Psych Test 3: Test bank

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe

a. Amygdala d. Temporal lobe

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

a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention

9. If an older adult patient must be physically restrained, who is responsible for the patient's safety? a. Nurse assigned to care for the patient b. Nursing assistant who applies the restraint c. Health care provider who ordered the application of restraint d. Family member who agrees to the application of the restraint

a. Nurse assigned to care for the patient

20. 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. Suggest that the child go to the gym and shoot baskets. b. Administer an antipsychotic medication. c. Place the child in a basket-hold. d. Call a staff member to seclude the child.

a. Suggest that the child go to the gym and shoot baskets.

23. When admitting older adult patients, health care agencies receiving federal funds must provide written information about: a. advance health care directives b. the financial status of the institution c. how to sign out against medical advice d. the institution's policy on the use of restraints

a. advance health care directives

4. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

b. Adventitious

8. Consider these health problems: Lewy body disease, Pick's disease, and Korsakoff's syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia

b. Dementia

13. A patient with stage 1 Alzheimer's 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

b. Impaired memory

10. A health care provider decided that the emotional distress of an older adult patient who experiences threatening auditory hallucinations warrants the use of risperidone (Risperdal). Which intervention should the nurse add to the patient's plan of care? a. Use disposable briefs for incontinence. b. Monitor for psychomotor changes. c. Implement a tyramine-free diet. d. Monitor for dehydration.

b. Monitor for psychomotor changes.

19. A patient with Alzheimer's 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 floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.

b. Place locks at the tops of doors.

13. A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

b. presents a clear and present danger to others.

15. When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

b. provide referral information verbally and in writing.

10. 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

c. Agnosia

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

c. Chronic low self-esteem

22. 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.

c. sit on the edge of the activity until able to regain self-control.

22. A patient 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."

d. "It is disappointing when someone you love no longer recognizes you."

13. 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 c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (ADHD)

d. Adult attention deficit hyperactivity disorder (ADHD)

17. Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old d. Riot at a rock concert

d. Riot at a rock concert

17. A patient with stage 2 Alzheimer's 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

d. agnosia

20. A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

a. "Are you thinking of suicide?"

13. A patient with whom the nurse is discussing advance directives asks, "What advantage does a durable power of attorney for health care have over a living will?" The nurse should reply that a durable power of attorney for health care: a. "Gives your agent the authority to make decisions about your care if you are unable to during any illness." b. "Can be given only to a relative, usually the next of kin, who has your best interests at heart." c. "Authorizes your physician to make decisions about your care that are in your best interest." d. "Can be used only if you have a terminal illness and become incapacitated."

a. "Gives your agent the authority to make decisions about your care if you are unable to during any illness."

9. A homeless patient with serious and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication, and housing for the patient was obtained in 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. "I am feeling safe and comfortable here. Nobody bothers me."

23. Which statement is a nurse most likely to hear from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My parents don't pay much attention to me."

a. "I'm fat and ugly."

4. A patient 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'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

a. "I'm fat and ugly."

2. A community member asks a nurse, "People with mental illnesses used to go to a state hospital. Why has that changed?" Select the nurse's accurate responses. Select all that apply. a. "Science has made significant improvements in drugs for mental illness, so now many people may live in their communities." b. "A better selection of less restrictive settings is now available in communities to care for individuals with mental illness." c. "National rates of mental illness have declined significantly. The need for state institutions is actually no longer present." d. "Most psychiatric institutions were closed because of serious violations of patients' rights and unsafe conditions." e. "Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings."

a. "Science has made significant improvements in drugs for mental illness, so now many people may live in their communities." b. "A better selection of less restrictive settings is now available in communities to care for individuals with mental illness." e. "Federal legislation and payment for treatment of mental illness have shifted the focus to community rather than institutional settings."

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult."

4. Which statements most clearly indicate that the speaker views mental illness with stigma? Select all that apply. 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. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." e. "People with mental illness are lazy. They get government disability checks instead of working."

26. A nurse wants to perform a preliminary assessment for suicidal ideation in an older adult patient. Which question would obtain the desired data? a. "What thoughts do you have about a person's right to take his or her own life?" b. "If you felt suicidal, would you communicate your feelings to anyone?" c. "Do you have any risk factors that potentially contribute to suicide?" d. "Do you think you are vulnerable to developing a depressed mood?"

a. "What thoughts do you have about a person's right to take his or her own life?"

6. A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers "yes" to which question? a. "Would you say your mood is often low?" b. "Are you having any trouble with your memory?" c. "Have you noticed an increase in your alcohol use?" d. "Do you often experience moderate-tosevere pain?"

a. "Would you say your mood is often low?"

15. 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: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg

3. A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting? a. A treatment plan will be determined. b. The health care provider will order neuroimaging studies. c. The team will request a court-appointed advocate for the patient. d. Assessment of the patient's need for placement outside the home will be undertaken

a. A treatment plan will be determined.

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

a. Access to housing c. Income to meet basic needs d. Availability of health insurance

16. A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Acute phase b. Outward adjustment phase c. Long-term reorganization phase d. Anger phase

a. Acute phase

3. A nurse should anticipate that which symptoms of Alzheimer's 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. Agraphia b. Hyperorality d. Hypermetamorphosis

2. A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Reassure the patient that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.

a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver.

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

a. Alzheimer's disease

23. Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

a. An unemployed husband with low self esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

5. A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care? a. Anger b. Concern c. Empathy d. Compassion

a. Anger

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

a. Assist the patient to identify triggers to binge eating.

14. 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 or riddles.

a. Assist the patient to perform simple tasks by giving step-by-step directions.

15. 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 depression b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend

a. Being raised by a parent with chronic major depression

5. A child with attention deficit hyperactivity disorder (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. Central nervous system stimulants

9. An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

a. Chronic low self-esteem, related to negative feedback from parents

3. A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

a. Confusion and disbelief

6. Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases

a. Coping mechanisms the patient is using

18. An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

a. Dementia

7. A person with serious 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. Develop a relationship

1. When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams

1. A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? Select all that apply. a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

a. Difficulty using a cell phone d. Rapid speech e. Trembling

20. Which employer's health plan is required to include parity provisions related to mental illnesses? a. Employer with more than 50 employees b. Cancer thrift shop staffed by volunteers c. Daycare center that employs 7 teachers d. Church that employs 15 people

a. Employer with more than 50 employees

8. A patient who is severely and persistently mentally ill and lives in a homeless shelter has the nursing diagnosis 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. Encourage mutual goal setting.

1. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? Select all that apply. a. Failure of older adults to receive necessary medical information b. Development of public policy that favors programs for older adults c. Staff shortages because caregivers prefer working with younger adults d. Perception that older adults consume a small share of medical resources e. More ancillary than professional personnel discriminate with regard to age

a. Failure of older adults to receive necessary medical information c. Staff shortages because caregivers prefer working with younger adults

11. Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or anti-anxiety medication.

a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking.

13. A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

a. History of family violence

14. 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. Inattention

6. 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

a. Ineffective coping

14. 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 coping, 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

a. Ineffective coping, related to seeking parental attention as evidenced by acting out

16. A patient tells the nurse at the clinic, "I haven't been taking my antidepressant medication as directed. I leave out the midday dose. I have lunch with friends and don't want them to ask me about the pills." Select the nurse's most appropriate intervention. a. Investigate the possibility of once-daily dosing of the antidepressant. b. Suggest to the patient to take the medication when no one is watching. c. Explain how taking each dose of medication on time relates to health maintenance. d. Add the nursing diagnosis—Ineffective therapeutic regimen management, related to lack of knowledge—to the plan of care.

a. Investigate the possibility of once-daily dosing of the antidepressant.

2. A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

a. Keep a cell phone fully charged. c. Have the telephone number for the nearest shelter. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

21. An older adult 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.

a. Label the bathroom door.

8. A nurse surveys the medical records for violations of patients' rights. Which finding signals a violation? a. No treatment plan is present in record. b. Patient belongings are searched at admission. c. Physical restraint is used to prevent harm to self. d. Patient is placed on one-to-one continuous observation.

a. No treatment plan is present in record.

4. Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

a. Pacing d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

1. A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach child rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

a. Parental sessions to teach child rearing practices b. Anger management counseling for the father c. Continuing home visits to provide support

5. Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics are the primary focuses of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

a. Patient behavior associated with the incident c. Intervention techniques used by staff d. Effect of environmental factors

1. 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. Peripheral edema c. Constipation d. Hypotension f. Lanugo

9. The staff development coordinator plans to teach the use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

a. Practice and teamwork

1. A patient with Alzheimer's 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 the 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. Provide clothing with elastic and hook and- loop closures. b. Label clothing with the patient's name and the name of the item. e. If the patient resists, use distraction and then try again after a short interval.

2. 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." Where should the nurse refer the patient? Select all that apply. a. Psychoeducation classes b. Vocational rehabilitation c. Social skills training d. Homeless shelter e. Crisis intervention

a. Psychoeducation classes b. Vocational rehabilitation c. Social skills training

2. A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. d. Select the person who will communicate with the patient.

9. Which principle takes priority for the psychiatric inpatient staff when addressing behavioral crises? a. Resolve behavioral crises with the least restrictive intervention possible. b. Rights of the majority of patients supersede the rights of individual patients. c. Swift intervention is justified to maintain the integrity of the therapeutic milieu. d. Allow patients the opportunities to regain control without intervention if the safety of other patients is not compromised.

a. Resolve behavioral crises with the least restrictive intervention possible.

8. A health care provider writes these new prescriptions for a resident in a skilled care facility: 2 G sodium diet; restraint as needed; limit fluids to 2000 ml daily; 1 dose milk of magnesia 30 ml orally if no bowel movement occurs for 3 days. Which prescription should the nurse question? a. Restraint b. Fluid restriction c. Milk of magnesia d. Sodium restriction

a. Restraint

19. An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision

26. A nurse cares for a patient 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. Selective serotonin reuptake inhibitor (SSRI)

1. A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

a. State the expectation that the patient will stay in control. d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."

a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table.

1. Which information should a nurse include in health teaching for adults who have with attention deficit hyperactivity disorder (ADHD) and their significant others? Select all that apply. a. Tendency for genetic transmission b. Prevention strategies related to substance abuse c. Negative reinforcement to help modify behaviors d. Psychostimulants for children (rarely effective in adults) e. Cognitive therapy to challenge internalized negative beliefs about self

a. Tendency for genetic transmission b. Prevention strategies related to substance abuse e. Cognitive therapy to challenge internalized negative beliefs about self

4. A 16-year-old adolescent with a conduct disorder (CD) has been in a residential program for 3 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. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences.

1. A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced

a. Threat to her life

10. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

a. Use accepting, nurturing, and empathetic communication techniques.

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest 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.

a. assess lung sounds and extremities.

18. 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. attention deficit ADHD. c. defiance of authority. d. anxiety over separation from a parent.

a. conduct disorder CD.

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

a. delirium

24. A parent 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 posttraumatic stress disorder. d. uses intellectualization to deal with problems.

a. displays resiliency.

21. A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

a. expresses frustration verbally instead of physically.

1. A nurse can best address factors of critical importance to successful community treatment for persons with mental illness by including assessments related to which of the following? Select all that apply. a. housing adequacy and stability b. income adequacy and stability c. family and other support systems d. early psychosocial development e. substance abuse history and current use

a. housing adequacy and stability b. income adequacy and stability c. family and other support systems e. substance abuse history and current use

2. A community mental health nurse plans an educational program for the staff members of a home health agency that specializes in the care of older adults. A topic of high priority should be: a. identifying clinical depression in older adults. b. providing cost-effective foot care for older adults. c. identifying nutritional deficiencies in older adults. d. psychosocial stimulation for those who live alone.

a. identifying clinical depression in older adults.

21. The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.

a. is experiencing a state of disequilibrium.

19. An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

a. maintaining the airway.

6. A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.

a. make sure adequate physical space exists between the nurse and the patient.

5. A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor's closet is locked, and all sharp objects are being used under staff supervision. These observations relate to: a. management of milieu safety b. coordinating care of patients c. management of the interpersonal climate d. use of therapeutic intervention strategies

a. management of milieu safety

7. A 78-year-old nursing home resident with hypertension and cardiac disease is usually alert and oriented. This morning, however, the resident says, "My family visited during the night. They stood by the bed and talked to me." In reality, the patient's family lives 200 miles away. The nurse should first suspect that the resident: a. may have a cognitive impairment associated with medication effects. b. may be developing Alzheimer's disease associated with advanced age. c. had a transient ischemic attack and developed sensory perceptual alterations. d. has a previously unidentified alcohol dependency and is beginning alcohol withdrawal delirium.

a. may have a cognitive impairment associated with medication effects.

16. A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

a. name two community resources that can be contacted.

1. Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who: a. present a clear danger to self or others. b. are noncompliant with medications at home. c. have no support systems in the community. d. develop new symptoms during the course of an illness.

a. present a clear danger to self or others.

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

a. prominent parotid glands.

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

a. remain safe in the present environment.

20. An adult has cared for a debilitated parent for 10 years. The parent's condition has recently declined, and the health care provider has recommended placement in a skilled care facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to: a. resolving the feelings associated with the threat to the person's self-concept b. maintaining the ability to identify situational supports in the community c. relying on the assistance from role models within the person's culture d. mobilizing automatic relief behaviors by the person

a. resolving the feelings associated with the threat to the person's self-concept

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

a. returning to premorbid levels of function

5. While conducting the initial interview with a patient in crisis, the nurse should: a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know the nurse controls the interview.

a. speak in short, concise sentences.

15. A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on: a. supporting emotional security and reestablishing equilibrium b. offering a long-term resolution of issues precipitating the crisis c. promoting growth of the individual d. providing legal assistance

a. supporting emotional security and reestablishing equilibrium

24. The highest priority for assessment by nurses caring for older adults who self-administer medications is: a. use of multiple drugs with anticholinergic effects b. overuse of medications for erectile dysfunction c. misuse of antihypertensive medications d. trading medications with acquaintances

a. use of multiple drugs with anticholinergic effects

21. An SSRI is prescribed for an older adult patient with depression. Nursing assessment should include careful collection of information regarding: a. use of other prescribed medications and over-the-counter products. b. evidence of pseudoparkinsonism or tardive dyskinesia. c. history of psoriasis and any other skin disorders. d. history of diarrhea and electrolyte imbalances.

a. use of other prescribed medications and over-the-counter products.

3. Which is the best comment for a nurse to use when beginning an interview with an older adult patient? a. "Hello, [call patient by first name]. I am going to ask you some questions to get to know you better." b. "Hello. My name is [nurse's name]. I am a nurse. Please tell me how you would like to be addressed by the staff." c. "I am going to ask you some questions about yourself. I would like to call you by your first name if you don't mind." d. "You look as though you are comfortable and ready to participate in an admission interview. Shall we get started?"

b. "Hello. My name is [nurse's name]. I am a nurse. Please tell me how you would like to be addressed by the staff."

1. A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse's best initial statement to this patient. a. "Everything is going to be all right. You are here at the clinic, and the staff will keep you safe." b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c. "You need to try to stop crying so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better."

19. During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better."

b. "In the past, how did you handle difficult or stressful situations?"

18. An 80-year-old patient has difficulty walking because of arthritis and says, "It's awful to be old. Every day is a struggle. No one cares about old people." Which is the nurse's most therapeutic response? a. "Everyone here cares about old people. That's why we work here." b. "It sounds like you're having a difficult time. Tell me about it." c. "Let's not focus on the negative. Tell me something good." d. "You are still able to get around, and your mind is alert."

b. "It sounds like you're having a difficult time. Tell me about it."

10. An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."

b. "My fingers are tingly."

22. An appropriate question for the nurse to ask to assess situational support is: a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

b. "Who can be helpful to you during this time?"

22. An adult man tells the nurse, "All my life, I have felt and acted like a woman while living in the body of a man. For the past year, I have lived and dressed as a woman. I'm changing 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?"

b. "Will you prescribe estrogen therapy?"

11. 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's disease was subsequently diagnosed. Which stage of Alzheimer's disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

b. 2 (moderate)

14. Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision.

23. A patient with burn injuries has had good coping skills for several weeks. Today, a newly assigned nurse is poorly organized. The patient's usual schedule was not followed. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization, and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members

b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?"

1. A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

b. Child and siblings are experiencing neglect.

18. An adult with attention deficit hyperactivity disorder (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 first 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

b. Cognitive therapy to help address internalized beliefs

3. Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

b. Collecting and preserving evidence d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

18. During morning care, a nursing assistant asks a patient 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

b. Confabulation

4. An older patient drinks a six-pack of beer daily. The patient tells the community health nurse, "I've been having trouble with my arthritis lately, so I take acetaminophen four times a day for pain." What are the nurse's priority interventions? Select all that apply. a. Inquiring about sleep disturbances caused by mixing alcohol and analgesic medications b. Determining the safety of the daily acetaminophen dose the patient is ingesting c. Advising the patient of the harmful effects of alcohol and acetaminophen on the liver d. Suggesting an increase in the acetaminophen dose because alcohol causes faster excretion e. Assessing the patient for declining functional status associated with medication-induced dementia

b. Determining the safety of the daily acetaminophen dose the patient is ingesting c. Advising the patient of the harmful effects of alcohol and acetaminophen on the liver

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

b. Focus interaction on familiar topics.

13. Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

b. Giving direction

5. A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

b. Have the patient fill out an abuse assessment screen.

17. A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety.

b. Help the patient identify incidents that trigger impulsive acting out.

15. 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

b. Inattention

13. A community mental health nurse has worked for 6 months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and stopped taking medications because of inadequate money. The patient says, "Only a traitor would make me go to the hospital." Which solution is best? a. Arrange a bed in a local homeless shelter with nightly onsite supervision. b. Negotiate a way to provide medication so the patient can remain at home. c. Hospitalize the patient until the symptoms have stabilized. d. Seek inpatient hospitalization for up to 1 week.

b. Negotiate a way to provide medication so the patient can remain at home.

25. A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.

b. Notify the health care provider and obtain a seclusion order.

1. What are the primary distinguishing factors between the behavior of children with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? The child with: (select all that apply). 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. ODD tests limits and disobeys authority figures. e. CD often violates the rights of others.

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

b. Observe for adverse effects of refeeding.

2. Which beliefs facilitate the provision of safe, effective care for older adult patients? Select all that apply. a. Sexual interest declines with aging. b. Older adults are able to learn new tasks. c. Aging results in a decline in restorative sleep. d. Older adults are prone to become crime victims. e. Older adults are usually lonely and socially isolated.

b. Older adults are able to learn new tasks. c. Aging results in a decline in restorative sleep. d. Older adults are prone to become crime victims.

8. A patient 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 are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.

b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment.

12. A patient with schizophrenia has been stable in the community. Today, the spouse reports the patient is delusional and explosive. The patient says, "I'm willing to take my medicine, but I forgot to get my prescription refilled." Which outcome should the nurse add to the plan of care? a. Nurse will obtain prescription refills every 90 days and deliver them to the patient. b. Patient's spouse will mark dates for prescription refills on the family calendar. c. Patient will report to the hospital for medication follow-up every week. d. Patient will call the nurse weekly to discuss medication-related issues.

b. Patient's spouse will mark dates for prescription refills on the family calendar.

20. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.

b. Periodically provide an update and progress report on the patient.

23. An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

b. Powerlessness

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

b. Psychostimulants

19. A 74-year-old patient is regressed and apathetic and responds to others only when they initiate the interaction. What form of therapy would be most useful to promote resocialization? a. Life review b. Remotivation c. Group psychotherapy d. Individual psychotherapy

b. Remotivation

7. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

b. Report the suspected abuse or neglect according to state regulations.

4. After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

b. Reported c. Penetration f. Declined

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

b. Rigidity, perfectionism

4. What is the priority nursing diagnosis for a patient with 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

b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait

15. After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

b. Risk for injury, related to partner's physical abuse when intoxicated

16. In a sad voice, a patient tells the nurse of the recent deaths of a spouse of 50 years and their adult child in an automobile accident. The patient has no other family and only a few friends in the community. What is the priority nursing diagnosis? a. Spiritual distress, related to being angry with God for taking the family b. Risk for suicide, related to recent deaths of significant others c. Anxiety, related to sudden and abrupt lifestyle changes d. Social isolation, related to loss of existing family

b. Risk for suicide, related to recent deaths of significant others

6. A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

b. Risk of domestic abuse

17. A community psychiatric nurse assesses that a patient with a mood disorder is more depressed than on the previous visit a month ago; however, the patient says, "I feel the same." Which intervention supports the nurse's assessment while preserving the patient's autonomy? a. Arrange for a short hospitalization. b. Schedule weekly clinic appointments. c. Refer the patient to the crisis intervention clinic. d. Call the family and ask them to observe the patient closely.

b. Schedule weekly clinic appointments.

20. An older adult with dementia lives with family and attends day care. After caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care.

25. A nurse and social worker co-lead a reminiscence group for eight "elite old" adults. Which activity is appropriate to include in the group? a. Performing mild aerobic exercises b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

b. Singing a song from World War II

3. A nurse assessing an older adult patient for suicide potential should include questions about mood and which other symptoms? Select all that apply. a. Increased appetite b. Sleep pattern changes c. Anhedonia and anergia d. Increased social isolation e. Increased concern with bodily functions

b. Sleep pattern changes c. Anhedonia and anergia d. Increased social isolation e. Increased concern with bodily functions

6. A patient living independently has command hallucinations to report terrorism to the Federal Bureau of Investigation (FBI) and to shout 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. Homelessness d. Lack of insurance parity

b. Stigma

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to under involvement with the victim. d. Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment.

3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b. Sympathy for the victim and anger toward the abuser

14. Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Assessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program.

b. Teaching stress reduction techniques to a beginning student nurse.

12. What behavior by a nurse caring for a patient 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.

b. The nurse uses an authoritarian manner when interacting with the patient.

16. A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule.

7. An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male nursing assistant and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."

b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable."

1. A student nurse visiting a senior center tells the instructor, "It's so depressing to see all these old people. They are so weak and frail. They are probably all senile." The student is expressing: a. reality. b. ageism. c. empathy. d. advocacy.

b. ageism.

3. A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is: a. suicidal. b. anxious and fearful. c. misperceiving reality. d. potentially homicidal.

b. anxious and fearful.

4. A 75-year-old patient comes to the clinic reporting frequent headaches. After an introduction at the beginning of the interview, the nurse should: a. initiate a neurologic assessment. b. ask if the patient can hear clearly as the nurse speaks. c. suggest that the patient lie down in a darkened room for a few minutes. d. administer medication to relieve the patient's pain before performing the assessment.

b. ask if the patient can hear clearly as the nurse speaks.

9. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." If this person's immediate family is unable to provide sufficient situational support, the nurse should: a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the patient, "You must be strong. Don't let this crisis overwhelm you." d. foster insight by relating the present situation to earlier situations involving loss.

b. ask what other relatives or friends are available for support.

11. An appropriate intervention for a patient 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 intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

b. avoid skipping meals or restricting food.

15. A 79-year-old white man tells a visiting nurse, "I've been feeling down lately. My family and friends are all dead. My money is running out, and my health is failing." The nurse should analyze this comment as: a. normal pessimism of older adults. b. evidence of suicide risk. c. a cry for sympathy. d. normal grieving.

b. evidence of suicide risk.

13. A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

b. explain that washing would destroy evidence.

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

b. failure to develop interpersonal skills.

12. Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of spousal abuse. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

b. has a history of spousal abuse.

2. A child with attention deficit hyperactivity disorder (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

b. improved ability to participate in play with other children

23. 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. hyperactivity b. impulsivity c. inattention d. defiance

b. impulsivity

2. Severe and persistent mental illness is characterized as a: a. mental illness of longer than 2 weeks' duration b. major chronic 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

b. major chronic mental illness marked by significant functional impairments

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

b. more efficiently use resources as the only manager responsible for coordinating

17. A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

b. plans coping strategies for fearful situations.

18. A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

b. provide written information concerning the physical and emotional reactions that may be experienced.

19. 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.

b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths.

7. 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.

b. states, "I feel bugs crawling on my legs and biting me."

20. A clinic nurse interviews four patients between 70 and 80 years of age. Which patient should have further assessment regarding the risk of alcohol dependence? The patient: a. with a history of intermittent problems of alcohol misuse early in life and who now consumes one glass of wine nightly with dinner. b. with no history of alcohol-related problems until age 65 years, when the patient began to drink alcohol daily "to keep my mind off my arthritis." c. who drank socially throughout adult life and continues this pattern, saying, "I've earned the right to do as I please." d. who abused alcohol between the ages of 25 and 40 years but now abstains and occasionally attends Alcoholics Anonymous.

b. with no history of alcohol-related problems until age 65 years, when the patient began to drink alcohol daily "to keep my mind off my arthritis."

21. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a pool ball at another adolescent, which comment by the nurse would set limits? a. "Attention, everyone. We are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Do not throw the ball. Put it back on the pool table." d. "Please do not lose control of your emotions."

c. "Do not throw the ball. Put it back on the pool table."

11. A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

c. "How did this happen to you?"

5. A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

c. "I'd like to talk with you about how you're feeling right now."

19. The parent of a child 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 doesn't mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

c. "Tics often change frequency or severity. That doesn't mean they aren't real."

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

c. "What do you eat in a typical day?"

8. A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

c. "You believe this would not have happened if you had not been alone?"

15. A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse should say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Was your husband angry if you did not have dinner ready on time?"

c. "You want to go home to prepare your husband's dinner?"

11. A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is _____________ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

c. 4 to 6

10. To provide comprehensive care to patients, which competency is more important for a nurse who works in a community mental health center than a psychiatric nurse who works in an inpatient unit? a. Problem-solving skills b. Calm external manner c. Ability to cross service systems d. Knowledge of psychopharmacology

c. Ability to cross service systems

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

c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips

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

c. Anorexia nervosa

18. A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm coming apart." Which nursing diagnosis applies? a. Decisional conflict, related to challenges to personal values b. Spiritual distress, related to ethical implications of treatment regimen c. Anxiety, related to changes perceived as threatening to psychological equilibrium d. Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs

c. Anxiety, related to changes perceived as threatening to psychological equilibrium

11. A suspicious and socially isolated patient lives alone, eats one meal a day at a nearby shelter, and spends the remaining daily food allowance on cigarettes. Select the community psychiatric nurse's best initial action. a. Report the situation to the manager of the shelter. b. Tell the patient, "You must stop smoking to save money." c. Assess the patient's weight; determine the foods and amounts eaten. d. Seek hospitalization for the patient while a new plan is being formulated.

c. Assess the patient's weight; determine the foods and amounts eaten.

7. 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.

c. Assist the adolescent to differentiate reality from perceptions.

5. What is the priority intervention for a patient 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

c. Careful observation and supervision

11. 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

c. Conduct disorder CD.

17. When making a distinction as to whether a patient is experiencing confusion related to depression or dementia, what information would be most important for the nurse to consider? a. The patient with dementia is persistently angry and hostile. b. Early morning agitation and hyperactivity occur in dementia. c. Confusion seems to worsen at night when dementia is present. d. A patient who is depressed is constantly preoccupied with somatic symptoms.

c. Confusion seems to worsen at night when dementia is present.

18. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."

c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?"

27. A nurse and social worker co-lead a reminiscence group for eight "young old" adults. Which activity is most appropriate to include in the group? a. Performing mild aerobic exercises b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

c. Discussing national leadership during the Vietnam War

2. An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional

25. 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. Dyspareunia c. Exhibitionism d. Sexual masochism

c. Exhibitionism

13. 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

c. Family therapy

14. An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

c. Honeymoon

2. A nurse prepares the plan of care for a 15-year-old adolescent with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will: select all that apply. a. 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. 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.

12. An adult tells the nurse, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

c. Ineffective coping, related to perceived loss of daughter

17. 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 term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

c. Lanugo

24. What is the priority need for a patient 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

c. Maintenance of nutrition and hydration

16. After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

c. Maturational

18. Which agency provides coordination in the event of a terrorist attack? a. U.S. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

c. National Incident Management System (NIMS)

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by alien monsters d. Completing alcohol withdrawal and beginning a rehabilitation program

c. Paranoid delusions of being followed by alien monsters

17. An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

c. Physical

25. Which intervention is appropriate to use for patients 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.

c. Reintroduce the health care worker at each contact.

15. Two patients in a residential care facility have 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."

c. Separate and distract the patients. Take one to the day room and the other to an activities area.

7. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

c. Situational

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

c. Tactile hallucinations

26. At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance." The nurse responds, "I think it would be worthwhile to have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency.

c. The nurse is having difficulty terminating the relationship.

4. A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care worker's behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

c. The patient interpreted the health care worker's behavior as potentially harmful.

16. 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.

c. Use the patient's glasses and hearing aids.

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients." Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. Wish for revenge d. Preoccupation with the incident

c. Wish for revenge

22. Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

c. Women's shelter

2. A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a pre-discharge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to: a. cancel the patient's discharge from the hospital. b. contact the landlord who evicted the patient to further discuss the situation. c. arrange a temporary place for the patient to stay until new housing can be arranged. d. document that the adverse medication reaction was feigned because the patient had nowhere to live.

c. arrange a temporary place for the patient to stay until new housing can be arranged.

8. Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

c. bite marks

12. A nurse working a rape telephone hotline should focus communication to: a. arrange long-term patient counseling. b. provide callers with a sympathetic listener. c. explain immediate steps that a victim of rape should take. d. obtain information to relay to the local police.

c. explain immediate steps that a victim of rape should take.

7. A student nurse prepares to administer oral medications to a patient with major depression, but the patient refuses the medication. The student nurse should: a. tell the patient, "I'll get an unsatisfactory grade if I don't give you the medication." b. tell the patient, "Refusing your medication is not permitted. You are required to take it." c. explore the patient's concerns about the medication, and report to the staff nurse. d. document the patient's refusal of the medication without further comment.

c. explore the patient's concerns about the medication, and report to the staff nurse.

11. The father of a child 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

c. family burden of mental illness

22. When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

c. helping the victim feel safe.

26. Which behavior indicates that the treatment plan for a child 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.

c. holds the parent's hand while walking.

9. A nurse administers medications to four patients with Alzheimer's 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)

c. memantine (Namenda)

19. Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

c. olanzapine (Zyprexa)

22. A patient with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor child rearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm

c. personality style that externalizes problems.

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

c. recognizing the symptoms of hypokalemia.

1. Health maintenance and promotion efforts for patients 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

c. screening for cancer, hypertension, and diabetes

24. 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

c. sexual self-awareness

26. When a nurse finds a patient 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."

d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

6. An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"

d. "Are you having thoughts of hurting yourself or others?"

10. 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 difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get the 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 off the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you."

d. "I don't see any bugs, but I know you are frightened so I will stay with you."

12. The parent of an adult who is severely and persistently mentally ill 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."

d. "Most patients are capable of employment at some level, competitive or supported."

10. 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 clinic."

d. "Talk with your health care provider about a referral to a mental health clinic."

2. A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying." b. "How did your wrist get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started to feel this way?"

d. "What was happening just before you started to feel this way?"

16. 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

d. 3-year-old who is mute, passive toward adults, and twirls while walking

1. 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. Mental retardation b. Oppositional defiant disorder (ODD) c. Pervasive developmental disorder d. Attention deficit hyperactivity disorder (ADHD)

d. Attention deficit hyperactivity disorder (ADHD)

17. 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. Posttraumatic stress disorder. c. Separation anxiety. d. Autistic disorder ASD.

d. Autistic disorder ASD.

14. A community psychiatric nurse facilitates medication compliance for a patient by having the health care provider prescribe depot medications by injection every 3 weeks at the clinic. For this plan to be successful, which factor will be of critical importance? a. Attitude of significant others toward the patient b. Nutritional services in the patient's neighborhood c. Level of trust between the patient and the nurse d. Availability of transportation to the clinic

d. Availability of transportation to the clinic

24. When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient's affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

d. Begin with the least restrictive measure possible.

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

d. Cardiovascular

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

d. Clarifying the nurse's own personal values

8. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by, "I can't take it anymore!"

d. Clarifying what the patient means by, "I can't take it anymore!"

10. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the husband's infidelity d. Coping with the reaction to the daughter's events

d. Coping with the reaction to the daughter's events

4. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

d. Denial

24. A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

11. What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

d. Desire to humiliate or control others

27. A patient 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 activities d. Developing personal autonomy

d. Developing personal autonomy

12. An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

d. Document injuries with a body map.

27. Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

12. 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

d. Establish firm limits

25. A parent 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 the domestic violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports.

d. Foster healthy characteristics and existing environmental supports.

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

d. Gain 1 to 2 pounds.

16. A nurse prepares a plan of care for a patient with adult attention deficit hyperactivity disorder (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.

d. Give encouragement and strategies for managing and organizing.

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

d. Imbalanced nutrition: less than body requirements

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

d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

18. 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 patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

d. Imbalanced nutrition: less than body requirements, related to self-starvation

11. An older adult patient brings a bag of medication to the clinic. The nurse finds one bottle labeled "Ativan" and one labeled "lorazepam," and both are labeled "Take two times daily." Bottles of hydrochlorothiazide, Inderal, and rofecoxib, each labeled "Take one daily," are also included. Which conclusion is accurate? a. Rofecoxib should not be taken with Ativan. b. The patient's blood pressure is likely to be very high. c. This patient should not self-administer any medication. d. Lorazepam and Ativan are the same drug; consequently, the dose is excessive.

d. Lorazepam and Ativan are the same drug; consequently, the dose is excessive.

9. The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape victim advocate.

d. Patient agrees to keep a follow-up appointment with the rape victim advocate.

2. Disturbed body image is the nursing diagnosis for a patient 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.

d. Patient expresses satisfaction with body appearance.

10. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

d. Physical injuries

19. 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 levels associated with eating.

d. Processing the heightened anxiety levels associated with eating.

6. Which environmental adjustment should the nurse make for a patient with delirium and 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.

d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

3. A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. 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

d. Rationalization

3. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Posttrauma response c. Disturbed thought processes d. Risk for other-directed violence

d. Risk for other-directed violence

2. A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

d. Severe

7. A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

d. Support the victim to separate issues of vulnerability from blame.

22. Which assessment finding for a patient 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

d. Systolic blood pressure: 62 mm Hg

3. A 5-year-old child with attention deficit hyperactivity disorder (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.

d. Take the child into another room with toys to act out feelings.

5. Which statement about aging provides the best rationale for focused assessment of older adult patients? a. Older adults are often socially isolated and lonely. b. As people age, they become more rigid in their thinking. c. The majority of older adults sleep more than 12 hours per day. d. The senses of vision, hearing, touch, taste, and smell decline with age.

d. The senses of vision, hearing, touch, taste, and smell decline with age.

23. 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

d. Voyeurism

21. Information from a patient's record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. chemical dependence.

d. chemical dependence.

14. Recognizing the risk for acquired immunodeficiency syndrome (AIDS) among older adults, nurses should provide health teaching aimed at: a. discouraging sexual expression b. using birth controls measures c. avoiding blood transfusions d. encouraging condom use

d. encouraging condom use

14. A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

d. exhibiting clues to potential aggression.

4. The relapse of a patient with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patient's thoughts are now more organized. The patient's family members are upset and say, "It's too soon about the patient being scheduled for discharge. Hospitalization is needed for at least a month." The nurse should: a. call the psychiatrist to come explain the discharge rationale. b. explain that health insurance will not pay for a longer stay for the patient. c. call security to handle the disturbance and escort the family off the unit. d. explain that the patient will continue to improve if medication is taken regularly.

d. explain that the patient will continue to improve if medication is taken regularly.

21. 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

d. fetishism

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

d. identify two alternative methods of coping with loneliness.

5. A patient 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 regime as: a. inadequate discharge planning b. poor therapeutic alliance with clinicians c. dislike of the side effects of antipsychotic medications d. impaired reasoning secondary to the schizophrenia

d. impaired reasoning secondary to the schizophrenia

22. An older adult patient with depression is being treated with sertraline (Zoloft). This medication is often chosen for older adult patients because it: a. has a high degree of sedation. b. is effective when given in smaller doses. c. has few adverse interactions with other drugs. d. is less affected by changes associated with aging.

d. is less affected by changes associated with aging.

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

d. play and talk about the play activity.

15. Which assessment finding for a patient in the community requires priority intervention by the nurse? The patient: a. receives Social Security disability income plus a small check from a trust fund. b. lives in an apartment with two patients who attend day hospital programs. c. has a sibling who is interested and active in care planning. d. purchases and uses marijuana on a frequent basis.

d. purchases and uses marijuana on a frequent basis.

21. A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

d. respiratory depression.

19. Which patient would a nurse refer to partial hospitalization? An individual who: a. spent yesterday in the 24-hour supervised crisis care center and continues to be actively suicidal. b. because of agoraphobia and panic episodes needs psychoeducation for relaxation therapy c. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up. d. states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."

d. states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."

12. An advance directive gives valid direction to health care providers when a patient is: a. aggressive b. dehydrated c. unable to verbally communicate d. unable to make decisions for him- or herself

d. unable to make decisions for him- or herself

25. After completing the contracted number of visits to the crisis clinic, an adult says, "I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group." The nurse can evaluate the patient's feelings about the care received as: a. not at all satisfied b. somewhat satisfied c. moderately satisfied d. very satisfied

d. very satisfied

6. The following patients are seen in the emergency department. The psychiatric unit has one bed available. Which patient should the admitting officer recommend for admission to the hospital? The patient who: a. experiencing dry mouth and tremor related to side effects of haloperidol (Haldol). b. experiencing anxiety and a sad mood after a separation from a spouse of 10 years. c. who self-inflicted a superficial cut on the forearm after a family argument. d. who is a single parent and hears voices saying, "Smother your infant."

d. who is a single parent and hears voices saying, "Smother your infant."