Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 15

Type: MCSA

The nurse knows that the client did not adhere to a medication plan in the past due to severe side effects. What information would be most important to include in the clients teaching?

1. The need to monitor all body changes on a continuous basis

2. Hopefulness about managing side effects

3. Reassurance that side effects will not occur

4. A detailed explanation of all potential side effects

Correct Answer: 2

Rationale 1: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Rationale 2: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Rationale 3: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Rationale 4: Side effects can be managed successfully and clients need to feel hopeful about their ability to work with the health care team in doing this. Although the client needs to know about potential side effects, the client should not be given only frightening information. Some side effects are a real possibility, and the nurse should not give false reassurance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate the different perspectives clients have about pharmacology into treatment regimens.

Question 16

Type: MCSA

A family member says to the nurse, I think my sister needs more medication because she says she cannot sit still and is moving her legs back and forth. The clients risperidone (Risperdal) was recently increased to 10 mg daily. What is the correct nursing response?

1. I will check with your sister because what you are describing sounds like a side effect called akathisia.

2. I will check to see what your sister has been prescribed because some clients get anxious when their medications are increased.

3. I will see if your sister has been prescribed a medication to counteract the dystonic reaction that she is having.

4. I will call the doctor and report that your sister is developing a tolerance to risperidone and the dose is not effective.

Correct Answer: 1

Rationale 1: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Rationale 2: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Rationale 3: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Rationale 4: Akathisia is the inability to sit still for more than a few minutes or the feeling of not being able to sit still. It is a side effect of antipsychotic medication that can be very distressing to the client. The nurse should assess the patient to determine if she has akathisia. It would not be typical for a client to get anxious just because the medications were increased. A dystonia would be an abnormal tonic muscle contraction. Risperidone is not addictive and clients do not develop tolerance to it.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 17

Type: MCSA

The nurse observes a client on an antipsychotic medication and notes a pill-rolling movement of the fingers and a tremor of the extremities. The nurse documents this as what type of side effect?

1. Drug-induced parkinsonism

2. Dystonia

3. Anticholinergic effect

4. Tardive dyskinesia

Correct Answer: 1

Rationale 1: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Rationale 2: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Rationale 3: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Rationale 4: One form of EPSE is drug-induced parkinsonism characterized by tremors, rigidity, and pill-rolling movements of the fingers. Dystonia is an involuntary tonic muscle contraction. Anticholinergic side effects include blurred vision, dry mouth, urinary retention, and constipation. Tardive dyskinesia is involuntary nonrhythmic movements of the mouth, face, etc.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 18

Type: MCSA

The spouse of a client on an antipsychotic medication asks the nurse why they routinely assess the client for movements, especially around the mouth and extremities. What nursing response is correct?

1. Abnormal involuntary movements can be an irreversible side effect of antipsychotic medications.

2. Antipsychotic medications can lead to this type of dystonia.

3. Abnormal involuntary movements can be easily treated and less annoying to the client.

4. Movements around the mouth herald the approaching medication tolerance that the client is developing.

Correct Answer: 1

Rationale 1: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance. Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Rationale 2: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance.

Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Rationale 3: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance.

Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Rationale 4: The nurse is assessing for tardive dyskinesia, an arrhythmic, involuntary movement that can be irreversible if not detected early. Antipsychotic medications do not lead to tolerance.

Abnormal involuntary movements are not easily treated. Dystonia is a side effect characterized by muscle spasms.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 19

Type: MCSA

When in the course of treatment with an antipsychotic medication would the nurse be most likely to assess tardive dyskinesia?

1. Within 72 hours of initiation

2. After long-term use

3. Within 48 hours of initiation

4. After three or more weeks of treatment

Correct Answer: 2

Rationale 1: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Rationale 2: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Rationale 3: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Rationale 4: Tardive dyskinesia has a late onset during the course of treatment with antipsychotic medications.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

Question 20

Type: MCMA

Which of the following are extrapyramidal side effects that the nurse would assess as symptoms of dystonia?

Standard Text: Select all that apply.

1. Decreased gastric motility and tachycardia

2. An inability to sit still

3. Forcing the back to arch and the neck to bend backward

4. Pulling the neck down into the shoulders

5. Spasms of the neck and back

Correct Answer: 2,3,4,5

Rationale 1: Decreased gastric motility and tachycardia. Decreased gastric motility and tachycardia may occur with a dopamine-acetylcholine imbalance in the extrapyramidal system.

Rationale 2: An inability to sit still. An inability to sit still is akathisia.

Rationale 3: Forcing the back to arch and the neck to bend backward. Forcing the back to arch and the neck to bend backward are examples of dystonia.

Rationale 4: Pulling the neck down into the shoulders. Pulling the neck into the shoulders is a type of dystonia.

Rationale 5: Spasms of the neck and back. Spasms of the neck and back are examples of dystonia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain acute extrapyramidal side effects to clients and families.

Question 21

Type: MCSA

The client is taking a medication to help cope with EPSEs but can not remember the name of the medication. The nurse would give the client information about which of the following medications that the client is receiving?

1. Risperidone (Risperdal)

2. Duloxetine (Cymbalta)

3. Loxapine (Loxitane)

4. Benztropine (Cogentin)

Correct Answer: 4

Rationale 1: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Rationale 2: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Rationale 3: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Rationale 4: Benztropine is an antiparkinson drug used to help manage the EPSEs of antipsychotic medications. Risperidone and loxapine are antipsychotic medications. Duloxetine is an antidepressant medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 22

Type: MCSA

The client reports difficulty remembering at home whether the client took the medication or just thought about taking the medication. Which of the following strategies would be most helpful for the nurse to suggest?

1. Obtaining and using a pill box

2. Wearing a rubber band to remember

3. Repeating the need to take the medications routinely

4. Putting the pill container near the breakfast table

Correct Answer: 1

Rationale 1: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Rationale 2: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Rationale 3: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Rationale 4: A pill box is the only method listed for which the patient can check the date and time to see whether or not the pill was taken.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 23

Type: MCSA

The nurse should monitor for which of the following in the client taking venlafaxine (Effexor)?

1. Increased weight

2. Prolonged QTc interval

3. Increased blood pressure

4. Tardive dyskinesia

Correct Answer: 3

Rationale 1: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Rationale 2: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Rationale 3: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Rationale 4: Sustained increased blood pressure has been noted in some clients, especially those on higher doses of venlafaxine. Weight, QTc intervals, and tardive dyskinesia are not typical side effects of venlafaxine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 24

Type: MCSA

Which of the following laboratory studies are routinely done on patients taking second generation antipsychotic medications?

1. Hemoglobin and hematocrit

2. Renal functions

3. Thyroid functions

4. Serum glucose levels

Correct Answer: 4

Rationale 1: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Rationale 2: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Rationale 3: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Rationale 4: Second generation antipsychotic medications have a risk of insulin resistance contributing to diabetes, so serum glucose levels are routinely monitored. Hemoglobin, thyroid function, and renal function are not typically affected by the second generation antipsychotic medications.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 25

Type: MCSA

The client has been taking fluvoxamine (Luvox) for years, has been symptom-free for one year, and is now considering taking a drug holiday. What nursing teaching is necessary?

1. The client should be symptom-free for at least two years before trying to go off the medication

2. The client should let the prescriber make these decisions and should not suggest this

3. A drug holiday should be avoided due to discontinuation symptoms

4. This is worth trying since the client has been symptom-free for a year

Correct Answer: 3

Rationale 1: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Rationale 2: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Rationale 3: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Rationale 4: Fluvoxamine should be gradually tapered to avoid discontinuation symptoms. The client should discuss the drug holiday with the prescriber.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare and contrast a plan of care for taking these medications for an indefinite period of time versus a six-month period of time.

Question 26

Type: MCSA

A client exhibiting which of the following antipsychotic side effects would require the nurses immediate intervention?

1. Neuroleptic malignant syndrome

2. Drowsiness

3. Parkinsonism

4. Impotence

Correct Answer: 1

Rationale 1: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Rationale 2: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Rationale 3: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Rationale 4: Neuroleptic malignant syndrome can be fatal. Parkinsonism, impotence, and drowsiness are not normally life-threatening conditions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 27

Type: MCSA

Which of the following laboratory studies is performed because the client is taking lithium?

Correct Answer: 4

Rationale 1: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Rationale 2: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Rationale 3: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Rationale 4: A thyroid goiter and hypothyroidism are side effects of lithium; therefore, thyroid function studies are performed periodically. Lithium is not metabolized in the liver and so does not require liver function studies. A CBC and hemoglobin are not needed because lithium does not frequently alter blood counts.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 28

Type: MCSA

Clients taking an MAOI should be taught to avoid completely which of the following foods?

1. White wines, cottage cheese, and ice cream

2. Steak, potatoes, and corn

3. Bread, apples, and hamburgers

4. Liver, sauerkraut, and yogurt

Correct Answer: 4

Rationale 1: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Rationale 2: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Rationale 3: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Rationale 4: Clients taking MAOIs are taught to avoid foods containing tyramine, such as, liver, aged cheeses, red wines, sauerkraut, and yogurt. Additionally, caffeine, colas, chocolate, soy products, aged fish, and processed meats contain tyramine in high amounts. White wines, cottage cheese, ice cream, bread, apples, hamburgers, steak, potatoes, and corn are allowed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 29

Type: MCSA

Because of the risk of postural hypotension, the client on clozapine (Clozaril) should be taught which of the following?

1. To wear sunscreen if going outdoors

2. To rise slowly from a lying position

3. To check for involuntary movements of the mouth

4. To have weekly blood work

Correct Answer: 2

Rationale 1: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Rationale 2: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Rationale 3: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Rationale 4: Antipsychotic medications have a risk for postural hypotension that could lead to a fall if the client rises too quickly. Wearing a sunscreen is necessary due to photosensitivity, not hypotension. Blood work checks for agranulocytosis. Mouth movements are not caused by hypotension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate nursing interventions to address the major side effects associated with psychotropic medications.

Question 30

Type: MCSA

Which of the following would indicate that the client needs more teaching related to coping with constipation as a side effect of antipsychotic medications?

1. I will regularly use enemas.

2. I will walk and stay active.

3. I will include fiber daily in my diet.

4. I will have an adequate intake of fluid.

Correct Answer: 1

Rationale 1: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Rationale 2: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Rationale 3: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Rationale 4: The client should not use enemas regularly as a way to deal with constipation. Including fiber in the diet as well as adequate fluids are useful strategies to cope with constipation. Avoiding a sedentary lifestyle and being active help resolve constipation.

Chapter 16. Psychotherapeutic Approaches for Addictions and Related Disorders

Multiple Choice

1. A patient diagnosed with alcoholism asks, How will Alcoholics Anonymous (AA) help me? Select the nurses best response.

a. The goal of AA is for members to learn controlled drinking with the support of a higher power.

b. An individual is supported by peers while striving for abstinence one day at a time.

c. You must make a commitment to permanently abstain from alcohol and other drugs.

d. You will be assigned a sponsor who will plan your treatment program.

ANS: B

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

2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:

0200: 118/78 mm Hg and 72 beats/min

0400: 126/80 mm Hg and 76 beats/min

0600: 128/82 mm Hg and 72 beats/min

0800: 132/88 mm Hg and 80 beats/min

1000: 148/94 mm Hg and 96 beats/min a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

What is the nurses priority action?

ANS: B a. Cardiovascular b. Respiratory

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

3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority?

ANS: B c. Neurologic d. Hepatic

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

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

ANS: C a. Disturbed sensory perception b. Ineffective coping

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

5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?

ANS: D c. Ineffective denial d. Risk for injury

The patients clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurses priority. The other diagnoses may apply but are not the priorities of care.

MSC: Client Needs: Safe, Effective Care Environment

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

ANS: B a. Check the patient every 15 minutes b. One-on-one supervision

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

7. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?

ANS: B c. Keep the room dimly lit d. Force fluids a. Sooner or later, alcohol will kill you. Then what will happen to your children? b. I hear a lot of defensiveness in your voice. Do you really believe this? c. If you were coping so well, why were you hospitalized again? d. Tell me what happened the last time you drank.

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

8. A patient diagnosed with an alcohol abuse disorder says, Drinking helps me cope with being a single parent. Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively?

ANS: D

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

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

ANS: B

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

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

ANS: B

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

11. A patient admitted to an alcoholism rehabilitation program tells the nurse, Im actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening. The patient is using which defense mechanism?

ANS: A c. Introjection d. Rationalization a. Bromocriptine (Parlodel) b. Methadone (Dolophine)

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

12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?

ANS: D c. Disulfiram (Antabuse) d. Naltrexone (ReVia) a. While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol. b. It will be important for you to structure life to avoid as much stress as you can and provide social protection. c. Addiction is a lifelong disease of self-destruction. You will need to observe your spouses behavior carefully. d. It is good that you are supportive of your spouses sobriety and want to help maintain it.

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

13. During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, After this treatment program, I think everything will be all right. Which remark by the nurse will be most helpful to the spouse?

ANS: A

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

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

ANS: C a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

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

15. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction.

ANS: A a. Simple and safe b. Active and bright

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

16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose?

ANS: A c. Stimulating and colorful d. Confrontational and challenging a Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

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

17. When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred?

ANS: A

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

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

ANS: A c. role reversal. d. homeostasis. a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patients breath sounds will be clear bilaterally and throughout lung fields.

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

19. In the emergency department, a patients vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome.

ANS: B a. Alcoholism is a lifelong disease. Relapses are expected. b. Use search and destroy tactics to keep the home alcohol free. c. Its important that you visit your family member on a regular basis. d. Make your loved one responsible for the consequences of behavior.

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

20. Family members of an individual undergoing a residential alcohol rehabilitation program ask, How can we help? Select the nurses best response.

ANS: D a. Learn about addiction and recovery. b. Develop alternate coping strategies.

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

21. Which goal for treatment of alcoholism should the nurse address first?

ANS: D c. Develop a peer support system. d. Achieve physiologic stability. a. 1-week detoxification program b. Long-term outpatient therapy

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

22. A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate?

ANS: D c. 12-step self-help program d. Residential program a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

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

23. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines.

ANS: A

Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

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

ANS: B

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

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

ANS: C a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

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

26. Which assessment findings are likely for an individual who recently injected heroin?

ANS: D

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

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

ANS: B c. opium intoxication. d. cocaine overdose. a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine National Research Council (IOM) c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

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

28. A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information?

ANS: A a. PCP b. Heroin

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

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

ANS: D c. Barbiturates d. Amphetamines

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

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

ANS: A a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

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

31. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurses best first action?

ANS: C

The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of ones own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

Multiple Response

1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, C, F

The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

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

ANS:

A, C, E

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

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

ANS: D, E a. I see, and use interested silence. b. I think you are drinking more than you report. c. Social drinkers have one or two drinks, once or twice a week. d. You describe drinking steadily throughout the day and evening. e. Your comments show denial of the seriousness of your problem.

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

4. A new patient beginning an alcoholism rehabilitation program says, Im just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening. Select the nurses most therapeutic responses. Select all that apply.

ANS: C, D

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

Chapter 17. Psychotherapy With Children

Question 1

Type: MCMA

There are many roles involved in caring for clients in the specialized area of child psychiatry. Which of the following diverse clinical functions includes the role of the nurse generalist working in child psychiatry?

Standard Text: Select all that apply.

1. Administer medication

2. Utilize knowledge and skills related to the mental health needs of clients

3. Prescribe psychotropic medications

4. Utilize knowledge related to the physical health needs of clients

5. Order diagnostic tests necessary to monitor effects of psychotropic medications

Correct Answer: 1,2,4

Rationale 1: Administer medication. The nurse generalist working in child psychiatry will administer medications that require strict and systematic monitoring

Rationale 2: Utilize knowledge and skills related to the mental health needs of clients. The nurse generalist working in child psychiatry will assess psychological symptoms.

Rationale 3: Prescribe psychotropic medications. Prescribing psychotropic medications is not within the scope of practice for a nurse generalist; these functions are performed by a physician or advanced practice nurse.

Rationale 4: Utilize knowledge related to the physical health needs of clients. The nurse generalist working in child psychiatry will assess physical symptoms.

Rationale 5: Order diagnostic tests necessary to monitor effects of psychotropic medications. Ordering diagnostic tests is not within the scope of practice for a nurse generalist; these functions are performed by a physician or advanced practice nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Compare the similarities and differences between generalist and specialist roles in child psychiatric nursing.

Question 2

Type: MCSA

A nurse generalist and advanced practice nurse both work on the staff of an inpatient unit. The advanced practice nurse has a comprehensive role as a primary caregiver in child psychiatry. Which of the following will be performed by the advanced practice nurse but not by the nurse generalist?

1. Explaining the treatment plan to a family

2. Performing admission assessments

3. Participating in discharge planning

4. Providing one-to-one counseling

Correct Answer: 4

Rationale 1: Child psychiatricmental health nurses are involved in treatment, consultation, education, and medication supervision and are the mainstay of hospital treatment programs where they are responsible for daily treatment plans, ongoing one-to-one or group counseling, and management of the childs medication regimen. You will see advanced practice nurses as the primary caregivers for children with mental health problems, providing direct psychotherapy, working with the family, and managing the childs medications.

Rationale 2: Child psychiatricmental health nurses are involved in treatment, consultation, education, and medication supervision and are the mainstay of hospital treatment programs where they are responsible for daily treatment plans, ongoing one-to-one or group counseling, and management of the childs medication regimen. You will see advanced practice nurses as the primary caregivers for children with mental health problems, providing direct psychotherapy, working with the family, and managing the childs medications.

Rationale 3: Child psychiatricmental health nurses are involved in treatment, consultation, education, and medication supervision and are the mainstay of hospital treatment programs where they are responsible for daily treatment plans, ongoing one-to-one or group counseling, and management of the childs medication regimen. You will see advanced practice nurses as the primary caregivers for children with mental health problems, providing direct psychotherapy, working with the family, and managing the childs medications.

Rationale 4: Child psychiatricmental health nurses are involved in treatment, consultation, education, and medication supervision and are the mainstay of hospital treatment programs where they are responsible for daily treatment plans, ongoing one-to-one or group counseling, and management of the childs medication regimen. You will see advanced practice nurses as the primary caregivers for children with mental health problems, providing direct psychotherapy, working with the family, and managing the childs medications.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Compare the similarities and differences between generalist and specialist roles in child psychiatric nursing.

Question 3

Type: MCSA

A growing role of the child psychiatricmental health nurse is:

1. Scrutinizing the public.

2. Promoting infant mental health.

3. Monitoring adult inpatient psychiatric clients.

4. Preventing mental health problems.

Correct Answer: 2

Rationale 1: A growing role for child psychiatricmental health nurses involves promotion of infant mental health in high-risk families in which the infants have medical complications or the parents have a history of mental illness or substance abuse. Monitoring adults and scrutinizing the public are not part of the child psychiatricmental health nurses role. Nurses can advocate for mental health issues, but they cannot prevent mental health problems.

Rationale 2: A growing role for child psychiatricmental health nurses involves promotion of infant mental health in high-risk families in which the infants have medical complications or the parents have a history of mental illness or substance abuse. Monitoring adults and scrutinizing the public are not part of the child psychiatricmental health nurses role. Nurses can advocate for mental health issues, but they cannot prevent mental health problems.

Rationale 3: A growing role for child psychiatricmental health nurses involves promotion of infant mental health in high-risk families in which the infants have medical complications or the parents have a history of mental illness or substance abuse. Monitoring adults and scrutinizing the public are not part of the child psychiatricmental health nurses role. Nurses can advocate for mental health issues, but they cannot prevent mental health problems.

Rationale 4: A growing role for child psychiatricmental health nurses involves promotion of infant mental health in high-risk families in which the infants have medical complications or the parents have a history of mental illness or substance abuse. Monitoring adults and scrutinizing the public are not part of the child psychiatricmental health nurses role. Nurses can advocate for mental health issues, but they cannot prevent mental health problems.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Compare the similarities and differences between generalist and specialist roles in child psychiatric nursing.

Question 4

Type: MCSA

When discussing indicators of emotionally disturbed children or children with disruptive behavior disorders with a group of student nurses, the psychiatric nurse states that one of the best indicators of emotionally disturbed children is that they have difficulty:

1. Seeking out peers.

2. Digesting a balanced diet.

3. Interpreting internal stimuli or external cues.

4. Following rules and norms of behavior.

Correct Answer: 4

Rationale 1: The central feature of a conduct disorder is repetitive and persistent behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. Look for behaviors that show aggression toward people and animals, destruction of property, deceitfulness or theft, or serious violations of parental or school rules. The ability to digest a balanced diet is not an indicator of an emotionally disturbed child. Children with a conduct disorder tend to find peers with similar issues. Interpreting internal stimuli or external cues is not related to conduct disorders.

Rationale 2: The central feature of a conduct disorder is repetitive and persistent behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. Look for behaviors that show aggression toward people and animals, destruction of property, deceitfulness or theft, or serious violations of parental or school rules. The ability to digest a balanced diet is not an indicator of an emotionally disturbed child. Children with a conduct disorder tend to find peers with similar issues. Interpreting internal stimuli or external cues is not related to conduct disorders.

Rationale 3: The central feature of a conduct disorder is repetitive and persistent behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. Look for behaviors that show aggression toward people and animals, destruction of property, deceitfulness or theft, or serious violations of parental or school rules. The ability to digest a balanced diet is not an indicator of an emotionally disturbed child. Children with a conduct disorder tend to find peers with similar issues. Interpreting internal stimuli or external cues is not related to conduct disorders.

Rationale 4: The central feature of a conduct disorder is repetitive and persistent behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. Look for behaviors that show aggression toward people and animals, destruction of property, deceitfulness or theft, or serious violations of parental or school rules. The ability to digest a balanced diet is not an indicator of an emotionally disturbed child. Children with a conduct disorder tend to find peers with similar issues. Interpreting internal stimuli or external cues is not related to conduct disorders.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Synthesize the key ideas in the biopsychosocial theories that help you understand the development of childhood psychiatric disorders.

Question 5

Type: MCSA

The nurse observes an 8-year-old child regressing to behavior that is characteristic of a toddler when faced with new situations. The child has been in several foster care families over the past three years. Which of the following interventions is appropriate for this child?

1. Providing for unmet needs

2. Providing consistency and continuity of caregivers

3. Ignoring the regressive behavior

4. Ignoring the negative behavior and reinforcing the positive behavior

Correct Answer: 2

Rationale 1: Defense mechanisms commonly employed by children are repression, reaction formation, and projection. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. Providing the child with consistency and continuity of caregivers will minimize situations that stimulate regression. The nurse will be able to evaluate the clients response to having consistency and continuity of caregivers. The nurse must recognize this behavior as a defense mechanism, and plan care that will strengthen the childs coping mechanisms. Providing for unmet needs is not specific or individualized and will be difficult to measure.

Rationale 2: Defense mechanisms commonly employed by children are repression, reaction formation, and projection. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. Providing the child with consistency and continuity of caregivers will minimize situations that stimulate regression. The nurse will be able to evaluate the clients response to having consistency and continuity of caregivers. The nurse must recognize this behavior as a defense mechanism, and plan care that will strengthen the childs coping mechanisms. Providing for unmet needs is not specific or individualized and will be difficult to measure.

Rationale 3: Defense mechanisms commonly employed by children are repression, reaction formation, and projection. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. Providing the child with consistency and continuity of caregivers will minimize situations that stimulate regression. The nurse will be able to evaluate the clients response to having consistency and continuity of caregivers. The nurse must recognize this behavior as a defense mechanism, and plan care that will strengthen the childs coping mechanisms. Providing for unmet needs is not specific or individualized and will be difficult to measure.

Rationale 4: Defense mechanisms commonly employed by children are repression, reaction formation, and projection. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. Providing the child with consistency and continuity of caregivers will minimize situations that stimulate regression. The nurse will be able to evaluate the clients response to having consistency and continuity of caregivers. The nurse must recognize this behavior as a defense mechanism, and plan care that will strengthen the childs coping mechanisms. Providing for unmet needs is not specific or individualized and will be difficult to measure.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Synthesize the key ideas in the biopsychosocial theories that help you understand the development of childhood psychiatric disorders.

Question 6

Type: MCSA

The parents of a premature infant are visiting their baby in the neonatal intensive care unit for the first time. The nurse observes the couple standing beside the incubator. Which of the following interventions will help facilitate the infants immediate mental health needs?

1. Notify the infants physician to come and talk with the parents

2. Facilitate stroking and touching their infant

3. Continue to observe their interactions to rule out a problem with bonding

4. Have them meet with other parents of premature infants

Correct Answer: 2

Rationale 1: Helping the parents stroke and touch their infant is the first step in facilitating the attachment process, which is essential to developing a socioemotional bond. Having the parents meet with the physician or other parents of premature infants will be beneficial but will not help meet the infants immediate mental health needs. The nurse will need to observe the new familys interactions, but intervening to help the parents interact with their infant would be the priority action.

Rationale 2: Helping the parents stroke and touch their infant is the first step in facilitating the attachment process, which is essential to developing a socioemotional bond. Having the parents meet with the physician or other parents of premature infants will be beneficial but will not help meet the infants immediate mental health needs. The nurse will need to observe the new familys interactions, but intervening to help the parents interact with their infant would be the priority action.

Rationale 3: Helping the parents stroke and touch their infant is the first step in facilitating the attachment process, which is essential to developing a socioemotional bond. Having the parents meet with the physician or other parents of premature infants will be beneficial but will not help meet the infants immediate mental health needs. The nurse will need to observe the new familys interactions, but intervening to help the parents interact with their infant would be the priority action.

Rationale 4: Helping the parents stroke and touch their infant is the first step in facilitating the attachment process, which is essential to developing a socioemotional bond. Having the parents meet with the physician or other parents of premature infants will be beneficial but will not help meet the infants immediate mental health needs. The nurse will need to observe the new familys interactions, but intervening to help the parents interact with their infant would be the priority action.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Synthesize the key ideas in the biopsychosocial theories that help you understand the development of childhood psychiatric disorders.

Question 7

Type: MCSA

The nurse is meeting for the first time with a child who was brought to the clinic with a mental health concern. When planning care for a child with a mental health problem, the nurse must understand both the childs mental health problems and the childs:

1. Previous hospitalizations.

2. Life experiences.

3. Physiological health problems.

4. Artistic ability.

Correct Answer: 2

Rationale 1: The nurse must understand the pathology involved in the childs mental health problems and the childs life experiences, as they may contribute to the childs problems as well as strengths. Physiological health problems, artistic abilities, and previous hospitalizations are components of the childs life experiences. These must be considered in order to develop interventions that are appropriate to the child.

Rationale 2: The nurse must understand the pathology involved in the childs mental health problems and the childs life experiences, as they may contribute to the childs problems as well as strengths. Physiological health problems, artistic abilities, and previous hospitalizations are components of the childs life experiences. These must be considered in order to develop interventions that are appropriate to the child.

Rationale 3: The nurse must understand the pathology involved in the childs mental health problems and the childs life experiences, as they may contribute to the childs problems as well as strengths. Physiological health problems, artistic abilities, and previous hospitalizations are components of the childs life experiences. These must be considered in order to develop interventions that are appropriate to the child.

Rationale 4: The nurse must understand the pathology involved in the childs mental health problems and the childs life experiences, as they may contribute to the childs problems as well as strengths. Physiological health problems, artistic abilities, and previous hospitalizations are components of the childs life experiences. These must be considered in order to develop interventions that are appropriate to the child.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Differentiate between the multicausal and interactive models of child mental illness.

Question 8

Type: MCSA

The nurse providing case management to a child with a mental illness will collect data from the childs parents, teachers, and other health care providers in order to:

1. Complete a mental status exam.

2. Complete a comprehensive evaluation.

3. Collaborate with individuals that are significant to the child.

4. Complete a personality profile.

Correct Answer: 2

Rationale 1: A comprehensive evaluation includes collecting data from the various individuals, including the childs parents, teachers, and other health care providers. The comprehensive assessment is important in order to gain understanding into the variables that impact the childs mental health. Data for the mental status exam and personality profile is not gathered from parents, teachers, and other health care providers. The purpose for gathering the data is to complete the comprehensive assessment; collaboration may be a result of the process.

Rationale 2: A comprehensive evaluation includes collecting data from the various individuals, including the childs parents, teachers, and other health care providers. The comprehensive assessment is important in order to gain understanding into the variables that impact the childs mental health. Data for the mental status exam and personality profile is not gathered from parents, teachers, and other health care providers. The purpose for gathering the data is to complete the comprehensive assessment; collaboration may be a result of the process.

Rationale 3: A comprehensive evaluation includes collecting data from the various individuals, including the childs parents, teachers, and other health care providers. The comprehensive assessment is important in order to gain understanding into the variables that impact the childs mental health. Data for the mental status exam and personality profile is not gathered from parents, teachers, and other health care providers. The purpose for gathering the data is to complete the comprehensive assessment; collaboration may be a result of the process.

Rationale 4: A comprehensive evaluation includes collecting data from the various individuals, including the childs parents, teachers, and other health care providers. The comprehensive assessment is important in order to gain understanding into the variables that impact the childs mental health. Data for the mental status exam and personality profile is not gathered from parents, teachers, and other health care providers. The purpose for gathering the data is to complete the comprehensive assessment; collaboration may be a result of the process.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Differentiate between the multicausal and interactive models of child mental illness.

Question 9

Type: MCSA

A nurse is describing the multicausal perspective of mental health and illness to the parents of a child recently diagnosed with a spectrum disorder. Which statement would the nurse utilize when describing this approach?

1. Exposure to drugs and alcohol has been associated with psychiatric disorders.

2. The feedback mechanism appears dysfunctional, creating neurotoxic effects on brain development and function.

3. The childs genetically determined attributes and life experiences interact to influence mental health outcomes.

4. Early psychological trauma may create deficits or abnormalities in brain structure.

Correct Answer: 3

Rationale 1: The childs genetically determined attributes and life experiences interacting to influence mental health outcomes explains the perspective of the multicausal model of mental health and illness. Discussing feedback mechanism dysfunction would provide a partial explanation of neuroendocrine reactivity. Discussing the effects of early psychological trauma on brain structure partially explains nervous system responsiveness. Discussing the association of exposure to drugs and alcohol to psychiatric disorders partially explains complications occurring during the perinatal period as a cause of some mental illnesses.

Rationale 2: The childs genetically determined attributes and life experiences interacting to influence mental health outcomes explains the perspective of the multicausal model of mental health and illness. Discussing feedback mechanism dysfunction would provide a partial explanation of neuroendocrine reactivity. Discussing the effects of early psychological trauma on brain structure partially explains nervous system responsiveness. Discussing the association of exposure to drugs and alcohol to psychiatric disorders partially explains complications occurring during the perinatal period as a cause of some mental illnesses.

Rationale 3: The childs genetically determined attributes and life experiences interacting to influence mental health outcomes explains the perspective of the multicausal model of mental health and illness. Discussing feedback mechanism dysfunction would provide a partial explanation of neuroendocrine reactivity. Discussing the effects of early psychological trauma on brain structure partially explains nervous system responsiveness. Discussing the association of exposure to drugs and alcohol to psychiatric disorders partially explains complications occurring during the perinatal period as a cause of some mental illnesses.

Rationale 4: The childs genetically determined attributes and life experiences interacting to influence mental health outcomes explains the perspective of the multicausal model of mental health and illness. Discussing feedback mechanism dysfunction would provide a partial explanation of neuroendocrine reactivity. Discussing the effects of early psychological trauma on brain structure partially explains nervous system responsiveness. Discussing the association of exposure to drugs and alcohol to psychiatric disorders partially explains complications occurring during the perinatal period as a cause of some mental illnesses.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Differentiate between the multicausal and interactive models of child mental illness.

Question 10

Type: MCSA

A mother told the nurse she was appalled that the nurse would dare to ask if she took any drugs during her pregnancy. The nurse explains that the information is important in understanding the childs health because embryonic exposure to toxins during pregnancy is the major risk factor for:

1. Depression in preschoolers.

2. Lactose intolerance.

3. Mental retardation.

4. Mental illness.

Correct Answer: 3

Rationale 1: The major risk factor for retardation is the early alteration of embryonic development because of exposure to toxins in utero (maternal drug use, for example) or chromosomal changes (such as Down syndrome). Depression in preschoolers, mental illness, and lactose intolerance are not associated with maternal drug use.

Rationale 2: The major risk factor for retardation is the early alteration of embryonic development because of exposure to toxins in utero (maternal drug use, for example) or chromosomal changes (such as Down syndrome). Depression in preschoolers, mental illness, and lactose intolerance are not associated with maternal drug use.

Rationale 3: The major risk factor for retardation is the early alteration of embryonic development because of exposure to toxins in utero (maternal drug use, for example) or chromosomal changes (such as Down syndrome). Depression in preschoolers, mental illness, and lactose intolerance are not associated with maternal drug use.

Rationale 4: The major risk factor for retardation is the early alteration of embryonic development because of exposure to toxins in utero (maternal drug use, for example) or chromosomal changes (such as Down syndrome). Depression in preschoolers, mental illness, and lactose intolerance are not associated with maternal drug use.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Incorporate an understanding of the potential risk factors for childhood mental illness into working with children in community settings

Question 11

Type: MCSA

A mother is concerned because her 6-year-old son stutters. She wants to know if she did anything during her pregnancy to cause this. Which of the following would be the best response? The nurse should:

1. Assess for impaired thermoregulation during the postnatal period.

2. Assess for a family history of the disorder.

3. Verbalize the implied by asking, Are you saying you feel responsible for his problem?

4. Ask if the mother had preeclampsia during labor.

Correct Answer: 2

Rationale 1: The only known predisposing factor for the development of a communication disorder is a family history of the disorder. For stuttering, especially, family and twin studies provide strong evidence of a genetic factor in its etiology. Since family history is the only known predisposing factor, asking about impaired thermoregulation or preeclampsia is not relevant.

Questioning the mothers feelings does not address the cause of the stuttering.

Rationale 2: The only known predisposing factor for the development of a communication disorder is a family history of the disorder. For stuttering, especially, family and twin studies provide strong evidence of a genetic factor in its etiology. Since family history is the only known predisposing factor, asking about impaired thermoregulation or preeclampsia is not relevant.

Questioning the mothers feelings does not address the cause of the stuttering.

Rationale 3: The only known predisposing factor for the development of a communication disorder is a family history of the disorder. For stuttering, especially, family and twin studies provide strong evidence of a genetic factor in its etiology. Since family history is the only known predisposing factor, asking about impaired thermoregulation or preeclampsia is not relevant.

Questioning the mothers feelings does not address the cause of the stuttering.

Rationale 4: The only known predisposing factor for the development of a communication disorder is a family history of the disorder. For stuttering, especially, family and twin studies provide strong evidence of a genetic factor in its etiology. Since family history is the only known predisposing factor, asking about impaired thermoregulation or preeclampsia is not relevant.

Questioning the mothers feelings does not address the cause of the stuttering.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Incorporate an understanding of the potential risk factors for childhood mental illness into working with children in community settings.

Question 12

Type: MCSA

A 7-year-old child recently experienced the death of the familys pet dog, which was the childs constant companion. The child is at risk for:

1. A conduct disorder.

2. Elimination disorder.

3. Angoraphobia.

4. Separation anxiety disorder.

Correct Answer: 4

Rationale 1: Separation anxiety disorder involves a developmentally inappropriate and excessive anxiety over separation from home or from attachment figures and may appear after a stressful life event such as the death of a pet. This childs dog may be viewed as an attachment figure, thus placing this child at risk for a separation anxiety disorder. Risk factors for conduct disorder are related to difficulties with parentchild interactions. Children with elimination problems may have psychosocial risk factors; however, the best response in this situation is to develop interactions to prevent separation anxiety disorder, which can be directly linked to the death of the childs companion. Angoraphobia is the fear of soft sweaters and rabbits and is not related to this situation.

Rationale 2: Separation anxiety disorder involves a developmentally inappropriate and excessive anxiety over separation from home or from attachment figures and may appear after a stressful life event such as the death of a pet. This childs dog may be viewed as an attachment figure, thus placing this child at risk for a separation anxiety disorder. Risk factors for conduct disorder are related to difficulties with parentchild interactions. Children with elimination problems may have psychosocial risk factors; however, the best response in this situation is to develop interactions to prevent separation anxiety disorder, which can be directly linked to the death of the childs companion. Angoraphobia is the fear of soft sweaters and rabbits and is not related to this situation.

Rationale 3: Separation anxiety disorder involves a developmentally inappropriate and excessive anxiety over separation from home or from attachment figures and may appear after a stressful life event such as the death of a pet. This childs dog may be viewed as an attachment figure, thus placing this child at risk for a separation anxiety disorder. Risk factors for conduct disorder are related to difficulties with parentchild interactions. Children with elimination problems may have psychosocial risk factors; however, the best response in this situation is to develop interactions to prevent separation anxiety disorder, which can be directly linked to the death of the childs companion. Angoraphobia is the fear of soft sweaters and rabbits and is not related to this situation.

Rationale 4: Separation anxiety disorder involves a developmentally inappropriate and excessive anxiety over separation from home or from attachment figures and may appear after a stressful life event such as the death of a pet. This childs dog may be viewed as an attachment figure, thus placing this child at risk for a separation anxiety disorder. Risk factors for conduct disorder are related to difficulties with parentchild interactions. Children with elimination problems may have psychosocial risk factors; however, the best response in this situation is to develop interactions to prevent separation anxiety disorder, which can be directly linked to the death of the childs companion. Angoraphobia is the fear of soft sweaters and rabbits and is not related to this situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Incorporate an understanding of the potential risk factors for childhood mental illness into working with children in community settings.

Question 13

Type: MCSA

A mother questions why it is important to list when her child sat up, began crawling, started walking, and was potty trained as she is bringing the toddler in because the child screams at night. The nurse explains to the mother that:

1. It is not normal for a young child to scream at night.

2. Children who scream at night have more difficulty with problem solving.

3. Children with mental disorders have difficulty with elimination at night.

4. A developmental history is part of assessing well-being of a child.

Correct Answer: 4

Rationale 1: The basics of an effective assessment include gathering cultural and developmental information, eliciting a history from the parents, and undertaking a clinical assessment of the child. These are developmental milestones. It is important to obtain information about the child to assist in identifying developmental progress. Night terrors are common in younger children and tend to happen when the child is in a deep sleep. The statements that children with mental disorders have difficulty with elimination at night and children who scream at night have more difficulty with problem-solving are incorrect.

Rationale 2: The basics of an effective assessment include gathering cultural and developmental information, eliciting a history from the parents, and undertaking a clinical assessment of the child. These are developmental milestones. It is important to obtain information about the child to assist in identifying developmental progress. Night terrors are common in younger children and tend to happen when the child is in a deep sleep. The statements that children with mental disorders have difficulty with elimination at night and children who scream at night have more difficulty with problem-solving are incorrect.

Rationale 3: The basics of an effective assessment include gathering cultural and developmental information, eliciting a history from the parents, and undertaking a clinical assessment of the child. These are developmental milestones. It is important to obtain information about the child to assist in identifying developmental progress. Night terrors are common in younger children and tend to happen when the child is in a deep sleep. The statements that children with mental disorders have difficulty with elimination at night and children who scream at night have more difficulty with problem-solving are incorrect.

Rationale 4: The basics of an effective assessment include gathering cultural and developmental information, eliciting a history from the parents, and undertaking a clinical assessment of the child. These are developmental milestones. It is important to obtain information about the child to assist in identifying developmental progress. Night terrors are common in younger children and tend to happen when the child is in a deep sleep. The statements that children with mental disorders have difficulty with elimination at night and children who scream at night have more difficulty with problem-solving are incorrect.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Modify a care plan according to the signs and symptoms associated with common childrens psychiatric disorders.

Question 14

Type: MCSA

Which of the following behaviors observed by the nurse will be important to disclose to the teacher of a child with a stereotypic movement disorder?

1. An episode of self-mutilation

2. Depression that results from feelings of inadequacy

3. Tendency to be hypoactive

4. Flexibility and ability to contribute to learning

Correct Answer: 1

Rationale 1: Some children with a spectrum disorder have many associated behavioral problems such as hyperactivity, aggressiveness, self-injurious behaviors such as head banging, and temper tantrums. This is important and relevant to discuss with the childs teacher who is a member of the treatment team. Problems with socialization and communication difficulties are also common, evidenced by deficits in spontaneous, imaginative play. Stereotypic movement disorder involves repetitive nonfunctional motor behavior (i.e., hand waving, self-biting, body rocking, or head banging) that interferes with normal activity or risks self-inflicted bodily injury. The behavior lasts 4 weeks or longer. These behaviors are seemingly driven and protective measures are usually needed so that medical treatment will not be necessary. These children will have difficulty adapting to change, so they will have great difficulty, if able at all, to be flexible or contribute to their learning. The childs tendency would be toward hyperactivity rather than hypoactivity.

Rationale 2: Some children with a spectrum disorder have many associated behavioral problems such as hyperactivity, aggressiveness, self-injurious behaviors such as head banging, and temper tantrums. This is important and relevant to discuss with the childs teacher who is a member of the treatment team. Problems with socialization and communication difficulties are also common, evidenced by deficits in spontaneous, imaginative play. Stereotypic movement disorder involves repetitive nonfunctional motor behavior (i.e., hand waving, self-biting, body rocking, or head banging) that interferes with normal activity or risks self-inflicted bodily injury. The behavior lasts 4 weeks or longer. These behaviors are seemingly driven and protective measures are usually needed so that medical treatment will not be necessary. These children will have difficulty adapting to change, so they will have great difficulty, if able at all, to be flexible or contribute to their learning. The childs tendency would be toward hyperactivity rather than hypoactivity.

Rationale 3: Some children with a spectrum disorder have many associated behavioral problems such as hyperactivity, aggressiveness, self-injurious behaviors such as head banging, and temper tantrums. This is important and relevant to discuss with the childs teacher who is a member of the treatment team. Problems with socialization and communication difficulties are also common, evidenced by deficits in spontaneous, imaginative play. Stereotypic movement disorder involves repetitive nonfunctional motor behavior (i.e., hand waving, self-biting, body rocking, or head banging) that interferes with normal activity or risks self-inflicted bodily injury. The behavior lasts 4 weeks or longer. These behaviors are seemingly driven and protective measures are usually needed so that medical treatment will not be necessary. These children will have difficulty adapting to change, so they will have great difficulty, if able at all, to be flexible or contribute to their learning. The childs tendency would be toward hyperactivity rather than hypoactivity.

Rationale 4: Some children with a spectrum disorder have many associated behavioral problems such as hyperactivity, aggressiveness, self-injurious behaviors such as head banging, and temper tantrums. This is important and relevant to discuss with the childs teacher who is a member of the treatment team. Problems with socialization and communication difficulties are also common, evidenced by deficits in spontaneous, imaginative play. Stereotypic movement disorder involves repetitive nonfunctional motor behavior (i.e., hand waving, self-biting, body rocking, or head banging) that interferes with normal activity or risks self-inflicted bodily injury. The behavior lasts 4 weeks or longer. These behaviors are seemingly driven and protective measures are usually needed so that medical treatment will not be necessary. These children will have difficulty adapting to change, so they will have great difficulty, if able at all, to be flexible or contribute to their learning. The childs tendency would be toward hyperactivity rather than hypoactivity.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Modify a care plan according to the signs and symptoms associated with common childrens psychiatric disorders.

Question 15

Type: MCSA

The school nurse is observing a young child who has episodes of rage toward peers during recess and at lunchtime. The advantage of conducting an assessment in this environment is:

1. This will assist in identifying the bullies who trigger the explosive episodes.

2. This provides an opportunity to collect data in the event that other children are injured and legal documentation is needed.

3. To provide data for the parents who are in denial about the problem.

4. This provides a picture of problems and strengths in a realistic context.

Correct Answer: 4

Rationale 1: Play has been described as the work of children. Observing the child interacting with peers during recess and lunchtime enables the nurse to observe the child during unstructured play, which is part of the mental status assessment. The nurse is not observing the child due to a potential lawsuit, to help identify bullies, or to provide data for the parents who are in denial, but as part of a nursing assessment.

Rationale 2: Play has been described as the work of children. Observing the child interacting with peers during recess and lunchtime enables the nurse to observe the child during unstructured play, which is part of the mental status assessment. The nurse is not observing the child due to a potential lawsuit, to help identify bullies, or to provide data for the parents who are in denial, but as part of a nursing assessment.

Rationale 3: Play has been described as the work of children. Observing the child interacting with peers during recess and lunchtime enables the nurse to observe the child during unstructured play, which is part of the mental status assessment. The nurse is not observing the child due to a potential lawsuit, to help identify bullies, or to provide data for the parents who are in denial, but as part of a nursing assessment.

Rationale 4: Play has been described as the work of children. Observing the child interacting with peers during recess and lunchtime enables the nurse to observe the child during unstructured play, which is part of the mental status assessment. The nurse is not observing the child due to a potential lawsuit, to help identify bullies, or to provide data for the parents who are in denial, but as part of a nursing assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Modify a care plan according to the signs and symptoms associated with common childrens psychiatric disorders.

Question 16

Type: MCSA

The nurse is assessing a depressed child who was referred by the elementary school nurse. What is the best approach to use when assessing the childs socialization?

1. Tell me about the friends you enjoy being with.

2. So you spend a lot of time with your friends?

3. You seem like a person who would have a lot of friends.

4. How many friends do you have at school?

Correct Answer: 1

Rationale 1: The nurse is using therapeutic communication and encouraging the client to talk about a positive aspect of life. You seem like a person who would have a lot of friends, is a judgmental observation that may also be viewed as a stereotypical comment. The question How many friends do you have at school? can be perceived as probing and intrusive, which is nontherapeutic. So you spend a lot of time with your friends? invites a yes or no response and does not facilitate exploring the childs feelings about the friends.

Rationale 2: The nurse is using therapeutic communication and encouraging the client to talk about a positive aspect of life. You seem like a person who would have a lot of friends, is a judgmental observation that may also be viewed as a stereotypical comment. The question How many friends do you have at school? can be perceived as probing and intrusive, which is nontherapeutic. So you spend a lot of time with your friends? invites a yes or no response and does not facilitate exploring the childs feelings about the friends.

Rationale 3: The nurse is using therapeutic communication and encouraging the client to talk about a positive aspect of life. You seem like a person who would have a lot of friends, is a judgmental observation that may also be viewed as a stereotypical comment. The question How many friends do you have at school? can be perceived as probing and intrusive, which is nontherapeutic. So you spend a lot of time with your friends? invites a yes or no response and does not facilitate exploring the childs feelings about the friends.

Rationale 4: The nurse is using therapeutic communication and encouraging the client to talk about a positive aspect of life. You seem like a person who would have a lot of friends, is a judgmental observation that may also be viewed as a stereotypical comment. The question How many friends do you have at school? can be perceived as probing and intrusive, which is nontherapeutic. So you spend a lot of time with your friends? invites a yes or no response and does not facilitate exploring the childs feelings about the friends.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct an assessment of a child with a mental health problem.

Question 17

Type: MCSA

The nurse is assessing a child diagnosed with conduct disorder. Which would be the most appropriate question to ask the parents?

1. Does your child have a history of cruelty to other people and animals?

2. Does your child unconsciously direct feelings and desires from other relationships toward others?

3. Does your child seem to be reassured by your presence?

4. Does your child readily seek out caregivers in times of stress?

Correct Answer: 1

Rationale 1: Characteristics of conduct disorder often manifest in behaviors that show aggression toward people and animals; these symptoms may appear as early as 5 or 6 years of age, but occur more typically in later childhood or early adolescence. Transference is a process whereby the child unconsciously directs feelings and desires from other relationships in life onto the therapist. A child who feels secure will readily seek out caregivers in times of stress and is reassured by the caregivers presence.

Rationale 2: Characteristics of conduct disorder often manifest in behaviors that show aggression toward people and animals; these symptoms may appear as early as 5 or 6 years of age, but occur more typically in later childhood or early adolescence. Transference is a process whereby the child unconsciously directs feelings and desires from other relationships in life onto the therapist. A child who feels secure will readily seek out caregivers in times of stress and is reassured by the caregivers presence.

Rationale 3: Characteristics of conduct disorder often manifest in behaviors that show aggression toward people and animals; these symptoms may appear as early as 5 or 6 years of age, but occur more typically in later childhood or early adolescence. Transference is a process whereby the child unconsciously directs feelings and desires from other relationships in life onto the therapist. A child who feels secure will readily seek out caregivers in times of stress and is reassured by the caregivers presence.

Rationale 4: Characteristics of conduct disorder often manifest in behaviors that show aggression toward people and animals; these symptoms may appear as early as 5 or 6 years of age, but occur more typically in later childhood or early adolescence. Transference is a process whereby the child unconsciously directs feelings and desires from other relationships in life onto the therapist. A child who feels secure will readily seek out caregivers in times of stress and is reassured by the caregivers presence.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Conduct an assessment of a child with a mental health problem.

Question 18

Type: MCSA

When planning a new childrens mental health clinic, the nurse understands the importance of including a play area. Play and toys are used to assess children with suspected mental disorders because:

1. Children do not usually relate to adults.

2. Children express themselves through play.

3. Only toys that are developmentally appropriate and specific to the childs biological age are used.

4. Play enables the nurse to assess cognitive ability.

Correct Answer: 2

Rationale 1: A mental status exam on a child consists of both a semi-structured interview and an unstructured play session with the child. Observing a child at play can also provide invaluable information about motor behavior, thought content, affect, and impulse control. There is a general belief that toys with ambiguous meaning and diverse uses foster symbolic play more effectively because they allow the child to project his or her own identity and function onto the toys. The children may or may not relate to adults, but that is not the reason for including the play area. Cognitive ability is only one of the areas of assessment, and not the overall reason for including the play area. Toys may or may not be specific to the childs biological age.

Rationale 2: A mental status exam on a child consists of both a semi-structured interview and an unstructured play session with the child. Observing a child at play can also provide invaluable information about motor behavior, thought content, affect, and impulse control. There is a general belief that toys with ambiguous meaning and diverse uses foster symbolic play more effectively because they allow the child to project his or her own identity and function onto the toys. The children may or may not relate to adults, but that is not the reason for including the play area. Cognitive ability is only one of the areas of assessment, and not the overall reason for including the play area. Toys may or may not be specific to the childs biological age.

Rationale 3: A mental status exam on a child consists of both a semi-structured interview and an unstructured play session with the child. Observing a child at play can also provide invaluable information about motor behavior, thought content, affect, and impulse control. There is a general belief that toys with ambiguous meaning and diverse uses foster symbolic play more effectively because they allow the child to project his or her own identity and function onto the toys. The children may or may not relate to adults, but that is not the reason for including the play area. Cognitive ability is only one of the areas of assessment, and not the overall reason for including the play area. Toys may or may not be specific to the childs biological age.

Rationale 4: A mental status exam on a child consists of both a semi-structured interview and an unstructured play session with the child. Observing a child at play can also provide invaluable information about motor behavior, thought content, affect, and impulse control. There is a general belief that toys with ambiguous meaning and diverse uses foster symbolic play more effectively because they allow the child to project his or her own identity and function onto the toys. The children may or may not relate to adults, but that is not the reason for including the play area. Cognitive ability is only one of the areas of assessment, and not the overall reason for including the play area. Toys may or may not be specific to the childs biological age.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub: