; and have impaired social, academic, or occupational functioning. There is no evidence of explosiveness or distractibility. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 401 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

The nurse finishes documenting the client interview and notices that new laboratory results have been posted in the electronic medical record (EMR). The nurse notes that the serum magnesium level is 1.22 mg/dL (0.50 mmol/L), and the normal range is 1.58 to 2.55 mg/dL (0.65 to 1.05 mmol/L). Which other result will need intervention? a. chloride of 99 mEq/L (99 mmol/L) b. potassium of 2.9 mEq/L c. glucose of 105 mg/dL d. sodium of 137 mEq/L

b. potassium of 2.9 mEq/L

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

b. states, I feel bugs crawling on my legs and biting me. A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 432-434 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

8. A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, "You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing": a. A higher dosage b. Once a week dosing c. A lower dosage d. A different drug

c. A lower dosage

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

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

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

c. Accompany the child to the gym and shoot baskets. The childs behavior warrants an active response. Redirecting the expression of feelings into nondestructive age-appropriate behaviors, such as a physical activity, helps defuse the situation here and now. This response helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to a more restrictive measure. Role-playing is appropriate after the childs anger is defused. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 406-408 (Box 21-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

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

c. Agnosia Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks. PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individuals extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

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

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

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

c. Anxiety and depression.

21. A soldier who served in a combat zone returned to the U.S. The soldiers spouse complains to the nurse, We had planned to start a family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? a. Reexperiencing c. Avoidance b. Hyperarousal d. Psychosis

c. Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individuals avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

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

c. Communication deficits Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 440 (Table 23-3) | Page 443 (Table 23-4) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

c. Depersonalization disorder Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

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

c. Do not throw the ball. Put it back on the pool table. Setting limits uses clear, sharp statements about prohibited behavior and guidance for performing a behavior that is expected. The incorrect options represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the childs developing self-control that may be ineffective. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 406-408 (Box 21-1) | Page 409 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

7. Ted, a former executive, is now unemployed due to manic episodes at work. He was diagnosed with bipolar I 8 years ago. Ted has a history of IV drug abuse, which resulted in hepatitis C. He is taking his lithium exactly as scheduled, a fact that both Ted's wife and his blood tests confirm. To reduce Ted's mania the psychiatric nurse practitioner recommends: a. Clonazepam (Klonopin) b. Fluoxetine (Prozac) c. Electroconvulsive therapy (ECT) d. Lurasidone (Latuda)

c. Electroconvulsive therapy (ECT)

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

c. Improved abilities to participate in cooperative play with other children The goal is improvement in the childs hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.

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

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

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

c. Ineffective coping related to adjustment to changes in family relationships Depression is often associated with impulse control disorder. The correct nursing diagnosis refers to the patients dysfunctional management of feelings associated with upcoming changes to the family. The teen displays self-imposed isolation. The distracters are not supported by data in the scenario. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 403-404 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

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

c. Ineffective coping related to inappropriate methods of seeking parental attention as evidenced by acting out The patient demonstrates a failure to follow age-appropriate social norms and an inability to problem solve by using adaptive behaviors to meet lifes demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient never mentioned hopelessness or disturbed personal identity. The problem relates to the patients perceptions of parental behavior rather than the actual behavior.

Which orders should the nurse anticipate? a. Provide the client with cold packs to place on her joints. b. Admit the client to a private room and keep her in reverse isolation. c. Infuse 5% Dextrose in 0.33% sodium chloride (NS) at 75 mL/hr via pump. d. Insert a 22 French indwelling urinary catheter with an urometer.

c. Infuse 5% Dextrose in 0.33% sodium chloride (NS) at 75 mL/hr via pump.

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

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

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

c. Medication is usually not prescribed for this problem. Lets discuss some behavioral strategies you can use. The parents are seeking a quick solution. Medications are generally not indicated for oppositional defiant disorder. Comorbid conditions that increase defiant symptoms, such as attention deficit hyperactivity disorder, should be managed with medication, but no comorbid problem is identified in the question. The nurse should give information on helpful strategies to manage the adolescents behavior. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 407-409 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

c. Memantine (Namenda) Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimers disease. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 450 (Table 23-10) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

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

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

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

c. Moderately severe cognitive decline In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimers can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 438-439 (Table 23-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. Adolescents with conduct disorder have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the amygdala. This reduction may be related to aggressive behavior and deficits of empathy. The less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. People with intermittent explosive disorder may have differences in serotonin regulation in the brain and higher levels of testosterone. Neuron destruction in the hippocampus is associated with memory deficits. The occipital lobe is involved with visual stimuli but not the processing of emotions. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 404 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

The nurse visits with the student who wanted to discuss a confidential concern. The student reports that she decided to have sex with her boyfriend of 9 months. The student reports that they had sex without a condom and now she has painful sores on her inner labia. The nurse suspects that the student has contracted herpes simplex virus (HSV). The nurse suspects that the student has contracted herpes simplex virus (HSV). What is the priority nursing action? a. Inform the student's parent/guardian. b. Consult with the student's healthcare provider. c. Refer the student for sexually transmitted disease testing and treatment d. Counsel the student about the importance of using condoms during sex.

c. Refer the student for sexually transmitted disease testing and treatment

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

c. Separate and distract the patients. Take one to the day room and the other to an activities area. Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

During interviews with a select group of students, the nurse is questioned about sexual and reproductive health. One student asks the nurse if any of the sexually transmitted diseases can be transmitted through oral sex. Which of the following is the correct response? a. It is rare for a sexually transmitted infection to be transmitted through oral sex. b. Sexually transmitted infections are only transmitted through vaginal or anal sex. c. Sexually transmitted infections can be transmitted through oral, vaginal or anal sex. d. Only viral sexually transmitted infections can be transmitted through oral sex.

c. Sexually transmitted infections can be transmitted through oral, vaginal or anal sex.

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

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

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

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

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

c. Sympathetic nervous system The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

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

c. Tactile hallucinations The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 432-434 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimers disease. Confusion is chronic, not acute. The patients cognition is too impaired to grieve.

Before giving cyanocobalamin, the nurse teaches the client about his medication. The client interrupts the teaching session and asks, "What happens if I just do not take the shots?" What is the best way for the nurse to respond? a. Are you not going to comply with this prescription? b. It sounds like you do not want to take these shots. c. You will gradually get very ill and die in 1 to 3 years. d. Let me talk to the healthcare provider and get you the tablets.

c. You will gradually get very ill and die in 1 to 3 years.

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

c. depression. Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

During the assessment, the nurse suspects that the client may have pernicious anemia. Which pathophysiological process promotes this condition? a. presence of Reed-Sternberg Cell b. diminished total iron-binding capacity c. destruction of gastric parietal cells d. inadequate intake of dietary folate

c. destruction of gastric parietal cells

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

c. hippocampus. The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

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

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

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

c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community. Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely.

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

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

Which food should the nurse offer to the client who is in a sickle cell crisis? a. peaches b. cottage cheese c. popsicles d. lima beans

c. popsicles

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

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

Testing for pregnancy and sexually transmitted infections at a school-based health center is an example of which level of prevention? a. prodromal prevention b. primary prevention c. secondary prevention d. tertiary prevention

c. secondary prevention

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

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

Follow-up after the diagnosis of a STD/STI is which level of prevention? a. primary prevention b. secondary prevention c. tertiary prevention d. prodromal prevention

c. tertiary prevention

Which is the best initial response by the nurse to explain SCD to the client's caregiver? a. "I have some written material that will explain all about the disease." b. "It is a disease of the blood that requires taking medication every day." c. "Your daughter will probably have episodes of severe joint pain and will need to be hospitalized." d. "Red blood cells become 'C' shaped, stiff, and sticky, which blocks the blood vessels."

d. "Red blood cells become 'C' shaped, stiff, and sticky, which blocks the blood vessels."

Several hours have passed and all medications have been given. The healthcare provider (HCP) is thinking about discharging client. The client's latest laboratory test results have arrived in his electronic medical record (EMR), and the nurse has performed another focused assessment. Which findings satisfy the nurse that the potassium electrolyte replacement medication has been effective? a. The client's mood and affect have improved significantly. b. The client's nausea and vomiting have resolved, and appetite has returned. c. Lack of tremoring when inflating the blood pressure cuff on the left arm. d. A 12-lead electrocardiography strip confirms a normal sinus rhythm and potassium level is 4.6 mEq/L (4.6 mmol/L).

d. A 12-lead electrocardiography strip confirms a normal sinus rhythm and potassium level is 4.6 mEq/L (4.6 mmol/L).

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

d. A 3-year-old who is mute, passive toward adults, and twirls while walking Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. Autistic spectrum disorder is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

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

d. Agnosia Agnosia is the inability to recognize familiar objects, parts of ones body, or ones own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient? Select all that apply. a. Increased attentiveness b. Getting up at night to urinate c. Improved vision d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult

d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult

The nurse anticipates an order for which diagnostic test by the ED HCP? a. Peripheral blood smear. b. Hemoglobin electrophoresis. c. Sickle-turbidity test (Sickledex). d. Blood cultures.

d. Blood cultures.

2. A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the court, We cant manage our teenager. The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescents behavior? a. Attention deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Intermittent explosive disorder d. Conduct disorder

d. Conduct disorder Conduct disorders are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. Criteria for ADHD and PTSD are not met in the scenario.

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

d. Dialectical behavioral therapy (DBT) The advanced practice nurse role includes individual, group, and family psychotherapist; educator of nurses, other professions, and the community clinical supervisor; consultant to professional and nonprofessional groups; and researcher. Dialectical behavioral therapy (DBT) is an aspect of psychotherapy. The distracters describe actions of a nurse generalist. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 408-409 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

10. Luc's family comes home one evening to find him extremely agitated and they suspect in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting? a. Hypodermic needles b. Fast food wrappers c. Empty soda cans d. Energy drink containers

d. Energy drink containers

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

d. Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

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

d. Give your child a kiss before you leave the preschool program. The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

During interviews with a select group of students, the nurse is questioned about sexual and reproductive health. One student asks the nurse about the transmission of herpes. Which information regarding herpes simplex virus (HSV) transmission should the nurse present? a. Herpes can be cured with antiviral medications if diagnosed early. b. Herpes can only be transmitted through oral sex. c. With increased sex education, the prevalence of herpes has decreased in recent years. d. Herpes can cause painful sores in the mouth, anus, and genital area.

d. Herpes can cause painful sores in the mouth, anus, and genital area.

14. An adolescent diagnosed with an impulse control disorder said, I just want to die. I spend all my time getting even with people who have done wrong to me. When asked about a suicide plan, the adolescent replied, Ill jump from the bridge near my home. My father threw kittens off that bridge, and they died because they couldnt swim. Rate the suicide risk. a. Absent c. Moderate b. Low d. High

d. High The suicide risk is high. The child is experiencing feelings of hopelessness and helplessness. The method described is lethal, and the means to carry out the plan are available. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 404-405 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, Someone get these bugs off me. What is the nurses best response? a. No bugs are on your legs. You are having hallucinations. b. I will have someone stay here and brush off the bugs for you. c. Try to relax. The crawling sensation will go away sooner if you can relax. d. I dont see any bugs, but I can tell you are frightened. I will stay with you.

d. I dont see any bugs, but I can tell you are frightened. I will stay with you. When hallucinations are present, the nurse should acknowledge the patients feelings and state the nurses perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patients perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 436 (Box 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

d. It is disappointing when someone you love no longer recognizes you. Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 438 | Page 440 (Table 23-3) | Page 441 | Page 443 (Table 23-5) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

d. Maintenance of nutrition and hydration In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 440 (Table 23-3) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

Which of the following is an example of prevalence of communicable disease? a. Individuals with chlamydia who test positive when re-tested. b. Sexual partners exposed to an individual infected with HIV. c. New diagnoses of gonorrhea in the community. d. Number of individuals in the county with hepatitis C.

d. Number of individuals in the county with hepatitis C.

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

d. Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support. Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse. Confrontation will not be effective. While its important to provide information, on-going support will be more effective.

Which intervention should the nurse implement? a. Explain that the other children should be extra nice to the client. b. Instruct the teacher to have the client sit at the front of the classroom. c. Encourage the client to participate in all playground activities. d. Request the client be allowed to go to the bathroom whenever she asks.

d. Request the client be allowed to go to the bathroom whenever she asks.

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

d. Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on-going.

Which behavior indicates to the nurse the caregiver understands about acute exacerbations of sickle cell disease? a. She is able to take the client's radial pulse within 4 beats of the nurse. b. She does not allow client to go outside unless she is with her. c. She measures client's fluid intake to remain under 1 liter a day. d. She demonstrates how to accurately read an oral thermometer.

d. She demonstrates how to accurately read an oral thermometer.

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

d. She should experience a reduction in hallucinations.

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

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

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

d. The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings. The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. Crying at 2 weeks after his death is expected and normal.

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

d. They are not actually ill.

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

d. To have a less positive outcome

Which sign or diagnostic result should the nurse expect to observe in a client due to hypokalemia? a. an arm tremor while taking the client's blood pressure b. hyperactive deep tendon reflex c. elevated serum glucose level d. a dampened or flattened t-wave on an ECG

d. a dampened or flattened t-wave on an ECG

8. The parent of a 6-year-old says, My child is in constant motion and talks all the time. My child isnt interested in toys but is out of bed every morning before me. The childs behavior is most consistent with diagnostic criteria for: a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder.

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

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

d. cognitive distortions associated with unresolved childhood abuse issues. Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

6. A 12-year-old has engaged in bullying for several years. The parents say, We cant believe anything our child says. Recently this child shot a dog with a pellet gun and set fire to a neighbors trash bin. The childs behaviors support the diagnosis of: a. attention deficit hyperactivity disorder. b. intermittent explosive disorder. c. defiance of authority. d. conduct disorder.

d. conduct disorder. The behaviors mentioned are most consistent with criteria for conduct disorder, for example, aggression against people and animals, destruction of property, deceitfulness, rule violations, and impairment in social, academic, or occupational functioning. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. The behaviors are not consistent with attention deficit and are more pervasive than defiance of authority. See related audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 401-403 (Table 21-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

d. continuously rocks in place for 30 minutes. Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. The distracters are expected findings for a 3-year-old.

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

d. create a scholarship fund at their child's high school. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

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

d. engages in cooperative play with other children. The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the childs aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.

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

d. throw flowers on the lake at each anniversary date of the accident. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.

an underlying symptom of ischemia is

Pain Ischemia is associated with pain.

Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

C, D, E

The nurse is reviewing the client's electronic medical record (EMR) and is discussing with the healthcare provider (HCP) the possible need for an interprofessional conference with the client due to the increasing complexity of his medical problems. The nurse uses a problem-solving approach with the client to facilitate interprofessional communication and assists the healthcare provider (HCP) with obtaining appropriate consults to better inform the team of identified issues for promoting the changes needed for this client. To begin this process, the nurse creates a list of known problems. Which problems should the nurse include in this evaluation? (Select all that apply. One, some, or all options may be correct.) a. social isolation b. chronic alcohol use c. chronic gastritis d. pernicious anemia e. electrolyte imbalances f. grief and loss

C, D, E, F

A client is displaying symptomatology reflective of a panic attack. In order to help the client regain control, the nurse responds: A. "You need to calm yourself." B. "What is it that you would like me to do to help you?" C. "Can you tell me what you were feeling just before your attack?" D. "I will get you some medication to help calm you."

C. "Can you tell me what you were feeling just before your attack?" A response that helps the client identify the precipitant stressor is most therapeutic.

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? A. "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite." B. "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." C. "The person may have excess energy, talk a lot, feel restless, and spend too much money." D. "The person may experience decreased energy and interest in activities beginning in the winter months."

C. "The person may have excess energy, talk a lot, feel restless, and spend too much money."

Which nursing diagnosis would be most useful for clients with anxiety disorders? A. Excess fluid volume B. Disturbed body image C. Ineffective role performance D. Disturbed personal identity

C. Ineffective role performance Anxiety disorders often interfere with the usual role performance of clients. Consider the client with agoraphobia who cannot go to work, or the client with obsessive-compulsive disorder who devotes time to the ritual rather than to parenting.

A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysthymia

D

Chapter 14: Depressive Disorders MULTIPLE CHOICE 1. A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

D

Client Needs: Physiological Integrity 26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed c. Smiling inappropriately b. Staring at the nurse d. Eyes pointed downward

D

Client Needs: Physiological Integrity 9. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth c. Nasal congestion b. Blurred vision d. Urinary retention

D

Client Needs: Physiological Integrity 15. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

D

Client Needs: Psychosocial Integrity 11. A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. c. interest and pleasure. b. over-involvement. d. ineffectiveness and frustration.

D

Client Needs: Psychosocial Integrity 22. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice c. Hot tea b. Orange juice d. Milk

D

Client Needs: Psychosocial Integrity 24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

D

23. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

D A matter-of-fact statement that the nurse's perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 18-19 (Case Study and Nursing Care Plan) | Page 18-71 (Box 18-5) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group? a. Tricyclic antidepressants b. Antipsychotic drugs c. Mood stabilizers d. Benzodiazepines

D Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Mood stabilizers are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

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

D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-13, 58 (Table 18-3) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

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

D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-13, 19 (Case Study and Nursing Care Plan), 58 (Table 18-3) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity

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

D The correct response is the only strategy that questions the patient's distorted thinking. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-19 (Case Study and Nursing Care Plan), 29, 30 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A patient's history shows drinking 4 to 6 L of fluid and eating more than 6,000 calories per day. Which part of the central nervous system is most likely dysfunctional for this patient? a. Amygdala b. Parietal lobe c. Hippocampus d. Hypothalamus

D The hypothalamus, a small area in the ventral superior portion of the brainstem, plays a vital role in such basic drives as hunger, thirst, and sex. See relationship to audience response question.

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

D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-30 (Case Study and Nursing Care Plan), 36, 61 (Table 18-5) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

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

D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 18-58 (Table 18-3), 61 (Table 18-5), 67 (Box 18-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Physiological Integrity

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

D The patient's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 18-12, 13, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Analysis/Diagnosis MSC: Client Needs: Physiological Integrity

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

D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 18-12, 13, 54 (Table 18-1) | Page 18-19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Physiological Integrity

An individual hiking in the forest encounters a large poisonous snake on the path. Which change in this individual's vital signs is most likely? a. Pulse rate changes from 90 to 72. b. Respiratory rate changes from 22 to 18. c. Complaints of intestinal cramping begin. d. Blood pressure changes from 114/62 to 136/78.

D This frightening experience would stimulate the sympathetic nervous system, causing a release of norepinephrine, an excitatory neurotransmitter. It prepares the body for fight or flight. Increased blood pressure, pupil size, respiratory rate, and pulse rate signify release of norepinephrine. Intestinal cramping would be associated with stimulation of the parasympathetic nervous system.

A patient asks, "What are neurotransmitters? My doctor said mine are imbalanced." Select the nurse's best response. a. "How do you feel about having imbalanced neurotransmitters?" b. "Neurotransmitters protect us from harmful effects of free radicals." c. "Neurotransmitters are substances we consume that influence memory and mood." d. "Neurotransmitters are natural chemicals that pass messages between brain cells."

D The patient asked for information, and the correct response is most accurate. Neurotransmitters are chemical substances that function as messengers in the central nervous system. They are released from the axon terminal, diffuse across the synapse, and attach to specialized receptors on the postsynaptic neuron. The distracters either do not answer the patient's question or provide untrue, misleading information.

5. Exercise and activity are included in a cardiac rehabilitation program for which purposes? (Select all that apply.) Increase cardiac output Increase serum lipids Increase blood pressure Increase blood flow to the arteries Increase muscle mass Increase flexibility

Increase cardiac output Increase blood flow to the arteries Increase muscle mass Increase flexibility A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure. Awarded 1.0 points out of 1.0 possible points. Continue

The nurse is performing an assessment on a 10 yo child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply. 1. abdominal pain 2. fever and malaise 3. anorexia and weight loss 4. painful enlarged inguinal lymph nodes 5. painless, firm, and movable adenopathy in the cervical area

1. abdominal pain 5. painless, firm, and movable adenopathy in the cervical area

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500mm3. On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1. initiate bleeding precautions 2. monitor closely for signs of infections 3. monitor the temperature every 4 hours 4. initiate protective isolation precautions

1. initiate bleeding precautions

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? A. The infant is becoming more active. B. There is an increase in intake of breast milk or formula. C. The infant is unable to maintain an adequate iron intake. D. A depletion of fetal hemoglobin occurs.

D. A depletion of fetal hemoglobin occurs. Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1. "the femur is the most common site of this sarcoma" 2. "the child does not experience pain at the primary tumor site" 3. "limping, if a weight-bearing limb is affected, is a clinical manifestation" 4. "the symptoms of the disease in the early stage are almost always attributed to normal growing pains"

2. "the child does not experience pain at the primary tumor site"

Which clinical management prevention concept would the nurse identify as representative of secondary prevention? A. Decreasing venous stasis and risk for pulmonary emboli B. Implementation of strict hand washing routines C. Maintaining current vaccination schedules D. Prevention of pneumonia in patients with chronic lung disease

D. Prevention of pneumonia in patients with chronic lung disease Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.

Which behavior would be characteristic of an individual who is displacing anger? A. Lying B. Stealing C. Slapping D. Procrastinating

D. Procrastinating A passive-aggressive person deals with emotional conflict by indirectly and unassertively expressing aggression toward others. Procrastination is an expression of resistance.

Which nursing intervention would be helpful when caring for a client diagnosed with an anxiety disorder? A. Express mild amusement over symptoms. B. Arrange for client to spend time away from others. C. Advise client to minimize exercise to conserve endorphins. D. Reinforce use of positive self-talk to change negative assumptions.

D. Reinforce use of positive self-talk to change negative assumptions. This technique is a variant of cognitive restructuring. "I can't do that" is changed to "I can do it if I try."

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of liquid oral iron supplement. Which instruction should the nurse tell the parents? 1. Administer the iron at mealtimes 2. administer the iron through a straw 3. mix the iron with cereal to administer 4. add the iron to formula for easy administration.

2. administer the iron through a straw

A 4 yo child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis? 1. lumbar puncture showing no blast cells 2. bone marrow biopsy showing blast cells 3. platelet count of 350,000mm3 4. white blood cell count 4500mm3

2. bone marrow biopsy showing blast cells

Questions 1. The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? A. Ischemia B. Pneumonia C. Myocardial infarction D. Peptic ulcer disease

Myocardial infarction Fatigue is an atypical symptom of myocardial infarction in women.

A 6 yo child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? 1. "i have a vase in the utility room, and i will get it for you" 2. "i will get the vase and wash it well before you put the flowers in it" 3. "the flowers from your garden are beautiful, but should not be placed in the child's room at this time" 4. "when you bring the flowers into the room, place them on the bedside stand as far away from the child as possible"

3. "the flowers from your garden are beautiful, but should not be placed in the child's room at this time"

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

NS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 210 (Table 12-3) | Page 219-220 TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

374. The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? 1. Platelet count 2. Hematocrit level 3. Hemoglobin level 4. Partial thromboplastin time (PTT)

4. Partial thromboplastin time Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.

A diagnosis of Hodgkin's disease is suspected in a 12 yo child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1. elevated vanillylmandelic acid urinary levels 2. the presence of blast cells in the bone marrow 3. the presence of EBV in the blood 4. the presence of Reed-Sternberg cells in the lymph nodes

4. the presence of Reed-Sternberg cells in the lymph nodes

Client Needs: Physiological Integrity 19. Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

A

Client Needs: Psychosocial Integrity 2. A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

A

Client Needs: Psychosocial Integrity 20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January c. June b. April d. September

A

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

A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness and will persist in trying to lose more weight. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-12, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? A. Disorientation and tremors B. Tachycardia and decreased blood pressure C. Increased anxiety and irritability D. Hyperventilation and lethargy

A. Disorientation and tremors Correct The patient is experiencing respiratory acidosis (pH and PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

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

ANS: A Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

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

Normally, most people sleep at night. What is the physiological rationale? a. The master biological clock responds to darkness with sleep. b. Darkness stimulates histamine release, which promotes sleep. c. Cooler environmental temperatures stimulate retinal messages. d. Stimulation of the sympathetic nervous system promotes sleep.

ANS: A The master biological clock in the suprachiasmatic nucleus (SCN) of the hypothalamus regulates sleep as well as other physiological processes. Darkness cues the clock for sleep. Light cues it for wakefulness. Light stimulates retinal messages. Histamine release is associated with wakefulness. Stimulation of the sympathetic nervous system promotes alertness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 367 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5. A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. "What kinds of things do you do to reduce or cope with your stress?" b. "Tell me about your family history—do any relatives have problems with stress?" c. "Tell me about exercise—how far do you typically run when you go jogging?" d. "Stress can interfere with sleep. How much did you sleep last night?"

ANS: A The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

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

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

1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists.

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. See relationship to audience response question.

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

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

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

ANS: C The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

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

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

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

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

11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the patient's ability to weigh alternatives to mutilating behavior.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful? a. "No complaints related to sexual function; to return next week." b. "Patient reports achieving orgasm last week; seems very happy." c. "Reports satisfaction with sexual encounters; feels partner is supportive." d. "Reports achieving orgasm occasionally; relationship with partner is adequate."

ANS: C Human sexuality, sexual expression, and expectations related to sexuality vary tremendously from person to person and across cultures. Therefore, the best indication of satisfactory treatment is that the patient is satisfied with what has been achieved. In this instance, "Patient reports satisfaction with sexual encounters; feels partner is supportive" best indicates that the patient is satisfied, and both presenting issues are progressing in a positive manner. Achieving orgasm once or occasionally may or may not represent satisfactory progress to the patient. "No complaints" does not necessarily mean that satisfaction exists.

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

5. An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient? a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose

ANS: C Increased confusion is a symptom that occurs in cognitively impaired patients who experience an infection. Severe headache occurs with migraines, meningitis, and other conditions. Flank pain occurs with pyelonephritis. Blood glucose typically increases with an infection.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

While performing an assessment, the nurse says to a patient, "While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?" The purpose of this question is to: a. identify areas of sexual dysfunction for treatment. b. determine possible homosexual urges. c. introduce the topic of masturbation. d. identify sexual misinformation.

ANS: D Misinformation about normal sex and sexuality is common. Lack of knowledge may affect an individual's sexual adjustment. Once myths have been identified, the nurse can give information to dispel the myth.

*Which statement about paraphilic disorders is accurate? a. Paraphilic behavior is controllable by willpower, but most persons with these disorders fail to do so. b. Persons with paraphilic disorders rarely experience shame and are not distressed by their acts.* c. Persons with paraphilic disorders prey primarily on female children between the ages of 12 and 15 years. d. Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon.

ANS: D Paraphilic disorders are uncommon; however, because persons with these disorders repeatedly enact behaviors associated with their disorders, paraphilic acts are relatively common. The majority of victims of pedophiles are males in early adolescence; those pedophiles who prefer females usually prefer prepubescent children. Some persons with paraphilic disorders experience shame and are at higher risk for suicide due to the stigma, shame, and embarrassment. Biological and psychological drives underlying paraphilic behavior can be very strong and often are not controllable by willpower alone. Persons with paraphilic disorders have difficulty controlling their behavior, even when very motivated to do so.

3. The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? a. Allow food selections from a menu with several choices. b. Schedule frequent field trips off the unit for cognitive stimulation. c. Plan for attendance at activities with several other patients on the unit. d. Plan for a structured daily routine of events and caregivers.

ANS: D Patients with a cognitive impairment benefit from a predictable routine and consistent caregivers. Trips off of the unit may confuse the patient and disrupt their normal routine. Offering too many selections causes confusion and can lead to agitation. Being in large groups for activities can overstimulate the patient and lead to agitation and fear.

A patient with rheumatoid arthritis reports, "For the past month I've been having a lot of trouble falling asleep. When I finally get to sleep, I wake up several times during the night." Which information should the nurse seek initially? a. "What have you done to try to improve your sleep?" b. "What would be a good sleep pattern for you?" c. "How much exercise are you getting?" d. "Do you have pain at night?"

ANS: D Patients with diseases such as arthritis may have sleep disturbance related to nightly pain. Because the pain is chronic, the patient may fail to realize it is the reason for the inability to sleep. The other options do not follow the patient's lead or begin problem solving without an adequate baseline. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 365 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery d. Relaxation breathing

ANS: D Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

A young adult says to the nurse, "I go to sleep without any problem, but I often wake up during the night because it feels like there are rubber bands in my legs." Which assessment question should the nurse ask to assess for restless legs syndrome (RLS)? a. "What type of birth control do you use?" b. "How much caffeine do you use every day?" c. "How much exercise do you get in a typical day?" d. "Does anyone else in your family have this problem?"

ANS: D Restless legs syndrome (RLS) is a sensory and movement disorder characterized by an unpleasant, uncomfortable sensation in the legs accompanied by an urge to move. Symptoms begin or worsen during periods of inactivity, such as sleep. Symptoms can have a significant impact on the individual's ability to fall asleep and stay asleep. There is likely to be a strong genetic component, especially when seen in individuals less than 40 years old. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 370 | Page 373 (Box 19-1) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. Behavior which is most consistent with this stage of relapse would include a. expressing feelings of anxiety. b. expressing feelings of being overwhelmed. c. bizarre behaviors and speech. d. presence of hallucinations.

ANS: D Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.

A person is prescribed sertraline (Zoloft) 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have: a. more dreams. b. excessive sleepiness. c. less slow-wave sleep. d. less rapid eye movement (REM) sleep.

ANS: D Sertraline (Zoloft) is an SSRI antidepressant medication, which suppresses REM sleep. Dreams would decrease because they occur during REM. Benzodiazepines reduce slow-wave sleep. SSRIs have a side effect of insomnia. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 369-370 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

A patient tells the nurse, "Everyone says we should sleep 8 hours a night. I can only sleep 6 hours, no matter how hard I try. Am I doing harm to my body?" Select the nurse's best response. a. "Tell me about strategies you have tried to increase your total sleep hours." b. "Lack of sleep acts as a stressor on the body and can cause physical changes." c. "If you have really tried to sleep more, maybe you should consult your health care provider." d. "If you function well with 6 hours of sleep, you are a short sleeper. That's normal for some people."

ANS: D Some individuals require less sleep than others do. Those who need less are called "short sleepers," compared with "long sleepers," who require more than 8 hours. The distracters do not provide information the patient is seeking or are untrue. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 368 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

A nurse sitting with a client diagnosed with anorexia nervosa notices that the client has eaten 80% of lunch. The client asks the nurse "What do you like better, hamburgers or spaghetti?" Which is the best response by the nurse? A. I'm Italian, so I really enjoy a large plate of spaghetti B. I'll weigh you after your meal C. Let's focus on your continued improvement. You ate 80% of your lunch D. Why do you always talk about food? Let's talk about swimming

Answer :C It is important to offer support and positive reinforcement for improvements in eating behaviors. Because clients diagnosed with anorexia nervosa are obsessed with food, discussion of food can provide unintended positive reinforcement for negative behaviors. In this answer, the nurse is redirecting the client.

Which anorexia nervosa symptom is physical in nature? A. Dry, yellow skin B. Perfectionism C. Frequent weighing D. Preoccupation with food

Answer: A Dry yellow skin is a physical symptom of anorexia. This is due to the release of carotenes as fat stores are burned for energy.

A client diagnosed with an eating disorder has a nursing diagnosis of low self esteem. Which nursing intervention would address this client's problem? A. Offer independent decision making opportunities B. Review previously successful coping strategies C. Provide a quiet environment with decreased stimulation D. Allow the client to remain in a dependent role throughout treatment

Answer: A Offering independent decision making opportunities promotes feelings of control. Making decisions and dealing with the consequences of these decisions should increase independence and improve the client's self esteem. Reviewing previously successful coping strategies is an effective nursing intervention for clients experiencing altered coping, not low self esteem. Altered coping is a common problem for clients with eating disorders, but this diagnosis is not stated in the questions.

A client on an inpatient unit has been diagnosed with bulimia nervosa. The client states' "I'm going to the bathroom and will be back in a few minutes." Which nursing response is most appropriate? A. Thanks for checking in B. I will accompany you to the bathroom C. Let me know when you get back to the day room D. I'll stand outside your door to give you privacy.

Answer: B Any client suspected of self induced vomiting should be accompanied to the bathroom for the nurse to be able to deter this behavior.

A client with a long history of bulimia nervosa is seen in the emergency department. The client is seeing things that others do not, is restless, and has dry mucous membranes. Which is most likely the cause of this client's symptoms? A. Mood disorders, which often accompany the diagnosis of bulimia nervosa B. Nutritional deficits, which are characteristic of bulimia nervosa C. Vomiting, which may lead to dehydration and electrolyte imbalance D. Binging, which causes abdominal discomfort

Answer: C Purging behaviors, such as vomiting, may lead to dehydration and electrolyte imbalance. Hallucinations and restlessness are signs of electrolyte imbalance. Dry mucous membranes indicated dehydration. Nutritional deficits are characteristic of bulimia nervosa, but the client symptoms described in the question do not reflect a nutritional deficit.

Which outcome indicates that the client's problem of impaired body image has improved? A. The client has gained up to 80% of body weight for age and size B. The client is free of symptoms of malnutrition and dehydration C. The client has not attempted to self induce vomiting D. The client has acknowledged that perception of being fat is incorrect

Answer: D When clients can acknowledge that their perception of being fat is incorrect, they perceive a body image that is realistic and not distorted. This is evidence that the client's impaired body image has improved. The outcome of A indicated that the nursing diagnosis of imbalanced nutrition: less than body requirements, not impaired body image, has been resolved. Being free of B is an outcome that indicates the nursing diagnosis of imbalanced nutrition, less than body requirement, not impaired body image has been resolved. Not attempting self induced vomiting is an outcome that indicates that the nursing diagnosis of altered coping, not impaired body image, has been resolved. Not resorting to the maladaptive coping mechanism of self induced vomiting indicates improvement in the client's ability to cope effectively with stressors.

Client Needs: Health Promotion and Maintenance 28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. c. cardiac dysrhythmia. b. hypertensive crisis. d. cardiogenic shock.

B

Studies of clients diagnosed with posttraumatic stress disorder suggest that the stress response of which of the following is considered abnormal? A. Brainstem B. Hypothalamus-pituitary-adrenal system C. Frontal lobe D. Limbic system

B. Hypothalamus-pituitary-adrenal system Studies of clients with posttraumatic stress disorder suggest that the stress response of the hypothalamus-pituitary-adrenal system is abnormal.

A nurse is explaining to a student nurse about perfusion. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. "Perfusion is a normal function of the body, and I don't have to be concerned about it." b. "Perfusion is monitored by the physician." c. "Perfusion is monitored by vital signs and capillary refill." d. "Perfusion varies as a person ages, so I would expect changes in the body."

C

Client Needs: Safe, Effective Care Environment 6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

C

an underlying symptom of pneumonia is

Pneumonia is associated with pain and shortness of breath.

2. Which statement made by the patient demonstrates an understanding of the effective use of newly prescribed lithium to manage bipolar mania? Select all that apply. a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day." b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider." c. "Lithium may help me lose the few extra pounds I tend to carry around." d. "I take my lithium on an empty stomach to help with absorption." e. "I've already made arrangements for my monthly lab work."

a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day." b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider." e. "I've already made arrangements for my monthly lab work."

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

a. A list of all medications the person currently takes Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 433-434 | Page 439 (Table 23-2) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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

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

The client agrees to the nurse's request to sit with him for a while to discuss his treatment plan. His usual disengaged and surly affect has changed significantly. Today he is pleasant and very glad to see the nurse. What question should the nurse ask the client first? a. Are you able to tell me about your treatment plan? b. Do you have any thoughts of harming yourself? c. Have you been drinking any alcohol at all today? d. How do you feel about your new diagnosis of alcohol misuse?

b. Do you have any thoughts of harming yourself?

23. The parent of a child diagnosed with Tourettes disorder says to the nurse, I think my child is faking the tics because they come and go. Which response by the nurse is accurate? a. Perhaps your child was misdiagnosed. b. Your observation indicates the medication is effective. c. Tics often change frequency or severity. That doesnt mean they arent real. d. This finding is unexpected. How have you been administering your childs medication?

c. Tics often change frequency or severity. That doesnt mean they arent real. Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourettes disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.

The nurse provides the student with instructions about ways to reduce the risk of HSV transmission. The nurse explains that a condom should always be worn between HSV outbreaks, and sexual activity should be avoided during the prodromal phase and when lesions are present. The nurse teaches the student how to recognize the prodromal stage of HSV. Which symptoms are indicative of the prodromal stage of genital HSV? a. Vesicular lesions on the genitals. b. Shallow moist ulcerations around the genitals c. Tingling, burning, or itching at the site the lesions will eventually appear. d. Crusting and epithelialization of the erosions.

c. Tingling, burning, or itching at the site the lesions will eventually appear.

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

d. Paranoia