Exam 4 Practice Questions
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. A. Monitor vital signs. B. Maintain NPO status. C. Provide a safe environment. D. Address hallucinations therapeutically. E. Provide stimulation in the environment. F. Provide reality orientation as appropriate.
A, C, D, F
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? A. "I no longer feel that I deserve the beatings my husband inflicts on me." B. "My attendance at the meetings has helped me to see that I provoke my husband's violence." C. "I enjoy attending the meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."
A. "I no longer feel that I deserve the beatings my husband inflicts on me." Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent. Focus on the subject the therapeutic effect of attending an Al-Anon group. Noting the wordsbenefiting from attending an Al-Anon group will direct you to the correct option.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? A. "Why don't you tell your wife about this?" B. "What do you find difficult about this situation?" C. "This is not the best time to make that decision." D. "I agree with you. You should get out of this situation."
B. "What do you find difficult about this situation?" The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations. Note the strategic word most . Use therapeutic communication techniques . Eliminate option 1 because of the word why , which should be avoided in communication. Eliminate option 3 because this option places the client's feelings on hold. Eliminate option 4 because the nurse
A nurse planning care for a patient diagnosed with bulimia nervosa should recommend the use of: A. Pharmacotherapy B. Cognitive-Behavioral Therapy C. Psychodynamic D. Rational Emotive Behavioral Therapy
B. Cognitive-Behavioral Therapy Cognitive-Behavioral therapy is indicated in the treatment of this eating disorder. While pharmacologic therapy may also be helpful, the nurse is not qualified to make this recommendation unless he/she is an Advanced Practice Nurse. CBT should be tried prior to, or in conjunction with, any other therapies due to its being an evidence-based therapy.
A patient diagnosed with an eating disorder asks to be excused from a meal to use the restroom. Select the nurse's best response. A. You cannot go until after you have finished your meal B. I will go to the restroom with you C. I know you want to go vomit, so lets talk about it instead. D. No one is permitted to leave the table during meals
B. I will go to the restroom with you The nurse allows the patient to attend to her basic needs but provides supervision that is appropriate for an eating-disordered patient, to ensure they are not using this as an opportunity to purge in some way (vomiting, laxatives, exercise, etc.)
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. manipulative C. detached D. guilt-producing
B. manipulative
The nurse interviews a patient who restricts food and is 25% underweight. The patient says, "I still need to lose weight. I'm not thin enough." The patient is using which defense mechanism? A. Rationalization B. Projection C. Denial D. Splitting
C. Denial The patient is in denial of the true nature of their weight and health status, unable to accept the actual reality of the situation.
A patient diagnosed with anorexia nervosa has the nursing diagnosis imbalanced nutrition, less than body requirements, related to inadequate food intake. The long-term goal of the treatment plan is that the patient will: A. Gain 1 to 3 lbs weekly B. Exhibit fewer signs of malnutrition C. Restore healthy eating patterns and normalize weight D. Identify cognitive distortions about weight and shape
C. Restore healthy eating patterns and normalize weight Though the other answers may be valid in one way or another, they do not answer the question, which is to provide a long term outcome for this particular nursing diagnosis.
A school nurse knows that school-age children often use defense mechanisms to cope with situations that might negatively affect their self-esteem. The nurse hears a child who is not invited to a sleepover say, "I don't have time to go to that sleepover. I have better things to do." The nurse concludes that the student is using the defense mechanism of: A. Denial B. Projection C. Regression D. Rationalization
D. Rationalization Rationalization is the offering of an explanation to oneself or others to allay anxiety. Denial involves avoiding the reality of a situation. Projection is blaming others for one's shortcomings. Regression is returning to an earlier more familiar mode of behavior.
The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is: 1. Lorazepam (ativan) 2. Phenobarbital (Luminal) 3. Chlopromazine (Thorazine) 4. Methadone hydrochloride (Methadone)
1. Lorazepam (Ativan) Lorazepam (Ativan) is most effective in preventing the signs and symptoms associated with withdrawalfrom alcohol. It depresses the CNS by potentiating GABA, an inhibitory neurotransmitter. 2. Phenobarbital (Luminal) is used to prevent withdrawal symptoms associated with barbiturate use 3. Chlorpromazine (Thorazine), an antipsychotic medication, is not used for alcohol withdrawal. 4. Methadone hydrochloride (Methadone) is used to prevent withdrawal symptoms associated with opioid use.
A nurse anticipates that most clients with phobias will use the defense mechanisms of: 1. Dissociation and denial 2. Introjection and sublimation 3. Projection and displacement 4. Substitution and reaction formation
3. Projection and displacement Clients with phobias cope with anxiety by placing it on specific persons, objects, or situations through the process of displacement and/or projection. 1. The person with a phobia recognizes and admits the exaggerated fear as a real part of the self. 2. Neither introjection, whereby a person internalizes and incorporates the traits of another, nor sublimation, whereby socially acceptable behavior is substituted for unacceptable instincts, is related to phobic activity. 4. A less-valued object is not substituted for one more highly valued (substitution) nor are the expressed feelings opposite to the experienced feelings of fear (reaction formation).
What priority nursing assessments should be made early in the refeeding process for a patient with anorexia nervosa? Select all that apply: A.Vital Signs B. Skin Integrity C. Peripheral Edema D. Lung and Heart Sounds E. Level of Consciousness
A, C, D
A patient is 5 feet 4 inches tall and weighs 85 lb, a 20% loss of body weight over the past year. The patient reports amenorrhea for 9 months. Vital signs are temperature (T) 96.6°F; pulse (P) 38 beats/min; blood pressure (BP) 70/42 mm Hg; respirations (R) 20 breaths/min. Skin turgor is poor. Lanugo is present. She says, "I need to lose 10 more pounds." These assessment findings indicate which medical diagnosis? A. Anorexia Nervosa B. Bulimia Nervosa C. Binge Eating Disorder D. Dissociative Identity Disorder
A. Anorexia Nervosa This patient clearly meets criteria for anorexia nervosa, and does not meet criteria for any of the other disorders based on the information in the questions.
An initial step in the nurse-patient relationship for a patient diagnosed with anorexia nervosa should be: A. Formulate the nurse-patient contract B. Exclude the family from the initial phase of treatment C. Recommend a therapeutic group D. Use intense communication
A. Formulate the nurse-patient contract The nurse-patient contract is very important with this eating disorder, and must be established early on in treatment as one of the primary steps.
Which finding indicates that a patient diagnosed with anorexia nervosa has met a major objective goal of psychotherapeutic management? A. The patient weighs 90% of Ideal/Average Body Weight B. The patient's residual volume is less than 30mL after tube feedings C. The patient states "I am no longer afraid of gaining weight" D. The patient reads cookbooks and plans nutritious meals
A. The patient weighs 90% of Ideal/Average Body Weight This is an objective measure, and always a major goal of psychotherapeutic management for this eating disorder.
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 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.
C. acknowledge manipulative behavior when it is called to his or her attention.
What is one way that assessment findings in individuals with bulimia and anorexia differ? A. Persons with bulimia tend to have lower body weights than those with anorexia. B. Fluid and electrolyte imbalance is more common in anorexia than bulimia C. Hormonal imbalance is more common in bulimia than anorexia D. Anorexia tends to begin at an earlier age than bulimia
D. Anorexia tends to begin at an earlier age than bulimia Anorexia tends to show signs at an earlier age than bulimia. The other answers are all incorrect (and opposite)
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand tremors, lethargy D. Hypertension, changes in level of consciousness, hallucinations
D. Hypertension, changes in level of consciousness, hallucinations Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions. Focus on the subject findings associated with withdrawal delirium. Review each option carefully to ensure that all the symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to the correct option.
