Mental Health Final

The nurse wants to assess a family's rational patterns by creating their genogram. Which statement best describes the purpose of such an analysis? A. "A genogram will help me see your family structure, history, and current functioning." B. "A genogram is a tool used for deciding on the best type of therapy for your family." C. "A genogram will assess risk for mental illness in future generations." D. "A genogram will help us determine the cause of Jeremy's schizophrenia."

A. "A genogram will help me see your family structure, history, and current functioning." By creating a genogram, nurses and therapists are able to map the family structure and record family information that reflects both history and current functioning. The other options do not describe the function of a genogram.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A client tells the nurse, "I just don't sleep more than 5 hours at night." The nurse assesses the client best for individual sleep requirements by asking which question? A. "Do you usually feel rested and alert when you get up?" B. "Are you taking any medication that could affect your sleep?" C. "When did this pattern of sleep start for you?" D. "Are you aware that some people require less sleep than others?"

A. "Do you usually feel rested and alert when you get up?" The most accurate way to determine an individual's sleep requirements is to ask if the person feels fully awake and functions effectively on the sleep he or she is getting. None of the other options address the issue from the client's perspective.

A client reports symptomatology that supports the diagnosis of sleep paralysis. The nurse effectively assesses the client by asking which question? A. "Have you ever fallen asleep while driving?" B. "Is it difficult for you to fall asleep?" C. "Do you ever have nightmares?" D. "Do you have a history of obsessive-compulsive behavior?"

A. "Have you ever fallen asleep while driving?" Clients with sleep paralysis can often also exhibit symptoms of narcolepsy such as extreme sleepiness resulting in falling asleep at inappropriate times. None of the other questions are directed toward this disorder.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) is reprimanded for taking the nurse's pen without asking first. He responds by shouting, "You don't like me! You won't let me have anything, even a pen!" The nurse is most therapeutic when responding with which statement? A. "I do like you, but I don't like it when you grab my pen." B. "You must ask for permission before taking someone else's things." C. "Liking you has nothing to do with whether I will loan you my pen." D. "It sounds as though you are feeling helpless and insecure."

A. "I do like you, but I don't like it when you grab my pen." This reply shows positive regard for the child while describing the behavior as undesirable. Feedback such as this helps the child feel accepted while making her aware of the effect her behavior has on others. None of the other options provide the necessary degree of positive regard.

Which statement made by a client would support the diagnosis of Illness anxiety disorder? A. "I know I have cancer, but the doctors just cannot find it." B. "I feel as though I'm outside my body watching what is happening." C. "I woke up one morning, and my left leg was paralyzed from the knee down." D. "I feel confused and disoriented."

A. "I know I have cancer, but the doctors just cannot find it." Previously known as hypochondriasis, illness anxiety disorder results in the misinterpretation of physical sensations as evidence of a serious illness. People experience extreme worry and fear about the possibility of having a disease. None of the other statements accurately support this illogical fear of illness.

Which statements identify a client's progress through the stages of grief? (Select all that apply.) Select all that apply. A. "If they find him, I'll never doubt miracles again." B. "He didn't die; I'm sure he will be found and be just fine." C. "I'll never understand why he risked his life by hitchhiking at night." D. "Knowing he's gone makes me so sad." E. "I will never accept he's gone; I will never give up looking for him."

A. "If they find him, I'll never doubt miracles again." B. "He didn't die; I'm sure he will be found and be just fine." C. "I'll never understand why he risked his life by hitchhiking at night." D. "Knowing he's gone makes me so sad." The five stages of grief identified by Kübler-Ross include denial, anger, bargaining, depression, and acceptance. The statement concerning never giving up demonstrates the inability to accept the individual's death.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity

A 24-year-old client diagnosed with borderline personality disorder (BPD) is admitted to the inclient psychiatric unit following a suicide attempt. Which client statements illustrate a primary coping style of persons with BPD? A. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." B. "I promise I am not feeling suicidal. I won't hurt myself." C. "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" D. "I will never again speak to any of my messed up family members. I know that this will help me to be more functional."

A. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." Rationale: A primary coping style used by clients with BPD is called splitting. Splitting is the inability to incorporate positive and negative aspects of oneself or others into a whole image. The individual may tend to idealize another person (friend, lover, health care professional) at the start of a new relationship and hope that this person will meet all of his or her needs. At the first disappointment or frustration, however, the individual quickly shifts to devaluation, despising the other person. The other options do not describe splitting, which is a primary coping style of clients with BPD. DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? A. "It makes sense that rape is a crime of violence, not a crime of sex." B. "I always thought rapes happened at night, but now I know that isn't true." C. "Who would have guessed that most rape victims know the rapist?" D. "So if you dress conservatively, your risk of being raped is small."

A. "So if you dress conservatively, your risk of being raped is small." Rapes have little to do with whether the victim dresses seductively because rape is a crime of violence rather than a crime of sex. The other options represent accurate information regarding the act of rape.

A sexual assault survivor tells the nurse, "I should have tried to fight him off! But I was so terrified that I could not move. I should have tried harder." Which response should the nurse make to reassure the client? A. "The way you behaved was the right thing to do at the time." B. "Try not to think about it. Put it out of your mind." C. "We each behave in characteristic ways in a crisis. That was your way." D. "Do you think others will think badly of you for not trying to fight?"

A. "The way you behaved was the right thing to do at the time." The victim should always be told that staying alive was the priority and that whatever she did to that end was the right thing to do. None of the other options provide reassurance as effectively as the correct option.

Which family situation should the nurse assess as warranting a referral for family therapy? A. A couple is having difficulty dealing with the erratic behavior of their bipolar son. They say, "We're at the end of our rope." B. A couple is having their first child. They say, "It's certainly going to be a change for us." C. The parents of a blended family with five children ranging in age from 5 to 15 years say, "It's never quiet, but the disagreements eventually get worked out." D. A husband and wife are sending a son off to college and planning their daughter's wedding. They say, "Soon we will be back to having an empty nest again."

A. A couple is having difficulty dealing with the erratic behavior of their bipolar son. They say, "We're at the end of our rope." The family in option C is the only family system clearly expressing an unmanageable degree of stress. The other systems may be undergoing stress but have not expressed distress.

A 23 years old is admitted with reports of abdominal pain, dizziness, and headache. When told that all the results of a physical workup have been negative, the client shares, "Now I am having back pain." Which notation in the client's medical record may alert the nurse to the possibility of malingering? A. A court date this week for drunk driving B. Was adopted at the age of 5 years C. A history of oppositional-defiant disorder D. A history of physical abuse by his stepfather

A. A court date this week for drunk driving Malingering is a process of fabricating an illness or exaggerating symptoms to gain a desired benefit or avoid something undesired, such as to obtain prescription medications, evade military service, or evade legal action. It is more common in men, those who have been neglected or abused in childhood, and those who have had frequent childhood hospitalizations. Adoption is not known to be a causative factor in malingering. A history of oppositional-defiant disorder is not known to a causative factor in malingering.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: DiagnosisMSC: NCLEX: Psychosocial Integrity

A client newly diagnosed with hypersomnolence asks about what medication will be prescribed to manage this disorder. The nurse will base his/her response based on what knowledge? A. A stimulant will most likely be prescribed. B. The client will be started on an anticholinesterase inhibitor. C. There is no effective medication treatment for hypersomnolence disorder. D. Medication therapy with benzodiazepines may be initiated.

A. A stimulant will most likely be prescribed. Pharmacotherapy with long-acting amphetamine-based stimulants such as methylphenidate and non-amphetamine-based stimulants such as modafinil are helpful in hypersomnolence disorder. The other options are incorrect because there is effective medication treatment; benzodiazepines are sedating and addictive; and anticholinesterase inhibitors are used for the treatment of dementia.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

Which situation is the best example of a double bind? A. A wife sighs while telling her husband, "You can go out with the boys tonight if it's what you really want to do." B. A man says, "I was surprised and delighted when my entry was chosen for an award." C. A mother tells her son, "Under no circumstances will I give you permission to stay out after midnight." D. A roommate states, "I would prefer to have you call if you think you are going to be late for dinner."

A. A wife sighs while telling her husband, "You can go out with the boys tonight if it's what you really want to do." A double bind is created when the verbal and nonverbal messages are incongruent, leaving the listener confused or trapped ("damned if he does and damned if he doesn't"). None of the other options present such a confused message.

Which issue should the nurse discuss when planning end-of-life care for a terminal ill client? (Select all that apply.) Select all that apply. A. Advance directive planning B. Curative therapies C. Cost of needed services D. Hospice admission E. Symptom management

A. Advance directive planning D. Hospice admission E. Symptom management Patients often turn to their nurse for assistance in understanding how to make end-of-life decisions. Appropriate topics include advance directive planning, hospice admission, and symptom management including pain medication. The discussion of financial issues should be referred to social services or a personal finance advisor. Curative therapies are not considered when the client has been identified as having a terminal diagnosis.

An older adult client tells the nurse that he prefers not to attend senior citizens meetings because "they are all old fuddy duddies who talk subjects to death but never take action." The nurse can hypothesize that the client is demonstrating which type of reaction? A. Ageism B. Projection of personal weaknesses C. Paranoid thinking D. Poor social skills

A. Ageism Ageism, a form of discrimination, is often exhibited by the elderly themselves. Proximity raises feelings of vulnerability. None of the other options appropriately identifies this reaction.

A 78-year-old patient diagnosed with Alzheimer's disease picks up a glass from the bedside table but does not recognize the purpose of the object. This inability is associated with which characteristic of the disorder? A. Agnosia B. Aphasia C. Apraxia D. Agraphia

A. Agnosia Agnosia is the loss of sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.DIF: Cognitive Level: Remember (Knowledge)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A 68-year-old recently retired client is referred to the mental health clinic for symptoms of depression, social isolation, and irritability. The client's son states, "My dad never used to be like this. My mom's been gone for 10 years and he has been doing fine." When the nurse asks the client directly about alcohol intake, he becomes defensive and refuses to discuss the issue. The nurse's response should be guided by what knowledge? (Select all that apply.): Select all that apply. A. Alcohol abuse often goes undetected in older adults. B. Depression plays a role in increased drinking. C. The client is exhibiting dysfunctional grieving. D. Older men are more likely to abuse substances other than alcohol. E. Being single is a risk factor for alcohol abuse. F. The client is most likely reacting to his retirement.

A. Alcohol abuse often goes undetected in older adults. B. Depression plays a role in increased drinking. E. Being single is a risk factor for alcohol abuse. The risk factors for heavy drinking in older adults are being male and single, having less than a high school education, low income, and smoking. Additionally, depression often plays a role in increased alcohol consumption in the elderly. Identifying alcohol and substance abuse is often difficult because the accompanying personality and behavioral changes associated with alcohol abuse frequently go unrecognized in older adults. Alcohol abuse is more common than is abuse of other substances. The client's wife died 10 years ago, and there is nothing in the scenario to indicate dysfunctional grieving. Although depression may be a factor, the reasons for depression are not the priority assessment at this time.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment

Who is the act of rape is best described? A. An act of violence using sex as the weapon B. An act prompted by early childhood neglect C. Assault by a stranger on an unsuspecting victim D. Sexual desire satisfied inappropriately

A. An act of violence using sex as the weapon Rape is a violent crime. Sex is only the medium for perpetrating the crime. None of the remaining options accurately and thoroughly describe the act of rape.

Which form of grief involves concerns for the future? A. Anticipatory B. Dysfunctional C. Disenfranchised D. Maladaptive

A. Anticipatory Anticipatory grief or anticipatory mourning is when a future loss is being mourned in advance. None of the other options are associated with premature mourning for a loss that is likely to occur in the future.

Which psychosocial disorder is more often initially seen in late life? (Select all that apply.) Select all that apply. A. Anxiety B. Bipolar disorder C. Dissociative disorder D. Schizophrenia E. Depression

A. Anxiety E. Depression Depression, risk for suicide, alcohol abuse, and anxiety are all disorders seen in mental illnesses in late life. Although it may be possible to experience these other disorders in older age, they are not usually first diagnosed in this age group; clients diagnosed with these disorders earlier in life may in fact have some symptom remission as they age.DIF: Cognitive Level: Understanding (Comprehension)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A client with paraphilia tendencies tells the nurse that "I'm disgusted with my lifestyle." What is the nurse's initial intervention? A. Assessing the client for the existence of suicidal ideations. B. Telling the client that the first step to managing this behavior is recognizing it as unhealthy. C. Recommending inpatient behavioral modification therapy. D. Assuring the client that this condition responds well to treatment.

A. Assessing the client for the existence of suicidal ideations. Such clients may be severely depressed and have suicidal ideations that must be recognized immediately. The priority intervention is to address client safety.

The nurse is preparing to set goals for a 10-year-old diagnosed with an impulse control disorder. To best ensure the expected therapeutic outcomes, the nurse includes goals that focus on what client need? A. Client centered and includes the client's input B. Family centered and long term in nature C. Age appropriate and achievable in a short period of time D. Simple and easily defined

A. Client centered and includes the client's input Whenever possible, outcomes should be client centered and agreed upon by both the nurse and the client or the client's designee. While the other options may be appropriate, they are not the priority.

Which statement is true of pharmacological therapies associated with the treatment of personality disorders? A. Clients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. B. Clients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these clients. C. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. D. Clients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors.

A. Clients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. Rationale: At this time in the United States, there are no specifically FDA-approved medications for treating personality disorders. Prescribers are using the medications "off-label" until evidence-based pharmacotherapies are proven to be safe and effective. There is evidence that mood stabilizers, antidepressants, and atypical antipsychotics are helpful in specific personality disorders. Pharmacologic evidence is lacking for the treatment of persons with narcissistic and obsessive-compulsive personality disorders. Although clients with personality disorders usually do not like taking medicine unless it calms them down and are fearful about taking something over which they have no control, providers do attempt to mediate symptoms with psychotropic agents for improved quality of life. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

It is most important for the nurse to employ which holistic strategy when managing clients diagnosed with a somatization disorder? A. Considering all dimensions of the patient, including biological, psychological, and sociocultural B. Incorporating spirituality and religion into treatment C. Involving every member of the family as well as the patient in treatment D. Utilizing many different therapeutic strategies or modalities for enhanced coping

A. Considering all dimensions of the patient, including biological, psychological, and sociocultural It is important to use a holistic approach in nursing care so that we may address the multidimensional interplay of biological, psychological, and sociocultural needs and its effects on the somatization process. All nurses need to be aware of the influence of environment, stress, individual lifestyle, and coping skills of each patient. The other options do not explain the concept of holistic care management to its fullest.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Which mental health disorder is an example of a somatoform disorder? A. Conversion disorder B. Depersonalization C. Dissociative identity disorder D. Dissociative fugue

A. Conversion disorder Somatic disorders include conversion disorders that are functional neurological disorders. None of the other options are associated with this classification of mental health disorders.

What therapeutic intervention should be prescribed for a client diagnosed with a somatoform disorder? A. Conveying an interest in the client rather than in the symptoms B. Encouraging the client to use benzodiazepines liberally C. Encouraging the client to rely on the nurse to meet the client's needs D. Steering conversation away from the client's feelings

A. Conveying an interest in the client rather than in the symptoms When the nurse focuses on the client rather than on the symptoms, the client's self-worth and coping skills are enhanced. The discussion related to client feelings is a major focus of therapy. Neither of the remaining options serves to help the client identify the causes of the illness and so would not serve as effective interventions.

The family members of a client with early-stage Alzheimer's disease cannot provide adequate supervision for the client. What would be a reasonable alternative for the nurse to explore with them to meet their current needs? A. Day care B. Acute care hospitalization C. Long-term institutionalization D. Group home residency

A. Day care Day care is a good option for clients with early-stage Alzheimer's disease. It provides supervision, a protected environment, and supportive interactions. The other options may be considered as the client moves into the advance stages of the disease disorder.

Which comorbid conditions are commonly associated with oppositional defiant disorder? (Select all that apply.) Select all that apply. A. Depression B. Conversion disorder C. Substance abuse D. Attention deficit hyperactivity disorder (ADHD) E. Anxiety

A. Depression D. Attention deficit hyperactivity disorder (ADHD) E. Anxiety Oppositional defiant disorder is related to a variety of other problems, including attention deficit hyperactivity disorder, anxiety, and depression. Neither of the remaining options are closely associated with this diagnosis.

A client diagnosed with bulimia nervosa uses enemas and laxatives to purge to maintain weight. What is the likely physiological outcome of this practice? A. Disruption of the fluid and electrolyte balance B. Elevated serum potassium level C. Elevated serum sodium level D. Increase in the red blood cell count

A. Disruption of the fluid and electrolyte balance Disruption of the fluid and electrolyte balance is usually the result of excessive use of enemas and laxatives. There would be a decrease in potassium and sodium levels while the concentration of, but not actual red cell count would be affected.

Which document allows an individual to appoint another person to make health care-related decisions for them if they become unable to do so for themself? A. Durable power of attorney for health care B. Advance directive C. Living will D. Do not resuscitate request

A. Durable power of attorney for health care A medical or healthcare power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care if you are unable to do so. An advance directive may include a living will, that may include the request not to resuscitate, and/or a power of attorney for health care.

What term best describes a family dynamic where boundaries are not clear and whose members are overinvolved with each other? A. Enmeshment B. Scapegoating C. Clear boundaries D. Rigid boundaries

A. Enmeshment When boundaries are diffuse, individuals tend to become "enmeshed." As a consequence, it is not clear who is in charge, who is responsible for decisions, and who has permission to act or take charge; family members are often overinvolved with each other. Clear boundaries are adaptive and healthy. They are well understood by all members of the family and give family members a sense of "I-ness" and also "we-ness." Scapegoating refers to a situation in which one member of the family is seen as the cause of all the problems. Rigid boundaries are characterized by the consistent adherence to rules and roles—some apparent and some less so—no matter what.

When working with a client demonstrating impulse control disorders, which nursing interventions have initial priority? (Select all that apply.) Select all that apply. A. Establishing a therapeutic nurse-client relationship B. Setting and enforcing limits C. Confronting the client concerning the disruptive behavior D. Presenting appropriate expectations E. Providing a safe environment

A. Establishing a therapeutic nurse-client relationship B. Setting and enforcing limits D. Presenting appropriate expectations E. Providing a safe environment The most important interventions with this population are to promote a climate of safety for the patient and for others, establish rapport with the patient, and set limits and expectations. Confronting behaviors is not an initial priority.

A client diagnosed with conduct disorder craves what experience? A. Excitement without concern for possible negative outcomes B. Control of situations and constantly strategizes for such power C. Friendship but from those older than themselves D. Material possessions but lacks focus and direction

A. Excitement without concern for possible negative outcomes People with conduct disorder crave excitement and do not worry as much about consequences as other people do. None of the other options demonstrates a need associated with conduct disorder.

A terminally ill, elderly client wants to ensure that his wishes about end-of-life care are followed and discusses them thoroughly with his daughter. Which action will best guarantee the client's wishes will be achieved? A. Execute the signing of advance directives B. Issue a directive to his physician C. Share his wishes with the nurse D. Write a living will

A. Execute the signing of advance directives With advance directives, an individual states how they want medical decision to be made if they lose the ability to make them for themself. No waiting period is required for the document to take effect. None of the other options would place the end of life care in the control of family as the correct option.

The primary difference between a factitious disorder and other somatic disorders is described in which statement? A. Factitious disorders have a symptomatology that is actually controlled by the client. B. Factitious disorders are always self-directed. C. Factitious disorders have their origins in depression and anxiety. D. Factitious disorders respond well to confrontation as a primary therapeutic technique.

A. Factitious disorders have a symptomatology that is actually controlled by the client. Factitious disorders, in contrast to other somatic disorders, are under conscious control. None of the other statements accurately describe these disorders.

A client diagnosed with delirium strikes out at a staff member. The nurse can most correctly hypothesize that this behavior is related to which characteristic symptom of delirium? A. Fear B. Anger C. Unmet social interaction D. Unmet physical need

A. Fear Clients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious clients who are fearful may strike out at others, seemingly without provocation. Anger may develop but it is triggered by fear. Neither of the remaining options are generally associated with the behavior described.

A 12-year-old male patient diagnosed with Tourette's disorder is visiting his healthcare provider. The nurse will prepare medication teaching on which class of medication to help manage the tics associated with this disorder? (Select all that apply.) Select all that apply. A. First-generation antipsychotics B. Alpha 2-adrenergic agonists C. Second-generation antipsychotics D. Anticholinesterase inhibitors E. Mood stabilizers

A. First-generation antipsychotics B. Alpha 2-adrenergic agonists C. Second-generation antipsychotics Drugs with Food and Drug Administration (FDA) approval for treating tics are the first-generation antipsychotics haloperidol and pimozide, and the second-generation antipsychotic aripiprazole.Clonidine hydrochloride, an alpha 2-adrenergic agonist, used to treat hypertension, is also prescribed for tics. While less effective and far slower acting than the antipsychotics, it has fewer side effects. The antianxiety drug clonazepam (Klonopin) is used as a supplement to other medications. It may work by reducing anxiety and resultant tics. The other options are not used or approved for the treatment of Tourette's disorder.DIF: Cognitive Level: Applying (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

When providing possible interventions to promote the safety of a client reporting symptoms of somnambulism, the nurse should include which intervention? A. Gating the stairways B. Avoiding the use of serotonergic medications C. Regular bedtime dose of a benzodiazepine D. Sleeping on a mattress placed on the floor

A. Gating the stairways Somnambulism or sleep walking can result in falls; gating the stairways may minimize that risk. None of the other options are associated with the dangers presented by sleepwalking.

During a family therapy session a wife states, "My husband is always angry. The children and I are always on edge. We can never relax." The nurse identifies the wife's communication technique using which term? A. Generalizing B. Placating C. Manipulating D. Distracting

A. Generalizing Generalization involves making global statements using "always" and "never" when dealing with problematic family issues. Generalization allows the speaker to avoid dealing with specific examples. None of the other options describes the provided conversation.

A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit which behaviors? A. Inflexible and maladaptive responses to stress B. Abnormal ego functioning C. Frequent episodes of psychosis D. Constant involvement with the needs of significant others

A. Inflexible and maladaptive responses to stress Personality patterns persist unmodified over long periods of time. Inflexible and maladaptive responses to stress are characteristic of individuals with a personality disorder. The other options present behaviors not necessarily associated with this disorder.

Which of the following statements are true regarding childhood-onset conduct disorder? (Select all that apply.) Select all that apply. A. It is characterized by disregard for the rights of others. B. It is more commonly diagnosed in males. C. It is usually outgrown by early adulthood. D. It is characterized by feelings of remorse and regret. E. Those with conduct disorder rationalize their aggressive behaviors. F. It is usually diagnosed in late teen years.

A. It is characterized by disregard for the rights of others. B. It is more commonly diagnosed in males. E. Those with conduct disorder rationalize their aggressive behaviors. Childhood-onset conduct disorder is more common in male clients and is seen before the age of 10 years. Hallmarks include disregard for the rights of others, physical aggression, poor peer relationships, and lack of feelings of guilt or remorse. The other options are the opposite of what is correct.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? A. It will be prescribed at a higher than typical dose. B. Long-term management of symptoms is best achieved with tricyclic antidepressants. C. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. D. It will reduce the need for cognitive therapy.

A. It will be prescribed at a higher than typical dose. Research has shown that antidepressant medication together with cognitive-behavioral therapy brings about improvement in bulimic symptoms. Fluoxetine (Prozac), an Selective serotonin reuptake inhibitors (SSRI) antidepressant, has FDA approval for acute and maintenance treatment of bulimia nervosa in adult patients. When fluoxetine is used for bulimia, it is typically at a higher dose than is used for depression. Although no other drugs have FDA approval for this disorder, tricyclic antidepressants helped reduce binge eating and vomiting over short terms.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

A woman suddenly finds she cannot see but seems unconcerned about her symptom and tells her husband, "Don't worry, dear. Things will all work out." Her attitude is an example of what process? A. La belle indifference B. Depersonalization C. Dissociative amnesia D. Regression

A. La belle indifference La belle indifference is an attitude of unconcern about a symptom that is unconsciously used to lower anxiety. Such indifference is not observed in any of the other options.

Research has indicated that the antisocial personality may be characterized by what behavior? A. Lack of remorse B. Learning difficulties C. Social isolation D. Difficulty with reality testing

A. Lack of remorse Individuals with an antisocial personality exhibit a lack of remorse when confronted with the results of their thoughtless, irresponsible behavior toward others. This disorder is not associated with any other behaviors suggested by the remaining options.

A client reports insomnia and shares that a friend has recommended a nonprescription hormone product that can be purchased at the local health food store. The nurse suspects that the medication contains which component? A. Melatonin B. A tranquilizer C. Lithium D. A benzodiazepine

A. Melatonin The use of melatonin appears to be helpful in treating sleep problems in the elderly. However, this practice is not without risk. Melatonin products are not approved by the U.S. Food and Drug Administration; therefore, variation may exist in the purity, safety, and effectiveness of the products. None of the other options can be purchased over the counter.

An 8-year-old patient is newly diagnosed with attention deficit hyperactivity disorder (ADHD). It is important that the parents be educated to the fact that symptoms will take which form? (Select all that apply). Select all that apply. A. Mood swings B. Poor school performance C. Impulsive behaviors D. Easily intimidated E. Low frustration tolerance

A. Mood swings B. Poor school performance C. Impulsive behaviors E. Low frustration tolerance Individuals with ADHD show an inappropriate degree of inattention, impulsiveness, and hyperactivity. Attention problems and hyperactivity contribute to low frustration tolerance, temper outbursts, labile moods, poor school performance, peer rejection, and low self-esteem. ADHD is not generally characterized by meekness or by being easily intimidated.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Which statement reflects a truth about rape? A. Most rapes are planned. B. Rapists are oversexed. C. Some women want to be raped. D. Most women are raped by strangers.

A. Most rapes are planned. Many myths about rape exist. Most rapes are not impulsive, spur-of-the-moment acts, but are carefully planned and orchestrated. All the remaining options are common myths about the act of rape.

An elderly client is cognitively impaired and terminally ill with breast cancer. When asked if she is in pain, she usually denies it by shaking her head, but the nurses note that she lies rigidly in bed and grimaces when she turns from side to side. In an attempt to obtain a more accurate assessment, the nurses might choose to use which assessment tool? A. Pain Assessment in Advanced Dementia (PAINAD) scale. B. Present Pain Intensity Rating Scale. C. Wong-Baker FACES Scale. D. McGill Pain Questionnaire (MPQ).

A. Pain Assessment in Advanced Dementia (PAINAD) scale. The PAINAD scale is used to evaluate the presence and severity of pain in patients with advanced dementia who no longer have the ability to communicate verbally. The scale evaluates five domains: breathing, negative vocalizations, body language, and consolability. The score guides the caregiver in the appropriate pain intervention. None of the other options would compensate for this client's cognitive status.

A 28-year-old married client who is seeking treatment after being raped tearfully asks the nurse, "What if I am pregnant?" The nurse's response should be guided by what knowledge? A. Pregnancy prevention is offered in the emergency department B. The risk of pregnancy after rape is high, up to 50%. C. Reproductive functions shut down during a violent attack, and as a result pregnancy does not occur. D. The client may be worried about how her spouse will accept the baby.

A. Pregnancy prevention is offered in the emergency department Pregnancy prevention is offered in the emergency department once pregnancy tests establish that the patient was not already pregnant before the assault. The risk of pregnancy is not high after rape. Reproductive functions do not shut down during a violent attack. The patient may be worried about her spouse's reaction; however at this time most important consideration is to give the patient pertinent education regarding rape and pregnancy.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

When preparing educational materials for the family of a client diagnosed with progressive dementia, the nurse should include information related to which local resources? (Select all that apply.) Select all that apply. A. Professional counseling B. Home health services C. Legal professionals D. Day care centers E. Family support groups

A. Professional counseling B. Home health services D. Day care centers E. Family support groups Most importantly, families need to know where to get help. Help includes professional counseling and education regarding the process and progression of the disease. Families especially need to know about and be referred to community-based groups that can help shoulder this tremendous burden (e.g., day care centers, senior citizen groups, organizations providing home visits and respite care, and family support groups). While legal professionals may be of interest to the family, client and family education does not include such services.

Under the Patient Self-Determination Act of 1990, what is the nurse's responsibility when a client is admitted to a long-term care facility? A. Provide written materials concerning the client's rights to make decisions about medical care and to formulate advance directives and also ask whether the client has an advance directive. B. Offer to act as the client's health care proxy for as long as he or she is a resident at the facility. C. Explain advance directives and the agency expectation that the client will formulate such directives within 24 hours after admission. D. Ask the client to explain the end-of-life choices he or she has made and document these in the nursing progress notes.

A. Provide written materials concerning the client's rights to make decisions about medical care and to formulate advance directives and also ask whether the client has an advance directive. Any agency serving Medicare and Medicaid clients is obligated to provide written materials to all clients concerning their rights under state law to make decisions about medical care, including the right to accept or refuse surgical or medical care and to formulate advance directives. The nurse is required to ask whether the client has executed advance directives and to document it. This act does not address the actions identified in any of the remaining options.

A newly admitted client has a diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be directed toward which classic client need? A. Respect need for social isolation. B. Involve in milieu and group activities. C. Set firm limits on behavior. D. Encourage expression of feelings.

A. Respect need for social isolation. Schizoid personality disorder has the primary feature of emotional detachment. Individuals do not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization.

At the first therapy session the family's father tells the therapist that "We wouldn't have to be here if our younger son wasn't such a brat. He seems so different from our other son. We never had difficulty with him misbehaving." The other sibling offers "He gets upset pretty easily." The nurse should suspect that the younger son is the focus of which family dynamic behavior? A. Scapegoating B. Boundaries resisting C. Differentiation D. Multigenerational transition.

A. Scapegoating A scapegoat is the person others blame for the family's distress. Those blaming the scapegoat are usually trying to keep the focus off their own painful issues and problems. The parents seem to be scapegoating the younger son. The information presented does not support any of the other options.

A 5-year-old who consistently omits the sound for 'r' and 's' when speaking is demonstrating which type of disorder? A. Speech B Specific learning C. Social communication D. Language

A. Speech Speech disorders are marked by problems in making sounds. Children may have trouble making certain sounds, or they may distort, add, or omit sounds. Such patterns are not associated with any of the other options.

A client who lives with an adult child is quite self-sufficient but tells the community health nurse that "it gets lonely being by myself so much of the time with only the television set for company." What suggestion should the nurse make to address the client's need for socialization? A. Spend time at the local senior's center three times a week. B. Attend a maintenance day care program daily. C. Attend an adult day health program daily. D. Have the neighborhood watch visit once daily.

A. Spend time at the local senior's center three times a week. A social day care gives the participants the opportunity for recreation and social interaction. Nursing, medical, or rehabilitative care is usually not provided. The client needs socialization but does not require other facets of care. The other options provide services that this client does not require.

A student nurse in the emergency department is assigned to care for a client convicted of the sexual abuse of a child. The student is repulsed by the client because of the nature of his crime and doesn't know how to care for the client under these circumstances. What action should the student nurse take? A. Talk with a faculty member or an experienced nurse in the emergency department. B. Suggest to the client that he request a different nurse. C. Refuse the assignment because personal feelings will prevent the student from providing good care. D. Perform the activities of care but not engage in conversation with the client.

A. Talk with a faculty member or an experienced nurse in the emergency department. Nurses may experience distress when providing care for someone who engages in what they view as objectionable, or even reprehensible, acts. This is sometimes compounded by knowing someone who was a victim or having been victimized ourselves. Talking with a faculty member, a nurse mentor, or someone at a mental health clinic can be helpful and important and may even result in better personal understanding and coping. Refusing an assignment is not an option. Performing the activities of care but not engaging in conversation does not appropriately or fully care for the patient. Telling the patient how she feels would be unprofessional and inappropriate and is putting the burden of our own feelings onto the patient.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

A client reports to the nurse that falling asleep can often take hours. Which intervention should the nurse implement? A. Teach the client how to do progressive relaxation. B. Advise the client to drink an ounce or two of brandy at bedtime. C. Suggest that the client seek a referral for polysomnography. D. Point out that reducing stress at work would be advisable.

A. Teach the client how to do progressive relaxation. Progressive relaxation relaxes muscle groups sequentially and generates a state of pleasant comfort and ease, a natural prelude to sleep. It is inappropriate to encourage the use of alcohol as a sleep aid since it is known to decrease stage 3 sleep. A referral for a sleep test is premature. While stress reduction is appropriate, concentrating only on work-related stress is not effective.

A 26-year-old client diagnosed with schizophrenia is having difficulty adjusting to the community after hospitalization. His family is dismayed by his poor hygiene and avolition. Which intervention should the nurse suggest? A. The client attending a psychoeducational group B. Encourage the family to ignore all symptoms except delusions. C. Close supervision of the client by the family D. Suggest group home living for the client in order to avoid family burnout.

A. The client attending a psychoeducational group Psychoeducation can help the family learn to accept the illness of a family member, learn to deal effectively with symptoms, and understand medications. None of the other options provide a realistic, effective intervention to manage this client's socialization and self-care issues.

Ageism is best explained as what? A. The discrimination against the elderly on the basis of age B. A prominent personality disorganization after the age of 65 C. A learned helplessness among elderly clients D. The behaviors of elderly persons that serve as barriers to health

A. The discrimination against the elderly on the basis of age Ageism is a destructive phenomenon, based on negative attitudes toward the elderly, that results in age-related discrimination. None of the other options accurately describe this form of discrimination.

Which statement about the adequacy of pain management in the elderly is supported by current research? A. They receive less analgesia than younger adults, which makes pain relief inadequate. B. They respond better to meperidine than to morphine sulfate when opiates are necessary. C. They excrete analgesics more rapidly and therefore need more frequent doses. D. They need smaller doses of pain medication to achieve adequate pain relief.

A. They receive less analgesia than younger adults, which makes pain relief inadequate. It is true that the older adult receives pain medication less frequently than younger adults resulting in ineffective pain management. None of the other statements are accurate.

A client explains that he is heterosexual but prefers to dress in feminine clothing. This characteristic behavior is suggestive of which sexual disorder? A. Transvestism B. Voyeurism C. Fetishism D. Exhibitionism

A. Transvestism Transvestism is a paraphilia that involves dressing in the clothing of the opposite sex. This behavior is not characteristic of any of the other options.

The client disagrees that her husband should seek a promotion since it will require the family to move. After she discusses the situation with their 12-year-old, the child tells her father she does not want to move. The client has engaged in which form of dysfunction family dynamics? A. Triangulation B. Diffuse boundaries C. Enmeshment D. A double bind

A. Triangulation Triangulation occurs when a two-person relationship is under stress and one person draws in a third person to stabilize the system by forming a coalition.

Which of the following are myths surrounding rape? (Select all that apply.) Select all that apply. A. Unless the assailant is armed, most women should be able to get away and avoid the rape. B. Most rapes occur away from home areas such as alleys and behind buildings. C. Rape is an expression of aggression and anger. D. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. E. Documented rape cases include women from 8 to 70 years old. F. Women are usually raped by a stranger. G. Women do not "ask" to be raped by their behavior or dress.

A. Unless the assailant is armed, most women should be able to get away and avoid the rape. B. Most rapes occur away from home areas such as alleys and behind buildings. D. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. E. Documented rape cases include women from 8 to 70 years old. F. Women are usually raped by a stranger. It is true that women do not "ask to be raped" by behaving or dressing in a particular manner. The other options are untrue statements.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment

What factors are consistently observed to increase the risk for sleep disturbances? A. alcohol and caffeine B. income and education C. Diet and exercise D. Gender and race

A. alcohol and caffeine There is a strong correlation between alcohol and caffeine use with sleep latency and efficiency problems. None of the other factors are as consistently observed as risk factors.

A child diagnosed with autism will demonstrate impaired development in which area? A. playing with other children B. swallowing and chewing C. Adhering to routines D. eye-hand coordination

A. playing with other children Autism affects the normal development of the brain in social interaction and communication skills. Symptoms associated with autism spectrum disorders include significant deficits in social relatedness, including communication, nonverbal behavior, and age-appropriate interaction. Other behaviors include stereotypical repetitive speech, obsessive focus on specific objects, over adherence to routines or rituals, hyper- or hypo-reactivity to sensory input, and extreme resistance to change. None of the other options are characteristically associated with autism.

What nursing diagnosis is appropriate for a client with Alzheimer's disease, regardless of the stage? A. risk for injury. B. acute confusion. C. impaired environmental interpretation syndrome. D. imbalanced nutrition.

A. risk for injury. Memory loss, agnosia, poor judgment, and the other symptoms of Alzheimer's disease contribute to placing the client at risk for injuries such as burns and falling down stairs. Risk for injury is always present for the client diagnosed with dementia. The remaining options suggest diagnoses that are associated with certain stages and degrees of cognitive impairment.

A client asks the nurse what kind of therapy will help. Based on current knowledge, what form of therapy is most appropriate for a client diagnosed with a conversion disorder? A. "Modeling will be used; as you see desired behaviors modeled by the therapist you will be able to also achieve the expected outcome." B. "Cognitive-behavioral therapy (CBT) has been shown to consistently provide the best outcome for these types of disorders." C. "A combination of antianxiety and antidepressant therapy is the most effective therapy." D. "Aversion therapy is often used because in effect you are punishing yourself by not being able to walk."

B. "Cognitive-behavioral therapy (CBT) has been shown to consistently provide the best outcome for these types of disorders." CBT is the most consistently supported treatment for the full spectrum of somatic disorders. All the other options are incorrect and do not describe the most used and effective therapy for this disorder.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Which question asked by the nurse demonstrates attention to the primary concern of palliative care? A. "Who will be your acting as your primary care provider?" B. "Has your pain medication been effective at keeping you comfortable"? C. "Do you want to receive your palliative care at home or in an institutional setting?" D. "Do you have a spiritual provider you want me to be contacted?"

B. "Has your pain medication been effective at keeping you comfortable"? Excellent symptom management is a hallmark of palliative nursing. Assessing pain management would reflect such a concern. While the other options present appropriate assessment questions, they do not address the primary issue of palliative care.

The nurse appropriately assesses an obese, hypertensive, Type 2 diabetic client when asking which question? A. "Do you regularly have nightmares?" B. "How much sleep do you usually get each night?" C. "Do you snooze when you sleep?" D. "Is getting to sleep a problem for you?"

B. "How much sleep do you usually get each night?" Short sleep duration has been associated with obesity, cardiovascular disease, hypertension, and diabetes. Neither nightmares nor snoring are as directly associated with short sleep duration. The remaining option is a general assessment question.

A client diagnosed with obsessive-compulsive personality disorder takes the nurse aside and mentions, "I've observed you interacting with that new patient. You are not approaching him properly. You should be more forceful with him." What response should the nurse provide to address the client's comment? A. "I see you are trying to control that patient's therapy as well as your own." B. "I will be continuing to follow the established care plan for the patient." C. "Your eye for perfection extends even to my nursing interventions." D. "That patient's care is really of no concern to you or to other clients."

B. "I will be continuing to follow the established care plan for the patient." Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on orderliness and control. These individuals get so preoccupied with details and rules that they may not be able to accomplish the tasks. Guard against engaging in power struggles with a client with obsessive-compulsive disorder.

One criterion for the diagnosis of primary insomnia is met when the client makes which statement? A. "I've had problems falling asleep for 3 weeks now." B. "I've actually missed work because I'm too tired to go." C. "I have these terrible nightmares when I fall asleep." D. "I was diagnosed with depression 2 months ago."

B. "I've actually missed work because I'm too tired to go." A criterion for primary insomnia listed in the DSM-5 is disruption of the normal routine as a result of the sleep disturbance. None of the other options relate to the stated criteria.

The mother of a 3-year-old boy just diagnosed with autism spectrum is tearful and states, "The doctor said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" What response should the nurse provide to the mother's statement? A. "If you have questions, its best to ask the doctor." B. "Starting him on treatment now gives your child a much greater chance for a productive life." C. "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." D. "If your child starts therapy now, he will be able to stop therapy sooner."

B. "Starting him on treatment now gives your child a much greater chance for a productive life." Early intervention for children with autism can greatly enhance their potential for a full, productive life. 3 years old is not too young to start therapy since the sooner therapy is started, the better the outcome. The patient will most likely not be able to stop therapy as interventions will continue indefinitely. Telling the mother to ask her provider abdicates the nurse's responsibility to provide education to patients and families.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: Outcome IdentificationMSC: NCLEX: Psychosocial Integrity

Which assessment question best demonstrates the nurse's understanding of a dying client's needs? A. "Do you have any concerns about paying for your end-of-life care?" B. "What are your hopes for your final days?" C. "Have you completed a Living Will?" D. "Are you aware of the pain control options available?"

B. "What are your hopes for your final days?" Care of the dying is a nursing responsibility. The focus of this care needs to shift toward the question, "What do you hope for at the end of your life?" rather than managing the cost of medical care. Pain management and advance directives are only individual aspects of end of life care.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

The family of a child diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type, is told the evaluation of their child's care will focus on symptom patterns and severity. What is the focus of child's evaluation? (Select all that apply.) Select all that apply. A. Physical growth B. Activities of daily living C. Personal perception D. Academic performance E. Social relationships

B. Activities of daily living C. Personal perception D. Academic performance E. Social relationships For the family and child with ADHD, evaluation will focus on the symptom patterns and severity. For those with ADHD, inattentive type, the focus of evaluation will be academic performance, activities of daily living, social relationships, and personal perception. For those with ADHD, hyperactive-impulsive type or combined type, the focus will be on both academic and behavioral responses.

A 16-year-old patient being treated for anorexia, has been prescribed medication to reduce compulsive behaviors regarding food now that ideal weight has been reached. Which class of medication is prescribed for this specific issue associated with eating disorders? A. Mood stabilizers B. Antidepressants C. Atypical antipsychotics D. Anxiolytics

B. Antidepressants The antidepressant fluoxetine has proven useful in reducing obsessive-compulsive behavior after the patient has reached a maintenance weight. Anxiolytics would be prescribed for anxiety. Atypical antipsychotic agents may be helpful in improving mood and decreasing obsessional behaviors and resistance to weight gain. Mood stabilizers are not specifically used in treatment of eating disorders.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

As an adult, a client who has been diagnosed with childhood-onset conduct disorder is at high risk for developing which comorbid disorder? A. Obsessive-compulsive disorder B. Antipersonality disorder C. Kleptomania D. Depression

B. Antipersonality disorder Individuals with childhood-onset conduct disorder are more likely to have problems that persist through adolescence, and without intensive treatment, they develop antisocial personality disorder as adults. Research does not support any of the other options.

A client arrested for an assault in which he savagely beat a classmate states, "The guy deserved everything he got." The behaviors described are most consistent with the clinical picture of which disorder? A. Schizotypal personality disorder B. Antisocial personality disorder C. Narcissistic personality disorder D. Borderline personality disorder

B. Antisocial personality disorder Clients with antisocial personality act out feelings without consideration for the rights of others. They feel no remorse for their antisocial acts. The description provided is not associated with any of the other suggested options.

Which intervention demonstrates the fulfillment of a moral duty a nurse has to a dying patient? A. Assuring the client has the information needed for informed consent B. Assisting the client in determining their preferences and goals for care C. Advocating for the client's right to privacy D. Treating the client respectfully

B. Assisting the client in determining their preferences and goals for care According to the American Nurses Association's Code of Ethics nurses have a moral duty to help patients determine these preferences and goals at the end of life. The remaining options relate to compliance with client rights.

Which social behavior is often a result of a child having been exposed to some form of abuse? A. Speech disorders B. Bullying others C. Eating disorders D. Delayed motor skills

B. Bullying others Children who have experienced abuse are at risk for identifying with their aggressor and may act out, bully others, become abusers, or develop dysfunctional interpersonal relationships in adulthood. None of the remaining options are as directly associated with abuse as bullying.

Which behavior consistently demonstrated by a child is a predictor of future antisocial personality disorder in adults? A. Sadness B. Callousness C. Remorse D. Guilt

B. Callousness Callousness may be a predictor of future antisocial personality disorder in adults. The remaining options would indicate a degree of empathy not observed in a client who is demonstrating antisocial tendencies.

Which statement about somatoform disorders is true? A. No relation exists between these disorders and early childhood loss or trauma. B. Clients lack awareness of the relations among symptoms, anxiety, and conflicts. C. Nurses perceive clients with these disorders as easy to care for. D. An organic basis exists for each group of disorders.

B. Clients lack awareness of the relations among symptoms, anxiety, and conflicts. Somatization disorders are believed to be responses to psychosocial stress, although the patient often shows no insight into the potential stressors. None of the other options accurately describe somatoform disorders.

The mother of a 6-year-old child expresses concern over the child's frequent temper outbursts. He deals with any frustration by bullying and hitting and seldom shows any remorse for his actions. The nurse who gathers this data will note that the child's behaviors are most consistent with which diagnosis? A. Oppositional defiant disorder B. Conduct disorder C. Attention deficit hyperactivity disorder (ADHD) D. Social phobia

B. Conduct disorder The data are most consistent with the aggressive pattern of childhood-onset conduct disorder of the aggressive type.

Which item of data should be routinely gathered during assessment of a client with a somatoform disorder? A. Potential for violence B. Dependence on medication C. Level of confusion D. Personal identity disturbance

B. Dependence on medication Many clients with somatoform disorder have received prescription medication for anxiety or pain relief and may have developed dependence. Assess not only for what the client has taken, but also for amounts and length of time over which the drugs have been prescribed. None of the other options are routinely associated with somatoform disorders.

During a family therapy session the mother says to her daughter, "I would like to know why you took the piece of pie that was left after dinner last night. You knew I wanted it." Later the father tells his daughter, "I know exactly why you did that." The nurse therapist should consider the possibility that the family is demonstrating which boundary issue A. Inflexible B. Diffused C. Disengaged D. Clear

B. Diffused A common phenomenon within families with diffuse boundaries is that individuals expect other members of the family to know what they are thinking. The described conversation is not reflective of any of the other options.

A client has been diagnosed with gender identity disorder. The nurse can expect that the client will evidence which characteristic? A. Self-humiliation during the sexual act B. Discomfort with biological gender C. Inability to maintain sexual arousal D. Intense sexual urges focused on an object

B. Discomfort with biological gender Gender identity disorder involves the lack of a match between biological gender and psychological gender anxiety. The client will state that he is a woman who was mistakenly given a man's body. None of the other options are associated with this disorder.

According to current theory, which statement regarding eating disorders is accurate? A. Eating disorders are rarely comorbid with other mental health disorders. B. Eating disorders are possibly influenced by sociocultural factors. C. Eating disorders are frequently misdiagnosed. D. Eating disorders are psychotic disorders in which patients experience body dysmorphic disorder.

B. Eating disorders are possibly influenced by sociocultural factors. The Western cultural ideal that equates feminine beauty with tall, thin models has received much attention in the media as a cause of eating disorders. Studies have shown that culture influences the development of self-concept and satisfaction with body size. Eating disorders are not psychotic disorders. There is no evidence that eating disorders are frequently misdiagnosed. Comorbidity for patients with eating disorders is more likely than not. Personality disorders, affective disorders, and anxiety frequently occur with eating disorders.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

A 17-year-old client is admitted to the psychiatric unit after threatening his mother during an argument and is diagnosed with conduct disorder. Which of the following would be an appropriate short-term outcome for this client? A. Maintains self-control during hospitalization B. Expresses feelings C. Mother will improve communication skills to interact with Eli. D. Engages in appropriate coping skills to manage stressors

B. Expresses feelings Expressing feelings is an appropriate short-term outcome and would be a good start to working with the client to establish rapport, develop coping skills, and set goals. Engaging in appropriate coping skills and maintaining self-control are desired outcomes. Outcomes for the client are being discussed, not outcomes for the client's mother.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: Outcome IdentificationMSC: NCLEX: Psychosocial Integrity

A primary health provider describes a client as "malingering." The nurse knows this means that the client is demonstrating which behavior? A. Experiencing symptoms that cannot be explained medically. B. Falsely claiming to have symptoms. C. Experiencing symptoms that have a physiological basis. D. Seeking medication to ease pain of psychological origin.

B. Falsely claiming to have symptoms. Malingering is a consciously motivated act to deceive based on the desire for material gain. The symptoms described are nonexisting and so none of the other options are correct statements of behavior.

What is the basic principle that is associated with hospice care? A. Family centered care B. Focus is on care not cure C. Promoting client autonomy D. Treating client suffering

B. Focus is on care not cure Hospice is a multidisciplinary team approach that focuses on patient care, not cures. Palliative care is patient and family-centered care that optimizes quality of life anticipating, preventing, and treating suffering. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs. Palliative caregivers promote patient autonomy, access to information, and choice. Hospice care incorporates many of the principles of palliative care.DIF: Cognitive Level: Comprehension (Understanding)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Which assessment tool is highly effective in uncovering multigenerational issues in a family? A. Focused interview B. Genogram C. Family function checklist D. Family assessment device

B. Genogram A genogram maps family structure and family information for at least three generations. It graphically depicts relational patterns and multigenerational issues. Demographics, sociocultural context, and critical events can be noted. While helpful, none of the remaining options focus on multigenerational issues.

The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when which assessment data is observed? A. Has serum potassium level of 3 mEq/L or greater. B. Has systolic blood pressure less than 90 mm Hg. C. Weighs 10% below ideal body weight. D. Has a heart rate less than 60 beats/min.

B. Has systolic blood pressure less than 90 mm Hg. Systolic blood pressure of less than 90 mm Hg is one of the established criteria signaling the need for hospitalization of a client with anorexia nervosa. It suggests severe cardiovascular compromise. None of the remaining options represent data aligned with the criteria for hospitalization.

When treating impulse control disorders, psychodynamic psychotherapy is directed toward which goal? A. Helping the client replace the rage with acceptable alternative feelings B. Identifying the triggers of the rage C. Mastering relaxation techniques D. Teaching the client self-distracting techniques

B. Identifying the triggers of the rage Psychodynamic psychotherapy focuses on underlying feelings and motivations and explores conscious and unconscious thought processes. In working with impulse control problems, the therapist may help the patient to uncover underlying feelings and reasons behind rage or anger. This may help them to develop better ways to think about and control their behavior. None of the other options are considered goals of this form of therapy.

A client, who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds, eats one tiny meal daily and engages in a rigorous exercise program. Which nursing diagnosis addresses this assessment data? A. Death anxiety B. Imbalanced nutrition: less than body requirements C. Ineffective denial D. Disturbed sensory perception

B. Imbalanced nutrition: less than body requirements A body weight of 80 pounds for a 16-year-old who is 5 foot, 3 inches tall is ample evidence of this diagnosis. There is no support in the data as presented to justify any of the other nursing diagnoses.

Which statement would be an appropriate long-term outcome for a rape client? A. Appropriately blame the rapist rather than blaming herself for the situation. B. Integrate of the rape event and resumption of an optimal level of functioning. C. Repress feelings of shame, embarrassment, and self-blame. D. Identify and develop coping skills necessary to reduce level of anxiety.

B. Integrate of the rape event and resumption of an optimal level of functioning. This is the ideal long-term result of treatment for rape trauma syndrome, that life will go on and the client will return to the usual pre-trauma level of functioning. Repressing is not a healthy coping mechanism. While not inappropriate, the remaining options are not long-term goals for such a client.

Anticipatory teaching of a rape victim should include information that a common survivor problem? A. Headaches and fatigue B. Intrusive thoughts C. Denial of the event D. Shock and numbness

B. Intrusive thoughts Just as in posttraumatic stress disorder, intrusive thoughts haunt the rape victim in the weeks and months during which long-term reorganization is occurring. Knowing that this is a common occurrence is reassuring to the client, who often is frightened by the symptom. While the other symptoms can occur, they are not commonly associated with rape recovery.

A usually quiet resident in a long-term care facility has become confused and has shouted out a number of times during the night. What is the nurse's initial action? A. Obtain an order for an as-needed dose of a sedative for the client. B. Investigate the reason for the client's behavioral change. C. Encourage the client to be quiet and go back to sleep. D. Place the client in a geriatric chair near the nurse's station.

B. Investigate the reason for the client's behavioral change. New-onset confusion and behavior change should not be treated with sedation, but rather should be investigated for the cause. Finding the cause and addressing it is more appropriate than using chemical restraint. Neither of the other options addresses the cause of the behavior.

A girl is overheard saying to her brother, "If you stick up for me with mom and dad, I will forget I heard you planning to sneak out after they are asleep." This can be assessed as what type of communication? A. Placating B. Manipulative C. Generalizing D. Scapegoating

B. Manipulative One example of manipulation occurs when a family member makes a request with strings attached so that the other person has difficulty refusing. This example is not associated with any of the other options.

A 69-year-old client with a recent history of cancer is undergoing workup for memory loss. The client asks the nurse, "Why am I having all these problems now? I thought life would get easier as I got older." The nurse's response should be guided by what knowledge? A. The client is exhibiting signs of acute depression. B. Older adults experience more medical and psychiatric illnesses. C. The client is an exception; older people usually have less medical and psychosocial issues than when younger. D. Older adults usually have a low risk for suicide.

B. Older adults experience more medical and psychiatric illnesses. Aging is accompanied by increased medical and psychiatric illness. This increase is brought about in part by increasingly stressful life events (e.g., the loss of a spouse, family members, and independence) and comorbid illness. Polypharmacy and drug reactions also play a part. There is nothing to indicate that the client is depressed. The elderly population is at high risk for suicide.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

Disorders that involve sexual behaviors associated with nonhuman objects are identified by which term? A. Sadomasochism B. Paraphilias C. Pedophilias D .Frotteurism

B. Paraphilias The essential features of paraphilias are recurrent and intense sexually arousing fantasies, sexual urges, or behaviors generally involving inanimate objects, the suffering or humiliation of oneself or a partner, or the use of children or other nonconsenting persons. This description does not accurate relate to any of the other options.

Which statement is true regarding antisocial personality disorder (APD)? (Select all that apply.) Select all that apply. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. A. Persons with APD are concerned with personal pleasure and power. B. Persons with APD display magical thinking. C. It is the least studied of the personality disorders. D. It is characterized by rigidity and inflexible standards of self and others. E. It is characterized by deceitfulness, disregard for others, and manipulation. F. Frontal lobe dysfunction is a brain change identified in APD.

B. Persons with APD display magical thinking. E. It is characterized by deceitfulness, disregard for others, and manipulation. F. Frontal lobe dysfunction is a brain change identified in APD. Rationale: APD is the most studied and researched personality disorder. Rigidity and inflexible standards describe obsessive-compulsive personality disorder. Magical thinking describes schizotypal personality disorder (STPD). People with APD usually present with depression because of the consequences of their behaviors, not because they care about the effects of their actions on others. DIF: Cognitive Level: Comprehension (Understanding) TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Personality

Care planning for the rape victim is facilitated if the nurse understands that rape trauma syndrome is actually a variant of which psychiatric disorder? A. A dissociative disorder B. Posttraumatic stress disorder (PTSD) C. A maturational crisis D. Obsessive compulsive disorder (OCD)

B. Posttraumatic stress disorder (PTSD) Most of those who have been raped are eventually able to resume their previous lives after supportive services and crisis counseling. However, many carry with them a constant emotional trauma: flashbacks, nightmares, fear, phobias, and other symptoms associated with posttraumatic stress disorder (PTSD). None of the other options are associated with this type of trauma.

A 31-year-old patient who has been referred to the sexual disorders clinic by a primary care provider. The client describing his problem states, "I can have an orgasm, no problem. It just happens way too soon." This description support what form of sexual dysfunction? A. Erectile disorder B. Premature ejaculation C. Delayed ejaculation D. Male hypoactive sexual desire disorder

B. Premature ejaculation In premature ejaculation, a man persistently or recurrently achieves orgasm and ejaculation before he wishes to. Erectile disorder (also called erectile dysfunction and impotence) refers to failure to obtain and maintain an erection sufficient for sexual activity. In delayed ejaculation, a man achieves ejaculation during coitus only with great difficulty. Male hypoactive sexual desire disorder is characterized by a deficiency or absence of sexual fantasies or desire for sexual activity.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: DiagnosisMSC: NCLEX: Psychosocial Integrity

Which assessment findings are associated with approaching death? (Select all that apply.) Select all that apply. A. Increased blood pressure B. Progressive weakness C. Decreased heart rate D. Increased drowsiness E. Loss of appetite

B. Progressive weakness D. Increased drowsiness E. Loss of appetite The process of dying varies based upon the underlying cause. Some general signs of approaching death include growing weakness, loss of appetite, and increased drowsiness, an increase in heart rate, and a decrease in blood pressure.

During family therapy the family's youngest daughter says, "They care more about my sister because she's older and gets straight As in school." Which nursing diagnosis should be given priority? A. Parental role conflict B. Relational problems C. Deficient knowledge D. Defensive coping

B. Relational problems This discourse concerns relational problems related to a mental disorder, a generic medical condition, or a sibling relational problem. No data suggests the other diagnoses.

Biological theorists suggest that the cause of eating disorders may be related to which factor? A. Body image disturbance B. Serotonin imbalance C. Dopamine excess D. Normal weight phobia

B. Serotonin imbalance The selective serotonin reuptake inhibitors have been shown to improve the rate of weight gain and reduce the occurrence of relapse. None of the remaining options are currently supported by any biological theories.

When attempting to determine the cause of low sexual drive in either a male or female client, the nurse can expect evaluation of the client's serum level of which hormone? A. Estrogen B. Testosterone C. Insulin D. Thyroxin

B. Testosterone Testosterone, present in both males and females, appears to be essential to sexual desire in both men and women. This is not true of any of the other options.

A terminally ill client expresses to the nurse the desire to discuss end-of-life issues. What is likely to be the greatest barrier to that discussion? A. The family's unwillingness to acknowledge the inevitable B. The nurse's reluctance to discuss death-related issues C. The client's lack of knowledge regarding the various issues D. The health provider's hesitancy to prescribe palliative care

B. The nurse's reluctance to discuss death-related issues Despite being trained to nonjudgmentally discuss difficult and sensitive issues with patients and families, nurses are often afraid to talk about death. Talking about death is difficult because of the emotions that are involved. While the other options may be factors, the nurse's attitude and willingness to engage in such a conversation initially have the greatest impact.

The family consists of the husband and his wife, their four children, the wife's 21-year-old sister, and client's elderly aunt. Which members are considered the client's nuclear family? A. The husband and his aunt B. The parents and their four children C. The wife and her sister D. The four children and the wife's sister

B. The parents and their four children The term nuclear family refers to parents and the children under the parents' care.

After stabilization of symptoms, what is the primary focus of treatment for a client diagnosed with anorexia nervosa? A. Improving interpersonal skills B. Weight restoration C. Learning effective coping methods D. Changing family interaction patterns

B. Weight restoration Weight restoration is the priority goal of treatment for the client with anorexia nervosa because health is seriously threatened by the underweight status. The other options are addressed are secondary to the physiological goal of weight restoration.

What class of medications is commonly prescribed for somatic disorders? A. mood stabilizers. B. anxiolytics. C. antidepressants. D. antipsychotics.

B. anxiolytics. Primary care providers prescribe anxiolytic agents for patients who seem highly anxious and concerned about their symptoms. Individuals experiencing many somatic complaints often become dependent on medication to relieve pain or anxiety or to induce sleep.

A 72-year-old patient is hospitalized diagnosed with pneumonia and experiencing delirium. The client points to the IV pole and screams, "Get him out of here! He's going to hurt me!". The nurse would use what term to document the response? A. hallucination. B. illusion. C. confabulation. D. delusion.

B. illusion. Illusions are errors in perception of sensory stimuli. The stimulus is a real object in the environment; however, it is misinterpreted and often becomes the object of the patient's projected fear. Hallucinations are false sensory stimuli. For example, individuals experiencing delirium may become terrified when they "see" giant spiders crawling over the bedclothes or "feel" bugs crawling on or under their bodies. A delusion is described as thinking or believing something that is not true and is seen more often in schizophrenia. For example, a patient may firmly believe that government agencies can read and are monitoring his or her thoughts or that neighbors can see him or her through walls. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

Hormone therapy for the purpose of surgical gender reassignment is initiated when the client has demonstrated what behavior? A. taken all legal steps to change name and legal status. B. successfully lived the cross-gender role in all aspects of life. C. taken on the dress and manners of the preferred gender. D. successfully demonstrated a genuine intent to change genders.

B. successfully lived the cross-gender role in all aspects of life. After living as a member of the desired gender, if the client still wishes to proceed with gender reassignment, hormone therapy can be initiated. All the other options are secondary to the correct option since none have presented the client with the challenges of this life altering change.

Which statement best illustrates support in giving care to a patient who has just been sexually assaulted? A. "Don't worry. It's hard now, but everything will be alright." B. "I'm so sorry for what you have been through." C. "I am going to stay with you. We can talk as long as you want to." D. "Let's talk about new coping skills you can use."

C. "I am going to stay with you. We can talk as long as you want to." The most effective approach for counseling in the emergency department or crisis center is to provide nonjudgmental care and optimal emotional support. Sympathy is not a therapeutic response and does not focus on the patient. Telling the patient not to worry is false reassurance. It is too soon to try to learn new coping skills because the patient is in an acute stress phase.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

It has been 6 months since a woman was raped. Which statement by the client would indicate that counseling has helped her to achieve an important long-term outcome? A. "My husband has been very supportive during this whole thing." B. "I am not pressing charges because I want this whole thing to be over with so I can move on." C. "I am not going to let that rapist be in control of my life. I know things will keep getting better." D. "I'm not having as many nightmares about the rape so I do get a little sleep at night."

C. "I am not going to let that rapist be in control of my life. I know things will keep getting better." The correct option expresses empowerment and hope for the future. Long-term outcome includes the absence of any residual symptoms after the trauma and would be indicated by healing of physical injuries, relief of anger in nondestructive ways, comfort in relationships, and feelings of empowerment and expression of hope. While there has been an improvement, having nightmares and not sleeping well indicates that the patient is still going through acute stress related to the rape. The fact that the husband is supportive is a positive statement regarding her husband but doesn't express her own indicators of recovery. Not pressing charges may indicate that the patient may not be dealing with the event in a healthy way by avoiding the trauma.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity

A client is brought to the hospital by an adult daughter, who visited this morning and found her parent to be confused and disoriented. When the client is admitted, the daughter states, "I'll take these glasses and hearing aid home, so they don't get lost." What is the nurse's best reply? A. "Don't worry. You can leave them at the bedside. We are insured for losses of this sort." B. "Because we do not have a copy of durable power of attorney, we cannot release them to you." C. "I would like to have your parent wear them. It will help there to be less confusion or retain more orientation." D. "That will be fine. I'll have you sign our hospital release form."

C. "I would like to have your parent wear them. It will help there to be less confusion or retain more orientation." Clients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids. None of the other options support this client need.

Which of the following statements by a woman who was sexually assaulted a year ago would indicate that she has recovered from the trauma? A. "I realize that I was partly to blame for the rape because of walking in an unsafe neighborhood." B. "I am sleeping better but still only get about 5 hours of sleep at night because of bad dreams about the rape." C. "My husband and I are having sex again and I enjoy it." D. "I don't walk home alone anymore because I am terrified it may happen again."

C. "My husband and I are having sex again and I enjoy it." Sexual assault survivors are considered to be recovered if they are relatively free of any signs or symptoms of acute stress disorder and posttraumatic stress disorder. Signs of recovery include sleeping well with few instances of nightmares or dreams, being only mildly fearful, having positive self-regard, and returning to prerape sexual functioning and interest. The closer the survivor's lifestyle is to how it was before the rape, the more complete the recovery has been. Not walking home because of being terrified indicates a high level of fear. Only sleeping 5 hours at night indicates sleeping is still seriously disturbed. Stating that she is partly to blame indicates that the patient is placing the blame for the rape on herself instead of the perpetrator.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity

Ever since participating in a village raid where explosives were used, a military veteran has been unable to walk. After all diagnostic testing were negative for any physical abnormalities, the client was diagnosed with conversion disorder. What is the nurse's best response when asked by the client, "Why can't I walk?" A. "Your legs don't work because your brain is screwed up." B. "You are overly anxious about having a severe illness." C. "Your emotional distress is being expressed as a physical symptom." D. "You are making up your symptoms as a cry for help."

C. "Your emotional distress is being expressed as a physical symptom." Conversion disorder is attributed to channeling of emotional conflicts or stressors into physical symptoms. Telling the patient her brain is "screwed up" is unprofessional and does not give any useful education. Symptoms of conversion disorder are not within the patient's voluntary control. Being overly anxious about having a severe illness describes illness anxiety disorder.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

What is the usual time period that medications to treat insomnia are usually prescribed? A. 1 to 2 months B. 3 weeks C. 2 weeks D. 1 to 2 days

C. 2 weeks Nurses frequently provide education about the benefits of a particular sleep medication, the side effects, untoward effects, and the fact that medications are usually prescribed for no longer than 2 weeks because tolerance and withdrawal may result.

Which child is demonstrating behaviors that support a diagnosis of adolescent onset conduct disorder? A. A 9-year-old male who smokes half a pack of cigarettes a day B. A 9-year-old female who engages in sexually provocative behaviors C. A 12-year-old male who steals a bicycle as a gang initiation D. A 12-year-old female who regularly bullies her younger siblings

C. A 12-year-old male who steals a bicycle as a gang initiation In adolescent-onset conduct disorder, no symptoms are present prior to age 10. Affected adolescents tend to act out misconduct with their peer group (e.g., early onset of sexual behavior, substance abuse, risk-taking behaviors). Males are more likely to fight, steal, vandalize, and have school discipline problems, whereas girls tend to lie, be truant, run away, abuse substances, and engage in prostitution.

The nurse caring for a client diagnosed with Alzheimer's disease can anticipate that the family will need information about which medication therapy? A. Immunosuppressants B. Antihypertensives C. Acetylcholinesterase inhibitors D. Benzodiazepines

C. Acetylcholinesterase inhibitors Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.

A client who lives with a daughter's family is often left alone during the day and even some evenings. The client has expressed being lonely and socially isolated. Considering the situation, which support option is most appropriate? A. Partial hospitalization B. Nursing home admission C. Adult day care D. Home health nursing care

C. Adult day care In adult day care settings, older adults are cared for during the day and stay in a home environment at night. These programs are meant to provide a safe, supportive, and nonthreatening environment and fulfill a vital function for older adults and their families. The programs allow older adults to continue their present living arrangements and maintain their social ties to the community; they also relieve families of the burden of 24-hour-a-day care for older adult dependents. Partial hospitalization is recommended for ambulatory clients who do not need 24-hour nursing care but require and would benefit from intensive, structured psychiatric treatment. Nothing indicates that the client needs skilled nursing home care at this time. Home health nurses generally visit clients in their home to see to medical needs and treatment. This option would not fulfill the need for social interaction.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

The nurse admitting an older, Hispanic, adult for a possible urinary tract infection is overheard stating, "I probably won't be able to get accurate information until the client's family comes in and can answer my questions." The nurse is exhibiting which bias? A. Gender bias B. Racism C. Ageism D. Cultural bias

C. Ageism The nurse appears to be demonstrating discrimination against ageism by assuming she is confused or demented because of her age and will not be able to provide accurate information. Ageism has been defined as a bias against older people based on advanced age. Ageism differs from other forms of discrimination in that it cuts across gender, race, religion, and socioeconomic status to reach the majority of persons who are more than 65 years old. Gender is not a factor in this scenario. Neither race nor culture tends to be factors in this behavior.DIF: Cognitive Level: Understanding (Comprehension)TOP: Nursing Process: DiagnosisMSC: NCLEX: Psychosocial Integrity

Question 1 of 8 The primary healthcare provider mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess for which nightly behavior? A. Depression B. Lethargy C. Agitation D. Mania

C. Agitation Sundowning involves increased disorientation and agitation occurring at night. None of the other options are associated with sundowning.

Which of the following classifications of medication may be prescribed in intermittent explosive disorder? A. Psychostimulants B. Antianxiety agents such as benzodiazepines C. Anticonvulsants D. Monoamine oxidase (MAO) inhibitors

C. Anticonvulsants Although considered off-label use, anticonvulsants may reduce outbursts and contribute to mood stabilization. The other options are incorrect for use in intermittent explosive disorder.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

What is the priority nursing intervention for a client diagnosed with borderline personality disorder? A. Respect the client's need for attention. B. Protect other clients from manipulation. C. Assess for suicidal and self-mutilating behaviors. D. Provide clear, consistent limits and boundaries.

C. Assess for suicidal and self-mutilating behaviors. One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress. While the other options may be appropriate, none have the priority of safety.

Assessment for oppositional defiant disorder should include which interventions? A. Assessing the history, frequency, and triggers for violent outbursts B. Assessing issues that result in power struggles and triggers for outbursts C. Assessing moral development, belief system, and spirituality for the ability to understand the impact of hurtful behavior on others, to empathize with others, and to feel remorse D. Assessing sibling birth order to understand the dynamics of family interaction

C. Assessing issues that result in power struggles and triggers for outbursts Oppositional defiant disorder is characterized by defiant behavior, power struggles, outbursts, and arguing with adults, so assessment of these factors would be important. Assessing for violent outbursts refers to assessment for intermittent explosive disorder. Oppositional defiant disorder is not characterized by violent behaviors. Assessing for the ability to understand the impact of hurtful behaviors on others refers to assessment for conduct disorder. Birth order is not known to play a part in oppositional defiant disorder.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A client who has recently received a terminal cancer diagnosis has expressed the desire to, "stay out of the hospital and die at home." Which nursing intervention will best help the client achieve this end-of-life goal? A. Encouraging adherence to the medical treatment plan B. Discussing available pain control measures C. Assistance with advance care planning D. Involving the client and his/her family in treatment decisions

C. Assistance with advance care planning Advance care planning has helped patients and their families achieve end-of-life goals, avoid hospitalization, and increase hospice and palliative care use. While the other options are appropriate interventions, none are as focused on assuring the client's end-of-life goals that are documented supporting their achievement.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

Which client, diagnosed with which personality disorder, will most likely require admission to a psychiatric unit as a result of developing a psychosis? A. Paranoid personality disorder B. Narcissistic personality disorder C. Borderline personality disorder D. Dependent personality disorder

C. Borderline personality disorder Clients with borderline disorder can decompensate into psychotic states under stress. Hospitalization is needed at these times. Psychosis is not generally associated with the other options.

What would be an appropriate expected outcome of the treatment plan for a client diagnosed with a conversion disorder that interferes with the ability to walk effective? A. Client will walk unassisted within 1 week. B. Client will return to a pre-illness level of functioning within 2 weeks. C. Client will be able to state two new effective coping skills within 2 weeks. D. Client will assume full self-care within 3 weeks.

C. Client will be able to state two new effective coping skills within 2 weeks. An appropriate outcome for somatization disorders is to be aware of negative coping strategies and learn new, effective skills for coping within a realistic timeframe. In the other options, the time frames of these outcomes are unrealistic.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: Outcome IdentificationMSC: NCLEX: Psychosocial Integrity

When a child demonstrates a temperament that prompts the mother to say, "She is just so different from me; I just can't seem to connect with her." The nurse should plan to provide which intervention? A. Educate the father regarding signs that the child is being physically abused. B. Encourage the mother to consider attending parenting classes. C. Counsel the mother regarding ways to better bond with her child. D. Suggest that the child's father become her primary caregiver.

C. Counsel the mother regarding ways to better bond with her child. All people have temperaments, and the fit between the child and parent's temperament is critical to the child's development. The caregiver's role in shaping that relationship is of primary importance, and the nurse can intervene to teach parents ways to modify their behaviors to improve the interaction.

A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning is confused and disoriented. The nurse can suspect that the client is displaying symptoms associated with which cognitive disorder? A. Amnesic disorder B. Selective inattention C. Delirium D. Dementia

C. Delirium Delirium is characterized by a disturbance of consciousness, a change in cognition (such as impaired attention span), and a fluctuating level of consciousness that develop over a short period of time. None of the other options share these characteristics.

The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of Alzheimer's disease. What finding would be out of character for the client who truly has early stage Alzheimer's disease? (Select all that apply.) A. Charming behavior designed to hide memory deficit B. Confabulation to compensate for forgotten information C. Easily frustrated by cognitive losses D. Avoidance of questions by subject changing

C. Easily frustrated by cognitive losses Frustration and anger are characteristics of the middle stage of Alzheimer's. During early-stage Alzheimer's disease the client is aware of memory impairment and may attempt to disguise it or cover it by being evasive or using confabulation. The remaining options are associated with the early stage of Alzheimer's disease.

What is the initial task of an outpatient clinic nurse who is working with a client experiencing a sexual disorder? A. Orient the client to the clinic's programs, use as part of therapy B. Assess the client's physical health C. Establish trust with the client D. Explain that the nurse is a therapeutic agent

C. Establish trust with the client The initial task in working with any client is to establish trust. While the other options are appropriate, the basis of facilitating openness and cooperation is an effective, mutually respective relationship between client and nurse.

The client who will most likely respond well to drug therapy for the management of compulsive deviant sexual behavior is one with which diagnosis? A. Antisocial personality disorder B. Fetishism C. Exhibitionism D. Low sexual drive

C. Exhibitionism Libido and compulsive deviant sexual behavior is best managed pharmacologically in individuals with high sexual drive such as exhibitionists. This is not true of the other options.

The emergency department nurse planning care for a rape survivor must realize that the emotional reaction displayed by many rape victims during the initial assessment and treatment is which emotion? A. Disinterest B. Aggression C. Fear D. Eagerness

C. Fear Rape is an act of violence, and sex is the weapon used by the perpetrator. Rape engulfs its victims in fear and anxiety, resulting in withdrawal for some and causing severe panic reactions in others. After being traumatized, the person who has been raped often carries an additional burden of shame, guilt, fear, anger, distrust, and embarrassment. None of the other options are generally associated with this form of trauma.

A depressed client is likely to report a sleep disorder that includes which characteristics? A. Sleepwalking B. Nightmares C. Frequent awakenings during the night D. Difficulty falling asleep

C. Frequent awakenings during the night Depressed clients often report normal sleep onset, followed by repeated awakenings during the second half of the night. While the other options may occur, they are not the most frequent characteristic.

A 38-year-old patient referred for sleep studies reports frequent daytime lethargy, unintended lapses into sleep, and never feeling rested on awakening in the morning. These symptoms support which sleep-related diagnosis? A. REM sleep behavior disorder B. Breathing-related sleep disorder C. Hypersomnolence D. Circadian rhythm disorder

C. Hypersomnolence The patient with hypersomnolence reports recurrent periods of sleep or unintended lapses into sleep, frequent napping, non-refreshing nonrestorative sleep regardless of the amount of time slept, and difficulty with full alertness during the wake period. Circadian rhythm sleep disorders occur when there is a misalignment between the timing of the individual's normal circadian rhythm and external factors that affect the timing or duration of sleep. Patients with REM sleep disorder display elaborate motor activity associated with dream mentation. Breathing-related sleep disorder is characterized by frequent upper airway obstruction.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: DiagnosisMSC: NCLEX: Physiological Integrity

A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to support which electrolyte imbalance? A. Hypercalcemia B. Hypernatremia C. Hypokalemia D. Hypolipidemia

C. Hypokalemia Vomiting causes loss of potassium, leading to hypokalemia. Vomiting is not the trigger for any of the other options presented.

Which nursing diagnosis should be investigated for clients with somatoform disorders? A. Self-care deficit B. Deficient fluid volume C. Ineffective coping D. Delayed growth and development

C. Ineffective coping Soma is the Greek word for "body," and somatization is the expression of psychological stress through physical symptoms. This information supports that clients generally demonstrate ineffecting coping of anxiety, loneliness, and risk of suicide. None of the other options are associated with somatoform disorders.

Which individual planned a role in the revision of nursing's position on Physician Assisted Suicide? A. Karen Anne Quinlan B. Brittany Maynard C. Jack Kevorkian D. Terri Schiavo

C. Jack Kevorkian Kevorkian was a Michigan physician-pathologist who claimed to have assisted at least 130 terminally ill patients to die making him the most well-known name associated with euthanasia and physician assisted suicide (PAS). In the last few years, nursing and medical associations have revised their position statements on PAS.

The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic? A. Purging to keep weight down B. Holding a distorted body image C. Maintaining a normal weight D. Doing more rigorous exercising

C. Maintaining a normal weight Many bulimics are at or near normal weight, whereas clients with anorexia nervosa are underweight. The other characteristics are commonly shared among persons with either disorder.

When providing care for a client diagnosed with borderline personality disorder, the nurse will need to consider strategies for dealing with which of the client's classic characteristics? A. Perfectionism and preoccupation with detail B. Grief, anger, and social isolation C. Mood shifts, impulsivity, and splitting D. Altered sensory perceptions and suspicion

C. Mood shifts, impulsivity, and splitting Borderline personality disorder has the central characteristic of instability in affect, identity, and relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned, but they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger. Their frequent use of the defense of splitting strains personal relationships and creates turmoil in health care settings. The remaining options suggest characteristics not associated with this disorder.

Which ethical concept regarding client care poses the greatest concern for a nurse providing end-of-life care for a client considering euthanasia? A. Beneficence B. Autonomy C. Nonmaleficence D. Individual liberty

C. Nonmaleficence An ethical concept relevant to euthanasia is that of nonmaleficence or doing no harm and considering whether helping to end life is an act of harm. None of the other ethical concepts is as directly related to the actions of nursing at the end of a client's life.

An older adult client is reporting symptomatology that suggests rapid eye movement (REM) sleep behavior disorder (RSBD). Which comorbid condition should the nurse assess for? A. Lymphoma B. Hypertension C. Parkinson's disease D. Acute renal failure

C. Parkinson's disease RSBD is seen in elderly males as they begin to develop neurological pathologies such as Parkinson's disease. None of the other options are directly associated.

A 9-year-old patient has been diagnosed with an intellectual development disorder (IDD). Which assessment findings support this diagnosis? (Select all that apply.) Select all that apply. A. Is capable of providing effective oral self-care B. Enjoy interacting with developmentally similar peers C. Physically lashes out when frustrated D. Reads below age level E. Unable to explain the phrase, "Raining cats and dogs"

C. Physically lashes out when frustrated D. Reads below age level E. Unable to explain the phrase, "Raining cats and dogs" IDD is characterized by severe deficits in three major areas of functioning: intellectual, social, and managing daily life. These children demonstrate difficulty with self care and with almost any social interactions.DIF: Cognitive Level: Analyzing (Analysis)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A slightly obese client reports falling asleep during the daytime even though she has slept all night. Her husband says she snores, and her blood pressure is noted to be in the low hypertensive range. The nurse anticipates that the client will be scheduled for which diagnostic test? A. Glycosylated hemoglobin B. Hypertension screening C. Polysomnography D. Positron emission tomography

C. Polysomnography Polysomnography consists of an electroencephalogram that records respirations, eye movements, and muscle tone during sleep. Sleep apnea becomes apparent if respirations cease frequently during sleep. None of the other options are focused on these behaviors.

A student nurse is working with an 82-year-old patient diagnosed with dementia. The student is frustrated at times by not knowing how best to care for or communicate with the client. Which of the statement by the student best illustrates best care practice? A. Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." B. Lighthearted banter: "You look great today in your new sweater, you handsome devil!" C. Positive regard: "I am glad to be here caring for you today. Let's talk about our plans for the day." D. Limit setting: "You cannot yell out in your room. You are upsetting other patients."

C. Positive regard: "I am glad to be here caring for you today. Let's talk about our plans for the day." Positive regard implies respect. It is the ability to view another person as being worthy of caring about and as someone who has strengths. The attitude of unconditional positive regard is the nurse's single most effective tool in caring for people with dementia. It induces people to cooperate with care and increases family members' satisfaction with care. Although the patient may not be able to verbalize plans for his day, this response conveys belief that the patient has something to offer and treats him with respect. It also shows that the nurse wants to care for the patient and conveys commitment to the relationship. Limit-setting may be necessary at times; however, it is not the most effective care tool. The other responses are nontherapeutic.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

What is the most beneficial nursing intervention directed toward minimizing the discomfort associated with conducting a sexually focused assessment? A. Assure the client that the responses will be kept confidential. B. Begin with the most relevant, non-personal question. C. Provide the client with a rationale for asking the questions. D. Project a relaxed, causal demeanor when questioning the client.

C. Provide the client with a rationale for asking the questions. Letting the client know why the questions are being asked increases openness and cooperation. While the other options are appropriate, the basis of facilitating openness and cooperation is an exchange of information between client and nurse.

A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse does not believe in abortion. What action the nurse should take? A. Ask the supervising nurse to reassign the client. B. Refer the woman for social services counseling. C. Report and document the request. D. Ask the client to reevaluate her request after 24 hours.

C. Report and document the request. The nurse's ethical beliefs should never interfere with client rights. The nurse should report and document the client's request.

Which factor can reduce the vulnerability of a child to etiological influences predisposing to the development of psychopathology? A. Child abuse B. Malnutrition C. Resilience D. Having a depressed parent

C. Resilience Resilience refers to developing and using certain characteristics that help a child to handle the stresses of a difficult childhood without developing mental problems. Resilient children can adapt to changes in the environment, form nurturing relationships with adults other than their parents, distance themselves from the emotional chaos of the family, and have social intelligence and the ability to use problem-solving skills.

A 37-year-old client, referred to the mental health clinic with a suspected personality disorder, is withdrawn and suspicious and states, "I've always preferred to be alone" and then adds, "I can read your thoughts whenever I want to." This presentation supports which psychiatric diagnosis? A. Avoidant personality disorder B. Obsessive-compulsive personality disorder C. Schizotypal personality disorder (STPD) D. Narcissistic personality disorder

C. Schizotypal personality disorder (STPD) Rationale: The main traits that describe STPD are psychoticism such as eccentricity, odd or unusual beliefs and thought processes, and social detachment by preferring to be socially isolated, as well as being overly suspicious or anxious. In obsessive-compulsive personality disorder the main pathological personality traits are rigidity and inflexible standards of self and others, along with persistence of goals long after they are necessary, even if they are self-defeating or negatively affect relationships. People with narcissistic personality disorder come across as arrogant, with an inflated view of their self-importance. They have a need for constant admiration, along with a lack of empathy for others, a factor that strains most relationships over time. Traits of avoidant personality disorder include low self-esteem, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

Splitting is a process in which the client demonstrates what behavior? A. Evidences lack of personal boundaries B, Places responsibility for his or her behavior outside the self C. Sees things as divided into "all good" or "all bad" D. Unconsciously represses undesirable aspects of self

C. Sees things as divided into "all good" or "all bad" Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An individual is not seen as a person with good and bad traits, but rather as all good or all bad. This behavior does not relate to any of the other options.

To provide discharge treatment and support, the nurse should realize that the most common outcome of acquaintance rape is which psychosocial dysfunction? A. Fear of men B. Anxiety C. Sexual distress D. Depression

C. Sexual distress Women who have been raped by acquaintances frequently develop symptoms that prevent them from participating in normal sexual relations. Sexual distress is more common among women who have been sexually assaulted by intimates; fear and anxiety are more common in those assaulted by strangers. Depression occurs in both groups.

Pyromania, a behavior associated with impulse control disorders, causes an individual to engage in what behavior? A. Self-mutilate B. Directing anger toward others C. Starting fires D. Stealing for thrill

C. Starting fires Pyromania is described as repeated, deliberate fire setting. This behavior does not include any of the other stated options.

The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention? A. Stressing the need to suppress overt conflict within the family B. Encouraging the family to use their usual social behaviors at meals C. Teaching the family about the disorder and the client's behaviors D. Urging the family to demonstrate greater caring for the client

C. Teaching the family about the disorder and the client's behaviors Families need information about specific eating disorders and the behaviors often seen in clients with these disorders. This information can serve as a basis for additional learning about how to support the family member. While the other options may be appropriate for specific client families, they are not as fundamental as the correct option.

A client asks the nurse to explain what basal sleep requirement is. What is the nurse's best response? A. The amount of sleep needed to transition to rapid eye movement (REM) sleep. B. The sleep time by your body needed to repair cellular damage. C. The amount of sleep needed to be fully awake and perform well in the daytime. D. The basal temperature of your body needed to induce the best sleep.

C. The amount of sleep needed to be fully awake and perform well in the daytime. Basal sleep requirement is the amount of sleep required to feel fully awake and able to sustain normal levels of performance during the periods of wakefulness. The other options do not describe basal sleep requirement.DIF: Cognitive Level: Understanding (Comprehension)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

Which statement is true about the characteristics of the oppositional defiant child? A. Girls display more blaming than do boys. B. The defiance is generally directed toward parents and siblings. C. These behaviors are a predictor of future mental health disorders. D. Arguing tends to be more prevalent in boys.

C. These behaviors are a predictor of future mental health disorders. Oppositional defiant disorder is often predictive of emotional disorders in young adulthood. None of the other statements are necessarily correct.

Which statement is descriptive of clients with a personality disorder? A. They have little difficulty with cognitive functioning. B. They have an ability to tolerate frustration and pain. C. They are resistant to behavioral change. D. They usually seek help to change maladaptive behaviors.

C. They are resistant to behavioral change. Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it very difficult, if not nearly impossible, to change. Change proceeds very slowly. None of the other options are generally associated with this disorder.

Which event would an older client diagnosed with early stage Alzheimer's disease have greatest difficulty remembering? A. His or her high school graduation B. The story of a teenage escapade C. What he or she ate for breakfast D. The births of his or her children

C. What he or she ate for breakfast Initially, recent memory is impaired, and remote memory remains intact.

At what point would the nurse expect a family to demonstrate the greatest dislocation in the family life cycle? A. When the couple renegotiates the marital system as a dyad B. When the couple is deciding whether to have children C. When a member is diagnosed with multiple sclerosis D. When the first child enters school

C. When a member is diagnosed with multiple sclerosis Family stress is often the greatest at times of serious illness, death, or divorce. While the other options can produce levels of stress, none are as stressful as coping with a family member's chronic illness.

Effective care of a client suspected of experiencing bulimia nervosa calls for the nurse to perform which assessment? A. body fat analysis. B. a range of motion assessment. C. inspection of the oral cavity. D. inspection of body cavities.

C. inspection of the oral cavity. Repeated vomiting often causes dental erosions and caries. None of the other options represent frequently engaged dysfunctional behaviors.

Ali is a 17-year-old patient diagnosed with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? A. "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." B. "I always purge when I'm alone so that I'm not a bad role model for my younger sister." C. "I purge only once a day now instead of twice." D. "I am a hard worker and I am very compassionate toward others."

D. "I am a hard worker and I am very compassionate toward others." An appropriate overall goal for the bulimic patient would include that the patient be able to identify personal strengths, leading to improved self-esteem. Purging only once a day instead of two is incorrect because the goal is to refrain from purging altogether. A goal is for the patient to express feelings without food references. Purging when alone is incorrect because the patient is still purging.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: Outcome IdentificationMSC: NCLEX: Psychosocial Integrity

What statement by a client would indicate that goals for treatment for a somatization disorder are being achieved? A. "I take my medications just as the physician prescribed." B. "I feel less anxiety than before." C. "My memory is better than it was a month ago." D. "I don't think about my symptoms all the time as I used to be."

D. "I don't think about my symptoms all the time as I used to be." This statement indicates that the client's preoccupation with the physical symptom has decreased, a highly desirable outcome. Neither medication adherence nor memory loss is associated with this disorder. The client would not acknowledge generalized anxiety as a symptom of their disorder.

Which statement by a patient who was educated about the importance of acquiring adequate sleep indicates a need for further teaching? A. "Getting less than 6 hours of sleep at night may increase my risk for medical problems." B. "Since I have to drive for my job, getting enough sleep will help me avoid accidents." C. "Getting enough sleep will increase my productivity at work." D. "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can."

D. "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can." Sleeping more than 8 hours per night is associated with up to a twofold increased risk of obesity, diabetes, hypertension, incident cardiovascular disease, stroke, depression, and substance abuse. The other options are all true.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

A client diagnosed with a chronic sleep disorders begins to cry and states, "I can't keep going like this! I work in a bank and if I can't function correctly I'll lose my job. I just don't think I'll get better." Which statement provides a therapeutic response to the client's concerns? A. "Don't worry! I'm sure with treatment everything will get better." B. "You are not alone. Many people who come for sleep studies are going through the same thing." C. "You seem so sad. May I ask if something else is troubling you?" D. "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work."

D. "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work." This response instills hope regarding the ability of the patient to improve and suggests positive strategies for daily functioning. The other responses are nontherapeutic.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

A cognitively impaired resident living at a long-term care unit has become unsteady when walking alone. The family is concerned about the potential for serious injury from falls and suggests that restraints be used. What is the nurse's best response to the family's request? A. "The federal government forbids the use of restraints on elderly residents." B. "Immobilization will cause constipation and necessitates the use of enemas." C. "You will need to make your request to the physician at the planning meeting." D. "Using restraints puts the resident at higher risk for serious injury, even death."

D. "Using restraints puts the resident at higher risk for serious injury, even death." This response would open the door to being able to explain the hazards of restraint use compared with the minor problems incurred when the client is unrestrained. None of the other options provides appropriate information regarding the use of restraints in this situation.

During the immediate post-rape period what verbal nursing intervention would best lower client anxiety and increase feelings of well-being? A. "When you leave you will be given follow-up appointments for pregnancy and sexually transmitted disease screening." B. "I know you feel confused. We will make all the necessary decisions for you." C. "Please tell me as much about the details of the rape as you can remember." D. "You are safe here. I will stay with you while you have your examination."

D. "You are safe here. I will stay with you while you have your examination." The presence of the nurse is reassuring, especially when the client is experiencing disorganization and the environment is confusing. Safety is the primary concern for both the client and the nurse. The nurse's presence conveys a sense of safety to the client. None of the other options address safety and well-being.

Which client is most likely to initially demonstrate behaviors suggesting a somatic disorder? A. 43-year-old female B. 33-year-old male C. 13-year-old male D. 23-year-old female

D. 23-year-old female The predominance of women with somatization is significant. It has been proposed that women are more aware of their bodily sensations, have different health-seeking behaviors when faced with physical and psychological distress, and use more health care services than men. In particular, young women aged 16 to 25 are more likely to receive a somatic diagnosis than men or older individuals.

Based on the current research, which patient is most likely to develop dementia? A. A worker in a factory where asbestos is found B. An office manager in a high-stress environment C. A bartender in a dark underground club/bar D. A former boxer and is now a trainer

D. A former boxer and is now a trainer Brain injury and trauma are associated with a greater risk of developing Alzheimer's disease and other dementias. People who suffer repeated head trauma, such as boxers and football players, may be at greater risk. The other options do not specifically represent known risk.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: DiagnosisMSC: NCLEX: Psychosocial Integrity

What is the most effective nursing intervention regarding the accurate assessment of sleep disorders? A. Assessment for substance abuse B. Information regarding sleep cycles C. Client description of the symptomatology D. A sleep diary

D. A sleep diary Self-reported sleep patterns may be biased, and so clinical tools such as a sleep diary are helpful in accurately estimating total sleep time.

A client diagnosed with osteoarthritis says she is unable to sleep because of aching in her hips and shoulders. Which medication would be appropriate in this situation? A. Meperidine B. A sedative-hypnotic C. Aspirin D. Acetaminophen

D. Acetaminophen Acetaminophen is an effective analgesic in the elderly. It does not produce the gastrointestinal bleeding seen with aspirin and nonsteroidal anti-inflammatory drugs. Meperidine, an opiate with metabolites that stimulate the central nervous system, may produce confusion. A sedative-hypnotic may produce daytime sedation or confusion.

A client diagnosed with Alzheimer's disease looks confused and cannot recall many common household objects by name, such as a pencil or glass. The nurse should document this loss of function using which term? A. Apraxia B. Aphasia C. Anhedonia D. Agnosia

D. Agnosia Agnosia is a loss of the ability to recognize familiar objects. The loss is not associated with any of the other options.

Which type of dementia has a clear genetic link? A. Multi-infarct dementia B. Alcohol-induced dementia C. Creutzfeldt-Jakob disease D. Alzheimer's disease

D. Alzheimer's disease Family members of people with Alzheimer's disease have a higher risk of developing the disease than does the general population. Research does not support such a claim for any of the other options.

What is the primary function of the nurse generalist in caring for families? A. Determining the new skills the family needs B. Conducting private family therapy sessions C. Prescribing psychobiological intervention D. Assessing the amount of stress on the system

D. Assessing the amount of stress on the system An important function of a nurse generalist is to assess cues from various family members that indicate the degree and amount of stress the family system is experiencing and report these so that appropriate interventions may be made in a timely manner by a qualified counselor. The remaining options are outside the scope of practice of a psychiatric nurse generalist.

A 7-year-old, who is described as impulsive and hyperactive, tells the nurse, "I am a dummy, because I don't pay attention, and I can't read like the other kids." The nurse notes that these behaviors are most consistent with which diagnosis? A. Attention deficit disorder B. Conduct disorder C. Autism D. Attention deficit hyperactivity disorder

D. Attention deficit hyperactivity disorder The data are most consistent with attention deficit hyperactivity disorder (ADHD) as described in the DSM-5. The other options present with characteristics and behaviors that differ from those in the scenario.

Studies have shown a correlation between mental disorders and which medical condition? A. Chronic renal failure B. Psoriasis C. Asthma D. Cardiovascular disease

D. Cardiovascular disease Studies in recent years have contributed to the growing body of evidence indicating a link between mental disorders and medical conditions such as cardiovascular disease and cancer. No such correlation has been proven between medical and any suggest psychiatric conditions.

The nurse feels uncomfortable talking with a young male client about his sexual problem. Which action should the nurse take? A. Ask another nurse to take over the interview, so you don't project your feelings onto the patient. B. Ask Lance whether he would feel more comfortable speaking with a physician about his problem. C. Pause the interview and take time to gather your thoughts and do positive self-talk. D. Continue the interview using an appropriate professional tone and matter-of-fact approach.

D. Continue the interview using an appropriate professional tone and matter-of-fact approach. Remembering your position as a professional and addressing the topics in a tone and manner appropriate of a professional will increase your comfort, along with the patient's. The response in the first option would be confusing to the patient and does not address your feelings or work to resolve them. Pausing the interview would not be appropriate because self-assessment is best done before patient interaction. Asking the patient whether he would feel more comfortable speaking with a physician projects your feelings of being uncomfortable onto the patient and does not carry out your professional role and responsibility.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

Which characteristics will the nurse assess in the client diagnosed with antisocial personality? A. A need for others to assume responsibility for decision making and seeking nurture B. Avoidance of interpersonal contact and preoccupation with being criticized C. Perfectionism, preoccupation with detail, and verbosity D. Deceitfulness, impulsiveness, and lack of empathy

D. Deceitfulness, impulsiveness, and lack of empathy Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others. Characteristics presented in the other options are not associated with this disorder.

Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image? A. Projection B. Humor C. Altruism D. Denial

D. Denial Denial of incongruence between body reality, body ideal, and body presentation is the mainstay of the client diagnosed with bulimia nervosa. None of the other mechanisms are as vital to their coping technique.

A 62-year-old patient who is recovering from a urinary tract infection that has required hospitalized for delirium. Based on research regarding possible post delirium complications, what are important areas for the provider to assess regularly after discharge? A. Sexual functioning B. Sleeping habits C. Symptoms of posttraumatic stress D. Depression and level of cognition

D. Depression and level of cognition Although delirium is usually a short-term condition, it may have long-term consequences. In patients with preexisting cognitive impairment, there is an acceleration of cognitive decline. Although there are reports of long-term cognitive impairment (in the absence of preexisting cognitive impairment) and functional decline following delirium, results of studies have been inconsistent. An association also exists with depression after delirium. Although a holistic examination would assess sleep, this is not the area that research has found to be problematic. A holistic examination would include sexual functioning, but it is not the priority at this time. Posttraumatic stress symptoms have been seen in younger patients who experienced delirium while hospitalized.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

Which nursing intervention is appropriate for the management of intermittent explosive disorder? A. Setting up loose boundaries so the client will feel relaxed B. Providing intensive family therapy C. Limiting decision-making opportunities to avoid frustration D. Establishing a trusting relationship with the client

D. Establishing a trusting relationship with the client Establishing rapport with the client is essential in working to set goals, boundaries, and consequences, and providing opportunities for goal achievement. Intensive family therapy would not be a basic level RN intervention. Boundaries and structure are essential. Opportunities for clients to make good decisions and reach goals should be given, not limited.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

A family consists of a husband, a wife, their three children, and the wife's mother. This family form is referred to using which term? A. Blended B. Indwelling C. Dyadic D. Extended

D. Extended An extended family (multigenerational) is a composite of three or more generations. None of the other options refer to this family composition.

Which subjective symptom should the nurse expect to note during assessment of a client diagnosed with anorexia nervosa? A. Hypotension B. Lanugo C. 25-lb weight loss D. Fear of gaining weight

D. Fear of gaining weight Fear of weight gain is the only subjective data listed, and it is universally true of clients diagnosed with anorexia nervosa. The remaining options are objective signs.

Which behavior is most indicative of a 4-year-old child diagnosed with Tourette's syndrome? A. Humming while performing activities that require concentration B. Difficulty in social relationships C. Difficulty in completing tasks on time D. Frequent eye blinking

D. Frequent eye blinking Persistent motor or vocal ticking is characteristic of Tourette's syndrome. Dysfunctional social relationship is an inconclusive symptom, especially for a 4-year-old. Humming can be a normal response of a child at play. Ineffective time management is usually associated with a child who demonstrates ADHD, not Tourette's syndrome.

A client hospitalized with anorexia nervosa has a weight that is 65% of normal. For this client, what is a realistic short-term goal for the first week of hospitalization regarding the physical impact of his/her weight? A. Verbalize awareness of the sensation of hunger. B. Develop a pattern of normal eating behavior. C. Discuss fears and feelings about gaining weight. D. Gain a maximum of 3 lb.

D. Gain a maximum of 3 lb. The critical outcome during hospitalization for anorexia nervosa is weight gain. A maximum of 3 pounds weekly is considered sufficient initially. Too-rapid weight gain can cause pulmonary edema. While all the remaining goals are appropriate, none have the physical focus that is the initial priority.

What characteristic behaviors will the nurse assess in the narcissistic client? A. Perfectionism and preoccupation with detail B. Dramatic expression of emotion, being easily led C. Angry, highly suspicious, aloof, withdrawn behavior D. Grandiose, exploitive, and rage-filled behavior

D. Grandiose, exploitive, and rage-filled behavior Narcissistic clients give the impression of being invulnerable and superior to others to protect their fragile self-esteem. None of the other options provide a description associated with narcissism.

The members of a family openly tell each other what they are thinking and feeling. A nurse listening to their interchanges would assess their communication using which term? A. Disengaged B. Double-bind C. Generalizing D. Healthy

D. Healthy Healthy communication is exemplified by being clear and direct in saying what you want and need. The other terms are used to describe some form of dysfunctional communication.

Which disorder is characterized by the client's misinterpretation of physical sensations or feelings? A. Somatic disorder B. Conversion disorder C. Factitious disorder D. Illness anxiety disorder

D. Illness anxiety disorder Previously known as hypochondriasis, illness anxiety disorder results in the misinterpretation of physical sensations as evidence of a serious illness. Illness anxiety can be quite obsessive, because thoughts about illness may be intrusive and difficult to dismiss, even when the patient recognizes that his or her fears are unrealistic. This is not an accurate description of any of the other options.

When a delirious client insists that a vacuum hose is a large, poisonous snake, the nurse recognizes that this client is experiencing what characteristic symptom? A. Hallucinations B. Agnosia C. Hypervigilant D. Illusion

D. Illusion Illusions are errors in the perception of a sensory stimulus. None of the other options are associated with this form of misperception.

Clients demonstrating characteristics of personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. Which nursing diagnosis best addresses this sort of interpersonal dysfunction? A. Spiritual distress B. Defensive coping C. Disturbed sensory perception D. Impaired social interaction

D. Impaired social interaction For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used. None of the other options appropriately deals with this type of dysfunctional behavior.

What initial intervention should the nurse suggest to the family members of a client diagnosed with Alzheimer's disease who has become incontinence of urine? A. Provide toileting on an as-needed basis. B. Apply disposable diapers. C. Encourage hourly toileting. D. Label the bathroom door with a picture.

D. Label the bathroom door with a picture. Labeling doors and various items with pictures can be helpful for a client who has forgotten where things are and what certain items are. The remaining options may need to be implemented eventually when such prompting is no longer effective.

Clients diagnosed with borderline personality disorder (BPD) exhibit negative effect, which includes rapidly moving from one emotional extreme to another. What term is used to describe this characteristic? A. Denial B. Splitting C. Impulsivity D. Lability

D. Lability Rationale: One of pathological personality traits seen in persons with BPD is negative effect, which is characterized by emotional lability, that is, rapidly shifting emotions from one extreme to another. Clients exhibiting this trait are often documented as being labile. None of the other options is used to describe this characteristic. DIF: Cognitive Level: Remember (Knowledge) TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

The family that consists of a married mother and father and three biological children all living together is referred to using which term? A. Other family B. Cohabitating family C. Blended family D. Nuclear family

D. Nuclear family A nuclear family consists of one or more children who live with married parents who are the biological or adoptive parents to all the children. Blended family refers to one or more children living with a biological or adoptive parent and an unrelated stepparent who are married to each other. Cohabitating family refers to one or more children living with a biological or adoptive parent and an unrelated adult who are cohabitating. "Other" refers to one or more children living with related or unrelated adults who are not biological or adoptive parents. This includes children living with grandparents and foster families.DIF: Cognitive Level: Remember (Knowledge)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

Which statement is true of the eating disorder referred to as bulimia? A. Patients with bulimia severely restrict their food intake. B. One sign of bulimia is lanugo. C. Patients with bulimia binge eat but do not engage in compensatory measures. D. Patients with bulimia often appear at a normal weight.

D. Patients with bulimia often appear at a normal weight. Patients with bulimia are often at or close to ideal body weight and do not appear physically ill. The other options do not refer to bulimia but rather refer to signs of binge eating disorder and anorexia nervosa.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

The client reveals to the nurse that, "I'm turned on by little girls, not adult women." This statement supports which possible diagnosis? A. Exhibitionism B. Hedonism C. Voyeurism D. Pedophilia

D. Pedophilia Pedophilia involves sexual fantasies, urges, or behaviors with a child aged 13 years or younger. This is not a characteristic of any of the other options.

The term "perceptual disturbance" refers to difficulty in which area of function? A. Can be one's way of thinking to accommodate new information B. Formulating words appropriately C. Performing purposeful motor movements D. Processing information about one's internal and external environment

D. Processing information about one's internal and external environment Perceptual distortion refers to impaired ability to process intellectual, sensory, and emotional data in a logical, meaningful way. None of the other options are associated with this inability.

A nuclear family consists of married parents, a 16-year-old daughter, and a 19-year-old son recently diagnosed with schizophrenia. The rest of the family is bewildered with his symptoms and express that they feel lost in knowing how to deal with things. Which of the following approaches to family therapy should the nurse implement at this time to provide support and give information to the family that will help them cope with their son's illness? A. Insight-oriented family therapy B. Multigenerational family therapy C. Behavioral family therapy D. Psychoeducational family therapy

D. Psychoeducational family therapy The primary goal of psychoeducational family therapy is the sharing of mental health care information. This helps family members better understand their member's illness, prodromal symptoms (symptoms that may appear before a full relapse), medications needed to help reduce the symptoms, and more. Psychoeducational family meetings allow feelings to be shared and strategies for dealing with these feelings to be developed. Insight-oriented therapy focuses on developing increased self-awareness, other awareness, and family awareness among family members. Behavioral family therapy focuses on changing behaviors of family members to influence overall patterns of family interactions. The last option is a distractor and is incorrect.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

What non-habit-forming melatonin receptor agonist is often prescribed for insomnia? A. Zaleplon B. Eszopiclone C. Zolpidem D. Ramelteon

D. Ramelteon Ramelteon is a short-acting melatonin receptor agonist that has been approved by the FDA for insomnia and is not habit forming. None of the other options are melatonin receptor agonists prescribed for insomnia.

Providing care to a client diagnosed with a somatization disorder can be frustrating owing to the client's lack of an organic illness. In order to best manage this barrier to care the staff should implement which personal intervention? A. Attend in-services that focus on the various aspects of somatic disorders. B. Provide a unified approach to the client's behavior so as to manage and lessen the barrier itself. C. Rotate care of the client among the entire nursing department staff to minimize the frustration. D. Regularly discuss their feelings about the client during the unit's interprofessional care meetings.

D. Regularly discuss their feelings about the client during the unit's interprofessional care meetings. It is helpful for health care workers, no matter the setting, to discuss responses to these patients in conferences with other health care members to allow for expression of feelings and, ultimately, to provide for consistent care. While the other options are appropriate, none are as staff oriented as the correct option.

Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa? A. Chronic low self-esteem B. Ineffective coping: impulsive responses to problems C. Disturbed body image D. Risk for injury: electrolyte imbalance

D. Risk for injury: electrolyte imbalance The client who engages in purging and excessive use of laxatives and enemas is at risk for metabolic acidosis from bicarbonate loss. This electrolyte imbalance is potentially life threatening. While appropriate none of the other options are as likely to risk the client's life.

Which statement accurately applies to exhibitionism? A. Generally viewed as a victimless crime. B. Rarely prosecuted. C. Generally viewed as an illness by the courts. D. Seldom a precursor to sexual assault or rape.

D. Seldom a precursor to sexual assault or rape. Exhibitionism is generally done more for shock value, and actual physical contact is rarely sought. None of the other options are accurate statements regarding this disorder.

Which statement provides accurate information regarding transvestic disorder? A. Most people with this disorder are homosexual. B. Transvestic behavior develops in middle adulthood. C. Only men are diagnosed with transvestic disorder. D. Sexual orientation has no bearing on transvestic disorder.

D. Sexual orientation has no bearing on transvestic disorder. Unlike in gender dysphorias, in transvestic disorder there are no sexual orientation issues, and people with transvestic disorder do not desire a sex change. Transvestites are usually heterosexual. Although more common in men, women are also diagnosed with transvestic disorder. Transvestic disorder usually develops early in life.DIF: Cognitive Level: Understand (Comprehension)TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A client confides to the nurse that she is sexually excited by dominating her partner and achieves orgasm only when she humiliates her partner. This admission supports which sexual disorder? A. Immature sexual gratification B. Orgasmic disorder C. Sexual pain disorder D. Sexual sadism

D. Sexual sadism Sexual sadism involves the need to give psychological or physical pain to achieve sexual gratification. No other option is supported by the statement.

When discussing somatic disorders from a cultural perspective, which statement is true? A. Somatic disorders are rarely observed in males. B. Secondary gain is seldom a factor in somatic disorders. C. Underdeveloped countries rarely tolerate somatic disorders. D. Somatic symptoms vary widely from culture to culture.

D. Somatic symptoms vary widely from culture to culture. The type and frequency of somatic symptoms vary across cultures. Currently, none of the other options have been supported by research.

Playing one staff member against another is an example of what defense mechanism? A. Social ineptitude B. Devaluation C. Impulsiveness D. Splitting

D. Splitting Splitting involves setting up individuals or groups to disagree. While the two parties are busy disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can enjoy the spectacle and do as he or she pleases. The example provided does not effectively describe any of the other options.

A nurse planning continuing education programs for nursing staff members at a multipurpose senior center will plan programs based on the knowledge that which mental health problem is most common among the elderly? A. Obsessive-compulsive disorder B. Agoraphobia C. Schizophrenia D. Suicidal ideation

D. Suicidal ideation In the United States, the suicide rate among the elderly is the highest for any age group. While present among this population, none of the other options is considered a common disorder.

When a nurse assesses the style of behavior a child habitually uses to cope with the demands and expectations of the environment, he or she is assessing characteristic? A. Cultural assimilation B. Resilience C. Vulnerability D. Temperament

D. Temperament Temperament is the behavior the child habitually uses to cope with the environment. It is a constitutional factor thought to be genetically determined. It may be modified by the parent-child relationship. None of the other options would reflect this characteristic.

Which factor will have the greatest impact on end-of-life nursing care in the coming decades? A. The decline in those entering the nursing profession B. Decrease in federal funding for healthcare C. Technological advancements D. The aging of the Baby Boomers generation

D. The aging of the Baby Boomers generation The US experienced an unprecedented birth rate in the 18 years after the end of World War II (1946-1964). This generation became known as the baby boomers. The 79 million baby boomers account for a staggering 26% of the total US population. The US Census Bureau (2018) estimates that the number of individuals over the age of 65 will nearly double from 43.1 million in 2012 to 83.7 million by 2050. Every day for the next 19 years, 10,000 baby boomers will turn 65. For the first time in history the number of older adults will surpass the number of children This burgeoning sector of the population will place unprecedented strains on a health care system where health spending is growing faster than the overall economy. As this population experiences terminal illness, the need for end-of-life care will increase as well. While the other options are factors, the greatest impact will come from the existence of unprecedented numbers of terminal ill and dying clients.

What are the foundational concerns regarding the use of restraint and seclusion when providing care to children? (Select all that apply.) Select all that apply. A. Parents may initiate a lawsuit if injury occurs. B. Staff tends to be undertrained in use of restraints in children. C. Staff have conflicted feelings leading to ineffectiveness. D. The principle of least restrictive intervention is a primary concern. E. Research suggests both are psychologically and physically harmful.

D. The principle of least restrictive intervention is a primary concern. E. Research suggests both are psychologically and physically harmful. Restraint and seclusion have been shown to be psychologically harmful and may also be physically harmful and result in injury or death. To ensure that the civil and legal rights of individuals are maintained, techniques are selected according to the principle of least restrictive intervention. This principle requires that you use more-restrictive interventions only after attempting less restrictive interventions to manage the behavior that have been unsuccessful. The other options are not correct reasons why restraint and seclusion are controversial in children.DIF: Cognitive Level: Understanding (Comprehension)TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

A dying client's family is concerned that the opioid pain medication being prescribed will hasten the client's death. What may be the basis for this concern? A. Addition to the opioid is a greater risk than is the possibility of a premature death. B. Pain management for the terminally ill is the primary concern of the health care team. C. The Rule of Double Effect (RDE) prevents the use of opioids to facilitate a client's death. D. There is little research evidence to support that appropriate opioid management will result in an earlier death.

D. There is little research evidence to support that appropriate opioid management will result in an earlier death. Pain is sometimes undertreated because the patient and/or family is concerned about sedation, addiction, and/or hastening the demise of their loved one. The RDE is a bioethical principle that allows a physician or APRN to make a decision, such as prescribing adequate pain medication, even though the pain medication might cause the patient to die sooner. There is little evidence, however, to support the concern that appropriate use of opioids will hasten death.DIF: Cognitive Level: Understanding (Comprehension)TOP: Nursing Process: PlanningMSC:NCLEX: Safe and Effective Care Environment

A 10-year-old who is frequently disruptive in the classroom begins to fidget in her chair and then moves on to disruptive behavior. What is the most appropriate initial technique for managing this sort of disruptive behavior? A. Therapeutic holding B. Quiet room C. Seclusion D. Touch control

D. Touch control The appropriate adult can move closer to the child and place a hand on her arm or an arm around her shoulder for a calming effect when the fidgeting is first noted. The closeness signals the child to use self-control. It is the least restrictive treatment approach and should be tried initially.

A nurse works with a nuclear family that includes an adult child diagnosed with schizophrenia. The child's mother confides that she and her husband "have not been getting along well." She states that her teenage daughter provides much support to her and claims that "she doesn't really like her dad much anymore and doesn't talk to him." The nurse suspects that the family is experiencing which family dysfunctional dynamic? A. Boundary blurring B. Neglect C. Emotional abuse D. Triangulation

D. Triangulation Triangulation refers to a family "triangle" of three. When the tension in a dyad (two people) builds, a third person (child, friend, or parent) may be brought in by one of the members. This third person of the dyad serves to help lower the tension by solving the crisis or offering understanding. Family triangles may create emotional instability in the long run and are not optimal for dealing with problems in an open and direct way. There is nothing that indicates abuse. There is nothing to indicate neglect. Boundary blurring occurs when boundaries are diffuse, or unclear.DIF: Cognitive Level: Analyze (Analysis)TOP: Nursing Process: DiagnosisMSC: NCLEX: Psychosocial Integrity

When parents share that their 8-year-old child seems to "always try to be annoying and hateful," the nurse suspects the child is demonstrating which characteristic? A. Depression B. Emotionally immature C. Anxiety D. Vindictiveness

D. Vindictiveness Vindictiveness is defined as spiteful, malicious behavior. The person with this disorder also shows a pattern of deliberately annoying people and blaming others for his or her mistakes or misbehavior. This child may frequently be heard to say "He made me do it!" or "It's not my fault!" The description is not associated with any of the other options.

Which intervention would be least useful for accurate assessment of the weight of a client diagnosed with anorexia nervosa? A. Do not reweigh client when client requests. B. Weigh 2 times daily first week, then three times weekly. C. Permit no oral intake before weighing. D. Weigh fully clothed before breakfast.

D. Weigh fully clothed before breakfast. Clients should be weighed daily first week, then three times weekly wearing only bra and panties or underwear before ingesting any food or fluids in the morning. Reweighing is not a request that should be afforded to the client.

Which nursing diagnosis should be considered for a child with attention deficit hyperactivity disorder ADHD? A. defensive coping B. impaired verbal communication C. Anxiety D. risk for injury

D. risk for injury The child's marked hyperactivity puts him or her at risk for injury from falls, bumping into objects, impulsively operating equipment, pulling heavy objects off shelves, and so forth.

A client, prescribed which class of antidepressant medication should be monitored for the development of premature ejaculation? A. Tricyclic antidepressants B. Monoamine oxidase (MAO) inhibitors C. Atypical antipsychotics D. selective serotonin reuptake inhibitor (SSRI) antidepressants

D. selective serotonin reuptake inhibitor (SSRI) antidepressants Treatments include antidepressants in the SSRI category. Conversely, pharmacotherapy may cause erectile dysfunction, and medications may need to be evaluated for change or dose reduction. The other options are not used for premature ejaculation.DIF: Cognitive Level: Apply (Application)TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

A poorly developed sense of empathy is thought to be the result of having what life experience? A. A family history of mental illness B. suffered head trauma at an early age C. a low serum testosterone level D. unmet physical and emotional needs

D. unmet physical and emotional needs A history of not having one's own needs met may indicate an individual who has a less well-developed sense of empathy. Research does not support any of the other options.