Psych exam 2

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A patient diagnosed with mental illness asks a psychiatric technician, "What's the matter with me?" The technician replies, "Your wing nuts need tightening." The nurse who overheard the exchange should take action based on: a. violation of the patient's right to be treated with dignity and respect. b. the nurse's obligation to report caregiver negligence. c. preventing defamation of the patient's character. d. supervisory liability.

A patient diagnosed with severe and persistent mentally illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care? a. Encourage mutual goal setting. b. Verbally communicate empathy. c. Reinforce participation in activities. d. Demonstrate an accepting attitude.

A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication? a. Beta-blockers b. Antipsychotic medications c. Tricyclic antidepressant agents d. Monoamine oxidase inhibitors

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patient's sense of humor by telling jokes.

A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance

A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurse's office, furnished with chairs, magazines, and bookcases

A patient says, "I often make careless mistakes and have trouble staying focused. Sometimes it's hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment." Which problem should the nurse document? a. Inattention b. Impulsivity c. Hyperactivity d. Social impairment

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

A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.

A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarify cation of feelings.

A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processes

A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse's initial priority? a. Develop a relationship b. Find supported employment c. Administer prescribed medication d. Teach appropriate health care practices

A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.

A person who is speaking about a contender for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial.

A professor's 4-year-old child has a fever of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which nursing diagnosis best applies to this scenario? a. Decisional conflict b. Unilateral neglect c. Disabled family coping d. Ineffective management of the therapeutic regimen

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

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for which problem? a. Major depressive disorder b. Bipolar disorder c. Schizophrenia d. Dementia

A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nursing intervention most suitable for assisting the student is to: a. explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. b. advise the student to discuss this experience with a health care provider. c. encourage the student to begin antioxidant vitamin supplements. d. listen without comment.

An 11-year-old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. a. Assign the child to a short time-out. b. Administer an antipsychotic medication. c. Place the child in a therapeutic hold. d. Call a staff member to seclude the child.

An adolescent is arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Ineffective impulse control, related to seeking parental attention as evidenced by acting out b. Disturbed personal identity, related to acting out as evidenced by prostitution c. Impaired parenting, related to showing preference for one child over another d. Hopelessness, related to feeling unloved by parents

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression

An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items.

An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer disease.

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

Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurobrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeciency syndrome (AIDS)-related dementia

Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, "Please document the administration of the medication I forgot to do. My password is alpha1." The nurse should: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patient's health care provider.

An adult diagnosed with ADHD says, "I've always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I can't keep a job." The nurse managing care should consider: a. aversive therapy to extinguish negative behaviors. b. cognitive therapy to help address internalized beliefs. c. group therapy to allow comparison of feelings with others. d. vocational counseling to identify needed occupational skills.

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate oral intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

As part of the stress response, the HPA axis is stimulated. Which structures make up this system? a. Hippocampus, parietal lobe, and amygdala b. Hypothalamus, pituitary gland, and adrenal glands c. Hind brain, pyramidal nervous system, and anterior cerebrum d. Hepatic artery, parasympathetic nervous system, and acoustic nerve

Cortisol is released in response to a patient's prolonged stress. Which initial effect would the nurse expect to result from the increased cortisol level? a. Diuresis and electrolyte imbalance b. Focused and alert mental status c. Drowsiness and lethargy d. Restlessness and anxiety

During morning care, a nursing assistant asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully."

For patients diagnosed with severe and persistent mental illness, what is the major advantage of case management? A case manager can: a. modify traditional psychotherapy. b. efficiently access and use resources. c. focus on social skills training and self-esteem building. d. bring groups of patients together to discuss common problems.

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. She wears layered, loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating disorder b. Anorexia nervosa c. Bulimia nervosa d. Pica

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 0.40 mg %. Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulram (Antabuse). d. has recently ingested both alcohol and sedative drugs.

Select the most appropriate outcome for a patient completing the fourth alcohol detoxication program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

Severe and persistent mental illness is characterized as a: a. mental illness with longer than 2 weeks' duration. b. major ongoing mental illness marked by significant functional impairments. c. mental illness accompanied by physical impairment and severe social problems. d. major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

The treatment team believes medication will help a patient diagnosed with adult ADHD. Which class of medications does the nurse expect will be prescribed? a. Benzodiazepines b. Psychostimulants c. Antipsychotics d. Anxiolytics

What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

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

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

When assessing a 2-year-old diagnosed with autism spectrum disorder, a nurse expects: a. hyperactivity and attention decits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent.

Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.

Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken.

Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermo-regulation d. Impaired oral mucous membrane

Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse.

Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.

Which nursing diagnosis is likely to apply to a homeless individual diagnosed with severe and persistent mental illness? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance.

A nurse prepares the plan of care for a 15-year-old adolescent diagnosed with moderate intellectual developmental disorder (IDD). What are the highest outcomes that are realistic for this person? (Select all that apply.) Within 5 years, the person will: a. live unaided in an apartment. b. complete high school or earn a general equivalency diploma (GED). c. independently perform his or her own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

c, d, e

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

c, d, e

Which assessment questions are most appropriate to ask a patient with possible obsessive compulsive disorder? Select all that apply. a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it diffcult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"

c, d, e

Which experiences are most likely to precipitate PTSD? Select all that apply. a. An 8-year-old child watches an R-rated movie with both parents. b. A young adult jumps from a bridge with a bungee cord with a best friend. c. An adolescent is kidnapped and held for 2 years in the home of a sexual predator. d. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. e. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

c, d, e

A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Post-traumatic stress disorder

c, e

A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders DSM5 b. State's nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric-Mental Health Nursing

c, e

Which assessment question would be most appropriate for the nurse to ask a patient who has possible generalized anxiety disorder (GAD)? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"

Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking

Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, "I need protection from dangerous bacteria trying to penetrate my skin."

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

Which is an important nursing intervention when giving care to a patient withdrawing from a CNS stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.

Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulram (Antabuse) d. naltrexone (Revia)

Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquire knowledge of the patient's sexual roles and preferences b. Develop an understanding of human sexual responses c. Assess the patient's sexual functioning d. Clarify the nurse's own personal values

Which nursing diagnosis is more applicable for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130lb patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I hate my doctor for not giving me what I ask for." d. "I felt empty and wanted to cut myself, so I called you."

Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxication program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever

d, e

When assessing a patient who has ingested unitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.

A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? a. Cachexia b. Leukocytosis c. Hyperthermia d. Hypertension

A patient tells a nurse, "My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can't find a single flaw." This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation

When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9yo in a group that uses: a. play activities exclusively. b. group discussion exclusively. c. talk focused on a specific issue. d. play then talk about the play activity.

A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. acrophobia. b. agoraphobia. c. social anxiety disorder (social phobia). d. Post-traumatic stress disorder (PTSD).

A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxication unit. d. tell the patient, "We cannot see you today because you've been drinking."

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

A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used? a. Bringing up an irrelevant topic b. Responding to physical needs c. Addressing false cognitions d. Focusing

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

A patient diagnosed with borderline personality disorder is hospitalized several times after self inflicted lacerations. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? a. Risk for self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

Which assessment finding would cause the nurse to consider an 8-year-old child to be most at risk for the development of a psychiatric disorder? a. Being raised by a parent with chronic major depressive disorder b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend

Which comment by a person experiencing severe anxiety indicates the possibility of obsessive compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving the car accident."

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionism. b. charm, drama, seductiveness; seeking admiration. c. diffculty being alone; indecisiveness, submissiveness. d. grandiosity, attention seeking, and arrogance.

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

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I am grossly underweight, but that's what I want." d. "I am a few pounds overweight, but I can live with it."

Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia

In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians' Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider.

C, d

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic

Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

A patient being treated in an alcohol rehabilitation unit reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted." Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, "I'm glad you feel comfortable talking to me about it." c. respect the nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead.

A 12-year-old child has been the neighborhood bully for several years. The parents say, "We can't believe anything our child says." Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child's behaviors are most consistent with: a. conduct disorder (CD). b. defiance of authority. c. anxiety over separation from a parent. d. attention deficit hyperactivity disorder (ADHD).

A 16-year-old adolescent diagnosed with conduct disorder (CD) has been in a residential program for three months. Which outcome should occur before discharge? a. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. b. The teen completes an application to enter a military academy for continued structure and discipline. c. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. d. The teen has an absence of anger and frustration for 1 week.

A child diagnosed with ADHD is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications

A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them."

A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol) to a pt with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best initial action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about skipping next month's dose." c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.

A nurse cares for a patient diagnosed with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic medication d. Mood stabilizer

A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Select the nurse's best response. a. "How are you taking care of yourself?" b. "Let's review your partner's diagnostic results." c. "I have some web-based programs for you to visit." d. "Your partner is lucky to have someone so devoted."

A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

In the emergency department, a patient's vital signs are: BP 66/40 P 140bpm; R 8 bpm and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 P less than 100bpm, and respirations at or above 12bpm b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

In what signicant ways is the therapeutic environment dierent for a patient who has ingested Dlysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temp 35.9° C; P 38bpm BP 60/40 b. 120 to 90 pounds over a 3-month period. Vital signs: temp 36° C, P 50bpm BP 70/50 c. 110 to 70 pounds over a 4-month period. Vital signs: temp36.5° C P 60 BPM, BP 80/66 d. 90 to 78 pounds over a 5-month period. Vital signs: temp 36.7° C; P 62BPM, BP 74/48

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

Physical assessment of a patient diagnosed with bulimia nervosa often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.

Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

Shortly after an adolescent's parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "If my parents loved me, then they would work out their problems." What nursing diagnosis is most applicable? a. Ineffective coping b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will "never get any treatment." Which reply by the nurse would be most helpful? a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist."

The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Sublimation c. Suppression d. Passive aggression

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

When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.

When working with a patient beginning treatment for alcohol abuse, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

Which action by a psychiatric nurse best supports a patient's right to be treated with dignity and respect? a. Consistently addressing a patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient's condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning.

Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."

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

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

Which statement is a nurse most likely to hear from a patient diagnosed with anorexia nervosa? a. "I would be happy if I could lose 20 more pounds." b. "My parents don't pay much attention to me." c. "I'm thin for my height." d. "I have nice eyes."

Which statement is mostly likely to be made by a patient diagnosed with agoraphobia? a. "Being afraid to go out seems ridiculous, but I can't go out the door." b. "I'm sure I'll get over not wanting to leave home soon. It takes time." c. "When I have a good incentive to go out, I can do it." d. "My family says they like it now that I stay home."

Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.

A professor's 4-year-old child has a temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? Select all that apply. a. Telephoning a grandparent to stay with the child at home for the day. b. Telephoning a colleague to teach his classes and staying home with the sick child. c. Taking the child to the university and keeping the child in a private offce for the day. d. Taking the child to a daycare center and hoping daycare workers will not notice the child is sick. e. Giving the child one dose of ibuprofen (Motrin) and taking the child to the daycare center.

a, b

Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patient's care because of concerns about counter-transference.

a, b

An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Which resources should the nurse suggest for the patient? Select all that apply. a. Psycho-education classes b. Vocational rehabilitation c. Social skills training d. Homeless shelter e. Crisis intervention

a, b, c

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

a, b, c

An individual says to the nurse, "I feel so stressed out lately. I think the stress is affecting my body also." Which somatic complaints are most likely to accompany this feeling? Select all that apply. a. Headache b. Neck pain c. Insomnia d. Anorexia e. Myopia

a, b, c, d

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

a, b, d

nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory

a, b, d

A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.

a, b, e

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

a, b, e

Which information should a nurse include in health teaching for adults diagnosed with ADHD and their significant others? SATA a. Tendency for genetic transmission b. Prevention strategies related to substance abuse c. Negative reinforcement strategies to help modify behaviors d. Selective serotonin reuptake inhibitors (SSRIs) are usually prescribed for hyperactivity e. Cognitive therapy may help resolve internalized negative beliefs about self

a, b, e

Which statements most clearly indicate that the speaker views mental illness with stigma? SATA a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." c. "Many mental illnesses are genetically transmitted. It's no one's fault that the illness occurs." d. "Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people." e. "People with mental illness are lazy. They get government disability checks instead of working."

a, b, e

A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder (GAD) who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allow only tyramine-free foods in diet. c. Restrict intake of caffeine. d. Avoid using alcohol and other sedatives. e. Take the medication on an empty stomach.

a, c, d

Which economic factors are most critical to the success of discharge planning for a patient diagnosed with severe and persistent mental illness? SATA a. Access to housing b. Individual psychotherapy c. Income to meet basic needs d. Availability of health insurance e. Ongoing interdisciplinary evaluation

a, c, d

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

a, c, d, f

A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of relapse prevention? SATA a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances

a, c, e

A patient asks a nurse, "What are neurotransmitters? My doctor says mine are out of balance." The best reply would be: a. "You must feel relieved to know that your problem has a physical basis." b. "Neurotransmitters are chemicals that pass messages between brain cells." c. "It is a high-level concept to explain. You should ask the doctor to tell you more." d. "Neurotransmitters are substances we eat daily that influence memory and mood."

A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden oors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.

A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's best response? a. "Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent." b. "Less restrictive settings are now available to care for individuals with mental illness." c. "Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed." d. "Psychiatric institutions are no longer popular as a consequence of negative stories in the press."

A child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: a. intelligence. b. impulsivity. c. inattention. d. defiance.

A child diagnosed with ADHD has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: a. increased expressiveness in communicating with others. b. improved ability to participate in play with other children. c. ability to identify anxiety and implement self-control strategies. d. improved socialization skills with other children and authority figures.

A man tells the nurse, "All my life, I have felt and acted like a woman while living in a man's body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity." Which request is the patient likely to make to the health care provider? a. "Can you refer me for psychological testing?" b. "Will you prescribe estrogen therapy?" c. "Will you alter my medical records?" d. "What should I tell my parents?"

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

A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline

A nurse prepares for an initial interview with a patient with suspected adult ADHD. Questions should be focused to elicit information about which problem? a. Headaches b. Inattention c. Sexual impulses d. Trichotillomania

A nurse set limits for a patient diagnosed with a borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're terrible." This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.

A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs of the patient are met. d. Because of increased risk for physical problems with re-feeding, obtaining patient permission is required.

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. encourage the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.

A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, "Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done." The nurse should document the patient's comment in which section of the assessment? a. Physical b. Spiritual c. Financial d. Psychological

A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.

A patient diagnosed with severe and persistent mental illness lives independently. This patient has command hallucinations and shouts warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, "You can't come back here. You cause too much trouble." What problem is the patient experiencing? a. Grief b. Stigma c. Recidivism d. Lack of insurance parity

A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars.

A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as an as-needed (PRN) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)

A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug

A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patient's symptoms rather than on the patient.

A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply should be based on the knowledge that buspirone: a. does not produce blood dyscrasias. b. does not cause dependence. c. can be administered as needed. d. is faster acting than diazepam.

A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner, using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.

A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What are they going to do?" Assessment findings include a tremulous voice, RR 28bpm, and pulse rate 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my family and friends." b. "I saw my best friend get killed by a roadside bomb. It should have been me instead." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education but I'm not sure how I will fit in with other college students."

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? a. "I can't give you those forms without your health care provider's knowledge." b. "I will get them for you, but let's talk about your decision to leave treatment." c. "Since you signed your consent for treatment, you may leave if you desire." d. "I'll get the forms for you right now and bring them to your room."

Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, "Stay in your room or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

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

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

Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"

Which scenario best demonstrates an example of eustress? An individual: a. loses a beloved family pet. b. prepares to take a 1 week vacation to a tropical island with a group of close friends. c. receives a bank notice there were insufficient funds in their account for a recent rent payment. d. receives notification that their current employer is experiencing financial problems and some workers will be terminated.

patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain

A nurse plans the care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

b, d

A patient undergoing alcohol rehabilitation decides to accept disulram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.

b, e

What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with: a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

b, e

A patient is admitted in a comatose state after ingesting 30 capsules of phentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.

A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a. attention deficit hyperactivity disorder (ADHD). b. childhood depression. c. conduct disorder (CD). d. autism spectrum disorder (ASD).

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression.

A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to: a. Verify the patient's learning style. b. Create outcomes and a teaching plan. c. Lower the patient's current anxiety level. d. Assess how the patient uses defense mechanisms.

A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine

A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient's behavior.

A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, "I'm feeling empty and want to cut myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level.

A patient diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the cause of the patient's ineffective management of the medication regimen as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. impaired reasoning secondary to schizophrenia. d. dislike of the side effects of antipsychotic medications.

A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."

A patient has the nursing diagnosis Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. ensuring the health of household members b. attempting to avoid interactions with others c. having persistent thoughts about bacteria, germs, and dirt d. needing approval for cleanliness from friends and family

A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy.

A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.

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

A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

A person has minor physical injuries after an automobile accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system is stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system? a. Thalamus b. Parietal lobe c. Hypothalamus d. Pituitary gland

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to: a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.

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

An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior? a. Voyeurism b. Frotteurism c. Exhibitionism d. Sexual masochism

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patient's glasses and hearing aids. d. Keep the room brightly lit at all times.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment

As a nurse prepares to administer a medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I will come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

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

Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is: a. sympathy. b. assertiveness training. c. sexual self-awareness. d. effective communication.

Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: "You're a better nurse than the day shift nurse said you were"; "Another nurse said you don't do your job right"; "You think you're perfect, but I've seen you make three mistakes." Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt producing.

For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.

Health maintenance and promotion efforts for patients diagnosed with severe and persistent mental illness should include education about the importance of regular: a. home safety inspections. b. monitoring of self-care abilities. c. screening for cancer, hypertension, and diabetes. d. determination of adequacy of a patient's support system.

If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. "I don't know why it happens." b. "I have always had poor impulse control." c. "That person should not have provoked me." d. "Inside I am a coward who is afraid of being hurt."

Shortly after a 15-year-old's parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "All the other kids have families. If my parents loved me, then they would stay together." Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescent's feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent's level of depression daily.

The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: a. attention deficit hyperactivity disorder (ADHD). b. post-traumatic stress disorder (PTSD). c. autism spectrum disorder (ASD). d. separation anxiety.

The father of a child diagnosed with schizophrenia says, "I lost my job, so we have no health insurance." The mother says, "I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture." The sibling says, "My parents don't pay very much attention to me." These comments signify: a. life-cycle stressors. b. psychobiologic issues. c. family burden of mental illness. d. stigma associated with mental illness.

The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy.

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That does not mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery.

Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "I know what you're up to; you're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

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

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints

What is the priority need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering

When a 5-year-old child is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: a. go to a quiet room until called for the next meal. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne)

Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships

Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. asks, "What's the matter with me?" b. stays in a room alone and paces rapidly. c. can concentrate on what the nurse is saying. d. states, "I don't want anything to eat. My stomach is upset."

The spouse of a patient who has delusions asks the nurse, "Are there any circumstances under which the treatment team is justified in violating the patient's right to confidentiality?" The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals b. Coax to gain compliance c. Offer rewards in advance d. Establish firm limits

A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12yo. The patient says, "That girl looked like she was 19 years old." Which defense mechanism is this patient using? a. Denial b. Identification c. Displacement d. Rationalization

A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health professional."

A 5-year-old child diagnosed with ADHD bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings.

A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this child's most likely problem? a. Tic disorder b. Oppositional defiant disorder (ODD) c. Intellectual development disorder (IDD) d. Attention deficit hyperactivity disorder (ADHD)

A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"

A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient

A nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)? a. After a fall, vehicle crash, or exposure to a blast b. Before departing Afghanistan to return to the United States c. One year after returning to the United States from Afghanistan d. Immediately upon return to the United States from Afghanistan

A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider.

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

A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "phentobarbital sodium." What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

A nurse prepares a plan of care for a patient diagnosed with adult ADHD. Which intervention should be included? a. Remind the patient of priorities and deadlines. b. Teach work-related skills such as basic computer literacy. c. Establish penalties for failing to organize and prioritize tasks. d. Give encouragement and strategies for managing and organizing.

A nursing diagnosis for a patient diagnosed with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, "Within 2 weeks the patient will: a. appropriately express angry feelings." b. verbalize two positive things about self." c. verbalize the importance of eating a balanced diet." d. identify two alternative methods of coping with loneliness."

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, "I have three good friends at school. We talk and sit together at lunch." What is the nurse's best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from an intimate partner violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports.

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

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

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The best nursing diagnosis is: a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.

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

A patient diagnosed with severe and persistent mental illness who recently moved to a homeless shelter says, "My life is out of control. I'm like a leaf at the mercy of the wind." The nurse formulates the diagnosis Powerlessness. Outcomes will focus on: a. instilling hope. b. controlling anxiety. c. planning social activities. d. developing personal autonomy.

A patient diagnosed with stage 2 Alzheimer disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality. b. aphasia. c. apraxia. d. agnosia.

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry. I will have someone stay here and brush o the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you."

A patient experiencing severe anxiety suddenly begins running and shouting, "I'm going to explode!" The nurse should: a. say, "I'm not sure what you mean. Give me an example." b. chase after the patient, and give instructions to stop running. c. capture the patient in a basket-hold to increase feelings of control. d. assemble several staff members and state, "We will help you regain control."

A patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are temperature (T), 98.6° F; pulse (P), 72 beats per minute (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected? a. T, 98.6°; P, 64; R, 14 b. T, 98.6°; P, 68; R, 12 c. T, 98.6°; P, 62; R, 16 d. T, 98.6°; P, 84; R, 22

A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. denial

A patient tells the nurse, "My sexual functioning is normal when my partner wears lace. Without it, I'm not interested in sex." This comment evidences: a. exhibitionism. b. voyeurism. c. pedophilia. d. fetishism.

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient's current serum potassium is 2.7mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia

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

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. repression. b. devaluation. c. identification. d. compensation.

A person's spouse fled charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I'm tired of being nagged. My spouse deserved the beating."

A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be diffcult to talk about private matters to someone you just met." d. "Being thin does not seem to solve your problems. You are thin now but still unhappy."

A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice.

A soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. Family outing to the seashore d. Fireworks display on July 4th

When a nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." a. "Post-traumatic stress disorder often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Post-traumatic stress disorder often strains relationships. I will suggest some community resources for help and support."

A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)? a. Immediately upon return to the United States from Afghanistan b. Before departing Afghanistan to return to the United States c. One year after returning from Afghanistan d. Screening should be ongoing

A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nurse can correctly assess the student's experience as: a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety.

A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates: a. acting out. b. projection. c. suppression. d. passive aggression.

A therapist recently convicted of multiple counts of Medicare fraud says, "Sure I over billed. Why not? Everyone takes advantage of the government, so I did too." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You're right. Federal law requires me to keep that information private." b. "Those kinds of thoughts will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am required to share information with the treatment team."

An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.

An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job." Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder (GAD) c. Borderline personality disorder d. Adult ADHD

An example of a breach of a patient's right to privacy occurs when a nurse: a. asks a family to share information about a patient's prehospitalization behavior. b. discusses the patient's history with other staff members during care planning. c. documents the patient's daily behaviors during hospitalization. d. releases information to the patient's employer without consent.

Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

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

In a team meeting a nurse says, "I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.

The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratiffcation to an appropriate time. d. little time elapsed between thought and action.

The manager of a health club put a hidden camera in the women's locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "Monitor for complications of re-feeding." Which body system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular

The parent of an adult diagnosed with severe and persistent mental illness asks the nurse, "Why are you making a referral to that vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? a. "We make this referral to continue eligibility for federal funding." b. "Are you concerned that we're trying to make your child too independent?" c. "If you think the program would be detrimental, we can postpone it for a time." d. "Most patients are capable of employment at some level, competitive or supported."

Psych exam 2

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