Kaplan and Sadock’s Synopsis of Psychiatry 11th Edition

Kaplan and Sadock's Synopsis of Psychiatry 11th edition TESTBANK

Chapter 1: Neural Sciences Test Bank

MULTIPLE CHOICE 1. A patient with depression mentions to the nurse, My mother says depression is a chemical disorder. What does she mean? The nurses response is based on the theory that depression primarily involves which of the following neurotransmitters? a. Cortisol and GABA b. COMT and glutamate c. Monamine and glycine d. Serotonin and norepinephrine ANS: D One possible cause of depression is thought to involve one or more neurotransmitters. Serotonin and norepinephrine have been found to be important in the regulation of depression. There is no research to support that the other options play a significant role in the development of depression.

2. A patient has experienced a stroke (cerebral vascular accident) that has resulted in damage to the Broca area. Which evaluation does the nurse conduct to reinforce this diagnosis? a. Observing the patient pick up a spoon b. Asking the patient to recite the alphabet c. Monitoring the patients blood pressure d. Comparing the patients grip strength in both hands ANS: B

Accidents or strokes that damage Brocas area may result in the inability to speak (i.e., motor aphasia). Fine motor skills, blood pressure control, and muscle strength are not controlled by the Broca area of the left frontal lobe.

3. The patient diagnosed with schizophrenia asks why psychotropic medications are always prescribed by the doctor. The nurses answer will be based on information that the therapeutic action of psychotropic drugs is the result of their effect on: a. The temporal lobe; especially Wernickes area b. Dendrites and their ability to transmit electrical impulses c. The regulation of neurotransmitters especially dopamine d. The peripheral nervous system sensitivity to the psychotropic medications ANS: C Medications used to treat psychiatric disorders operate in and around the synaptic cleft and have action at the neurotransmitter level, especially in the case of schizophrenia, on dopamine. The Wernickes area, dendrite function, or the sensitivity of the peripheral nervous system are not relevant to either schizophrenia or psychotropic medications.

4. A student nurse mutters that it seems entirely unnecessary to have to struggle with understanding the anatomy and physiology of the neurologic system. The mentor would base a response on the understanding that it is: a. Necessary but generally for psychiatric nurses who focus primarily on behavioral interventions b. A complex undertaking that advance practice psychiatric nurses frequently use in their practice c. Important primarily for the nursing assessment of patients with brain traumacaused cognitive symptoms d. Necessary for planning psychiatric care for all patients especially those experiencing psychiatric disorders ANS: D

Nurses must understand that many symptoms of psychiatric disorders have a neurologic basis, although the symptoms are manifested behaviorally. This understanding facilitates effective care planning. The foundation of knowledge is not used exclusively by advanced practice psychiatric nurses nor is it relevant for only behavior therapies or brain trauma since dealing with the results of normal and abnormal brain function is a responsibility of all nurses providing all types of care to the psychiatric patient.

5. A patient asks the nurse, My wife has breast cancer. Could it be caused by her chronic depression? Which response is supported by research data? a. Too much stress has been proven to cause all kinds of cancer. b. There have been no research studies done on stress and disease yet. c. Stress does cause the release of factors that suppress the immune system. d. There appears to be little connection between stress and diseases of the body ANS: C Research indicates that stress causes a release of corticotropin-releasing factors that suppress the immune system. Studies indicate that psychiatric disorders such as mood disorders are sometimes associated with decreased functioning of the immune system. Research does not support a connection between many cancers and stress. There is a significant amount of research about stress and the body. Research has shown that there are some connections between stress and physical disease.

6. A patient who has a parietal lobe injury is being evaluated for psychiatric rehabilitation needs.

Of the aspects of functioning listed, which will the nurse identify as a focus of nursing intervention? a. Expression of emotion b. Detecting auditory stimuli c. Receiving visual images d. Processing associations

ANS: D The parietal lobe is responsible for associating and processing sensory information that allows for functions such as following directions on a map, reading a clock, dressing self, keeping appointments, and distinguishing right from left. Emotional expression is associated with frontal lobe function. Detecting auditory stimuli is a temporal lobe function. Receiving visual images is related to occipital lobe function.

MSC: NCLEX: Psychosocial Integrity 7. At admission, the nurse learns that some time ago the patient had an infarct in the right cerebral cortex. During assessment, the nurse would expect to find that the patient: a. Demonstrates major deficiencies in speech b. Is unable to effectively hold a spoon in the left hand c. Has difficulty explaining how to go about using the telephone d. Cannot use his right hand to shave himself or comb his own hair ANS: B The cerebral hemispheres are responsible for functions such as control of muscles. The right hemisphere mainly controls the motor and sensory functions on the left side of the body. Damage to the right side would result in impaired function on the left side of the body. The motor cortex controls voluntary motor activity. Brocas area controls motor speech. Cognitive functions are attributed to the association cortex. The right side of the bodys motor activity is controlled by the left cerebral cortex.

8. A patient with chronic schizophrenia had a stroke involving the hippocampus. The patient will be discharged on low doses of haloperidol. The nurse will need to individualize the patients medication teaching by: a. Including the patients caregiver in the education b. Being careful to stress the importance of taking the medication as prescribed

c. Providing the education at a time when the patient is emotionally calm and relaxed d. Encouraging the patient to crush or dissolve the medication to help with swallowing ANS: A The hippocampus plays a major role in short-term memory and, hence, in learning. Taking the medication as prescribed and providing the education at a time when the patient is calm and relaxed is information or considerations that all patients should be given. The medication does not necessarily need to be crushed or dissolved since the stroke would not have caused difficulty with swallowing.

9. The physician tells the nurse, The medication Im prescribing for the patient enhances the gaminobutyric acid (GABA) system. Which patient behavior will provide evidence that the medication therapy is successful? a. The patient is actively involved in playing cards with other patients. b. The patient reports that, I dont feel as anxious as I did a couple of days ago. c. The patient reports that both auditory and visual hallucinations have decreased. d. The patient says that, I am much happier than before I came to the hospital.

ANS: B GABA is the principle inhibitory neurotransmitter. The medication should provide an antianxiety effect. Alertness, psychotic behaviors, and mood elevation are not generally affected by gaminobutyric acid.

10. The patients family asks whether a diagnosis of Parkinsons disease creates an increased risk for any mental health issues. What question would the nurse ask to assess for such a comorbid condition? a. Has your father exhibited any signs of depression? b. Does your father seem to experience mood swings?

c. Have you noticed your father talking about seeing things you cant see? d. Is your dad preoccupied with behaviors that he needs to repeat over and over?

ANS: A Serotonin and its close chemical relatives, dopamine and norepinephrine, are the neurotransmitters that are most widely involved in various forms of depression. Most researchers agree that the immediate cause of parkinsonism is a deficiency of dopamine and so a patient with Parkinsons disease should be monitored for depression, The other mental health disorders (bipolar disorder, hallucinations, and obsessive compulsive disorder) have not been connected to Parkinsons disease.

11. Which explanation for the prescription of donepezil (Aricept) would the nurse provide for a patient in the early stage of Alzheimers disease? a. It will increase the metabolism of excess GABA. b. Excess dopamine will be prevented from attaching to receptor sites. c. Serotonin deficiency will be managed through a prolonged reuptake period. d. The acetylcholine deficiency will be managed by inhibiting cholinesterase.

ANS: D Decreased levels of acetylcholine are thought to produce many of the behavioral symptoms of Alzheimers disease. The inhibiting action the drug has on cholinesterase will slow down the breakdown of acetylcholine and so delay the onset of symptoms. The other neurotransmitters (GABA, dopamine, and serotonin) are not currently believed to play a role in Alzheimers disease.

12. There remains a stigma attached to psychiatric illnesses. The psychiatric nurse makes the greatest impact on this sociological problem when: a. Providing educational programming for patients and the public b. Arranging for adequate and appropriate social support for the patient

c. Assisting the patient to achieve the maximum level of independent functioning d. Regularly praising the patient for seeking and complying with appropriate treatment ANS: A Much of the stigma attached to psychiatric illness is due to a lack of understanding of the biologic basis of these disorders. Therefore, effective patient, family, and public teaching is an important function of the role of the psychiatric mental health nurse. While the remaining options are appropriate, they are not directed towards eliminating social stigma but rather empowering the patient.

13. The wife of a patient with paranoid schizophrenia tells the nurse, Ive learned that my husband has several close relatives with the same disorder. Does this problem run in families?

The response based on recent discoveries in the field of genetics would be: a. Your children should be monitored closely for the disorder. b. Research tends to support a familiar tendency to schizophrenia. c. There is no concrete evidence; it is just as likely a coincidence. d. Only bipolar disorder has been identified to have a genetic component.

ANS: B Familial tendencies appear with several psychiatric disorders including schizophrenia. To insinuate that the children are at such risk would not be supported by research.

14. A patient whose symptoms of mild depression have been managed with antidepressants is concerned about the affect of accepting a promotion that will require working the night shift.

What will be the basis of the response the nurse gives to address the patients concern? a. The connection between a new job and possible depression does exist. b. The medication can be adjusted to manage any increase in depression. c. The interruption in normal wake-sleep patterns can influence mood disorders.

d. The change in sleep routine can be managed with a healthy sleep hygiene routine.

ANS: C Many psychiatric and medical disorders occur more frequently or are exacerbated when sleep patterns and biologic rhythms are disrupted. While the remaining options contain true information regarding the management of depression that is a result of sleep disruption, they do not effectively address the patients concern.

15. The nurse is discouraged because the patient exhibiting negative symptoms of schizophrenia has shown no improvement with the planned interventions to reduce the symptoms. The mentors remark that helps place the problem in perspective is: a. You arent responsible for the behavior of any other person. b. Patients can be perverse and cling to symptoms despite our efforts. c. Negative symptoms have been associated with genetic pathology. d. It will take several trail and error attempts to get the right combination care.

ANS: C A complex disorder, such as schizophrenia, most likely has multiple contributing factors, including genetic predisposition, prenatal development, and the environment. Nurse frustration can be alleviated by helping the nurse realize that negative symptoms may be the result of actual brain dysfunction, rather than psychologically determined behaviors; thus the remaining options are not appropriate since they do not address the complexity of the problem.

MULTIPLE RESPONSE 1. What assessment data would reinforce the diagnosis of temporal lobe injury in patient who experienced head trauma? Select all that apply. a. Inability to balance a checkbook b. Uncharacteristically aggressive

c. Affect fluctuates dramatically d. Increased interest in sexual behaviors e. Difficulty remembering the names of family members ANS: C, D, E The temporal lobe is involved with memory as well as increased sexual focus and altered emotional responses. Personality and intellectual function is not centered in the temporal lobe.

2. A patient has begun experiencing dysfunction of the hypothalamus. What nursing interventions will the nurse include in the patients plan of care? Select all that apply. a. Reinforcing clear physical boundaries b. Assisting the patient with completing daily menus c. Learning about healthy sleep hygiene habits d. Monitoring and recording temperature every 4 hours e. Monitoring and recording blood pressure every 4 hours ANS: B, C, D The hypothalamus is responsible for regulation of sleep-rest patterns, body temperature, and physical drives of hunger. Social appropriateness and blood pressure is not controlled by the hypothalamus.

3. The nurse is preparing a patient for a positron emission tomography (PET) scan. Which instructions will the nurse include? Select all that apply. a. There will likely be a 30 to 45 minute wait between the injection and the beginning of the scan. b. A blindfold and earplugs may be used to help decrease reaction to the environment during the scan. c. Make every attempt to lie still during the scan because movement will affect the imaging produced.

d. No food or fluids are to be ingested for at least 8 full hours before the scan and none during the scan. e. Staying awake during the scan is important since the results are altered when the patient is in any phase of the sleep state.

ANS: A, B, C, E Appropriate patient preparation for a PET scan would include information regarding the time interval between injection of the isotope and the actual scan, the fact that steps will be taken to minimize the effects of sights and sounds during the scan, lying still is critical to achieving a quality image, and that being asleep during the scan will alter the results. It is not necessary to fast before or during the scan.

4. A patient with schizophrenia is described as having difficulty with executive functions. What patient dysfunction can the nurse expect to assess behaviorally? Select all that apply. a. Invades the personal space of others frequently b. Consistently fails to bring money when going to buy snacks c. Cannot remember the names of staff who often provide care d. Requires repeated reinforcement on how to make a sandwich e. Frequently speaks of hurting himself or of hurting other patients ANS: A, B, D Executive functions include reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgment, focusing on tasks, responding to social cues, and attending in appropriate ways to incoming stimuli. Memory is not considered an executive function and risk for harm to self and others is not generally a diagnosis appropriate for such a patient.

5. The unit physicians have ordered magnetic resonance imaging (MRI) tests for the following patients. For which patients would the nurse decline to make test arrangements without further discussion with the physician? Select all that apply. a. A patient who is claustrophobic

b. A patient who is breastfeeding c. A patient who has an allergy to iodine d. A patient who had a total knee replacement e. A patient who is taking a neuroleptic medication ANS: A, D Patients with claustrophobia are often unable to complete this type of study, because the MRI machine is enclosed, and patients are required to remain motionless. Metal implants are contraindications for MRIs since metal affects the scan. Breastfeeding, iodine sensitivity, and neuroleptic medication therapy are not contraindications for an MRI. Chapter 2: Contributions of the Psychosocial Sciences MULTIPLE CHOICE 1. Which understanding is the basis for the nursing actions focused on minimizing mental health promotion of families with chronically mentally ill members? a. Family members are at an increased risk for mental illness. b. The mental health care system is not prepared to deal with family crises. c. Family members are seldom prepared to cope with a chronically ill individual. d. The chronically mentally ill receive care best when delivered in a formal setting.

ANS: A When families live with a dominant member who has a persistent and severe mental disorder the outcomes are often expressed as family members who are at increased risk for physical and mental illnesses. The remaining options are not necessarily true.

2. Which nursing activity shows the nurse actively engaged in the primary prevention of mental disorders?

a. Providing a patient, whose depression is well managed, with medication on time b. Making regular follow-up visits to a new mother at risk for post-partum depression c. Providing the family of a patient, diagnosed with depression, information on suicide prevention d. Assisting a patient who has obsessive compulsive tendencies prepare and practice for a job interview ANS: B Primary prevention helps to reduce the occurrence of mental disorders by staying involved with a patient. Providing medication and information on existing illnesses are examples of secondary prevention which helps to reduce the prevalence of mental disorders. Assisting a mentally ill patient with preparation for a job interview is tertiary prevention since it involves rehabilitation.

3. Which intervention reflects attention being focused on the patients intentions regarding his diagnosis of severe depression? a. Being placed on suicide precautions b. Encouraging visits by his family members c. Receiving a combination of medications to address his emotional needs d. Being asked to decide where he will attend his prescribed therapy sessions ANS: D A primary factor in patient treatment includes consideration of the patients intentions regarding his or her own care. Patients are central to the process that determines their care as their abilities allow. Under the guidance of PMH nurses and other mental health personnel, patients are encouraged to make decisions and to actively engage in their own treatment plans to meet their needs. The remaining options are focused on specifics of the determined plan of care.

4. When a patients family asks why their chronically mentally ill adult child is being discharged to a community-based living facility, the nurse responds:

a. It is a way to meet the need for social support. b. It is too expensive to keep stabilized patients in acute care settings. c. This type of facility will provide the specialized care that is needed. d. Being out in the community will help provide hope and purpose for living.

ANS: D Hospitalization may be necessary for acute care, but, when patients are stabilized, they move into community-based, patient-centered settings or are discharged home with continued outpatient treatment in the community. Concentrated efforts are made to reduce the patients sick role by providing opportunities for the development of a purposeful life and instilling hope for each patients future. Although social support is important, such a living arrangement is not the only way to achieve it. Although acute care is expensive, it is not the major concern when determining long-term care options. Community-based facilities are not the only option for specialized care.

5. What is the best explanation to offer when the mother of a chronically ill teenage patient asks, Under what circumstances would he be considered incompetent? a. When you can provide the court with enough evidence to show that he is not able to care for himself safely. b. It is not likely that someone his age would be determined to be incompetent regardless of his mental condition. c. He would have to engage in behavior that would result in harm to himself or to someone else; like you or his siblings. d. If the illness becomes so severe that his judgment is impaired to the point where the decisions he makes are harmful to himself or to others.

ANS: D When a person is unable to cognitively process information or to make decisions about his or her own welfare, the person may be determined to be mentally incompetent. Providing self-care is not the only criteria considered. Age is not a factor considered. The decision is often based on the potential for such behavior.

6. Which psychiatric nursing intervention shows an understanding of integrated care? a. A chronically abused woman is assessed for anxiety. b. A manic patient is taken to the gym to use the exercise equipment. c. The older adult diagnosed with depression is monitored for suicidal ideations. d. A teenager who refuses to obey the units rules is not allow to play video games.

ANS: A The majority of health disciplines now recognize that mental disorders and physical illnesses are closely linked. The presence of a mental disorder increases the risk for the development of physical illnesses and vice versa. Assessing a chronically abused individual for anxiety call should attention to the psychiatric disorder that could develop from the abuse. The remaining options show interventions that are appropriate for the mental disorder.

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 7. What reason does the nurse give the patient for the emphasis and attention being paid to the recovery phase of their treatment plan? a. Recovery care, even when intensive, is less expensive than acute psychiatric care. b. Effective recovery care is likely to result in fewer relapses and subsequent hospitalizations. c. Planning for recovery care is time consuming and involves dealing with many complicated details. d. Recovery care is usually done on an outpatient basis and so is generally better accepted by patients.

ANS: B Much attention is paid to recovery care since effective recovery care helps improve patient outcomes and thus minimize subsequent hospitalizations. Recovery care is not necessarily less expensive than acute care. Although effective recovery care planning may be time consuming

and detail oriented, that is not the reason for implementing it. Recovery care is not necessarily well accepted by patients.

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 8. The nurse is attending a neighborhood meeting where a half-way house is being proposed for the neighborhood when a member of the community states, We dont want the facility; we especially dont want violent people living near us. The response by the nurse that best addresses the publics concern is: a. In truth, most individuals with psychiatric disorder are passive and withdrawn and pose little threat to those around them. b. The mentally ill seldom behave in the manner they are portrayed by movies; they are people just like the rest of us. c. Patients with psychiatric disorder are so well medicated that they do not display violent behaviors. d. The mentally ill deserve a safe, comfortable place to live among people who truly care for them.

ANS: A A major reason for the existence of the stigma placed on persons with mental illness is lack of knowledge. The main fear is of violence, although only a small percentage of patients with mental illness display this behavior. Providing the public with accurate information can help reduce stigma. The remaining options do not directly address the concerns stated.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 9. Which activity shows that a therapeutic alliance has been established between the nurse and patient? a. The nurse respects the patients right to privacy when visitors are spending time with the patient.

b. The patient is eagerly attending all group sessions and working independently on identifying their personal stressors. c. The patient is freely describing their feelings related to the physical and emotional trauma they experienced as a child with the nurse. d. The nurse dutifully administers the patients medications on time and with appropriate knowledge of the potential side effects.

ANS: C A primary aspect of working with patients in any setting and particularly in the psychiatric setting is the development of a therapeutic alliance with the patient. Such an alliance is established on trust. It is a professional bond between the nurse and the patient that serves as a vehicle for patients to freely discuss their needs and problems in the absence of the nurses criticism or judgment. Any nurse has an obligation to respect the patients rights and administer care effectively. The patients willingness to participate in the plan of care reflects self motivation.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 10. Mental health care reform has called for parity between psychiatric and medical diagnoses.

Which is an example of such parity? a. Depression treatment is not paid for as readily as is treatment for asthma. b. The mentally ill patient will be protected by law against social stigma. c. Medical practitioners are trained to be proficient at treating mental disorders. d. Psychiatric service reimbursement will be equivalent to that of medical services.

ANS: D The term parity as used here refers to payments for mental health services that equal payment schedules for medical or surgical conditions. The remaining options(B and C) do not relate to

financial reimbursement or funds allocated for mental health care being equal to those of medical diagnoses.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity MULTIPLE RESPONSE 1. Which assessment findings suggest to the nurse that this patient has characteristics seen in an individual who has reached self-actualization? Select all that apply. a. Reports to have, found peace and security in my religious faith b. Effectively changed occupations when a chronic vision problem worsened c. Has consistently earned a six-figure salary as an architect for the last 10 years d. Has been in a supportive, loving relationship with the same individual for 15 years e. Provides free literacy tutoring help at the local homeless shelter 3 evenings a week ANS: A, B, D, E Characteristics of self actualization would include: spiritual well-being, open and flexible, relationally fulfilled, and generosity toward others. Salary doesnt necessarily reflect selfactualization.

2. Which nursing activities represent the tertiary level of mental health care? Select all that apply. a. Providing a depression screening at a local college b. Helping a mental-challenged patient learn to make correct change c. Reporting an incidence of possible elder abuse to the appropriate legal agency d. Regularly assessing a patients understanding of their prescribed antidepressants

e. Providing a 6-week parenting class to teenage parents through a local high school ANS: B, D Tertiary prevention reduces the residual effects of the disorder such as depression and mental retardation. There is no quaternary level of prevention. Primary prevention reduces occurrences of mental disorders such as screenings and parenting classes, and secondary prevention reduces the prevalence of disorders as evidenced by assessing knowledge.

MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance 3. Which nursing actions indicate an understanding of the priority issues currently facing psychiatric mental health nursing today? Select all that apply. a. Working on the facilitys Safe Use of Restraints Policy revision committee b. Advocating for increased salaries for all levels of psychiatric mental health nurses c. Attending a political rally for increased state funding for mental health service providers d. Offering an in-service to facility staff regarding the cultural implications of caring for the Hispanic patient e. Joining the state nursing committee working on the role and scope of practice of the advanced practice psychiatric nurse ANS: A, C, D, E Priority issues include funding, safety issues in psychiatric treatment centersparticularly the use of patient restraints, quality-of-care issues, access to health care for minority populations, and standardization of advanced practice nurse roles.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

4. Which assessment findings describe risk factors that increase the potential risk for mental illness? Select all that apply. a. Possesses high tolerance for stress b. Is very curious about how things work c. Admits to being a member of an ethnic gang d. Only practicing Jew among school classmates e. Has a younger sibling who is mentally challenged ANS: C, D, E Risk factors are internal predisposing characteristics and external influences that increase a persons vulnerability and potential for developing mental disorders. Types of risk factors and examples include the following: having a mentally-challenged family member in the home; belonging to a punitive gang; and being the object of reject or bullying. The remaining options are protective factors.

5. Which nursing actions show a focus on the fundamental goals that guide psychiatric mental health nurses in providing patient care? Select all that apply. a. Offering an informational session of identifying signs of depression at a local senior center b. Attending a workshop on evidence practice interventions for the chronically depressed patient c. Keeping strict but appropriate boundaries with a patient diagnosed with a personality disorder d. Asking a parent who has just experienced the death of a child if they could consider talking with a grief counselor e. Identifying what help a patient diagnosed with Alzheimers disease will need with instrumental activities of daily living (IADLs) ANS: A, B, D, E

Standard objectives guide PMH nurses and members of related disciplines in the care of patients (individuals, families, communities, and organizations). The objectives and criteria are as follows: the promotion and protection of mental health, the prevention of mental disorders, the treatment of mental disorders, and recovery and rehabilitation. Keeping appropriate boundaries is a generalized nursing responsibility.

Chapter 3: Contributions of the Sociocultural Sciences MULTIPLE CHOICE 1. Which nursing action is a reflection of Hildegard Peplaus theoretic framework regarding psychiatric mental health nursing? a. Basing patient outcomes on expected instinctual responses b. Discussing a patients feelings regarding parents and siblings c. Providing the patient with clean clothes and wholesome food d. Centering professional practice in a state run psychiatric facility ANS: B Peplaus pioneering endeavors and contributions were largely influenced by interpersonal psychotherapy. She believed that disorders evolved in the social context of interpersonal interactions. (i.e., what went on between people). Instinctual responses are more related to intrapersonal interactions. Florence Nightingale was instrumental in the holistic approach to nursing care, whereas Linda Richards practice was centered on institutional care of the mental ill.

2. The nurse is attempting to provide a safe environment for a patient at great risk for self-harm.

Which intervention shows an understanding of evidence-based practice (EBP)? a. Using physical restraints only after all other options have been proven ineffective b. Referring to the facilitys policies manual for guidelines for applying physical restraints

c. Collecting data regarding the short-term effects of using physical restraints on an aggressive patient d. Requiring constant monitoring of a patient whose inability to self-regulate anger has required the use of physical restraints ANS: B Health care systems are participating in the shift in nursing practice by encouraging research in their facilities and by implementing interventions that increase nurses knowledge about EBP. Nurses are participating to make evidence-based nursing practices available for their use, and they are helping to determine the outcomes that will benefit patients. The remaining options are examples of long-standing practice related to the use of physical restraints.

MSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity 3. Which statement by the patient reflects patient education that was based on the concept of integrated patient care? a. I know Im anxious when I get a tension headache. b. My anxiety is a result of stressors I dont cope well with. c. Medication has helped me tremendously with anxiety control. d. Anxiety runs in my family; my entire family is trying to deal with it.

ANS: A Integrated patient care is the recognition of the interplay between physical and mental health. In integrated care, these disorders are not treated as separate illnesses; rather, they are treated together. The remaining options make no mention of a relationship between mental and physical illness.

4. The nurse demonstrates objective patient care when: a. Being sympathetic to the patients recent loss of a spouse b. Protecting the anxious patient by eliminating stressors in the milieu

c. Responding to the patient by stating, I know exactly how you feel. d. Facilitating the patients exploration of various stress reduction techniques ANS: D The nurse demonstrates objectivity by helping the patient to process and organize thoughts that are directed toward the solving of his or her own problems. With sympathy, the nurse loses objectivity and moves into his or her own personal feelings. Removing all stress does not allow the patient to develop necessary coping skills.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 5. Which nursing intervention would be appropriately addressed during the orientation phase of the nursepatient relationship? a. Self reflection by the nurse regarding personal biases and prejudices regarding the patient b. Patient works at prioritizing personal needs and develops realistic expected outcomes c. Establishing the contract between the nurse and the patient regarding mutual needs and expectations d. Patient commits to the reinforcement of positive personal characteristics while working on problems and concerns ANS: C A contract or agreement is established during the orientation phase of the relationship. The contract defines limits and expectations of both the patient and the nurse. Self Reflection occurs during the pre-orientation phase while the remaining options are addressed during the working phase of the relationship.

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity

6. Which action on the part of a novice psychiatric mental health nurse shows a need for future development of altruism? a. Excusing a patient from attending group because, all that talking makes me so anxious b. Not permitting two patients who are physically attracted to each other to engage in public displays of affection c. Placing a physically aggressive patient in restraints when they are unable to internally calm their anger d. Self-reflecting on why I continue to work with patients who are so emotionally damaged they will never be normal ANS: A This option shows a misguided kindness that will ultimately have a negative impact on the patients treatment. The remaining options show responsible nursing interventions that include self-reflection of personal motivation for such work.

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 7. The greatest negative outcome resulting from a nurses fear of a mentally ill patient is that the: a. Nurse will reinforce negative stereotyping of the mentally ill. b. Patient will experience increased bias against the nursing staff. c. Publics fearfulness of the mentally ill will continue to be exaggerated. d. Therapeutic alliance between the nurse and patient will not develop effectively.

ANS: D Unrealistic preconceived images, stereotyping, and biases have an effect on nurses that, when resulting in fear, will negatively impact the therapeutic effectiveness of the nurse and the care provided. The remaining options do not have the priority that providing quality patient care has.

TOP: Nursing Process: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 8. Which action on the part of a novice mental health nurse will best minimize fear related to effectively working with the psychotic patient? a. Be knowledgeable about psychotropic medications and their affect on psychosis. b. Always arrange for staff support when working one-on-one with a psychotic patient. c. Take advantage of opportunities to attend workshops devoted to the care of the psychotic patient. d. Recognize that the psychotic patient is not in control of their behaviors due to their altered though processes.

ANS: C Fear breeds avoidance, but knowledge and preparation diminish fear and bring confidence. Being prepared before entering the psychiatric setting includes having knowledge and understanding of mental disorders. The remaining options do not provide confidence but rather means of controlling or avoiding the psychotic patient.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care, Psychosocial Integrity 9. Which response by the nurse manager to a novice mental health nurse is most effective when the nurse asks, How do I justify not keeping a patients secret? a. Never promise the patient that you will keep a secret for them. b. Always stop the patient from telling you something as a secret. c. Let the patient know that you will not keep a secret that could ultimately cause harm or affect their treatment. d. Keep reminding yourself that you are not the patients friend but rather a professional mental health provider.

ANS: C

Nurses and other healthcare professionals do not keep secrets or make promises to patients when the secret may interfere with the patients treatment or put them or others at risk for harm. The remaining options offer appropriate nursing actions but do not effectively answer the nurses question.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment, Psychosocial Integrity 10. The nurse is effectively facilitating the nurse-patient relationship when: a. Sharing with an angry patient who is verbally abusive that, Although I can accept that you are angry, I cannot and will not accept your verbal abuse. b. Focusing on the patients life experience without relating to the similarities of ones own experiences c. Objectively providing constructive criticism that is directed to helping the patient identify inappropriate behaviors d. Refraining from abandoning the patient regardless of the frustration the interaction causes ANS: A Accepting the patients feelings is essential; however, it is not necessary to accept all of the patients behaviors. Assist the patient by setting limits on patient behaviors that are self-defeating or that threaten the patient or others in any way. Setting these limits allows for mutual respect in the therapeutic alliance. The remaining options enhance the patients clinical experience rather than the nurse-patient relationship.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. An often expressed intrinsic reward of psychiatric mental health nursing is: a. Seeing the seriously ill recover their health b. Working with patients of all ages and walks of life c. Working with well-trained, caring health care providers

d. Having time to really focus on the human who is the patient ANS: D Psychiatric mental health nurses are able to spend the time to know the patient not only as a patient but as an individual. This is an opportunity most nurses whose practice is based on the physical care of the patient is not afforded. The remaining options are not necessarily unique to psychiatric nursing.

MSC: NCLEX: Psychosocial Integrity 12. Which statement is an example of an inference? a. He is an alcoholic because his wife nags a lot. b. He states he binges after arguing with his wife. c. You say your alcohol intake exceeds a quart a day. d. So you are saying that you were drinking earlier today.

ANS: A An inference is an interpretation of behavior that is made by finding motive and forming conclusions without having all the necessary information. The nurse interprets the patients behavior, decides on a reason, assigns a motive, and forms a conclusion. The remaining options are validations of observations.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which interactions are likely outcomes of a well-established therapeutic alliance? Select all that apply. a. The nurse states, Im not here to judge but rather to help. b. The patient states, I really think I can handle this problem now.

c. The patient asks his abusive father to attend counseling with him. d. The nurse sets boundaries for a patient who has few social skills. e. The patient with anger issues voluntarily goes into the seclusion room.

ANS: A, B, C, E The alliance serves as a vehicle that provides patients with an opportunity to freely discuss their needs and problems in the absence of judgment and criticism, to gain insight into their abilities, to practice new coping skills, and to heal emotional wounds. Setting boundaries is not an outcome of such an alliance.

2. Which nursing interventions are directly related to the principles on which a therapeutic alliance is based? Select all that apply. a. Graciously declining to, Come visit when I get discharged. b. Establishing the topic to be discussed at each group session c. Explaining to the patient the purpose of terminating the alliance d. Sharing how the nurse also has experienced the same problems e. Providing subjective feedback to the patients efforts at therapy ANS: A, B, C The principles that focus on the development and maintenance of a healthy alliance include: the relationship is therapeutic rather than social; the focus remains on the patients needs and problems rather than on the nurse; the relationship is purposeful and goal directed; the relationship is objective rather than subjective in quality; and the relationship is time-limited rather than open-ended. The sharing of experiencing is not patient centered.

3. The nurse is attempting to minimize the groups display of resistance during a therapy session.

Which patients are at risk for displaying such behavior? Select all that apply a. The patient who is cognitively impaired b. The patient who is older and well educated

c. The patient who is aggressive and attention seeking d. The patient who has attended similar therapy groups in the past e. The patient who has been diagnosed with paranoid schizophrenia ANS: A, D, E A patient who redirects the focus away from himself or herself by changing the subject is engaging in resistance behavior. Patients divert the topic for one or more of several reasons: a fear of being judged; avoiding the repetition of material that has been previously discussed; or the inability to stay cognitively focused. The attention-seeking patient may attempt to monopolize the discussion but not necessarily be at risk for resisting the topic. Age and education are not risk factors.

Chapter 4: Theories of Personality and Psychopathology Test Bank MULTIPLE CHOICE 1. The nurse leading parent education classes bases instruction on Eriksons developmental stages. It follows that the nurse will plan to instruct the parents that a helpful strategy to foster a childs initiative would be to: a. Offer several different options for dressing and encourage the child to select one of them. b. Allow the child to help wash the unbreakable dishes used to serve breakfast. c. Provide one-on-one parentchild time each evening before bed. d. Enroll the child in a weekend, age-appropriate sports program.

ANS: B This strategy will allow the child to demonstrate initiative by washing dishes without worrying about breakage. Making clothes selections is a strategy related to development of autonomy.

Providing one-on-one time promotes trust. Age appropriate sports program is related to competence.

MSC: NCLEX: Health Promotion and Maintenance 2. Which of the following responses would the nurse expect from a 12-year-old regarding stealing? a. You are never allowed to steal. b. You go to jail is you steal someone elses things. c. My parents would punish me if I was caught stealing. d. Stealing food when you dont have anything to eat is alright.

ANS: D Before the ages of 10 or 11 years, children consider moral dilemmas differently from older children. For younger children, rules are absolute and come from an authority figure. Older children learn that rules are changeable in certain situations. According to Piaget, younger children base moral judgment on consequences, whereas older children base judgment on motives.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance, Health Promotion and Maintenance 3. A nursing diagnosis of hopelessness would be considered for an individual who: a. Was consistently overprotected by family members b. Was raised by parents who were strict disciplinarians c. Had inconsistent, unpredictable physical care as an infant d. As a teenager always felt unaccepted by his social peers ANS: C

A sense of hope is the outcome of Eriksons stage of trust versus mistrust. Inconsistent, unpredictable, and discontinuous care would lead to hopelessness and to a mistrust of self and the world. No data are given to support any of the other diagnoses.

TOP: Nursing Process: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity 4. An adolescent has been a consistently, poor academic student due to a learning disorder.

Which statement overheard by the nurse would support the possibility of a problem with the developmental stage competence versus inferiority? a. Its too hard to get good grades. b. Ill never be able to get into a good college. c. My parents are disappointed that I do so poorly in school. d. I dont want people to know I can barely read or write.

ANS: B According to Erikson and the stage of competence versus inferiority, during school years (6 to 12 years of age), children gain new knowledge, learn new skills, and grow more competent. If they lack successes in learning or productivity, children may develop a sense of inferiority. The other options reflect problems with autonomy and guilt.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity 5. A parent is concerned with the interpersonal skills of her 12-year-old son. Based on interpersonal theory, the nurse asks: a. Does your son belong to team or club with friends or classmates? b. Does he feel bad when he does something he knows he shouldnt do? c. How does he tend to act when he doesnt get exactly what he wants?

d. How confident is he in situations that are generally unfamiliar for him?

ANS: A According to Sullivan, the expected development of the preadolescent permits him or her to work with peers toward a common goal and to develop a sense of oneness. Development of a social conscience is not related to interpersonal skill development. Coping with frustration develops in late adolescence. Confidence is suggested as a developmental issue of 12- to 18year-olds in Eriksons model.

TOP: Nursing Process: Outcome Identification MSC: NCLEX: Health Promotion and Maintenance 6. The parents of an 8-year-old are attempting to help their child comprehend new information.

Which intervention suggested by the nurse shows an understanding of the cognitive development theory for this age group? a. The use of drawing and illustrations b. Comparing the childs experiences to the new material c. Encouraging the child to talk about this new information d. Asking the child to give a reason for how they feel about new information ANS: B Comparing a known to an unknown will help this age group understand new information.

Drawings and illustration as well as talking about new information are effective methods for the younger aged child. Providing rationales is too advanced for this age group.

7. According to Piaget, which of the following would the nurse consider normal when assessing a 6-year-old? a. Playing with an imaginary friend b. Talking about their best friend

c. Enjoying putting puzzles together d. Knowing its wrong to tell a lie ANS: A Preoperational stage (2-7 years) children begin to exhibit pretend play. The need to make friends and the development of a conscious are observed in the concrete operations stage (7-11 years).

The ability to problem solve is seen in the formal operations stage (11-16 years).

8. Which developmental level would be characterized by a child being able to focus, to coordinate, and to imagine a series of events? a. Preoperational b. Concrete operational c. Formal operational d. Postoperational ANS: B In the concrete operational level, the child can focus and coordinate and imagine a series of events. In the preoperational stage, the child is unable to relate two classifications at one time and is present-oriented. At the formal operations level, the child can think abstractly and in future orientation. Postoperational is not a stage of cognitive development.

9. Which strategy will the nurse include in the plan of care for a 6-year-old child for whom operant conditioning has been recommended? a. Periodically asking the child to attempt to solve increasingly difficult puzzles b. Consistently offering praise when the child puts his dirty clothes in the hamper c. Expecting the child to rinse and to place his dirty dishes in the sink d. Conditioning the child to expect punishment when he misbehaves ANS: B

A 6-year-old can learn to comply with requests when adults reinforce compliance with positive reinforcement. The remaining options do not reinforce compliance but rather state expectations.

10. A child who has been physically abused becomes emotionally distorted when told that the parent will no longer be allowed to visit. Which principle of social learning theory is most likely for the childs response? a. The child views the abuse to be more desirable than the parent leaving. b. The parent has fostered a fear in the child that increases when they are apart. c. The child believes that he is responsible for the parent now being punished. d. The parent has likely told the child that he deserved the abuse as a punishment.

ANS: A Social theory states that reinforcement value is subjective and influenced by past experiences.

For most children, parental punishment is a negative outcome with low reinforcement value.

However, for some children who suffer from parental abuse, the abuse has a high reinforcement value, because it is more desirable than abandonment. The remaining options are not supported by the social theory.

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity 11. Which nursing intervention supports the principles on which the cross-links theory of aging is based? a. Applying an elastin sustaining moisturizer to an adult patients skin b. Assessing a patients family history for genetic diseases and disorders c. Questioning a patient regarding long-term exposure to environmental toxins d. Assisting an adult patient is selecting foods that are high in vitamins A, C, and E ANS: A Cross-links form in elastin in connective tissue. Elastin is similar to collagen in that it maintains tissue flexibility and permeability. The effects of cross-linking in elastin fibers are most

pronounced in the changes that occur in facial skin with aging. Skin becomes brittle, dry, and saggy, and it appears translucent. Applying appropriate moisturizes helps minimize the effects.

Genetic history is relevant to the genetic theory of aging. Exposure to environmental toxics applies to the biological theory of aging. Vitamin A, C, and E consumption related to the freeradical theory of aging.

12. The nurse determines that a patient is showing a decline in explicit memory. Which characterizes such a deficiency? a. Inability to remember how to operate a common kitchen appliance b. Difficulty remembering the name of a place visited 20 years ago c. Being unsuccessful at retaining new information d. Forgetting the ingredients of a favorite recipe ANS: B Explicit memory, which is the ability to recall a specific name or place, tends to decline with aging. Working memory, which is the type of memory that is needed to perform daily activities, does not show an aging decline.

13. A patient is experiencing distress with midlife transition. Which statement provides support that the patient is successfully managing this stressor? a. I wont give up on my dream to be rich. b. Being rich doesnt necessarily make a person happy. c. Ill never be rich but I can save enough to live comfortably. d. I wasnt being realistic when I set being rich as my lifes goal.

ANS: C The midlife transition occurs between the ages of 40 and 45 years. Individuals face the realization that the failure to accomplish all of lifes goals leads first to disappointment and then

to the reformulation of earlier goals. The remaining options do not show a reforming of original goals.

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity 14. According to Maslows hierarchy of needs, the nursing strategies a psychiatric nurse would use to assist in meeting self-esteem needs of elderly patients would include: a. Providing privacy when spouses are visiting b. Arranging for the spouses to dine with the patients when visiting c. Including both the patients and spouses in all educational sessions d. Attending to patient hygiene and dress in preparation for spousal visits ANS: D Promoting an attractive physical appearance will assist patients in meeting the need for selfesteem. Patients receive positive feedback when appearance is attractive. The remaining options are not directly focused on self-esteem but rather belonging and safety.

15. A patient is involved in a smoking cessation program that encourages self-control therapy interventions. Which intervention would the nurse suggest to this patient? a. Limiting the act of smoking to certain times of the day b. Keeping a behavioral diary that tracks when the patient smokes c. Identifying the factors that initially encouraged the patient to start smoking d. Making plans that involve spending the money saved when the smoking stops ANS: B Self-control therapy is based on self-regulation concepts, for example, keeping track of ones smoking behaviors with the use of a behavioral diary helps to identify cues associated with the habit. Taking steps to then remove or avoid some of the cues is a way to alter the environment.

The remaining options are more reflective of behavior modification therapy.

16. A 70-year-old male has the nursing diagnosis situational low self-esteem related to forced retirement. Using Maslows hierarchy of human needs, the nurse is confident the patient is meeting the outcome of experiencing self-worth when the patient: a. Moves to a secure apartment building b. Exercises regularly with friends at the gym c. Attends his grandchildrens school functions d. Volunteers at the local homeless shelter each week ANS: C Feelings of worth, self-confidence, and adequacy are desired outcomes for a patient with low self-esteem. Security is associated with Maslows need for safety and security and would be an appropriate outcome for a patient experiencing fear. Self-fulfillment is related to selfactualization needs and might be associated with a wellness diagnosis. Acceptance is related to love and belonging needs and could be associated with a social isolation diagnosis.

17. The spouse of a patient recently diagnosed with early stage Alzheimers disease asks, Is there anything I can do to help delay the progression of this disease? Which strategy has the greatest potential for preserving the protective abilities of immune cells related to the disease? a. Minimize contact with the public during cold and flu season. b. Enroll the patient in an exercise program that meets regularly. c. Provide supplements to enhance the patients immune system. d. Identify creative ways to keep the patient mentally challenged.

ANS: D Research has demonstrated links between creative activities and the consequential positive feelings with the increased production of protective immune cells. Creativity is also possibly linked to delaying the onset of Alzheimers disease. Continually challenging oneself mentally is a way to build up reserves of neurologic structures and connections. The remaining options,

although related to the immune system, are more directly focused on the physical affects rather than the cognitive ones.

MULTIPLE RESPONSE 1. A nurse is using Piagets model to assess a childs developmental stage. Which behaviors would determine that a child is successfully achieving the skills required of the formal operations level of development? Select all that apply. a. Becomes sad when the family pet dies b. Plans a trip to attend a basketball game c. Identifies two different bowls that hold 1 cup d. Selects the appropriate clothing for a ski trip e. Enjoys solving what if types of word problems ANS: B, D, E The formal operations level includes the ability for future thinking and for problem-solving complex issues. The remaining options reflect concrete operations level abilities.

MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is assessing a child according to Kohlbergs developmental theory. Which statement would support the belief the child is showing appropriate behaviors of the pre-conventional state? Select all that apply. a. If I pick up my toys, can I get an ice cream cone? b. I cant watch cartoons when I dont pick up my toys. c. I always pick up my toys because mommy needs my help. d. When I pick up all of my toys I make mommy very happy. e. If I dont pick up my toys, mommy could trip on them and fall.

ANS: A, B, E

The pre-conventional stage (4-10 years) involves a punishment-obedience orientation as well as an instrumental relativist orientation. The remaining options are reflective of a higher level of development.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Which activities should the nurse evaluate in an assessment of an older patients functional status? Select all that apply. a. Possessing the ability to prepare nutritious meals independently b. Having the financial resources available to live independently c. Performing regular, simple maintenance on their primary residence d. Effectively toileting themselves for both bowel and bladder elimination e. Safely moving around their residence without an increased risk for falls ANS: A, D, E Functional assessment usually consists of evaluating two areas. The first area, ADLs, includes categories of personal care such as bathing, grooming, toileting, and transferring. The second area, IADLs, addresses activities that are important for the individual to be able to function in the community. IADLs include shopping, preparing meals, and getting around. Financial resources and maintenance skills are not included in such an assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance 4. Which older adult patients medical conditions appear to support the hypothesis upon which the immunologic theory of aging is based? Select all that apply. a. Has, at age 64, been diagnosed with type 2 diabetes b. Has been treated for multiple sclerosis since age 30 c. Is managing a 36-year history of chronic Graves disease

d. Has begun to experience symptoms of rheumatoid arthritis e. Is experiencing a flare up of celiac disease, which was diagnosed at age 26 ANS: A, D Immune function significantly declines with aging. Rheumatoid arthritis and mature-onset diabetes are two diseases that are commonly experienced during older age that are caused by alterations to the immune system. Although the remaining options reflect disease processes associated with the immune system, they manifested in early adulthood.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance 5. The nurse manages the care for several older adult patients. Which strategies shows an understanding of the effects of aging on cognitive function? Select all that apply. a. Allowing ample time for completion of patient activities b. Breaking complicated patient activities into single tasks c. Planning patient activities that can be completed rather quickly d. Excluding complex problem-solving patient activities in the daily routine e. Planning for complex patient activities to be introduced early in the day ANS: A, B, C With aging, the ability to maintain the attention span through the completion of complex tasks diminishes. Another segment of attention that shows some decrements with aging is vigilance, which is the ability to sustain attention over longer periods of time. Increased reaction time that results in decreased speed of performance is an obvious change that occurs with normal aging.

Problem-solving ability is a higher cognitive function. There is little knowledge regarding normal changes in higher cognitive functioning during aging and so the remaining options are not based on evidenced-based practice.

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

6. According to most biological theories of aging, predisposing factors create the affects seen in aging. Which behaviors are considered predisposing factors regarding aging? Select all that apply. a. Diagnosis of a chronic genetic disease b. Lack of healthy diet and regular exercise c. Family history of several different cancers d. Occupation that involved working with toxins e. Radiation exposure from numerous diagnostic studies ANS: A, C, D, E One method of classifying biologic theories of aging relates to categorizing predisposing factors as intrinsic or extrinsic to the organism. Intrinsic or genetic theories focus on the process of aging as internal to the organism. Certain genetic diseases, including several types of cancers and high-cholesterol syndromes that lead to heart disease, have a negative impact on life expectancy.

Extrinsic or nongenetic theories propose that aging occurs as a result of environmental factors that act on the organism, such as radiation, ozone, drugs, and toxic substances which, researchers have theorized, damage cellular structures, thereby leading to aging and death. Diet and exercise are not considered either intrinsic or extrinsic factors to biological theories of aging.

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance, Physiological Integrity: Physiological Adaptation 7. The nurse is preparing to educate a group of middle-aged adults on longevity strategies.

Which behaviors would the nurse stress? Select all that apply. a. Having warm and caring people in your life b. Engaging in age-appropriate exercise on a regular basis c. Accepting the fact that aging negatively impacts your life d. Seeking help if changes of aging cause depression or anxiety

e. Avoiding retirement for as long as possible in order to keep active ANS: A, B, D A Harvard study identified factors of middle adulthood that promote longevity and include experiencing a warm and caring relationships, having effective adaptive or coping strategies, and getting adequate exercise. Aging does not necessarily affect life negatively and there are numerous ways to remain both physical and mentally active after retirement.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation , Health Promotion and Maintenance 8. A nurse is working with a group of older adults attending a seminar on the physical and emotional effects of aging. Which patient statements are good predictors of positive well being and perceived mortality? Select all that apply. a. Being satisfied with growing older b. Feeling younger than my birthdays say I should c. Retirement gives me time to do the things Ive put off doing. d. Not having to deal with the stress of any major chronic illnesses e. At least I dont have to worry about having enough money to retire.

ANS: A, B, C A research study of more than 400 older adults between the ages of 70 and 100 examined how satisfaction with aging is an indicator of positive well-being and possible predictor of death.

Researchers found that feeling older and being dissatisfied with how one is aging are related to an increased mortality risk over time. Persons who were satisfied with their aging or who felt younger than their years generally had longer survival. Self-perception of aging predicted mortality even after controlling for known mortality predictors such as illness, old age, gender, and socioeconomic status.

Chapter 5: Examination and Diagnosis of the Psychiatric Patient MULTIPLE CHOICE 1. A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans.

ANS: B Prescriptive privileges are granted to masters-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning.

2. A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: more than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness ANS: C Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as would a suicide attempt.

3. A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority? a. Implement suicide precautions. b. Offer high-calorie snacks and fluids frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

ANS: A Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

4. The desired outcome for a patient experiencing insomnia is, Patient will sleep for a minimum of 5 hours nightly within 7 days. At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: a. consistently demonstrated.

c. sometimes demonstrated.

b. often demonstrated.

d. never demonstrated.

ANS: D Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at night.

Therefore, the outcome must be evaluated as never demonstrated. See relationship to audience response question.

5. The desired outcome for a patient experiencing insomnia is, Patient will sleep for a minimum of 5 hours nightly within 7 days. At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses next action? a. Continue the current plan without changes.

b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Examine interventions for possible revision of the target date.

ANS: D Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

6. A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, Encourage patient to attend one psychoeducational group daily? a. Assessment

c. Implementation

b. Analysis

d. Evaluation

ANS: C Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

MSC: Client Needs: Psychosocial Integrity 7. Before assessing a new patient, a nurse is told by another health care worker, I know that patient. No matter how hard we work, there isnt much improvement by the time of discharge.

The nurses responsibility is to: a. document the other workers assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the workers impression by contacting the patients significant other.

d. discuss the workers impression with the patient during the assessment interview.

ANS: B Assessment should include data obtained from both the primary and reliable secondary sources.

The nurse, bearing in mind the possible effects of counter-transference, should evaluate biased assessments by others as objectively as possible.

8. A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurses next best action? a. Report the findings to the health care provider. b. Assess the patient for a history of renal problems. c. Assess the patients family history for cardiac problems. d. Arrange for the patients hospitalization on the psychiatric unit.

ANS: B Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the patients history for renal problems and then share the findings with the health care provider.

MSC: Client Needs: Physiological Integrity 9. A patient states, Im not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.

Which nursing intervention should have the highest priority? a. Self-esteembuilding activities

c. Sleep enhancement activities

b. Anxiety self-control measures

d. Suicide precautions

ANS: D

The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

10. Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. Patient will: a. show improved use of language. b. demonstrate improved social skills. c. become more independent in decision making. d. select and participate in one group activity per day.

ANS: D The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.

11. Nursing behaviors associated with the implementation phase of nursing process are concerned with: a. participating in mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

ANS: D Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

12. Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. I can always trust my family. b. It seems like I always have bad luck. c. You never know who will turn against you. d. I hear evil voices that tell me to do bad things.

ANS: D The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations and may create risks for violence. The other statements are vague and do not clearly identify the patients chief symptom.

13. Which entry in the medical record best meets the requirement for problem-oriented charting? a. A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL (Prolixin) 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV. b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV. c. Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg po and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV. d. Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, Im no longer bothered by the voices.

ANS: B Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for

evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.

14. A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action. a. Record the patients answers to questions on the nursing assessment form. b. Ask an advanced practice nurse to perform the assessment interview. c. Call for a mental health advocate to maintain the patients rights. d. Obtain important information from the family member.

ANS: D When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.

See relationship to audience response question.

MSC: Client Needs: Safe, Effective Care Environment 15. A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do?

Which aspect of the mental status examination is the nurse assessing? a. Behavior

c. Affect and mood

b. Cognition

d. Perceptual disturbances

ANS: B Assessing cognition involves determining a patients judgment and decision making. In this case, the nurse would expect a response of Call my doctor if the patients cognition and judgment are intact. If the patient responds, I would stop eating or I would just wait and see what happened,

the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

16. An adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? Youll just tell my parents whatever you find out. Which response by the nurse is appropriate? a. That isnt true. What you tell us is private and held in strict confidence. Your parents have no right to know. b. Yes, your parents may find out what you say, but it is important that they know about your problems. c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team. d. It sounds as though you are not really ready to work on your problems and make changes.

ANS: C Adolescents are very concerned with confidentiality. The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse.

The incorrect responses are not true, will not inspire the confidence of the patient, or are confrontational.

17. A nurse wants to assess an adult patients recent memory. Which question would best yield the desired information? a. Where did you go to elementary school? b. What did you have for breakfast this morning? c. Can you name the current president of the United States? d. A few minutes ago, I told you my name. Can you remember it?

ANS: B

The patients recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the patients fund of knowledge.

18. When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. Are you having difficulty hearing when I speak? b. How can I make this assessment interview easier for you? c. I notice you are frowning. Are you feeling annoyed with me? d. Youre having trouble focusing on what Im saying. What is distracting you?

ANS: A The patients behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

19. At what point in an assessment interview would a nurse ask, How does your faith help you in stressful situations? During the assessment of: a. childhood growth and development

c. educational background

b. substance use and abuse

d. coping strategies

ANS: D When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patients faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics.

20. When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling.

c. milieu management.

b. health teaching.

d. psychobiological intervention.

ANS: C Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patients physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution.

Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications.

21. After formulating the nursing diagnoses for a new patient, what is a nurses next action? a. Designing interventions to include in the plan of care b. Determining the goals and outcome criteria c. Implementing the nursing plan of care d. Completing the spiritual assessment ANS: B The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.

22. Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge

c. Social isolation

b. Ineffective coping

d. Powerlessness

ANS: C Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

23. QSEN refers to: a. Qualitative Standardized Excellence in Nursing b. Quality and Safety Education for Nurses c. Quantitative Effectiveness in Nursing d. Quick Standards Essential for Nurses ANS: B QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

24. A nurse documents: Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker. Which nursing diagnosis should be considered? a. Defensive coping

c. Risk for other-directed violence

b. Decisional conflict

d. Impaired verbal communication

ANS: D The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.

MSC: Client Needs: Psychosocial Integrity

25. A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurses next comment? a. How did you get to the United States? b. Would you like for a family member to help you talk with me? c. An interpreter is available. Would you like for me to make a request for these services? d. Are you comfortable conversing in English, or would you prefer to have a translator present?

ANS: D The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patients responses; a translator is a better resource.

26. The nurse records this entry in a patients progress notes: Patient escorted to unit by ER nurse at 2130. Patients clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, Let me out of here. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation.

How should this documentation be evaluated? a. Uses unapproved abbreviations b. Contains subjective material c. Too brief to be of value d. Excessively wordy e. Meets standards

ANS: E This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

MULTIPLE RESPONSE 1. A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply. a. The patient was uncooperative b. The patients subjective responses c. Only data obtained from the patients verbal responses d. A description of the patients behavior during the interview e. Analysis of why the patient was unresponsive during the interview ANS: B, D Both content and process of the interview should be documented. Providing only the patients verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patients behavior would be speculation, which is inappropriate.

TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment 2. A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI)

b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE) ANS: A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, BDAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with anti-psychotic medications. The CCSE assesses cognitive function.

MSC: Client Needs: Psychosocial Integrity 3. What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Unmet patient needs currently present c. Goals and outcomes for the plan of care d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions ANS: B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

MSC: Client Needs: Safe, Effective Care Environment 4. A patient is very suspicious and states, The FBI has me under surveillance. Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, Tell me about the problem as you see it.

c. Seek information about when the problem began. d. Tell the patient, Your ideas are not realistic. e. Reassure the patient, You are safe here.

ANS: B, C, E During the assessment interview, the nurse should listen attentively and accept the patients statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine development of trust between the nurse and patient.

Chapter 6: Classification in Psychiatry Test Bank MULTIPLE CHOICE 1. The patient asks the nurse, Ive heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process? The response that explains the need for nurses to understand and use the nursing process is: a. Do you think you have a better method we might use? b. The nursing process is a systematic problem-solving method encompassing all components necessary to care for patients. c. Using the nursing process is a way of legitimizing our profession and placing us on an equal footing with the pure sciences. d. The nursing process is a unidimensional, static, linear approach used to guide nurses as they make clinical judgments.

ANS: B This response best explains the importance of the nursing process by description and relationship to patient care. Suggesting that the patient may have a better method is challenging and does not

address the question posed by the patient. Providing legitimacy to the profession is a very limited explanation for use of the nursing process. The nursing process is not one-dimensional, static, or linear.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. When preparing to conduct a nursing history and assessment on a patient transferred from the emergency department (ED) whose family believes the patient to be a questionable historian due to cognitive impairment, the nurse initially begins the interview by: a. Reviewing the ED chart b. Contacting the admitting physician c. Directing the questions to the family members d. Establishing a line of communication with the patient ANS: D The nurse should begin establishing the nursepatient relationship by initially directing the questions to the patient. The nurse can confirm information and/or obtain supplementary information from the sources identified by the other options.

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 3. The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patients life processes when stating in the patients plan of care that: a. Patient outcomes were partially attained. Implementation of present plan to continue. b. Patient will initiate and support conversation with nurse therapist by (date 3 weeks in future). c. Oral medication for anxiety should be administered when depression is assessed to be at the moderate level.

d. Impaired verbal communication r/t impoverished thoughts secondary to depression as evidenced by monosyllabic responses.

ANS: D This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process. The remaining options reflect other steps, such as evaluation and intervention planning.

MSC: NCLEX: Safe and Effective Care Environment 4. When engaging in outcomes identification, the nurse: a. Interviews and collects patient-focused data b. Re-assesses the patients physical and emotional status evaluation c. Reviews the patients existing problems and projects the results of the nursing care d. Considers the patients presenting symptoms and identifies nursing-related problems ANS: C Outcomes are projections of expected influence that nursing interventions will have on the patient. Interviewing and collecting data is involved in the assessment process, re-assessing is involved in the evaluation process, and identifying related nursing problems is involved in determining appropriate nursing diagnoses.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. While discussing assessment of suicidal patients, a novice nurse mentions, I was taught to always base my care on concrete, evidence-based scientific reasoning and never to rely on intuition. Which response by the experienced nurse shows understanding of intuitive reasoning? a. Thats wise, because intuition went out of favor with the scientific revolution.

b. Critical thinking and intuition are at opposite poles. Keep relying on your expertise. c. Its possible that intuition about suicidality is generated by transfer of feelings from the patient to the nurse. d. Its been determined that intuition is nothing more that extrasensory perception, so some folks have it, and some dont.

ANS: C A strong hunch or a gut feeling is an example of intuitive reasoning that is believed to come from the therapeutic relationships sharing of feelings between nurse and patient. Most nurses agree that intuition is compatible with scientific reasoning, because both are likely linked to practice and experience. A nurse learns intuitive reasoning through clinical practice rather than from school or books.

6. A nurse shows effective critical thinking skills directed towards nursing care of a cognitively impaired patient who continues to socially isolate by: a. Clearly stating that the patient must socially interact once daily b. Documenting that the patient continues to resist socialization c. Asking the patient to identify which unit activity they are willing to attend d. Suggesting that staff take the patient with them when running errands off the unit ANS: D Critical thinking in this case involves the creation of alternative solutions to a problem that was not resolved by conventional methods. The remaining options, although not inappropriate, do not show critical thinking skills 7. A depressed patient shares with the nurse that he, has been thinking about ending it all. Based on NANDA recommendations, the nurse: a. Implements suicide precautions for this patient b. Includes Risk for Self Harm to the patients care plan

c. Documents regarding the patients safety every 15 minutes d. Reviews the patients chart for references to past incidences of hopeless ANS: B NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a risk diagnosis if the problem has not occurred yet. The remaining options, although not inappropriate, do not related to NANDA. 8. The nurse shows an understanding of the appropriate use of nursing outcomes regarding triggers for a patient diagnosed with chronic alcohol abuse when stating: a. Can you work on identifying three situations that cause you to abuse alcohol? b. Ill help you to identify three triggers for your drinking during todays session. c. Im pleased youve identified three situations that trigger your abuse of alcohol. d. Do you think you will be able to avoid the three triggers that cause you to drink?

ANS: C Outcomes sometimes referred to as behavioral goals are used to describe and evaluate the effectiveness of nursing interventions. The correct option shows that the patient was successful at accomplishing an outcome inferring the nursing interventions were successful. The remaining options do not indicate an evaluation of success or failure.

9. When a patient experiencing acute depression asks what the difference is between a medical and a nursing diagnosis, the nurse responds best when stating: a. Actually they are very similar in that they both are concerned with helping you get better and lead a happier life. b. Medical diagnoses are focused on why you are depressed whereas nursing diagnoses are concerned about making your life less sad. c. Nursing diagnoses are more directed at caring for you, unlike medical diagnoses that focus on finding the cause for your problem.

d. The medical diagnosis identifies that you are experiencing depression whereas the nursing diagnosis identifies how the depression is affecting you.

ANS: D The medical diagnosis involves identifying a mental or physical problem that results in the symptoms that negatively affect a patients life. Although the nurse is knowledgeable about the disorders and their treatments, the nursing diagnosis focuses mainly on the patients responses to the disorder and the effects that the disorder has on the patient. The types of diagnoses have different foci that result in different actions and concerns.

10. A nurse best shows an understanding of the role of evidence-based research in achieving therapeutic patient care outcomes when: a. Subscribing to and reading a monthly psychiatric research nursing journal b. Working on a committee to revise current facility policies regarding the use of chemical restraints c. Registering to attend a psychiatric workshop on newly developed psychotropic medication therapies d. Asking an experienced staff member to review the interventions being proposed for a newly admitted patient ANS: B Evidence-based practice is based on evidence and scientific principles that have been developed through research. The more closely clinical practice reflects relevant research, the more likely it is that patients will receive the best available care. The option that infers action directed at implementing the research is the one that shows best understanding. Reliance only on experience is not reflective of quality nursing care.

11. When caring for a patient admitted with a diagnosis if bipolar disorder, managed care regulations is the driving force behind the nurses use of: a. NANDA nursing diagnoses b. Short-term stress management therapy

c. A specialized clinical pathway for such patients d. Generic instead of brand name medications ANS: C Managed care regulations have brought about the use of clinical pathways (also called critical pathways or a care maps) which are standardized multidisciplinary planning tools that monitor patient care through projected caregiver interventions and expected patient outcomes with a projected timeline of success. NANDA nursing diagnoses are not related to regulations or payment concerns. The implementation of short-term stress management therapy in an acute care psychiatric environment would not be driven by managed care regulation or payment concerns.

The use of generic medications when appropriate is primarily cost driven.

12. A benefit of the implementation of clinical pathways is evidenced when the patient states: a. I know my doctors and nurses really care about me. b. My medication has really helped lessen my symptoms. c. I have hopes that I will be able to lead a productive, healthy life. d. My care team has really helped me manage most of my problems.

ANS: D Clinical pathways are tools that among other things promote interdisciplinary care thus providing for holistic care of the patient. The remaining options do not involve the additional recognized benefits of clinical pathways that include cost effectiveness and access to patient status reports.

13. A nurse shows the best understanding of the legal importance of the patients chart when stating: a. You always document in ink and never erase or use white out in the nursing notes. b. Its a document that shows proof that the patient received care that met the expected standards.

c. Patient charts are carefully protected from unlawful access by inappropriate individuals or institutions. d. The patient has a legal right to the information contained in the chart but not the original documentation itself.

ANS: B The patients chart is a legal document that effectively communicates patient outcomes, medications, treatments, responses, and unusual incidents reflecting the healthcare systems attempts at meet the standard of care appropriate for this patient. The other options are not as inclusive in describing the legal status of the chart.

MSC: NCLEX: Safe and Effective Care Environment 14. The nurse best fulfills the obligation to be accountable for providing care that meets the expected standards of care when: a. Developing a therapeutic relations with the patient b. Applying evidence-based nursing practice to the plan of care c. Providing appropriate discharge planning to meet the patients needs d. Evaluating the effectiveness of interventions through achievement of outcomes ANS: D Evaluation of the patients progress and the nursing activities involved are critical because nurses are accountable for the standards of care in each discipline. Although the other options reflect appropriate and expected nursing interventions, they are not the primary means of assuring that standard of care has been met.

15. The nurse assesses a patients judgment by asking: a. Why did you run away? b. When did you first start hearing voices? c. What would you do if you smelled smoke in your home?

d. Do you believe you hear voices, or do you think it is in your mind?

ANS: C Judgment is the ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions. Judgment may be assessed by asking a question that has a common-sense answer. The other options ask about motivation, elicits historical information about the illness or seeks information about insight.

MSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity 16. The nurse responsible for the care plan of a patient diagnosed with cognitive impairment includes rationales for the nursing interventions primarily to: a. Provide a means for outcome evaluation b. Account for the reasoning that drives the nursing action c. Support the patients success in achieving the expected outcome d. Provide information to aide in the implementation of the nursing action ANS: B Rationales primarily reflect nurses accountability for their actions by explaining why the action is necessary and expected to positively impact the patients condition. Rationales are not used to support or evaluate the success of the intervention nor to educate how the action should be preformed.

MSC: NCLEX: Safe and Effective Care Environment 17. A patient who has a nursing diagnosis of ineffective coping related to ineffective problem solving has been involved in treatment for 6 months. The nurse determines that the planned interventions require revision when the patient states: a. I really dont think my psychiatrist actually helps me. b. I cant decide if I should get my own apartment or not.

c. I cant accept that I will never be able to comfortably make decisions. d. I dont think Im liked well enough to seek election as a committee chairperson.

ANS: B Nursing interventions describe a specific course of action or a therapeutic activity that helps the patient to move toward a more functional state; in this case problem solving. The statement indicates indecision and suggests that problem solving is still a patient problem. Showing dislike of the physician actually shows a decision. Not accepting the realization of ineffective decision making is not related to ineffective coping but rather shows focus on affecting the problem.

Expressing the perception that one is not liked concerns self-esteem.

MSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity 18. To best facilitate interdisciplinary communication regarding the plan of care for a patient diagnosed with paranoid schizophrenia, the nurse: a. Requires weekly meetings of the care team b. Ensures the team includes members from all appropriate disciplines c. Uses the standardized NIC classification system of care interventions d. Recognizes the need for team access to patient records and makes them available ANS: C The Nursing Interventions Classification (NIC) is the first comprehensive standardized classification of interventions. The NIC states that one should not change intervention labels and definitions so that there is no confusion across settings. Although not inappropriate, the remaining options do not directly minimize confusion related to communication.

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 19. When reviewing the history of a newly admitted patient diagnosed with severe chronic depression, the nurse is most concerned about patient safety issues when noting:

a. The patients Axis II includes a diagnosis of mental retardation b. Documentation that the patient has been noncompliant regarding medications c. The patients current Global Assessment of Functioning (GAF) Scale rating is 9 d. Reference to a recent physical injury resulting from the patients impulsive behavior ANS: C The Global Assessment of Functioning (GAF) Scale is one of the tools use to assess patient functioning and possible prognosis. It is coded on a numerical continuum, with 1 indicating little danger and 10 indicating severe or persistent danger, and possible suicidal potential. Mental deficiency may contribute to issues of safety but it is not a significant risk factor. Noncompliance may contribute to the patients depression but it is not the greatest concern identified. Although past history is considered a predictor of future behavior, this is more related to the safety of others than to the patient.

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity 20. An appropriate nursing diagnosis for a patient who manifests a psychological problem through frequent expressions of unfounded or excessive guilt or shame, states that he is unable to deal with situations, and has a hesitation to try new things would be: a. Hopelessness b. Powerlessness c. Ineffective coping d. Chronic low self-esteem ANS: D The behaviors mentioned in the situation are congruent with criteria for the diagnosis of chronic low self-esteem. The patients symptoms go beyond powerlessness. Hopelessness does not

involve feelings of guilt and shame. The data is not consistent with a diagnosis of ineffective coping.

MSC: NCLEX: Safe and Effective Care Environment; Psychological Integrity 21. A well-stated outcome criteria for a patient with a nursing diagnosis of risk for loneliness related to social isolation would include The patient will: a. No longer experience loneliness by the end of the fifth day of hospitalization. b. Agree to attend two on-unit, staff-directed group sessions daily. c. Continue to maintain social solitude 50% of the time. d. Interact with a peer on a daily basis by discharge.

ANS: D Outcome criteria for a risk diagnosis are developed from the risk factorsin this case, social isolation. Outcomes meet criteria when they are measurable, specific, and present a timeline for completion. The correct option meets all criteria. There is no stated means by which to measure loneliness. Agreeing to attend is not specifically directed at affecting social isolation since interaction is not an expectation. Social solitude promotes social isolation.

22. Care planning for a patient diagnosed with paranoid schizophrenia will include: a. Analyzing effectiveness of care provided b. Determining the patients needs and problems c. Establishing realistic patient-focused outcome criteria d. Identifying priorities of care based on the patients condition ANS: D Establishing priority nursing diagnoses is part of the process of planning. Determining needs is part of assessment. Analyzing effectiveness is an evaluation activity. Establishing realistic expectations is part of outcome identification.

23. The expert nurse is confident that the novice nurse understands the principles that guide the planning of patient care interventions when the: a. Novice nurse asks the patient to identify their primary concerns b. Patient successfully achieves the agreed upon nursing outcomes c. Expert nurse requests that the novice nurse observe several care planning sessions d. Novice nurse includes interventions that are supported by evidence-based practices ANS: A Working with the patient to determine treatment priorities is a characteristic of good care planning. Although successful achievement of expected outcomes and inclusion of EBP interventions reflect appropriate care planning, such success is influenced by many different factors. Although appropriate, observing care planning sessions does not necessarily affect successful care planning on the part of the novice nurse.

Chapter 7: Schizophrenia Spectrum and Other Psychotic Disorders MULTIPLE CHOICE 1. A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis? a. Uses a rhyming form of speech b. Refuses to eat any unwrapped foods c. Laughs when watching a sad movie d. Maintains an immobilized state for hours ANS: D Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing. Paranoid

thinking is characteristic of paranoid schizophrenia. Inappropriate affect and clanging are seen in disorganized schizophrenia.

2. What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence? a. Decide their own daily schedule. b. Decide which unit groups they will attend. c. Choose which clinic staff member to work with. d. Choose between two outfits to wear each morning.

ANS: D An early step would be to make choices about nonthreatening matters when presented with limited alternatives. The remaining options represent decisions that are too complicated for the patient to make initially.

MSC: NCLEX: Psychosocial Integrity 3. What is the priority nursing diagnosis for a catatonic patient? a. Ineffective coping b. Impaired physical mobility c. Impaired social interaction d. Risk for deficient fluid volume ANS: D The highest priority for the patient is maintenance of basic physiologic needs, such as hydration.

Mobility is of lesser physiological importance than fluid volume. The remaining options do not have priority over a physiological need.

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts? a. Risk for violence b. Defensive coping c. Impaired memory d. Disturbed thought processes ANS: D Delusions and loose associations suggest disturbed thought processes.

5. Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts? a. Accept that delusion is illogical. b. Distinguish external boundaries. c. Explain the basis for the delusions. d. Engage in reality-oriented conversation.

ANS: D Delusions are not reality oriented; thus an appropriate outcome would be that patient will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the patient still holds to the belief.

6. Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking? a. Confronting the delusion b. Refuting the delusion with logic

c. Exploring reasons the patient has the delusion d. Focusing on feelings suggested by the delusion ANS: D Focusing on feelings suggested by the delusion will help meet patient needs and help the patient stay based in reality. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it.

7. Which assessment observation supports a patients diagnosis of disorganized schizophrenia? a. Reports suicidal ideations b. Last relapse was 6 years ago c. Consistent inappropriate laughing d. Believes that the government is out to get me ANS: C The presence of disorganization and inappropriate affect identifies this disorder as disorganized schizophrenia. The symptoms of residual schizophrenia have long periods of remission.

Schizoaffective disorder presents with severe mood disorders along with symptoms of schizophrenia. Paranoid schizophrenia is characterized by persecutory or grandiose delusions.

8. A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating: a. Derealization b. Inappropriate affect c. Impaired impulse control d. Inability to manage anger ANS: C

Command hallucinations may be so intense that the patient cannot control the impulse to do what the hallucination tells him to do; thus the patient has impaired impulse control. This is not an anger management problem. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. No evidence of inappropriate affect is given.

9. An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be: a. Providing large muscle activities to relieve stress b. Attempting to determine triggers to hallucinations c. Engaging patient in activities designed to permit success d. Encouraging verbalization of feelings in a safe environment ANS: C All are useful interventions for a patient with schizophrenia; however, engaging the patient in specifically designed activities is the only option that addresses improving self-esteem.

10. A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as: a. Social isolation b. Disturbed thinking c. Altered mood states d. Poor impulse control ANS: B The nurse interprets the patients statements that were not reality-based as indicating disturbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options.

11. A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits: a. A neologism b. Loose associations c. Delusional thinking d. Circumstantial speech ANS: A A newly coined word having meaning only for the patient is called a neologism (meaning, new word). It is associated with autistic thinking. The patients speech does not show associative looseness or circumstantiality. The use of a neologism is not delusional in and of itself, but it suggests delusional thinking may be present.

12. A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be: a. Thats really too bad that you are being treated that way. b. Who do you mean when you say everybody? c. What difference does frobitzing make? d. Why do they frobitz?

ANS: B This response will help clarify the patients thinking and change the focus from global to specific.

In this situation, sympathizing with the patient is a nonproductive response. The remaining options appear to accept the neologism thus supporting the patients delusional thinking.

13. Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms? a. Communicating using only rhyming phases b. Claims that worms are crawling in my brain c. Maintaining both arms suspended awkwardly overhead d. Shows no emotion when telling the story of a sisters recent death ANS: D Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms.

14. By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil? a. Respond verbally to the voices. b. Verbalize the reason the voices say he is evil. c. Identify events that increase anxiety and promote hallucinations. d. Integrate the voices into his personality structure in a positive manner.

ANS: C An appropriate outcome for a patient with hallucinations is recognition of events that precede the onset of hallucinations. Trigger events or situations usually cause increased feelings of anxiety.

The remaining options are neither desirable nor appropriate.

15. Which response by the nurse would best assist a patient in de-escalating aggressive behavior? a. Tell me whats going on. b. Why are you getting so upset? c. If you throw something, you will be restrained. d. Its time for group therapy. You can talk there.

ANS: A Using how, what, and when to gather information is a nonthreatening approach. It will promote patient verbalization and explanation of events without causing the patient to become defensive.

Mentioning restraints sounds threatening even though it may be meant to remind the patient of limits. Why questions are demanding and threatening to patients. Sending the patient into group therapy sidesteps the problem.

16. A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority? a. Orienting the patient to the unit b. Reinforcing reality with the patient c. Establishing a nonthreatening relationship d. Assessing the patient for physical problems ANS: D Patients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the patients needs. A patient who is stuporous may not be able to attend to information given about unit rules and protocols. While establishing a therapeutic nurse-patient relationship is an important intervention, it does not have priority according to Maslows hierarchy. Because the patient is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslows hierarchy.

17. Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic? a. I can see how you would be upset over this turn of events. b. New findings suggest this disorder is biological in nature.

c. Dont be so hard on yourself; your daughter needs you to be strong. d. Its difficult to see what produces stress for the child at the time its occurring.

ANS: B Many individuals in the mental health field attribute the development of schizophrenia to multiple causes centering on biological theories. The remaining options do little to provide the mother with new information.

18. Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins? a. In fraternal twins, the chance of the other twin developing the disorder is quite small. b. Studies show that 50% of twins develop schizophrenia when it is present in the other twin. c. No one can say what will happen, so we will hope for the best for you and both of your sons. d. You poor woman! I wish I could tell you that your other son he will be free of the disorder.

ANS: A Current research supports the correct option, whereas the remaining options are not factual and show expressed sympathy rather than empathy.

19. The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific?

The response based on the dopamine hypothesis is: a. Breakdown of dopamine produces LSD, which in large amounts produces psychosis. b. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations.

c. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations. d. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect.

ANS: B The statement is correctly based on the dopamine hypotheses while the remaining options are neither known to be true nor based on that theory 20. What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)? a. Reduction in the number of brain cells that crave dopamine b. Dopamine receptors are blocked, making dopamine less available c. Dopamine receptors are enhanced, making more dopamine available d. Medication causes an increased cellular production of dopamine ANS: B Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations.

Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications.

21. During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive: a. Haloperidol (Haldol) b. Chlorpromazine (Thorazine) c. Olanzapine (Zyprexa) d. Phenelzine (Nardil)

ANS: C Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more effective than typical antipsychotics in blocking serotonin receptors and reducing the negative symptoms of schizophrenia. Haloperidol (Haldol) and chlorpromazine (Thorazine) are typical antipsychotic medications while phenelzine (Nardil) is an MAOI antidepressant.

22. What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)? a. Development of pseudoparkinsonism b. Development of dystonic reactions c. Improvement in tardive dyskinesia d. Worsening of anticholinergic symptoms ANS: C Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive dyskinesia as well as improve both positive and negative symptoms of schizophrenia. Pseudoparkinsonism and dystonic reactions are associated with typical antipsychotic medication. Anticholinergic symptoms are not intense with the use of atypical antipsychotic medication.

23. A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology.

Based on this information, the nurse can expect that the patient will: a. Be scheduled for a magnetic resonance imaging (MRI) test b. See a mental health specialist for extensive psychological testing c. Have an immunologic assay performed within 2 days of the admission d. Participate in a dexamethasone suppression test (DST) administered by the staff ANS: A The MRI will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). Psychologic testing may be performed but will be less definitive

in ruling out organic pathology. Immunologic studies are not indicated. The DST is related to depression.

24. In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors? a. Day hospitalization b. Attending a psychosocial club c. Living with his elderly mother d. Spending free time in the mall ANS: B A psychosocial club is organized to provide the 4 Ss and is not costly to patients. Day hospitalization would not be possible because of the lack of insurance benefits. Living with his mother might fall short of stimulation and support. Spending time in the mall lacks structure, socialization, and support.

25. A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient? a. Providing high-calorie drinks hourly b. Assessing for lower extremity edema bid c. Taking the patient to activities therapy once daily d. Encouraging the patient to sit or lie down for 30 minutes hourly ANS: B Patients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be

concerned about the pressure exerted by standing on one foot for long periods of time. Such encouragement would probably be met with resistance by the patient. High-calorie drinks would be necessary if the patient failed to eat at meals. The patient probably would not be able to cognitively process what is required to participate in activities.

26. Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned? a. Explaining that others eat the food and are not harmed b. Allowing the patient to select food from vending machines c. Encouraging the patient to discuss why someone would poison the food d. Taking steps to prevent the patient from verbalizing the delusional thoughts ANS: B Patients who think hospital food is being poisoned will sometimes eat wrapped foods that have not been opened, and occasionally, they may eat food brought from the outside by a trusted person. Delusions are fixed, false beliefs that cannot be refuted by logic. The patient will probably state that the others have been given the antidote to the poison. Encouraging discussion about the delusion is not therapeutic. Although it is wise to minimize the amount of discussion about delusions, refusing to allow the patient to speak about the delusions will not foster a therapeutic alliance.

27. Prior to discharge, the nurse plans to teach the patient and family about relapse. Which items will the nurse include in the teaching? a. Recognizing warning signs of relapse b. Using street drugs judiciously and only in small amounts c. Lowering medication dosage to manage emerging side effects d. Notifying the nurse of warning signs present for more than one month ANS: A

The patient and family must be aware of signs of impending relapse. These signs are usually similar to those that the patient experienced prior to hospitalization and will be patient-specific.

The nurse should be notified ASAP, rather than waiting two weeks. Patients should never adjust medication dosage. Street drug use often precipitates relapse since many street drugs are dopaminergic.

28. Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management? a. Use only verbal instruction. b. Teach material in small segments. c. Offer opportunities for making numerous choices. d. Plan the teaching for a time when the patient has been recently medicated.

ANS: B Patients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. Teaching should be scheduled when the patient is most alert. A large number of choices may be confusing for the person, but a few simple choices may be included.

29. The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife? a. This disorder generally responds well with treatment and follow-up. b. All types of schizophrenia by their nature are chronic relapsing disorders. c. Outcomes are related to the patients pre-hospital symptoms of disorganization. d. The typical outcome for this diagnosis is that total remission is not achievable.

ANS: A

The prognosis for paranoid schizophrenia is good with appropriate treatment and effective follow-up. The remaining options are not correct when considering this type of schizophrenia 30. A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on? a. Social isolation b. Deficient knowledge c. Situational low self-esteem d. Impaired cognitive functioning ANS: D Schizophrenia may alter cognitive functioning, including memory, retention, attention, and the processing of incoming information. Altered cognition accounts for many of the symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can adjust plans to take the deficits into account. The patient is not exhibiting symptoms that would warrant any of the other options.

31. A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome? a. Introduce a distraction like reading. b. Use positive talk to offset the insults. c. Sing or whistle to compete with the voices. d. Increase the daily dose of an antipsychotic medication.

ANS: C This action provides an alternative to listening to the voices and gives the patient a sense of control. The patient should not adjust medication independently. Reading will not be particularly effective, because the voices are uncontested in a quiet atmosphere. Positive talk is generally used to positively affect self-esteem.

32. A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is: a. Tell me what the voices are saying. b. I believe you hear voices, but I dont hear them myself. c. The voices are not real. Theyre a product of your imagination. d. Do you think the voices would go away if we went into your room to talk?

ANS: B By voicing his or her own reality related to the voices, the nurse does not deny the patients experiences but helps the patient distinguish actual voices from those resulting from internal stimulation. Discussing what the voices are saying serves only to validate the reality of the voices. Challenging the voices will cause the patient to defend his perceptions and thereby reinforce the importance of the hallucination. Asking to move validates the reality of the voices and is not a helpful action since the voices go where the patient goes.

33. A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient? a. To minimize the need to whisper, utilize nonverbal techniques when possible. b. Stay physically close to this patient and use touch as a tool to interact with him. c. Treat this patient matter-of-factly. Be direct; dont talk about him or others in his presence. d. Interact with this patient only when necessary. The fewer interactions, the fewer misinterpretations there will be.

ANS: C This approach is important when providing care for a patient who is misinterpreting reality and is suspicious of the motives of others. Ostracizing the patient is non-therapeutic. Patients often misinterpret touch as threatening. This might promote loss of control. Using nonverbal

communication techniques would be nontherapeutic as it would increase patient anxiety and promote loss of control.

34. A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient: a. For cognitive therapy b. To assertiveness training c. To a day hospital program d. For psychosocial rehabilitation ANS: D Psychosocial rehabilitation helps patients readjust to community living by promoting development of necessary skills. Social skills training and job skills training programs are usually available. The patient does not need the more intensive services found in a day hospital.

Cognitive therapy will not offer the needed community living skills training. Assertiveness training is only a small portion of the community living skills the patient needs.

35. A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should: a. Administer the medication and monitor the vital signs every 4 hours. b. Give a lower dose of the medication for 24 hours and monitor the blood pressure. c. Prepare to administer a prn dose of the anticholinergic drug benztropine (Cogentin). d. Hold the medication and immediately describe the patients symptoms to the doctor.

ANS: D

These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immediately.

The other options are inappropriate in light of the seriousness of the situation.

MULTIPLE RESPONSE 1. Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply. a. Project confidence and control. b. Provide a show of force when appropriate. c. Ask the agitated patient why they are feeling so aggressive. d. Move to within 5 feet of the patient to help contain their movement. e. Provide the patient with several options as means of de-escalating the crisis.

ANS: A, B, E The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking why is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation.

2. Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply. a. Schedule regular staff crises simulations. b. Encourage the staff to discuss the details of unit crises. c. Attempt to identify staff who are ineffective during crises. d. Review documentation that describe the details of unit crises. e. Review unit crises management policies for needed updates.

ANS: A, B, D, E

The correct options empower the staff while improving/maintaining their crises management skills. The failures of the process should be identified without blaming staff for ineffective crises management.

Chapter 8: Mood Disorders MULTIPLE CHOICE 1. The nurse learns at report that a newly admitted manic patient is demonstrating grandiosity.

Which statement would be most consistent with this symptom? a. I cant do anything anymore. b. Im the worlds most astute financier. c. I can understand why my wife is upset that I overspend. d. I cant understand where all the money in our family goes.

ANS: B An individual who is demonstrating grandiosity has an exaggerated view of his abilities. The other options are more moderate statements and lack that element of exaggeration.

2. The nurse will base a discussion of dysthymia on the fact that the condition: a. Typically has an acute onset b. Involves delusional thinking c. Is chronic low-level depression d. Does not include suicidal ideation ANS: C Dysthymia is identified as a chronic low-level depression frequently lasting over a period of several years without remitting. Dysthymia has a slow, insidious onset. Delusional thinking is not a common manifestation of dysthymia. Suicidal thoughts are seen among dysthymic patients.

3. What is the priority nursing diagnosis for a patient exhibiting signs of acute mania that include exaggerated physical activity, agitation, insomnia, and anorexia? a. Risk for injury b. Chronic low self-esteem c. Noncompliance d. Insomnia ANS: A Risk for injury is the priority diagnosis. Possible injuries include dehydration, which may result from not drinking and trauma, which may result from bumping into objects or from physical altercations. The other options are valid diagnoses, but not of highest priority.

4. A patient has been admitted with a diagnosis of atypical depression. In planning interventions, the nurse would expect to consider the characteristic symptom of: a. Seasonal episodes b. Leaden paralysis c. Psychomotor agitation d. Increased depression in the morning ANS: B Behavioral characteristics of atypical depression include the feeling that ones limbs are so heavy they cannot be lifted or moved (leaden paralysis). Seasonal mood changes are characteristic of seasonal affective disorder. Psychomotor agitation and depression that is greater in the morning than in the evening are characteristics more likely to be observed in patients with melancholic depression.

5. An inappropriately dressed patient has not slept for 3 days while making excessive, expensive long-distance phone calls. When the patient can be heard singing loudly in the examining room, the nurse makes initial plans to focus on:

a. Assessing needs for food, liquids, and rest b. Setting strict limits on dress and behavior c. Conducting an in-depth suicide assessment d. Obtaining a complete psychosocial assessment ANS: A Patients with mania frequently ignore their basic physiologic needs, as evidenced by not sleeping for 3 days, thus making these assessments the priority. Limits, although appropriate to consider, are not the priority. The manic state precludes a thorough assessment initially. Suicide assessment is not a priority at this time but reckless behavior could result in personal injury.

6. Which statement by the patient would indicate the need for additional education regarding the prescribed lithium treatment regimen? a. I will restrict my daily salt intake. b. I will take my medications with food. c. I will have my blood drawn on schedule. d. I will drink 8 to 12 glasses of liquids daily.

ANS: A Patients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. The patient should have 2 to 3 liters of fluid daily. Taking lithium with food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is important to prevent toxicity.

7. The nurse would evaluate that patient education regarding lithium therapy for an individual with bipolar disorder as effective if the patient states: a. I can stop my lithium when I feel better. b. I can continue with my diuretic and cardiac medications. c. I will probably need to take the lithium for the rest of my life.

d. I will taper my lithium when a therapeutic serum level is achieved.

ANS: C Most patients with bipolar disorder require long-term maintenance on lithium or other antimanic medication. Patients should never stop medication without consulting the physician. When a therapeutic level is achieved, the patient will continue on maintenance doses of lithium. Diuretics are contraindicated for the patient on lithium.

8. A patient who has been taking lithium carbonate 300 mg tid comes to the Outpatient Department with a list of medications he is taking. Which of the medications on the list would require re-evaluation of lithium dosage? a. HydroDIURIL daily b. Navane bid c. Ativan at bedtime d. Cefobid daily ANS: A Diuretics alter fluid and electrolyte balance, increasing risk for lithium toxicity; therefore HydroDIURIL is correct. Antipsychotic medications are frequently prescribed concurrently with lithium to manage acute symptoms of mania, so no re-evaluation of lithium dose is necessary for Navane. Antianxiety drugs are not contraindicated with concurrent lithium use, so no lithium dose re-evaluation is necessary for Ativan. Antibiotics do not alter fluid and electrolyte balance, so readjustment of lithium dosage is not required for Cefobid.

9. Which outcomes would be appropriate to determine early favorable response to antidepressant medication? a. The patient will complete own self-care activities. b. The patient will demonstrate assertive communication skills. c. The patient will describe signs and symptoms of major depression.

d. The patient will make plans to attend one community social activity a week.

ANS: A Ability to manage basic ADLs demonstrates improvement in major depression. Understanding the disorder may occur later when patient cognition has improved enough to be able to process information. Initiation of community social activity occurs when the patient has increased energy. Assertive communication is learned and practiced after the depression lifts.

10. Prior to initiating medication therapy with phenelzine (Nardil), the nurse should plan to determine the patients: a. Mood and affect b. Activity level c. Cognitive ability to understand information about the medication d. Support network and its members willingness to participate in treatment ANS: C Phenelzine (Nardil) administration requires strict adherence to a restricted diet. The patient must have the cognitive ability to understand the food and medication interactions that may cause a serious reaction.

11. A patient who has a history of bipolar disorder recently underwent orthopedic surgery and was discharged to return home. When visited by the home care nurse, the nurse documented the following: slow and soft speech; sad facial expression; and patient crying when describing extreme fatigue, low mood, and the feeling that he will never get well. He has refused to bathe and perform ADLs for several days. Which nursing diagnosis would be appropriate? a. Self-care deficit secondary to possible depression b. Situational low self-esteem related to immobility c. Deficient knowledge related to depression and surgery d. Disturbed thought processes related to bipolar disorder

ANS: A Refusal to perform tasks of bathing, grooming, and other ADLs provides evidence of a self-care deficit. The other symptoms documented by the nurse are characteristic of depression. No data are present to suggest the diagnoses given in the other options.

12. The nurse caring for an extremely withdrawn patient with depression wants to assist her to become more interactive. The best approach would be to say: a. I know youll feel better if you leave your room. b. You look so gloomy sitting here all by yourself. c. Lets explore how it feels to sit alone here all day and feel sad. d. I need another person for a card game and Id like you to be my partner.

ANS: D This direct approach invites the patient to participate in a kind, but firm manner. The patient is not given an option to simply say yes or no. It is not therapeutic to give false reassurance. The remaining options focus too intensively on negative thoughts and feelings.

13. Which nursing diagnosis would relate to the primary nursing concern related to a recently written prescription for amitriptyline (Elavil) 50 mg tid? a. Anxiety b. Ineffective coping c. Risk for self-injury d. Chronic low self-esteem ANS: C Patients with depression are at increased risk for suicide when they have been on antidepressant medication for 2 weeks, because they are regaining some energy but may not have achieved full therapeutic effect with mood improvement. Poor coping is important but it is not the priority.

Evidence of noncompliance is lacking. The medication is not prescribed for anxiety disorders.

14. What information concerning amitriptyline (Elavil) 50 mg tid would the nurse give the patient regarding the expected outcome of this medication therapy? a. Complying with this therapy will cure your depression. b. This medication is expected to improve brain chemical imbalance. c. Amitriptyline will help re-establish your ability to think clearly again. d. Elavil will be particularly effective at assisting you in regaining your independence.

ANS: B Antidepressant medication works by re-establishing the balance of neurotransmitters in the brain, particularly serotonin and norepinephrine. Antidepressants do not promise a cure for depression.

Cognitive therapy, rather than antidepressants, addresses thinking issues. Learned helplessness is addressed by cognitive therapy.

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 15. Which principle should the nurse apply when planning nursing care for a patient who was voluntarily admitted after a suicide attempt? a. Patients who attempt suicide and fail will not try again. b. The more specific the plan, the greater the risk for suicide. c. Patients who talk about suicide are less likely to attempt it. d. Patients who attempt suicide and fail do not really want to die.

ANS: B Patients whose suicidal ideation includes a vague, diffuse plan or no plan at all are not at as high a risk for attempting suicide as an individual who has a well-developed plan and the means to carry it out. The nurse will need to continually reassess the patient. None of the remaining options are true statements concerning suicide attempts.

16. An appropriate nursing strategy to assist a patient who was involuntarily admitted after a suicide attempt is:: a. Avoiding any focus on the topic of suicide b. Encouraging patient to verbalize personal feelings c. Supporting patient focus on others rather than self d. Discussing the impact of suicidal thoughts on the family ANS: B Verbalization helps relieve pent-up feelings and emotional pain. Avoidance of the topic is nontherapeutic for a suicidal patient. The remaining options may serve to increase the patients feelings of guilt.

17. Which principle should the nurse apply when planning care for a patient who is diagnosed with bipolar disorder and currently in the manic phase? a. Manic patients respond well to peer pressure. b. Decreasing stimulation tends to diminish symptoms. c. Increasing stimulation tends to encourage the patient to focus. d. Detailed activities will facilitate the patients ability to self control behavior.

ANS: D The only statement that is a valid principle is the option related to activity and its impact on controlling behavior. The other statements are inaccurate.

18. Which nursing intervention is most therapeutic when the nurse is managing the aggressive, disruptive behaviors of a manic patient whose attempts to control the milieu has been rejected by the other patients? a. Advising that the patient to accept the wishes of the group b. Suggesting that the patient either quiet down or leave the room

c. Accompanying the patient to a quieter part of the unit d. Ignoring the patients outbursts because they are surly related to the mania ANS: C Escorting the patient to a less stimulating environment will assist the patient to remain in control of behavior. It is unlikely that the patient would respond to verbal suggestions to leave the area unaccompanied or accept the groups wishes and would likely see the suggestions as a threat that would further escalate the impending loss of control. The behavior cannot be ignored since it will likely lead to an acceleration of the mania.

19. What information would serve as the basis for the nurses reply when asked whether the cycling of moods from depressed to manic is a constant pattern seen in bipolar disorders? a. Clinical observation tells us that mood disorders tend to remit and recur. b. Most cyclic behavior can be managed with the appropriate forms of therapy. c. Mood disorders generally see a decrease in cyclic affecting within 5 years of onset. d. Persons with higher cognitive abilities will generally exhibit fewer cyclic episodes.

ANS: A Mood disorders tend to remit and recur throughout the patients lifetime. There is no current research to support the other options.

20. The individual who displays the history and symptoms most consistent with a medical diagnosis of seasonal affective disorder (SAD) is: a. 26 years of age and complains of 3 consecutive years of depressed mood beginning in November and remitting in April b. 64 years of age and complains of anhedonia, early morning awakening, psychomotor retardation, weight loss, and excessive feelings of guilt

c. 46 years of age and complains of dysphoric mood for 3 years, poor concentration, loss of interest in social activities, indecision, low energy, and low self-esteem d. 38 years of age and complains of sadness, loss of ability to react to positive stimuli, weight gain, hypersomnia, leaden paralysis of limbs, and sensitivity to interpersonal rejection ANS: A Marked seasonal changes in mood typify seasonal affective disorder. Depression begins in October or November and lifts in March or April and must occur for at least 2 consecutive years.

The other options are lacking in the identifying period of time when the symptoms are exhibited.

21. A patient with suspected seasonal affective disorder asks the nurse, Ive been feeling down for 3 months. Will I ever feel like myself again? The response that builds on an understanding of this disorder is: a. Spontaneous improvement usually comes in 6 months to a year. b. Can you tell me what you mean when you say feel like myself? c. People who have seasonal mood changes often feel better when spring comes. d. Usually patients with this disorder see improvement during the fall and winter.

ANS: C Seasonal affective disorder is a condition in which the patient experiences depression beginning in the fall, lasting throughout the winter, and remitting in spring in the northern hemisphere. Fall and winter is not reflective of any diagnostic category of mood disorder. Spontaneous improvement occurs only with the change of seasons and available sunlight. Questioning is a response that does not address the point of understanding SAD. 22. A Chinese-American patient comes to the mental health clinic after referral by her primary care physician. She complains of nervousness, headaches, fatigue, and vague GI symptoms for which no organic basis has been established. The symptoms began about 9 months ago when her favorite aunt died. The most appropriate independent nursing action would be to:

a. Prescribe a trial course of antianxiety medication. b. Plan strategies for cognitive behavioral therapy. c. Arrange admission to the inpatient unit for a complete workup and psychologic testing. d. Confer with the psychiatrist about the cultural association between depression and somatic symptoms.

ANS: D Expression of symptoms is influenced by ethnicity and culture. When depressed, Asian and Asian-American patients describe somatic symptoms, whereas patients of Western cultures may focus on mood and cognitive symptoms. Option d is an appropriate independent intervention the nurse should take. Options a, b, and c would be considered collaborative, rather than independent, interventions.

23. A patient with melancholic depression paces and wrings her hands for hours at a time while repeating, Im a bad person. Staff members have been unsuccessful in their attempts to promote rest. Which intervention is most appropriate in promoting rest? a. Instructing the patient to lie down for 15 minutes of every hour b. Asking the patient to fold and stack bath towels and washcloths c. Making the patient aware of the negative effects of fatigue on mood d. Reassuring the patient that she is accepted and not considered a bad person ANS: B The psychomotor energy of agitation must be expended; it may be channeled into simple, repetitive activity. Standing in one place to fold towels is an improvement over pacing. This patient will be unable to comply with the request to lie down. A severely depressed patient will not be able to cognitively process this sort of information. Reassurance will not appreciably affect the need for psychomotor activity.

24. What measure will facilitate communication with a patient who is depressed and evidencing psychomotor retardation and withdrawal?

a. Ask the patient to indicate yes or no with finger signals. b. Arrange to spend time with the patient at prearranged intervals. c. Give concrete and concise directions rather than asking questions. d. Speak loudly and rapidly to the patient to focus his or her attention.

ANS: B This measure will promote the establishment of rapport and demonstrate respect and acceptance of the patient. It will facilitate patient willingness to communicate thoughts and feelings without making unnecessary demands on the patient; a headshake or nod would work as well. Patients should not simply be ordered about; they should be asked to respond without placing excessive demands. Patients with psychomotor retardation have the ability to hear, but their ability to process information may be slowed, requiring well-paced simple communication.

25. Which measure consistent with the use of cognitive therapy could the nurse incorporate into the treatment plan of a chronically depressed patient? a. Approach the patient with cheerful affect and optimistic remarks. b. Ignore the patients pessimistic statements; give attention for positive thinking. c. Identify negative evaluations and challenge pessimistic beliefs. d. Seek to uncover unconscious conflicts about significant relationships.

ANS: C Cognitive therapy addresses symptom removal by identifying and correcting distorted negative thinking. An overly cheerful mannerism is an insensitive nontherapeutic approach that will reinforce patient negative thinking about self. To ignore negative statements while reinforcing positive thinking is considered a behavioral approach. Seeking to uncover unconscious conflicts is a psychodynamic approach.

26. Which symptom related to thought-flow disturbance is the nurse most likely to assess in a newly admitted patient who is diagnosed with bipolar disorder, manic episode?

a. Slow, halting speech b. Flight of ideas c. Schemata d. Anhedonia ANS: B Flight of ideas is a continuous rapid flow of speech marked by jumping from topic to topic. It is a manifestation of thought disorder associated with inability to filter stimuli causing increased distractibility. Slow speech would be seen in depression. Neither schemata or anhedonia are symptoms of a thought-flow disorder.

27. Therapeutic interactions between the nurse and a manic patient will be facilitated when the nurse: a. Uses a calm, matter-of-fact approach to structuring b. Focuses primarily on enforcing rigid limits on behaviors c. Implements a laissez-faire approach to the patients symptoms d. Encourages the patient to use humor and wit to redirect energy ANS: A A calm, matter-of-fact approach minimizes patient need for defensiveness and minimizes power struggles. The use of rigid limit setting leads to power struggles and escalation of patient hyperactive, aggressive behavior. Structure and judicious limit setting are more therapeutic. A laissez-faire approach is nontherapeutic; manic patients usually need structure. Encouraging humor and wit is generally ineffective since patients with mania cannot maintain control of emotions and may shift from witty to angry in seconds.

28. A patient who is experiencing a manic episode approaches the nurse and with pressured speech states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. The priority nursing action is to:

a. Measure the patients temperature and pulse. b. Offer to have the dietitian visit to discuss his diet. c. Tell the patient he can lead exercises at the community meeting. d. Show relief when the patient ends the interaction and walks away.

ANS: A During a manic episode, the patient may be inattentive to physical needs or illness. The brief remark about burning up could suggest fever. Thirst may accompany fever, be a sign of dehydration, or be related to lithium administration. More information is needed. Because hyperactive patients have difficulty remaining still, taking the temperature and pulse will give priority information. If necessary, BP can be taken later. A nutritional consult is not a priority intervention. It is not appropriate to foster increased hyperactivity. To show relief would be disrespectful on the part of the nurse.

29. A patient with bipolar disorder reveals to the clinic nurse that she may be 4 weeks pregnant.

Which action will the nurse take? a. Confer with the physician about ordering a pregnancy test and discontinuing lithium. b. Educate the patient to the risk to the fetus as a result of exposure to the lithium in her blood. c. Suggest to the physician that the lithium dose should be increased for better symptom control. d. Remind the patient that barrier birth control methods should be used to prevent pregnancy during lithium therapy.

ANS: A The first need is to learn whether the patient is pregnant. Lithium ingestion by the mother can cause fetal damage. Lithium should be discontinued, not increased, if pregnancy is confirmed. It is premature to discuss fetal malformations before the pregnancy is confirmed. Options b and c are inappropriate and harmful. Birth control information has no value unless the pregnancy test is negative.

30. Which nursing measure would be relevant to protecting the physiologic integrity of a patient during a manic episode when marked hyperactivity is present? a. Provide appropriate attire for patient to wear. b. Set firm limits on behavior injurious to others. c. Monitor the patients weight at the same time daily. d. Use genuineness to develop a therapeutic alliance with the patient.

ANS: C Hyperactivity expends huge amounts of calories and interferes with caloric intake, thus resulting in rapid weight loss. Monitoring weight daily protects the patients physiologic integrity. The other options are concerned with psychosocial integrity.

31. Care planned for a patient with adjustment disorder will be most effective if the nurse knows adjustment disorders are a group of disorders that: a. Involve psychotic thinking in adolescents b. Address issues of anxiety and depression c. Include behaviors that are seen primarily in the child and adolescent population d. Manifest as transient episodes of dysfunction in response to specific stressors ANS: D Adjustment disorders are short-term disturbances in mood or behavior resulting from identifiable stressors. Psychotic features are not present. Adjustment disorders can occur in any age group.

Anxiety and depression may be present, but emphasis is on identifying and resolving the specific issue.

32. The nurse manager, teaching a class to new staff members about working with patients with adjustment disorders, will specify that the intervention most helpful in working with patients with this diagnosis is:

a. Entering pertinent data in the patients medical record b. Including family members in the interdisciplinary treatment plan c. Identifying the precipitating stressful event and current problems d. Reducing the patients level of anxiety to prevent behavioral escalation ANS: C Identification of the precipitating stressful event and interpretation of the existing problem are fundamental to working with the patient to reduce symptoms. Including family in treatment planning is secondary to identification of the stressor and the problem. Anxiety will remain high until the problem and the stressor are identified. Data entry is not directly related to the question posed.

33. When a father states, I dont understand what the doctor means by saying my daughter has an adjustment disorder. The nurse explains that this disorder often results from: a. Failure of existing coping skills b. Lack of stable emotional support c. Denial that a problem truly exists d. Overcompensation to present a controlled appearance ANS: A When existing coping skills are not adequate to deal with a stressor, and new coping skills have not been developed, symptoms appear. These symptoms may fit the DSM-IV-TR criteria for adjustment disorder. The lack of emotional support is not applicable to the situation. The disorder does not result from use of denial since patients usually recognize that a problem exists.

Overcompensation is not related to the onset of adjustment disorder.

34. Which question would be most effective in helping a patient with an adjustment disorder identify the event that triggered the maladaptive response? a. Can you tell me about your support system?

b. Have you ever been in psychotherapy before? c. Did you experience any stressful events recently? d. How do you usually handle problems in your life?

ANS: C This question will determine whether the patient is able to identify a particular stressor that has affected her life recently. Asking about support systems will help gain information about important persons in the patients life. History of psychotherapy will provide information about mental health. Previous methods will provide information about use of coping strategies.

35. A teenager is admitted to the adolescent unit with a diagnosis of adjustment disorder with depression. Which information collected from the assessment interview will be given highest priority when planning the patients care? a. Patient frequently disregards curfew. b. Patients parents were divorced 8 years ago. c. Patient states she finds no pleasure in living. d. Patient is failing most of her high school classes.

ANS: C Finding no pleasure in living should suggest the need for further assessment of suicide potential.

Safety needs take priority over problems suggested by other data collected.

36. The nurse has been working with a patient who has adjustment disorder with depressed mood. Which finding would permit the nurse to accurately evaluate that the crisis has been resolved? a. Absence of presenting symptoms b. Decreased need for medications c. Increased socialization with peers

d. Significant increase in the patients appetite ANS: A When the presenting symptoms are absent, the nurse can evaluate the problems as resolved. Most patients with adjustment disorders do not require medication, so this is not a good indicator. Data do not substantiate that the patient is experiencing problem socializing. This could indicate the patient is overeating as a means of dealing with stress.

37. Which of the following statements would correctly serve as a basis for teaching a family the usual outcome of an adjustment disorder? a. The symptoms will likely resolve completely. b. The patient may continue to be in danger of self-harm. c. Medications are frequently used to mask the symptoms. d. Relaxation is an effective tool to decrease and manage stress.

ANS: A The prognosis for most patients with adjustment disorders is good. In the majority of cases, identification of the stressor and use of effective coping strategies result in resolution. Continued self-harm is not a usual outcome for an adjustment disorder. Medications are not used routinely to treat adjustment disorders. Relaxation techniques are interventions rather than outcomes.

38. Which activity would be a constructive outlet for tension and anxiety while enhancing selfesteem for a patient with adjustment disorder with anxious mood? a. Knitting scarves for a homeless shelter b. Painting a paint-by-number scenic picture c. Working on a large, colorful picture puzzle d. Engaging in regular, age-appropriate physical exercise ANS: D

Physical exercise may assist in relieving tension and promoting feelings of well-being. Knitting is tedious and requires steadiness, which the patient may not have if symptoms of anxiety include jitteriness. Painting requires fine motor coordination, not always present if a patient is anxious.

Some patients find puzzles frustrating and become even more tense while working on one.

39. The major rationale for careful ongoing assessment of a patient with adjustment disorder is: a. Characteristic symptoms abate but take at least 6 months to do so. b. The disorder may be a precursor to a more serious mental health problem. c. Practitioners become less discerning as they become more familiar with the patient. d. Patients with adjustment disorders have a high risk for self-harm, especially suicide.

ANS: B Adjustment disorders usually improve with identification of the stressor and development of coping strategies to relieve stress. If symptoms worsen, new treatment strategies must be developed to treat the more serious mental health disorder that has become apparent. There is no research to support the remaining options.

MULTIPLE RESPONSE 1. When assessing a patient diagnosed with a mood disorder, which abnormal diagnostic tests would be considered a possible factor in the manifestation of the disorder? Select all that apply a. RBC (red blood cell) b. ECG (electrocardiogram) c. BUN ( blood urea nitrogen) d. TSH (thyroid stimulating hormone) e. Blood glucose ANS: A, D, E

Anemia, hyper- or hyperthyroidism, and diabetes mellitus are all medical conditions that can occur simultaneously with mood disorders. There is no research to support a strong connection between renal or cardiac disorders with mood disorders.

2. Which statements regarding a hypomanic episode are true? Select all that apply. a. Behavior has been observed in the patient for at least 4 days. b. Patient appears unaware of potentially dangerous situations. c. Hospitalization is generally required to stabilize the behavior. d. Patient is engaging in behaviors that are normally uncharacteristic of them. e. Primary difference between mania and hypomania is the nature of the activity.

ANS: A, B, D Manic and hypomanic episodes share symptom criteria, and they differ primarily with regard to their severity and duration but not the nature of the activity. Hypomanic episodes are not severe enough to cause significant impairment in social and occupational functioning or to require hospitalization. However, for diagnosis, it must be evident that the mood and behavioral disturbances of hypomania represent a definite change in the persons usual functioning that lasts for at least 4 days. As judgment declines, patients sometimes fail to recognize the consequences of their actions and the presence of possible danger.

Chapter 9: Anxiety Disorders MULTIPLE CHOICE 1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety.

Which action should the nurse perform first? a. Verify the patients learning style. b. Lower the patients current anxiety. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.

ANS: B A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patients anxiety level. Use of defense mechanisms does not apply.

2. A woman is 57, 160 lbs, and wears a size 8 shoe. She says, My feet are huge. Ive asked three orthopedists to surgically reduce my feet. This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a. Social anxiety disorder b. Body dysmorphic disorder c. Separation anxiety disorder d. Obsessive-compulsive disorder due to a medical condition ANS: B Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patients feet are proportional to the rest of the body. In obsessive-

compulsive or related disorder due to a medical condition, the individuals symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others.

People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.

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

ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is non-therapeutic; the patient likely does not have an answer. The patient may be unable to determine what he or she would like the nurse to do in order to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.

4. A patient fearfully runs from chair to chair crying, Theyre coming! Theyre coming! The patient does not follow the staffs directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for the patients safety. b. encourage clarification of feelings. c. respect the patients personal space. d. offer an outlet for the patients energy.

ANS: A

Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patients energy can occur when the current panic level subsides. Respecting the patients personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.

5. A patient fearfully runs from chair to chair crying, Theyre coming! Theyre coming! The patient does not follow the staffs directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Fear

c. Self-care deficit

b. Risk for injury

d. Disturbed thought processes

ANS: B A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goaldirected motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.

6. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of: a. flooding.

c. relaxation technique.

b. desensitization.

d. cognitive restructuring.

ANS: D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.

7. A patient undergoing diagnostic tests says, Nothing is wrong with me except a stubborn chest cold. The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued.

Which defense mechanism is the patient using? a. Displacement

c. Projection

b. Regression

d. Denial

ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development.

Displacement shifts feelings to a more neutral person or object. Projection attributes ones own unacceptable thoughts or feelings to another.

8. A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurses comments and asks, What do you mean? What are they going to do?

Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patients level of anxiety? a. Mild

c. Severe

b. Moderate

d. Panic

ANS: B Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

9. A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language.

c. Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family.

ANS: B Giving information in a calm, simple manner will help the patient grasp the important facts.

Introducing extraneous topics as described in the distracters will further scatter the patients attention.

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

ANS: B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.

11. A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a. Have you been a victim of a crime or seen someone badly injured or killed? b. Do you feel especially uncomfortable in social situations involving people? c. Do you repeatedly do certain things over and over again? d. Do you find it difficult to control your worrying?

ANS: D Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.

12. A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurses office, furnished with chairs, files, magazines, and bookcases ANS: A Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurses office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe.

13. A person has minor physical injuries after an auto accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is the persons level of anxiety? a. Mild

c. Severe

b. Moderate

d. Panic

ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually

present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, The nurse manager had a headache the day I was interviewed.

Which defense mechanism is evident? a. Introjection

c. Projection

b. Conversion

d. Splitting

ANS: C Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom.

Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

15. A patient tells a nurse, My new friend is the most perfect person one could imagine: kind, considerate, and good-looking. I cant find a single flaw. This patient is demonstrating: a. denial.

c. idealization.

b. projection.

d. compensation.

ANS: C Idealization is an unconscious process that occurs when the individual attributes exaggerated positive qualities to another. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

16. A patient experiences a sudden episode of severe anxiety. Of these medications in the patients medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone (BuSpar)

c. amitriptyline (Elavil)

b. lorazepam (Ativan)

d. desipramine (Norpramin)

ANS: B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication.

Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurses response? a. Altruism

c. Intellectualization

b. Suppression

d. Reaction formation

ANS: A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurses reaction is conscious rather than unconscious. There is no evidence of suppression.

Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.

18. A person who feels unattractive repeatedly says, Although Im not beautiful, I am smart. This is an example of: a. repression.

c. identification.

b. devaluation.

d. compensation.

ANS: D Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.

19. A person speaking about a rival for a significant others affection says in an emotional, syrupy voice, What a lovely person. Thats someone I simply adore. The individual is demonstrating: a. reaction formation.

c. projection.

b. repression.

d. denial.

ANS: A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization

c. Introjection

b. Compensation

d. Regression

ANS: A Rationalization involves unconsciously making excuses for ones behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

MSC: Client Needs: Psychosocial Integrity 21. A student says, Before taking a test, I feel very alert and a little restless. The nurse can correctly assess the students experience as: a. culturally influenced.

c. trait anxiety.

b. displacement.

d. mild anxiety.

ANS: D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. See relationship to audience response question.

MSC: Client Needs: Psychosocial Integrity 22. A student says, Before taking a test, I feel very alert and a little restless. Which nursing intervention is most appropriate to assist the student? a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects. b. Advise the student to discuss this experience with a health care provider. c. Encourage the student to begin antioxidant vitamin supplements. d. Listen attentively, using silence in a therapeutic way.

ANS: A Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem.

Listening without comment will do no harm but deprives the patient of health teaching.

Antioxidant vitamin supplements are not useful in this scenario.

Chapter 10: Obsessive-Compulsive and Related Disorders MULTIPLE CHOICE 1. A patient who was savagely attacked by a bear has no memory of the event. Which statement best explains the patients inability to remember the attack? a. The woman lost consciousness and was not cognitively aware of what happened during the attack b. The brain has produced a chemical anemia that will repress the memories of the attack indefinitely. c. The patient is unconsciously using a defense mechanism to protect against the repeated memory of the attack. d. It is a temporary suppression of the attack; her memory will return when she is physically and emotionally ready to handle the memories.

ANS: C Defense mechanisms are used unconsciously to protect us from threats to the physical, mental, and social aspects of ourselves. The memory of the event may or may not come back but this is not generally related to the patients ability to handle the memories. Memory may be lost or impaired as a result of brain trauma but not as likely from a chemical alteration.

2. Which assessment finding exhibited by a patient being assessed for posttraumatic stress disorder (PTSD) would be considered a defining behavior and support such a diagnosis? a. Can describe the attack in great detail b. Experiences dramatic swings in affect c. Describes vivid flashbacks of being attacked d. Is preoccupied with the need to tell someone about the attack

ANS: C One defining behavior that is seen when an individual has PTSD is that the person reexperiences the traumatic event. This takes place by having recurrent and intrusive disturbing recollections of the trauma, including thoughts, images, or perceptions about the incident. The person sometimes experiences recurrent dreams of the incident and acts or feels as though the event was recurring in the present (flashback). Generally the PTSD patient cannot remember all the details of the trauma nor are they particularly interested in re-telling the events of the trauma.

The patient generally has a very limited range of affect.

3. What is the basis for assessing a male patient who is agoraphobic for panic attacks? a. Men are more likely to experience panic attacks. b. An overwhelming number of agoraphobic patients also have panic attacks. c. Patients are often unaware that the symptoms they are experiencing are those of panic. d. Panic attacks are generally the cause of a patient developing phobias like agoraphobia.

ANS: B Almost all patients who present with agoraphobia in clinical samples have a current diagnosis or history of panic disorder. Males are not more likely than females to experience panic attacks.

Patients are not usually unaware of panic attack symptoms. Panic attacks dont cause, but are often triggered by, phobias.

4. Discharge preparation for a patient includes the administration of the Hamilton Anxiety Scale (HAS). When asked by the patient to explain the purpose of the assessment the nurse responds: a. It is an assessment tool used to evaluate the symptoms of anxiety. b. The tool is used to help confirm the diagnosis of anxiety disorder. c. This tool helps determine if your symptoms have improved with treatment. d. It helps identify the presence of any other disorder associated with anxiety.

ANS: C The HAS is a valid and time-tested tool that gives the most objective measure of the degree to which anxiety has been effectively treated. The HAS does not evaluate for symptoms of anxiety or act as a diagnosis tool for anxiety or another other associated disorder.

5. A patient is admitted for treatment for persistent, severe anxiety. Which nursing diagnosis would help effectively direct patient care? a. Disturbed sensory perception related to narrowed perceptual field b. Risk for injury related to closed perception c. Hopelessness related to total loss of control d. Risk for other-directed violence related to combative behavior ANS: A A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should be considered. Data are not present to support the other diagnoses.

MSC: NCLEX: Psychosocial Integrity 6. The patient was an awkward child who was ridiculed by his father for his inability to catch a ball. As an adult, the patient developed panic attacks at the time his company established afterwork team sporting activities. Which data discussed during the nursing interview provides insight to the possible cause of this anxiety disorder when applying the behavioral model? a. He always avoids sports because Im short and not the least bit athletic. b. When in fifth grade, the patient caused his team to lose the big softball game. c. The company he works for places tremendous emphasis of successful team work. d. As a child he wore a leg brace that prevented him from participating in school sports.

ANS: A

In behavioral models that are based on learning theory, the etiology of anxiety symptoms is a generalization from an earlier traumatic experience to a benign setting or object. As a result, he associates embarrassment and shame with sports events and develops panic attacks. The same kinds of cognitive operations that link embarrassment with sporting events link the cognition of the expectation of embarrassment with the idea of a sporting event, and the individual begins to experience panic attacks while merely thinking about being involved. The remaining options are not as likely to bring about the embarrassment and shame that would produce such a response.

7. The nurse is working with the family of a patient with obsessive-compulsive disorder (OCD).

Which concept should the nurse incorporate in the teaching plan? a. The thoughts, images, and impulses are voluntary. b. The family should pay immediate attention to symptoms. c. The thoughts, images, and impulses tend to worsen with stress. d. OCD is a chronic disorder that does not respond to treatment.

ANS: C Stress is known to increase the intensity of OCD symptoms. Families should be taught this relationship and the need to reduce stress in the patients life as much as possible. The symptoms are not under the patients voluntary control. It is nontherapeutic to immediately focus on the symptoms, since to do so contributes to secondary gain. OCD responds well to medication and therapy.

8. Which question would assist the nurse in determining whether the patient has been experiencing anxiety? a. Have you had difficulty concentrating lately? b. Have you been feeling sad and especially lonely? c. Do you have a history of failed personal relationships? d. Do you frequently experience difficulty controlling your anger?

ANS: A

Concentration difficulties occur when moderate or greater levels of anxiety are present.

Loneliness is more related to mood. A failed personal relationship is more related to poor selfesteem. Inability to control anger is related to poor impulse control.

9. The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patients increasing anxiety level. Which patient behavior is likely an early indication of escalating anxiety? a. Talking rapidly b. Pacing around the unit c. Staring out the window d. Refusing to go to therapy ANS: B Recognize the patients use of relief behaviors (e.g., pacing, wringing of hands) as indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant patients.

10. The nurse has been working with a patient who experiences anxiety. Which intervention should the nurse implement initially when the patient is observed pacing and wring her hands? a. Asking how she has managed anxiety effectively in the past b. Distracting her by offering to help her make a telephone call c. Asking her what she believes is causing her increased anxiety d. Teaching her to take deep, relaxing breaths to manage the anxiety ANS: A First help the patient to build on the coping methods that the patient used to manage anxiety in the past. Coping methods that were previously successful will generally be effective in subsequent situations. Distraction is not usually successful initially. Assessing for the cause of the anxiety will not, in this situation, be helpful in managing it; often times patients are not aware

of the cause. Teaching will not be effective while the patient is experiencing anxiety but should be done when the patient is relaxed and able to focus.

11. The nurse is working with a patient with an anxiety disorder whose treatment includes cognitive behavioral therapy. Which statement by the patient gives the nurse reason to assume that the patient has an understanding of the basis of this type of therapy? a. My abusive childhood has resulted in my overreaction to stress. b. My delusional thoughts of extreme anxiety are what cause my panic attacks. c. My brain chemistry causes me to overreact to common stress by getting so anxious. d. Ive learned to react to my daily stress by having anxious thoughts and panic attacks.

ANS: D The success of this approach centers on the patients understanding that the symptoms are a learned response to thoughts or feelings about behaviors that occur in daily life. Cognitive therapy helps patients identify target symptoms and change the cognitions associated with them.

This is a psychodynamic model explanation. Anxiety disorders have no relationship to delusions.

Brain chemistry is not a usual cause of anxiety but rather can be altered by anxiety.

Process: Evaluation MSC: NCLEX: Psychosocial Integrity 12. Which verbal intervention would the nurse use when helping a patient who is experiencing severe to panic-level anxiety? a. I will stay with you to make sure you remain safe. b. First, you must stop pacing and wringing your hands. c. How can I help you get control of yourself and this anxiety? d. Can you tell me what was happening just before you got upset?

ANS: A A patient who is experiencing severe to panic-level anxiety requires brief, directive verbal interchanges aimed at increasing feelings of safety and security. It is not likely the patient will be able to stop the physical behaviors. Severely anxious patients are not able to evaluate their situation and give direction to the nurse or are they able to relate antecedent events to increasing anxiety.

13. The nurse notes that a patient being treated for an anxiety disorder is becoming more anxious sitting in a congested, noisy room waiting to see the therapist. Which intervention will the nurse implement initially to assist the patient in de-escalating his anxiety? a. Offering to reschedule the patients appointment b. Taking the patient to an unoccupied interview room c. Notifying the therapist of the need to see the patient stat d. Requesting oral prn anxiolytic medication for the patient ANS: B A congested, noisy environment is not conducive to maintenance of low anxiety. Moving the patient to a less stimulating environment may be all that is needed for the patient to lower his anxiety level. The other options may not be necessary if the nurse intervenes effectively.

14. A patient is ordered medication therapy to manage the symptoms of anxiety disorder. Which statement by the patient indicates an understanding of the typical classification of medication prescribed for this disorder? a. Tricyclic antidepressants are particular good for panic attacks. b. I have to give up beer while taking monamine oxidase inhibitors (MAOIs). c. Selective serotonin reuptake inhibitors (SSRIs) help with panic attacks as well. d. Benzodiazepines are usually effective when taken for chronic anxiety like mine.

ANS: C

SSRIs are the most widely prescribed medication to treat panic disorder. They are effective and have a low side-effect profile. Tricyclic antidepressants are not effective for panic attacks and have more side effects than SSRIs. MAOIs are effective but require knowledge of and compliance with a special diet and are not the first choice in this situation. Benzodiazepines are effective but produce alterations in sensorium and other side effects and are not used for longterm management.

15. A patient with OCD tells the nurse, Thinking these thoughts and doing all my rituals is beyond being silly. I have few friends and I know others laugh behind my back. I sometimes think I can control things, but I always find I cant. I dont know if I can continue to live this way.

Which assessment question shows the nurse has an understanding of this patients priority risk? a. Are you feeling hopeless? b. Do you think you are socially isolated? c. Have you been thinking about hurting yourself? d. Do the rituals affect how you feel about yourself?

ANS: C Patients with anxiety disorders should always be assessed for the presence of depression and suicidal ideation, the priority risk to safety. This patient has admitted feeling powerless to control the symptoms, in addition to wondering if she can continue to live the way she has been. There is ample reason for asking about suicidal ideation. The remaining options address hopelessness, social isolation, and low self-esteem. While appropriate nursing concerns, they dont have the priority self-harm has for this patient.

16. The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes. The head nurse tells the staff, You will need to assess for acute stress reactions as well as treating physical problems. Which patient is exhibiting symptoms characteristic of acute stress reaction? a. A male whose moods swing between mania and depression b. A female who reports still hearing her daughters pleas for help

c. A male who keeps repeating I dont understand whats going on? d. A female who is rocking her young son and repeating it will be okay.

ANS: C Acute stress reactions are characterized by indications of dissociation, such as dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory hallucinations would be consistent with re-living a traumatic event. Comforting and reassuring a child in this manner is not characteristic of an acute stress reaction.

17. A nurse is reprimanded by the nurse manager. Shortly thereafter, a patients family member reports that the nurse curtly told them You cant come in now. You know you need to wait until visiting hours. The incidence should be discussed based on the knowledge that the defense mechanism the nurse used was: a. Displacement b. Projection c. Sublimation d. Suppression ANS: A Displacement is transferring a response or feeling toward one person onto another less threatening person. Projection is attributing strong faults to another and is not displayed in this scenario. Sublimation is channeling maladaptive thoughts into socially acceptable behaviors.

Suppression is intentionally avoiding thinking about problem areas.

18. During a nursing assessment, a teenage patient smiles and states, I dont care what you say. I want to be just like Mike, the leader of our gang. The nurse understands the defense mechanism being used is: a. Denial b. Humor

c. Splitting d. Identification ANS: D Identification is wishing or trying to be like someone else. Denial is an unconscious refusal to acknowledge some reality. Humor is not being used. Splitting is viewing oneself and others as all bad or all good.

19. A young, married female patient is attracted to a male nurse. When the nurse sets clear boundaries, the patient falsely accuses him of sexual harassment. The nursing supervisor recognizes the defense mechanism of: a. Projection b. Splitting c. Suppression d. Displacement ANS: A Projection is attributing strong conflicting feelings to another person. Splitting is seeing others and oneself as all good or all bad. Suppression is incorrect because the person avoids thinking about problem areas. Displacement, or transferring a feeling to a less threatening person, is not being used in this scenario.

20. A college-aged patient complains that, when I begin to take a test, I freeze up and my mind goes blank. The nurse will react based on the understanding that this patients anxiety level is: a. Mild b. Moderate c. Severe d. Panic

ANS: C In severe anxiety, a person may freeze and problem solving is difficult. A person is relatively relaxed and comfortable in mild anxiety. A person in moderate anxiety may feel energized and focused. A person at panic level has total loss of control.

21. A college student diagnosed with high levels of anxiety is being prepared for discharge.

Which discharge criteria is appropriate for this patient? a. The patient will avoid situations that cause anxiety. b. The patient will use learned anxiety-reducing strategies. c. The patient will return to living at home with supportive parents. d. The patient will state, I know medication is what I need to control my anxiety.

ANS: B Using anxiety-reduction strategies will promote maximal functioning. Trying to avoid stressful situations is impractical and encourages avoidance, therefore limiting activities and not supporting the development of coping mechanisms. Moving back into the parents home promotes dependency, and medication therapy is not necessarily the only treatment for anxiety.

MULTIPLE RESPONSE 1. A patient is being evaluated for a possible diagnosis of panic disorder with agoraphobia.

Which nursing assessment findings support this diagnosis? Select all that apply. a. Patient states, Ive had these fears for more than 6 years. b. Patient describes having a panic attack several times a month. c. Patient is embarrassed by the limitations the disorder causes. d. Stated, I never even think about going shopping in a crowded mall. e. Condition began after beginning treatment for a chronic intestinal problem.

ANS: A, B, C, D

To meet the first DSM-IV-TR criterion for panic disorder with agoraphobia, the person must experience recurrent, unexpected panic attacks, with at least one attack followed by one of the following for a month: (1) persistent concern about having additional attacks; (2) worry about the implications of the panic attacks; or (3) a significant change in behavior as a result of the attacks.

The second criterion is that the individual experiences agoraphobia. Agoraphobic fears typically involve being in a crowd. The third criterion is that the person avoids agoraphobic situations or has anxiety about having a panic attack. This person will not go to an area or event where he or she has experienced an agoraphobic reaction. The fourth criterion states that panic attacks are not caused by the direct effects of a substance, a medication, or a medical condition.

2. The nurse has identified a nursing diagnosis of disturbed thought processes for a patient with obsessive-compulsive disorder. What abilities displayed by the patient would be related to an appropriate outcome for this problem? Select all that apply. a. Can identify when obsessions are worsening b. Speaks of obsessions as being embarrassing behaviors c. Describes lessening anxiety when compulsive rituals are interrupted d. Plans to ignore obsessive thoughts and so minimizes resulting stress e. Limits time focusing on obsessive thoughts to 15 minutes, 4 times a day ANS: A, C, E It is desirable for the patient to experience a sense of being able to identify and control the obsessive thinking and the resulting anxiety. Identifying the behaviors as embarrassing is not showing control nor is ignoring the behaviors.

3. Which lifestyle changes should the nurse incorporate in the nursing care plan for a patient with generalized anxiety disorder? Select all that apply. a. Stop smoking. b. Limit caffeine intake. c. Eliminate stress from your life.

d. Practice a relaxation technique daily. e. Limit worrying to specific times each day.

ANS: A, B, D, E CNS stimulants, including caffeine and nicotine, increase anxiety symptoms such as heart rate and muscle tension. Relaxation techniques are invaluable in the management of stress and anxiety. Limiting the time to allow worrying will help control the invasive thoughts. One cannot avoid stressful situations and attempting to do so does not help in managing its affects.

4. A nursing interview for a patient being admitted for depression reveals that the patient has been taking a benzodiazepine for anxiety for 3 years. Which actions by the nurse reflect an understanding of the effects of this classification of drugs? Select all that apply. a. The nurse asks how much of the drug the patient takes daily. b. The admitting physician is notified of the patients medication history. c. The nurse prepares to discuss the process of detoxification with the patient. d. The nurse suggests to the patient that the dosage is likely to be increased. e. The patient is interviewed regarding how well the anxiety has been controlled.

ANS: A, B, C Benzodiazepines are relatively safe and effective for short-term use to control the debilitating symptoms of anxiety. However, longer-term treatment with these drugs raises issues of tolerance, abuse, and dependence. The medication dosage would not be increased. The effectiveness of the medication is irrelevant but rather the length of the therapy is the prime concern.

5. A patient comes to the ED exhibiting severe physical and emotional symptomology. When no physical cause can be found for the symptoms, the patient is diagnosed with severe anxiety with panic attack symptoms. Which assessment data supports this diagnosis? Select all that apply. a. Blood pressure 158/90; 15 minutes later 130/80

b. Claims that she feels like she going to die c. Random but controlled thoughts d. Unable to follow instructions e. Dry, flushed skin ANS: A, B, D Blood pressure will begin to drop in a panic attack as the sympathetic nervous system release occurs; the patient may express an emotional sensation of doom and the patient will not be able to concentrate and so will be unable to follow instructions. Thoughts during a panic attack are uncontrolled and the skin is diaphoretic.

6. Which considerations should a nurse include when conducting a mental health assessment on a culturally diverse patient Select all that apply. a. Men and women are equally likely to seek psychiatric health care. b. The role that spirits and magic play in a patients belief system is cultural based. c. Rituals are only deemed obsessive when applied to the patients cultural standards. d. Agoraphobia is more difficult to assess in cultures that restrict female socialization. e. The nurse should consider the universal application of the Diagnostic and Statistical Manual (DSM-IVTR).

ANS: B, C, D Some cultures restrict womens participation in public activities; thus agoraphobia is less commonly diagnosed. Fears of magic and spirits are present in many cultures and are pathologic only when they are deemed excessive in the context of that culture. Many cultures have rituals to mark important events in peoples lives. The observation of these rituals is not indicative of OCD unless it exceeds norms for that culture, is exhibited at times or places that are inappropriate for that culture, or interferes with social functioning. Most research that supports the development of the Diagnostic and Statistical Manual, ed 4, text revision (DSM-IVTR) classification occurred in

the United States; consequently, symptoms that define disorders are representative of U.S. culture. Overall, women are more likely than men to present for treatment or to come in contact with health care providers.

Chapter 11: Trauma- and Stressor-Related Disorders ULTIPLE CHOICE 1. Although stress may result from either a positive or a negative event, the physical effects are similar. Which statement best describes the long term effects of stress? a. Eustress is likely to result in short term stress. b. Chronic distress can take a toll on the individual. c. Stress usually manifests in physical symptoms first. d. Distress generally results in more effective coping skills.

ANS: B Distress is damaging to an individual whether it is a result of either positive or negative stress.

This stressor can become chronic if the conflict is not resolved. Distress can take a toll on an individuals body as well as on his or her emotional state. Eustress occurs as a result of a positive stress such as from anticipation of a childs birth but such stress is not necessarily short term and can result in the same symptoms as distress. Distress is less likely to occur if previous stress has brought about good coping skills.

2. When explaining the fight-or-flight response to stress, the nurse identifies that the role of the pituitary gland is to: a. Minimize the secretion of cortisol. b. Facilitate the conservation of energy. c. Secrete adrenocorticotropic hormone. d. Encourage fleeing from the stressor.

ANS: C The pituitary gland secretes adrenocorticotropic hormone, which stimulates the adrenal cortex to release cortisol. Cortisol is involved in helping the entire body to react to the stress by mobilizing the energy reserves so that the body can rapidly respond to the stressors by either fighting or fleeing.

3. It is believed that an individuals locus of control has a major role to play in how stress will be handled. Which statement characterizes an internal locus of control? a. Ill need to manage my money better in order to get out of debt. b. The economy has really caused my finances to be in a real mess. c. I dont think Ill ever be able to save enough to pay off my bills. d. Having a family makes being able to stay out of debt really difficult.

ANS: A Individuals who demonstrate an internal locus of control view their capability to have personal success or failure as having to do with their own efforts and their ability to complete a task. An individual with an external locus of control views task completion as having to do with circumstances beyond his or her control. The options involving the economy, never being able to pay off the bills, and having a family exhibit external control locus.

4. A nurse manager is attempting to address issues of work-related stress and dissatisfaction on the unit. Which administrative intervention has been identified through research as providing the most positive impact on staff morale even when job demands are high? a. Scheduling so that all staff gets two weekends off a month b. Arranging for extra staff when patient activity is above the unit average c. Offering a paid vacation day to anyone who has no absents for six months d. Assuring that no staff will be mandated overtime more than twice monthly ANS: C

Workplaces with positive social interactions involve less stress, even when the job demands are high. When there is competition among workers, negative interactions among staff members, and no assistance when the workload becomes overwhelming, job dissatisfaction and stress is evident. The nurse manager will best impact the stress and resulting dissatisfaction by arranging for help with patient care when the need exists. Although the other options are not inappropriate, they do not address the issue research has identified as the primary cause of stress in the workplace.

5. The nurse suggests that a patient help manage the stressors that are triggering generalized anxiety by implementing compartmentalization. Which activity provides proof that the patient is employing this healthy defense mechanism? a. Attends a meditation class 3 times a week right after work b. Uses chocolate as a reward when keeping stress under control c. Counts to 10 before responding to a coworker who is a source of stress d. Shares with the office manager the situations that regularly cause increased stress ANS: A The person who uses compartmentalization learns to leave the stressor in a designated space. An example of this mechanism would be regularly attending a class that serves to separate the stressful work environment from ones private life. Using food as a reward may not be healthy and as with the remaining options, it is not examples of compartmentalization.

6. The spouse of a patient exhibiting symptoms of chronic stress asks how they can help their spouse. Which suggestion by the nurse shows an understanding of a family members role in the management of stress? a. Offer to discuss the problem with the person who is most responsible for causing their spouses stress. b. Listen attentively when their spouse talks about the stressors and provide hugs to show your support.

c. Help the spouse limit the amount of time each day they devote to discussing and otherwise dwelling on the stress. d. Provide the spouse with a variety of options and techniques for dealing with the stressors and the resulting physical symptoms.

ANS: B People need people to prevent isolation to promote their ability to deal with stress. In a study, it was found that individuals who had significant relationships that involved an expression of affection had a reduction in the fight-or-flight response when stressed. Those who regularly received hugs from their romantic partners had a decrease in resting heart rate and a healthy functioning limbic-hypothalamic-pituitary-adrenal axis. Conversely, individuals who lacked such support showed a higher level of stress and an increased possibility of developing an illness.

Offering to confront the source of the stress is not supporting the spouse in learning to manage stress. Limiting time to dwell on obsessive thoughts may be therapeutic, but when a spouse implements this technique too often, it suggests a lack of patience and understanding of the problem. The spouse may not be qualified to provide such therapeutic options; that is the role of a mental health professional.

7. The patient is being introduced to mindfulness-based stress reduction to help manage chronic stress. The patient is first taught to focus on: a. What is causing the stress b. Both inhaling and exhaling c. Relaxing each major muscle group d. Visualizing their life without the stress ANS: B It is helpful to teach individuals a generic method of relaxation by first concentrating on the rhythm of breathing. Paying attention to each breath as one takes in a respiration and releases an expiration provides a focus for the meditation. The remaining options are not steps included in mindful mediation.

MULTIPLE RESPONSE 1. What is the role of the brain in producing the fight-or-flight stress response? Select all that apply. a. The medulla oblongata increases heart rate. b. Blood flow is increased by the medulla oblongata. c. The hypothalamus is stimulated via the limbic area. d. The reticular formation coordinates the brains sensory and motor tracks. e. Adrenocorticotropic hormone production is increased in the hypothalamus.

ANS: A, B, C, D The brain (specifically the medulla oblongata) is responsible for the heart rate, the blood pressure rate, and the respiration rate. When a stressor is detected, the autonomic nervous system tells the medulla oblongata to increase the blood flow to certain organs (e.g., the muscles) to allow the individual to prepare for fight-or-flight. The brain receives an increase in oxygenated blood to increase awareness and the ability to think and respond to the stressor. The blood in the brain has an increase in glucose, epinephrine, and norepinephrine to assist the individual with reacting to the stressor. The reticular formation supports the coordination of the sensory and motor tract of the individuals brain. This provides the individual with the ability to fight or flee. The limbic area of the brain communicates with the hypothalamus that the stress is occurring. The pituitary gland secretes adrenocorticotropic hormone which stimulates the adrenal cortex to release cortisol.

2. Nursing interventions appropriate to the generalized adaptation syndrome (GAS) exhaustion state include which of the following? Select all that apply. a. Planning care to best conserve the patients energy b. Assessment for respiratory disorders such as asthma c. Monitoring of exacerbation of compulsive ritual behaviors d. Frequent assessment of pain management related to headaches

e. Planned periods to reinforce effective relaxation techniques ANS: A, B, D, E If the individuals body does not adapt and the stressor continues to be prominent, then the third stage, called the exhaustion stage, occurs. The exhaustion stage can manifest itself in the form of illnesses such as infections, headaches, hypertension, asthma attacks, chronic fatigue syndrome, depression, anxiety disorders, and many other chronic conditions.

3. Which are expected outcomes for a patient who is effectively implementing a decision tree to enhance their problem-solving abilities? Select all that apply. a. A large, complex problem will be turned into a series of smaller, manageable problems. b. The patient will not be overwhelmed and made to feel powerless by the problem. c. The problem and the resulting stress will be clearly and concisely defined. d. All resulting stress will be eliminated and the patient will feel empowered. e. Several different options for resolving the problem will be formulated.

ANS: A, B, C, E A decision tree enhances the persons ability to think through a problem without getting stuck in a pattern of feeling overwhelmed and therefore unable to determine ways to reduce the effect of the stressful situation. The decision tree provides individuals with opportunities to problem solve by breaking down a problem or a stressor into smaller increments. Defining a problem clearly and determining options for solving it can help a person to think about more than one way to work on the problem or stressor. The use of a decision tree will not remove all stress but rather empower the individual to strive to solve the problem causing the stress.

4. The patient has been taught to use the stop, divert, and reframe method to deal with stress.

Which responses indicate that the patient can affective utilize the technique when preparing to take a written examination? Select all that apply.

a. Is heard declaring that, Its only a test; if I fail this one I will just study harder for the next one.. b. Is observed opening a notebook and focusing on a family picture taken during a recent vacation c. Is heard stating, Stop thinking that you cant correctly answer the question. You can and you will. d. Is observed asking the test monitor to be allow to sit somewhere quiet and away from other people e. Is heard saying, I will read the question thoroughly, find the key word, and then look at the options Im given.

ANS: B, C, E Stop interrupts the negative train of thought. Divert allows focus on something that will rapidly reduce the stress. Reframe reinforces what you can do to reduce the stressor. The remaining options do not address any of the identified steps in this stress management method.

Chapter 12: Dissociative Disorders Test Bank MULTIPLE CHOICE 1. Which question would the nurse performing an admission interview for a patient with suspected dissociative amnesia disorder identify as a priority? a. What help would you like us to give you? b. Are you experiencing a high level of anxiety? c. Do you find rituals make you feel more comfortable? d. How would you describe your childhood memories?

ANS: D Due to a recent increase in reported cases of dissociative amnesia involving previously forgotten early childhood memories, assessing such memories would have priority with this patient.

Obsessive-compulsive disorder is not generally viewed as a co-morbid disorder of dissociative amnesia. The remaining options would not provide much specific information for this patients condition.

2. Which nursing assessment finding would support a diagnosis of somatoform disorder? a. Patient reports a family history of depression b. The onset of symptoms beginning at age 38 c. An abnormality of the patients left heart ventricle d. Complaints of diarrhea and an erratic menstrual cycle ANS: D The diagnosis of somatization disorder requires that symptoms indicate there is involvement of multiple organ systems (e.g., gastrointestinal, reproductive, neurologic). Structural anomalies

would indicate a medical problem exists. An early onset of symptoms (prior to age 30) is not recognized as a criterion for the diagnosis. A family history of depression is not a criterion for the diagnosis.

3. To differentiate between somatoform and conversion disorders, the nurse will direct the assessment to determine the presence of the critical defining factor associated with conversion disorder. Which is true about a conversion reaction? a. Symptoms are generally associated with pain or sexual function. b. Symptoms are not accounted for by a medical condition. c. Symptoms are precipitated by psychological factors. d. Symptoms are under the patients voluntary control.

ANS: C Symbolic psychological factors are identified as being related to the onset or exacerbation of a conversion symptom. An absence of a medical cause is present in both the case of conversion and somatization disorders. The conversion symptom is not limited to pain or sexual function nor is not under voluntary control.

4. A diagnosis of dissociative identity disturbance has been identified for a patient who has stated that he is unable to distinguish between himself and his surroundings. What is an appropriate outcome for this patient? a. Refers to himself as the patient b. Identifies the onset of increasing anxiety c. Uses manipulative behaviors to meet needs d. Displays ability to suppress feelings of dissatisfaction ANS: B Dissociative identity disturbance is exacerbated when the patients anxiety escalates.

Identification of increasing anxiety permits the patient to exercise anxiety-management strategies

and prevent dissociation. The patient should be expressing such feelings to others. The patient should refer to himself in the first person. Use of manipulative behavior is not desirable in this or any other patient.

5. A patient comes to the ED stating that he suddenly became deaf. It is determined that his wife has recently asked for a divorce. What is the basis for the possibility that this patient is experiencing a conversion disorder? a. Inventing the symptom helps in diverting attention from the marital problems. b. Such a traumatic life change is likely to result in some form of mental illness. c. The loss is a protective mechanism to help deal with overwhelming anxiety. d. Men often exhibit this disorder since it is more accepted than showing sadness.

ANS: C The scenario suggests that the patient is experiencing symptoms of conversion disorder, an anxiety disorder in which the symptom affects voluntary sensory or motor function and mimics a neurological disorder as a result of extreme anxiety, such as learning of his wifes desire to divorce him. There is no organic basis for the hearing loss but it is not under the patients voluntary control. Most traumas are not dealt with by developing a mental illness but by rather coping effectively. Males are as likely as females to display conversion disorder symptoms.

6. A patient reports severe pain during intercourse since being sexually assaulted three years ago.

What is the first step in confirming the diagnosis of a pain disorder? a. Evaluating the patients understanding of the emotional effects of the assault b. Asking the patient to keep a journal of her feelings regarding the assault c. Assessing the patient for posttraumatic stress disorder d. Ruling out a physical cause of the pain ANS: D

While psychological factors have an important role in the onset, severity, exacerbation, or maintenance of the pain, initially the presence of a physical cause of the pain must be ruled out.

The assessment of the patients understanding of the disorder or recording of feelings regarding the trauma are not priorities until a diagnosis of pain disorder is made. Posttraumatic stress disorder is not generally characterized with reports of sustained pain.

7. A patient has developed an acute loss of hearing and is diagnosed with a conversion disorder.

Which nursing diagnosis would be most appropriate? a. Hearing impairment b. Panic-level anxiety c. Disturbed sensory perception d. Denial due to a medical condition ANS: C The diagnosis of conversion disorder in this case results in a disruption of the patients ability to perceive sensations, not a true loss or impairment of hearing. There is no evidence to support panic-level anxiety or a medical condition causing denial.

8. A patient experiencing the sudden onset of blindness is diagnosed with a conversion disorder.

Which nursing intervention would be most therapeutic? a. Suggesting to the patient that this is possibly malingering b. Assisting him to make an appointment with an ophthalmologist c. Providing nursing care in a supportive but matter-of-fact manner d. Providing an occupational therapy consult to address the needs of a blind person ANS: C Interacting in a supportive but matter-of-fact way reduces the potential for any secondary reward on the part of the patient. The patient is not feigning illness, so is not a malingerer. An

appointment with an eye doctor is not needed since the source of the blindness is not physical.

The person is not permanently blind, so occupational therapy at this point is not a priority.

9. A patient is being evaluated for the diagnosis of hypochondriasis. Which assessment observation of the patient would serve to confirm this diagnosis? a. Reports, Pain in my back is certainly from a spinal tumor. b. Patient expresses no concern over her sudden loss of hearing. c. Patient shows insight into the role stress plays in the illness. d. Reports, I dont like doctors and so I havent been to one in years.

ANS: A With this disorder, the individual focuses on fears of having or the idea of having a serious medical disorder on the basis of his or her misinterpretation of bodily symptoms such as assuming pain is the result of a tumor. La belle indifference, showing little or no concern, occurs with conversion disorders. Individuals with hypochondriasis make multiple visits to physicians with health concerns. Showing insight into the condition would not be displayed at the time of diagnosis, since such improvement is a result of appropriate treatment.

10. A patient who inaccurately believes he has stomach cancer is recommended cognitive theory to help address this false believe. Which intervention is most consistent with a cognitive theory approach? a. Continuing to challenge the patient about the rationality of his belief b. Assisting him to reinterpret the meaning of the sensations his body is creating c. Urging him to have a second opinion consult with another medical specialist d. Rewarding him with praise and acceptance when he states, I do not have cancer.

ANS: B Cognitive theorists believe that patients with somatic symptoms misinterpret the meaning of body functions and sensations and become overly alarmed by them and so help patients to

reinterpret the meaning of body sensations. Continuing to challenge the patient regarding the belief is not therapeutic and should be avoided. Reinterpretation of thoughts is an appropriate cognitive approach. Rewarding appropriate behavior is a behavioral technique. Encouraging a second opinion is not helpful at this point since it is not likely to change his belief.

11. The ED nurse is caring for a patient with a dissociative fugue. Which assessment finding would support this diagnosis? a. Reports of pain in both legs and abdomen b. An inability to recall how and when he arrived in this city c. Change in voice and attitude suggesting two distinct personality states d. Inability to see since witnessing an accident that resulted in two deaths ANS: B The inability to recall the past is indicative of a fugue disorder. The remaining options are not characteristics of dissociative fugue.

12. A nurse interviews a 17-year-old patient and notes these assessment data: excessive grooming, checking in the mirror, and preoccupation with perceived physical imperfections. The nurse suspects: a. Hypochondriasis b. Factitious disorder c. Somatoform disorder d. Body dysmorphic disorder ANS: D These symptoms are indicative of a body dysmorphic disorder.

13. The nurse reinforces the recommendation of group therapy for a patient with a somatization disorder. What knowledge is this recommendation based upon?

a. Group therapy is the one therapy of choice for this anxiety disorder. b. Group therapy is therapist driven and managed to eliminate stress on the patients. c. The group will support the patient in all complaints of physical illness as well as emotional distress. d. This therapy allows the patient to learn what has successfully worked for other patients with the disorder.

ANS: D An advantage of group therapy is that it is an opportunity for the patient to learn from the successes and failures of others with similar symptoms. The group therapist will not allow members to support dysfunctional verbalizations. This disorder is treated with a variety of treatment modalities. This therapy is done with cooperation between therapist and patients.

14. A family member asks the nurse about possible medications to treat somatization disorders.

Which statement by the nurse shows an understanding of the recognized medication therapy for this disorder? a. Hypnotics, taken appropriately will help with your major complaints. b. Lithium will require regular monitoring to assure therapeutic blood levels. c. Antidepressant therapy may take several weeks to bring about symptom relief. d. Anticonvulsants are often used to treat the side effects of these type of disorders ANS: C Pharmacologic therapy for somatization disorders commonly include antidepressants, which can take weeks of administration before positive effects are noted. The remaining classifications are not generally used to treat somatization disorders.

15. A patient has a somatization disorder. Which statement by the patient would indicate a need for additional patient teaching? a. I have learned that my family can be a support system.

b. I will let my therapist know if I think suicidal thoughts. c. Drinking strong coffee really helps me combat my fatigue. d. Nicotine makes my heart race, so I need to stop smoking.

ANS: C Educating the patient about the importance of limiting caffeine, nicotine, and other central nervous system stimulants is important since these substances can increase physical symptoms of anxiety (e.g., rapid heart rate, jitteriness) that may cue other somatic concerns. Drinking strong coffee each day may cause physical symptoms that could cue other somatic concerns; this statement indicates a need for more teaching. The remaining options are all positive thoughts or actions for a patient.

16. A patient is diagnosed with body dysmorphic disorder. Which question assesses for the presence of a common co-morbid mental disorder? a. Do you every have suicidal thoughts? b. Do you worry about being terminally ill? c. Do you see yourself as having problems controlling your anger? d. Do you engage in repetitive, ritualistic behaviors to help control anxiety?

ANS: A Anxiety and depression are common comorbid mental health conditions seen in patients diagnosed with body dysmorphic disorder due to their constant dissatisfaction with their appearance. Obsessive-compulsive disorder, poor impulse control, and somatization disorders are not generally seen in such patients.

17. Which adult patient is most likely a candidate for the diagnosis of factitious disorder? a. An educated African immigrant

b. A health care facility employee c. A cognitively challenged female d. A middle-aged American male ANS: B The adult patients diagnosed with factitious disorder are often knowledgeable regarding medical terminology, and many work in the health care. The other options are not commonly associated with the disorder.

MULTIPLE RESPONSE 1. A patient is being treated for somatoform disorder with psychotherapy and medication therapy. Which interventions are appropriate for the patients plan of care? Select all that apply. a. Instructing the patient in use of imagery to distract themselves when feeling anxious b. Educating the patient on the identification of side effects related to anxiolytic therapy c. Monitoring the patients vital signs to assess for the side effects of benzodiazepine administration d. Discussing the need for long-term cognitive therapy in order to eliminate the symptoms of the disorder e. Asking the patient to explain the role serotonin selective reuptake inhibitors (SSRIs) play in the management of his symptoms.

ANS: A, B, C, E Pharmacologic interventions are symptom oriented and include anxiolytics for associated anxiety, antidepressants for associated depression, and short-term benzodiazepine therapy.

Monitoring for orthostatic hypotension is recommended when benzodiazepines are prescribed.

Instructing the patient to perform visual imagery (guided imagery) will reduce anxiety by distracting his or her focus on somatic concerns. When used, cognitive therapy is implemented short term.

2. What discharge criteria would be appropriate for a patient with a somatization disorder? Select all that apply. a. Increased willingness to relinquish the sick role b. Decreased anxiety related to possible health issues c. Increased caloric intake and demonstrated weight gain d. Decrease the use of laxatives, sleeping pills, and diuretics e. Experiencing decreased frequency of auditory hallucinations ANS: A, B Minimization of the use of sickness to gain control and decreased anxiety related to health and wellness are the outcomes that relates specifically to somatization disorder. The remaining options are not typically associated with this disorder.

3. The nurse is evaluating a patient diagnosed with a dissociative disorder for discharge criteria.

Which statements made by the patient indicate that discharge criteria have been met? Select all that apply. a. Ive learned to identify my personal stressors. b. Meditation is a wonderful support in managing my stress. c. Its getting better; Im sleeping about 5 hours most nights. d. I know I have to rely on myself to get this problem under control. e. Ill talk with my doctor before making any changes to my medicines.

ANS: A, B, E Discharge criteria would include behaviors and attitudes that show insight and some control over the disorder. Compliance with medication therapy, identification of stressors and using learned stress-reducing strategies such as mindfulness meditation are examples of such behaviors. There is a need for more nightly sleep and a willingness to seek help and support are important unmet criteria with this patient.

Chapter 13: Psychosomatic Medicine MULTIPLE CHOICE 1. The nurse is assessing a patient who is complaining of hearing voices. What is this patient experiencing? a. Delusions b. Flight of ideas c. Disorganized thinking d. Hallucinations ANS: D Hallucinations are false sensory perceptions that are experienced without an external stimulus but seem real to the patient. Auditory hallucinations are prominent in a schizophrenic patient.

Additional sensory hallucinations include those of touch, sight, smell, and body sensation.

Delusions are false beliefs that persist despite evidence to the contrary. Flight of ideas is characterized by rapid changes in thought from one topic to another. Disorganized thinking is commonly associated with psychoses and consists of a flight of ideas during which the individual jumps from one idea or topic to another one.

MSC: NCLEX Client Needs Category: Psychosocial Integrity 2. A patient with schizophrenia has been nonadherent with his home medication regimen. He requires frequent admissions to the intensive psychiatric unit for treatment of acute psychotic episodes. Which medication regimen would be appropriate for this patient? a. Daily home nursing visits to administer the prescribed oral medication b. Continuous inpatient hospitalization for medication therapy c. Administration of depot antipsychotic medication d. Subcutaneous medication administration

ANS: C Depot antipsychotic medications are long acting injections that may be used with noncompliant patients and may assist in avoiding repeated hospital admissions. Daily home nursing visits are not an efficient way to ensure medication compliance. Continuous inpatient hospitalization is not an efficient way to ensure medication compliance. Subcutaneous medication administration is not an option for this patient.

MSC: NCLEX Client Needs Category: Psychosocial Integrity 3. What is the most common cause of nonadherence to antipsychotic pharmacologic treatment? a. Expense b. Increased symptoms of chemical dependency c. Extrapyramidal effects d. Inability of the patient to understand the need to take medications ANS: C Extrapyramidal effects are the most common reason for nonadherence to antipsychotic therapy.

The four categories of extrapyramidal effects are dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. Although expense may be a concern, it is not the most common reason for noncompliance. Chemical dependency is not a feature of therapy with antipsychotic drugs. Although knowledge deficit is a concern, it is not the most common reason for noncompliance.

4. Which type of adverse effects is present when a patient displays prolonged tonic contractions of the tongue, oculogyric crisis, and torticollis? a. Dystonic reactions b. Pseudoparkinsonism c. Akathisia d. Tardive dyskinesia

ANS: A Dystonic reactions are the first extrapyramidal symptoms to occur when a patient is taking antipsychotic agents. Dystonias are spasmodic movements of muscle groups such as tongue protrusion, rolling back of the eyes (oculogyric crisis), jaw spasms (trismus), or neck torsion (torticollis). Pseudoparkinsonism is characterized by tremor and rigidity. Akathisia is characterized by subjective feelings of anxiety and restlessness, accompanied by pacing and the inability to remain in one place for extended periods. Tardive dyskinesia is characterized by persistent involuntary hyperkinetic movements.

5. The nurse is teaching a patient who is taking clozapine (Clozaril) to have weekly blood tests for the first 6 months of treatment to monitor for which potential complication? a. Agranulocytosis b. Vitamin deficiencies c. Clotting abnormalities d. Polycythemia ANS: A The use of clozapine requires a baseline and weekly white blood cell (WBC) counts because of the high incidence of agranulocytosis. Clozapine does not cause vitamin deficiencies. Clozapine does not interfere with clotting abilities. Clozapine does not affect red blood cell volume.

6. A male patient becomes verbally aggressive and insists the nurse is poisoning him as she attempts to administer haloperidol (Haldol). Which action will the nurse take? a. Support the patients decision to refuse the medication. b. Discreetly ask an assistant to put the medication in the patients food. c. Firmly redirect the patient to take the medication. d. Speak privately with the patient and reinforce medication action.

ANS: C

During episodes of acute psychosis, the patient is out of touch with reality and often does not understand the need for medication in stabilizing his or her condition. Target symptoms such as agitation, suspicion, and paranoia are common. Health care providers must be supportive yet firm in their expectations. An open and direct manner in handling patients who are highly suspicious is critical. Delusions should not be supported. The patient is not competent to determine his need for medication. It is dishonest to hide medication in a patients food and destroys a trusting relationship. Reasoning with the patient is unlikely to change his mind; he needs external structure for making decisions when he is aggressive and paranoid.

7. Which statement is true regarding the adverse effects associated with antipsychotic medications? a. Tardive dyskinesia is a common, reversible condition. b. Painful dystonic reactions can occur in the first 72 hours of initiation of therapy. c. Neuroleptic malignant syndrome (NMS) is a common adverse effect. d. Pseudoparkinsonian symptoms can cause Parkinsons disease.

ANS: B Approximately 90% of all dystonic reactions occur in the first 72 hours of antipsychotic therapy.

These symptoms are often frightening and painful. Tardive dyskinesia is present in 20% to 25% of patients and may become irreversible. NMS is not a common adverse effect.

Pseudoparkinsonism is not related to Parkinsons disease.

8. To what does potency of an antipsychotic medication refer? a. Severity of adverse effects associated with the drug b. Length of time that it takes to reach a therapeutic blood level of the drug c. Milligram doses used for the medication d. Effectiveness of the drug in alleviating psychotic behavior ANS: C

Low and high potency refers only to the milligram doses used for the medications and does not suggest any difference in effectiveness. Potency is not related to severity of adverse effects or onset of action. Potency does not refer to effectiveness.

9. Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect? a. Extrapyramidal symptoms b. Allergic reactions c. Idiosyncratic reactions d. Therapeutic responses ANS: A There are four categories of extrapyramidal symptoms: dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. These are not allergic reactions, idiosyncratic reactions, or therapeutic responses.

10. Which is an appropriate nursing intervention for a patient who has recently been prescribed clozapine (Clozaril)? a. Assess for signs and symptoms of hypoglycemia. b. Encourage a low fiber diet. c. Measure the patients waist circumference. d. Monitor for insomnia.

ANS: C Waist circumference baseline measurement is appropriate because of the weight gain and onset of diabetes with use of these medications. Hypoglycemia and insomnia do not occur with this medication. A low fiber diet is not appropriate.

11. A young male patient taking an antipsychotic is experiencing an oculogyric crisis. The nurse prepares to administer:

a. diphenhydramine. b. haloperidol. c. aripiprazole. d. risperidone.

ANS: A Acute dystonic reactions may be controlled by intramuscular injections of diphenhydramine.

Haloperidol, aripiprazole, and risperidone are not used for dystonic reactions.

MULTIPLE RESPONSE 12. A patient admitted to the hospital is exhibiting psychotic behavior. Which sign(s) and/or symptom(s) would support the diagnosis of psychosis? (Select all that apply.) a. Constant eye contact during the admission history b. Deterioration of social functioning c. Reporting that the FBI has solicited important secret information from his phone conversations d. Confirmation of hearing voices in his head e. Changing the topic of conversation inappropriately ANS: B, C, D, E Social deterioration, disordered thinking (including delusions), disordered perception, (including hallucinations), and flight of ideas are symptoms of psychotic behavior. It is uncommon for a psychotic patient to maintain eye contact.

13. Why is a combination of antipsychotic agents with benzodiazepines useful in initial treatment of the agitated patient? (Select all that apply.) a. Antipsychotics are not effective for 2 days.

b. Benzodiazepines allow for lower dosages of antipsychotic agents to be used, thereby decreasing serious adverse effects seen with high dose therapy. c. It assists in calming the psychotic patient. d. It allows for rapid increase in dosing of the antipsychotic agents to expedite treatment of hallucinations. e. It effectively treats extrapyramidal adverse effects associated with antipsychotic agents.

ANS: B, C The use of benzodiazepines allows lower dosages of antipsychotic agents to be used.

Benzodiazepines assist in calming the agitated psychotic patient. Antipsychotic medications can be effective in a matter of minutes when injected. Benzodiazepines do not facilitate the increase of antipsychotic medications or treat extrapyramidal adverse effects associated with antipsychotic agents.

TOP: Nursing Process Step: Implementation 14. Which is/are extrapyramidal adverse effect(s) of antipsychotic agents? (Select all that apply.) a. Spasmodic movements of muscle groups b. Masklike expression c. Lip smacking d. Inability to sit in one place for an extended period e. Weight gain ANS: A, B, C, D Dystonic reactions, pseudoparkinsonism, tardive dyskinesia, and akathisia are extrapyramidal symptoms of antipsychotic agents. Antipsychotic drug therapy often causes substantial weight gain, but this is not classified as a extrapyramidal adverse effect.

15. Which sign(s) and symptom(s) may occur in neuroleptic malignant syndrome? (Select all that apply.) a. Fever b. Hypertension c. Severe extrapyramidal symptoms d. Alterations in consciousness e. Bradycardia ANS: A, B, C, D Fever, severe extrapyramidal symptoms, hypertension, and alterations in consciousness (such as stupor, mutism, and coma) are characteristic of neuroleptic malignant syndrome. Bradycardia is not a sign of neuroleptic malignant syndrome.

MSC: NCLEX Client Needs Category: Physiological Integrity 16. Which adverse effect(s) may occur as a result of antipsychotic drug therapy? (Select all that apply.) a. Acute dystonia b. Akathisia c. Weight loss d. Neuroleptic malignant syndrome e. Hypoglycemia f.

Tardive dyskinesia

ANS: A, B, D, F Antipsychotic drugs can cause neuroleptic malignant syndrome and motor dysfunctions such as dystonia, akathisia, and tardive dyskinesia. Antipsychotic drugs may cause weight gain and hyperglycemia.

17. A patient admitted to a psychiatric facility is hallucinating, pacing, and acting highly suspicious. Based on this information, the nurse will take which action(s)? (Select all that apply.) a. Use the most restrictive restraints available to subdue the patient. b. Be open and direct when handling the patient. c. Encourage a variety of interactions with others. d. Provide high-protein, high-calorie foods. e. Reinforce hallucinations.

ANS: B, D Nursing interventions for patients with psychosis must be individualized and based on patient assessment data. The nurse should be open and direct when handling patients who are highly suspicious. High-protein, high-calorie foods are appropriate for the individual to eat while pacing or highly active. If physical restraints are necessary, they should be the least restrictive possible for the circumstances. Interactions should be minimized when perceptions are altered.

Hallucinations should not be reinforced.

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Psychosocial Integrity 18. The psychiatric nurse is educating an elderly patient and family about antipsychotic drug therapy. When providing this education, the nurse will include which statement(s)? (Select all that apply.) a. Hallucinations may be reduced within 1 week of starting. b. Rapid increase in dosages will increase frequency of adverse effects. c. Older patients should be observed for hypertension. d. Tardive dyskinesia may be reversible in early stages e. Full therapeutic response may require 6 to 8 weeks to be achieved.

ANS: B, D, E

Rapid increases in dosages of antipsychotic medication will not reduce the antipsychotic response time but will increase the frequency of adverse effects. Tardive dyskinesia may be reversible in early stages, but it becomes irreversible with continued use of the antipsychotic medication. Reduction in hallucinations, delusions, and thought disorders often requires 6 to 8 weeks for a full therapeutic response to be achieved. Older patients should be observed for hypotension.

Chapter 14: Chronic Fatigue Syndrome and Fibromyalgia 1.A client is going to have tender points examined to determine the diagnosis of fibromyalgia.

The nurse should instruct the client the number of tender points that must be positive for the diagnosis would be: 1.

11.

2.

13.

3.

15.

4.

17.

ANS: 1 The presence of at least 11 of 18 tender points is considered diagnostic for fibromyalgia. The other higher numbers would just be useful to confirm the diagnosis.

2.A client is surprised to learn that she has been diagnosed with osteoporosis since she does not smoke, is not underweight, and exercises. The nurse should assess if the client has any secondary conditions which could cause the disorder, including: 1.

diabetes mellitus.

2.

heart failure.

3.

fibromyalgia.

4.

lactose intolerance.

ANS: 4 Mild malabsorption syndrome as seen with lactose intolerance is a contributing factor to secondary osteoporosis. Secondary osteoporosis is not associated with diabetes mellitus, heart failure, or fibromyalgia.

3. During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (select all that apply)? a. sleep disturbances. b.

multiple tender points.

c.

cardiac palpitations and dizziness.

d.

multijoint pain with inflammation and swelling.

e. widespread bilateral, burning musculoskeletal pain.

ANS: A, B, C, E These symptoms are commonly described by patients with FMS. Cardiac involvement and joint inflammation are not typical of FMS. 4. What is the distinguishing feature of primary fibromyalgia syndrome? a.

Joint pain and stiffness throughout the body

b.

Degeneration and atrophy of skeletal muscles in back and lower limbs

c.

Localized areas of constant pain

d.

Specific trigger points for pain and tenderness

ANS: D

Chapter 15: Feeding and Eating Disorders MULTIPLE CHOICE 1. The mother of a teen with an eating disorder expresses a concern that the family is responsible for the problem. Which question will best help the nurse identify another influence that is likely to have played a role in the teenagers eating disorder? a. Does she have an after-school job? b. Does she have access to nutritious foods? c. Is there a family history of underweight adults? d. Is your daughter interested in clothes and fashion?

ANS: D Women in this culture are bombarded by the fashion industry and media messages equating beauty with thinness. Although it is true that eating disorders are less common in countries where food is not abundant, in this culture persons with eating disorders tend not to choose nutritious foods. Workplace competition with men would be of greater significance than this broad statement. The biologic tendency to be overweight may influence some persons.

2. Long-term prognosis for eating disorders is improved dramatically when treatment includes long-term cognitive-behavioral therapy. What statement provides the best explanation to the patient for this component to the treatment plan? a. This will help you identify a healthy, weight restoration diet. b. Medication alone will not help you from relapsing back to your old habits. c. In order to manage your disorder, you have to understand the root problems. d. Prognosis has been proven to be much better with both medication and therapy.

ANS: C

Individuals need to resolve the core problems related to their eating behavior as well as the underlying psychological issues. Outcome literature indicates that long-term cognitivebehavioral, family, or interpersonal therapy, often in combination with antidepressant medication, results in the most sustained improvement. Long-term outcome studies show a more promising prognosis for those patients who continue treatment. Weight restoration is necessary but not sufficient for recovery. The options that discuss the components of treatment do not sufficiently explain the reasoning behind cognitive and behavior therapy.

3. The nurse is identifying outcomes for a teenager diagnosed with anorexia nervosa. Which outcome has the greatest impact on long-term prognosis? a. Verbalize underlying psychological issues. b. Demonstrate effective coping skills related to conflict management. c. Demonstrate improvement in body imagine reflecting a realistic viewpoint. d. Consume adequate calories appropriate for age, height, and metabolic needs.

ANS: B Long-term prognosis is dependent on the patients ability to cope with the stressors that are at the root of the emotional problems such as conflict with family. Verbalization of underlying stressors is not a guarantee that there will be progress towards managing them. Acceptance of ones body and adequate calorie intake is possible only after coping skills are learned and used.

4. Which statement is the basis for the cross-cultural assessment practices of eating disorders? a. Mediterranean cultures are more likely to exhibit symptoms. b. Male-dominated cultures are more likely to accept this disorder. c. Westernized cultures tend to have similar numbers of diagnosed cases. d. Access to food is the primary factor in determining incidence of the disorder.

ANS: C

The incidence and prevalence of eating disorders around the world are similar among European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries. Access to food is not necessarily a cultural factor.

5. The nurse observes a distorted thinking pattern in a teenage patient diagnosed with an eating disorder. Which statement characterizes personalization by the patient? a. Ive got to be thin to get a good job. b. There is no such thing as a healthy carbohydrate. c. My mother and dad fight all the time because Im fat. d. My whole family will be disgraced if I dont get into a good college.

ANS: C The basis of personalization of thinking is that an individual compare themselves endlessly with others and perceive others behavior as a direct reaction to them. Believing the problems the parents are experiencing is a direct result of the patients weight is an example of such thinking.

The thought that a job depends solely on weight or that all carbohydrates are bad are examples of dichotomous thinking. Feeling responsible for the familys reputation is a reflection of control fallacy thinking.

6. A 16-year-old patient has anorexia nervosa. Which term used to describe the menstrual history is characteristic of this disorder? a. Amenorrhea b. Dysmenorrhea c. Premenstrual syndrome d. Heavy menstrual flow ANS: A

Amenorrhea is common in patients with eating disorders, possibly due to altered hypothalamic function. The remaining options are not usually related to changes resulting from an eating disorder.

7. A 14-year-old patient newly admitted to the eating disorders unit refuses to eat meals and angrily shouts at the nurse, You cant make me eat! Ill do whatever I want to do. Which nursing intervention demonstrates an understanding of the priority safety issue for this anorexic patient? a. Placing the patients favorite low calorie beverages in open view b. Assigning a staff member to one-on-one observation of the patient c. Unlocking the patients bathroom only at specific times during the day d. Explaining to the patient that they will be required to keep an eating journal ANS: B The patient, especially when stressed, is capable of self-mutilation and needs to be protected from doing so. The issues of hydration, purging, and therapy work do not have the priority that physical safety has.

8. A nursing intervention that will be planned to occur early in the nurse-patient relationship with a patient with an eating disorder is: a. Using confrontation to attack denial b. Placing the patient in a therapeutic group c. Formulating a therapeutic nurse-patient alliance d. Attacking enmeshment by separating patient and family ANS: C An alliance is formulated early to give the patient an opportunity to participate in treatment and increase the patients sense of control, thus eliminating power struggles. Confrontation is rarely used early in the relationship. Placement in a group and anti-enmeshment techniques would normally take place after the contract has been agreed on.

9. A patient is being assessed for a binge-eatingassociated eating disorder. Which assessment question is directed towards collecting data on the most commonly abused substance among this patient population? a. How much alcohol do you drink on a weekly basis? b. Do you use amphetamines to help control your weight? c. Do you rely on laxatives to control your bowel movements? d. How many packs of cigarettes do you smoke on a daily basis?

ANS: A Eating disorder symptoms predict the type of drug use, with bingeing associated more with alcohol and tranquilizer abuse, purging associated more with the abuse of multiple drugs, and restricting associated more with amphetamine.

10. The nurse is caring for a patient who is being treated for comorbid eating and affective disorders. For which medication would the nurse expect to prepare a patient teaching plan? a. Fluoxetine (Prozac) b. Diazepam (Valium) c. Lorazepam (Ativan) d. Lithium ANS: A SSRIs are effective in treatment of depression and have been found to be useful in treatment of eating disorders. Benzodiazepines like Valium and Ativan are used for anxiety reduction.

Lithium is used for bipolar disorder.

11. A patient who is hospitalized with anorexia nervosa states during a one-to-one session with the nurse, Im freaking out. Im losing it. Which nurse response would be most therapeutic at this time?

a. Would you feel better if I called your parents? b. Just sit here and relax that will help you regain control. c. May I sit with you while you think about what is happening? d. Please tell me what thoughts are going through your head right now.

ANS: D Helping the patient identify thoughts will facilitate the learning of effective coping mechanisms to deal with the stress. The patient needs to learn to bear and deal effectively with her own discomfort. The nurse is taking control without allowing the patient the opportunity to deal with her own issues. The nurse should encourage the patient to deal with her feelings and issues, rather than sit passively with her.

12. Accomplishment of which expectation should be considered most critical prior to discharging a patient with anorexia nervosa? a. Attainment of minimum normal weight b. Resumption of normal menstrual cycle c. Reduction of periods of active exercise to three times daily d. Knowledge of nutritional value of foods required for a balanced diet ANS: A Attaining the desired weight is the priority discharge goal because it best indicates patient compliance with the treatment plan. Resumption of the menstrual period may take an extended time. Having knowledge of nutrition does not ensure that the patient will apply it. Exercising three times a day is considered excessive.

13. Which patient statement demonstrates the expected emotional response to bingeing? a. I know its bad but I cant help bingeing. b. Everyone indulges in bingeing some times.

c. After I binge I feel happy for a little while. d. Bingeing isnt bad if I do it only when Im stressed.

ANS: C Serotonin levels and mood both improve with bingeing. This affect on serotonin would not result in rationalization, denial, or a sense of guilt and hopelessness.

14. Which intervention best monitors the health status of a patient newly admitted for a diagnosis of bulimia nervosa? a. Scheduling a bone mineral density screening b. Performing a portable electrocardiogram (ECG) c. Obtaining a urine sample for a urine analysis d. Arranging for a serum potassium level to be drawn ANS: D Patients with bulimia nervosa require initial assessment for acute fluid and electrolyte imbalances (particularly serum potassium) for the presence of life-threatening imbalances. Bone mineral density screening for osteopenia and osteoporosis and assessment is appropriate but it does not have priority over of the blood work to identify an acute life-threatening condition. The remaining options are not diagnostic tests that are generally required of this diagnosis.

15. In an art therapy session, a patient with anorexia nervosa was asked to draw a picture of herself. Which drawing would likely depict the patients view of herself? a. A tall, slim girl with obvious muscle definition b. A shapely figure of a model who she really admires c. A malnourished teenager with thin, lanky extremities d. A grossly obese figure lacking feminine characteristics ANS: D

Patients with eating disorders have alexithymia (i.e., difficulty naming their feelings) and they often have difficulty finding the words needed for talk therapy. Therefore, the use of expressive arts therapy allows for nonverbal self-disclosure and the experiential exploration of the inner experience. It also bypasses intellectual defenses and helps the patient to be more present in his or her bodily experience. The patient would be able to draw what she is unable to verbally describe. The other options do not reflect the anorexic patients self-view of their body.

16. A teenager admitted to the eating disorders unit has begun displaying behaviors that reflect possible secondary gains related to the hospitalization. What is the basis for this behavioral change? a. The patient has moved into the guilt phase of the recovery process. b. The attention has reinforced the initial food-focusing behaviors. c. The medication therapy has not yet brought about the expected results. d. The increase of calories had help clarify the patients thought processes.

ANS: B Unfortunately, secondary gains, such as the attention generated from the hospitalization, reinforce the behavior associated with the eating disorder. There is no phase of the recovery identified with the expression of guilt. Clarity of ones thinking nor the expected effects of medication therapy would contribute to secondary gains.

17. How does the mortality rate among patients diagnosed with eating disorders compare to those with other psychiatric diagnoses? a. More deaths are attributed to substance abuse than to eating disorders. b. This disorder is associated with the highest death rate among all other disorders. c. This disorder has fewer associated deaths that any other impulse control disorder. d. More related deaths are recorded compared to those associated with schizophrenia.

ANS: B

The mortality rate with eating disorders is higher than that seen with any other psychiatric diagnoses, and it has been reported at 4% to 20% of death among this population.

18. A patient being treated for an eating disorder is prescribed refeeding. Which outcome is the primary reason a patient receiving this treatment is closely monitored by the nursing staff? a. Complies with treatment commendation made by treatment team b. Regularly consumes and tolerates between 3000 to 4000 kcal/day c. No physical signs or symptoms of an electrolyte imbalance are observable d. Discharge depends on patients ability to demonstrate a gain of 3 pounds per week ANS: C Although all options are outcomes requiring nursing assessment and monitoring, the acute and serious nature of electrolyte imbalances has priority over the remaining options.

19. The interdisciplinary care team has suggested family-based therapy as a part of the care plan of a teenager diagnosed with an eating disorder. Which statement is the basis for this recommendation? a. This approach encourages family involvement in the patients recovery. b. The family is often dysfunctional, enmeshed, and in need of counseling. c. This approach has shown a significant impact on successful long-term prognosis. d. The family implements the behavioral contract as established by the plan of care.

ANS: C Outcome studies of this approach to anorexia show a 90% improvement rate as compared with an 18% improvement rate for those receiving individual therapy. Five-year follow-up studies show that 70% of patients remained in recovery with this type of treatment. The remaining options are all correct but they do not directly address the impact on long-term prognosis.

20. A parent of a teenager being treated for anorexia nervosa asks the nurse what, Being an enmeshed family means. Which question provides the best response to the question? a. What do you think that statement means? b. Who told you your family was enmeshed? c. Are the members of your family expected to be independent and self-reliant? d. Does your family place importance on being successful and accepted by others?

ANS: D An enmeshed family often puts a lot of importance on body image, social acceptance, and achievement. Expecting independence and self-reliance is not compatible with enmeshed family dynamics. The remaining options do not address the parents question.

21. A patient with severe weight loss as a result of anorexia nervosa has refused meal trays and supplemental feedings for 3 days since being admitted to the hospital and so refeeding has been ordered. Which intervention will initiate this treatment? a. Scheduling a nutrition consult with the hospital dietitian b. Tube feedings until the patient eats 90% of all meals for 1 day c. IV infusions beginning immediately and continuing for 48 hours d. Placing the patient on suicide precautions and one-to-one observation ANS: B The priority is to begin refeeding, a procedure that involves tube feedings that are continued until the patient is voluntarily eating sufficient quantities. Refeeding takes place using foods and fluids via the GI tract, rather than by the parenteral route. Although refeeding is very threatening to the patient, since they have no control over the weight gain that will occur, suicide precautions are not indicated at this point, but careful assessments will continue. A nutritional consult is not useful at this point in the treatment since the patient is not making choices regarding eating.

22. A patients plan of care is being managed by an interdisciplinary team familiar with the etiology of eating disorders. Which team principle is most important to the successful treatment of this patient population? a. The team must preserve the patients sense of autonomy. b. The patient must be an active member of the care planning team. c. The patients family must be included in the decision-making process. d. The plan of care must demonstrate collaboration and consistency by the team.

ANS: D In order to best assure a good prognosis, the plan of care has to include consistent and collaborative efforts by all members of the interdisciplinary team. Although the remaining options are goals to be strived for, they do not have the importance that collaborative and consistent care planning has for successful treatment.

23. Which concern has the greatest priority for a patient admitted with a diagnosis of bulimia nervosa? a. Social isolation b. Imbalanced fluid volume c. Compromised family coping d. Disturbed perception of body image ANS: B The physical harm that can result for a fluid imbalance has priority over any of the psychological options presented.

24. A patient diagnosed with bulimia nervosa is hospitalized for treatment of electrolyte imbalance. Which response by the nurse to the patients request to use the bathroom immediately after eating lunch is most therapeutic?

a. No one is allowed to leave the dining room during meals. b. Okay, but as you know I will accompany you to the bathroom. c. Weve discussed that there are other options than to induce vomiting. d. I think I understand your plan, and I cannot permit you to carry it out.

ANS: B To best ensure a good prognosis, the plan of care has to include consistent and collaborative efforts by all members of the interdisciplinary team. The patient is most likely attempting to purge to manage weight gain and the nurse must attempt to prevent that behavior. Refusing to allow the request does not account for the fact that the patient might actually need to void or defecate. Assuming the patients motivation in this manner is confrontational and nontherapeutic, suggesting that other options are available is not addressing the immediate request.

25. After ignoring a unit rule regarding being weighed, a patient receiving treatment for an eating disorder tells the nurse, I cant get weighed this morning, because I drank a glass of juice a few minutes before breakfast. Which statement by the nurse is consistent with treatment principles? a. Im pleased that you took in some calories. b. This is weight day. Please step on the scale. c. We need to discuss why you chose to ignore the rules about being weighed. d. The rule is weigh before eating; now we have to put it off until tomorrow.

ANS: B The nurse needs to create a structured and supportive environment with clear, consistent, and firm limits. This helps to establish a predictable routine and promotes internal control that the patient currently lacks. This response is calm, matter-of-fact, and firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in which a power struggle is likely to arise. The patient should not be praised for behavior that broke the rules.

Although the issue needs to be discussed, this is not the time to address it. The remaining option suggests that the patient will not be weighed according to schedule.

MULTIPLE RESPONSE 1. A patient is being assessed for possible anorexia nervosa. Which behaviors are supportive of such a diagnosis? Select all that apply. a. Eats only red apples and green grapes b. Exercises 3 times a day every day c. Has lost 25 pounds but wears only pre-loss clothing d. Becomes extremely agitated whenever expected to eat e. Reports fantasies about being able to eat without gaining weight ANS: A, B, C, D 2. Which reports describe behaviors that meets the criteria for a diagnosis of binge eating? Select all that apply. a. Sister reports, She is so sad after she finishes. b. Claims, I cant control myself when I get that way. c. The patient reports, making myself vomit at least twice a week. d. Mother reports seeing the patient, eat entire loaf of bread for lunch. e. Maintains that, I look okay now but I do this so I dont gain any weight.

ANS: A, B, C, D All described behaviors are characteristic of binge eating except for the belief that body image is currently acceptable.

3. Which assessment findings support a diagnosis of bulimia nervosa? Select all that apply. a. Loose watery stool b. Red rash on extremities c. Blood pressure of 88/58

d. A potassium level of 2.8 mEq/L e. Reports of mild muscle cramping ANS: A, C, D, E A red rash on the extremities is not a characteristic of bulimia. All other options can be related to the disorder.

4. The mother of a teenager is concerned that the child may be anorexic. Which report of the teenagers behavior is support of such a diagnosis? a. Insists she likes really baggy clothes b. Will eat only lean protein, fruits, and vegetables c. Has had one menstrual period in the last 2 years d. Although she has grown 3 inches, she has gained no weight e. Regularly claims that she will eat later but seldom does ANS: A, C, D, E A willingness to eat lean meats, fruits, and vegetables would not be characteristic of a patient exhibiting anorexia. The remaining options could be seen in such a patient.

t.

Chapter 16: Normal Sleep and Sleep-Wake Disorders Test Bank MULTIPLE CHOICE 1. Which assessment observation would not support a diagnosis of narcolepsy? a. Sleep study reports excessive, loud snoring. b. Sleep study shows evidence of sleep paralysis. c. Patient reports needing to drink pots of coffee to stay awake at work. d. Patient reports, When I get sleepy I actually see things that arent really there.

ANS: A Snoring is a characteristic obstructive sleep apnea, not narcolepsy. Classic symptoms of narcolepsy include excessive daytime sleepiness, sleep paralysis, and hallucinations 2. An adult patient diagnosed with narcolepsy is being educated on the medication therapy that is prescribed. Which explanation is provided for the central nervous system stimulant dextroamphetamine (Dexedrine)? a. The apnea will be lessened by this medication. b. It will help control the sporadic loss of muscle tone. c. This medication will minimize the daytime sleepiness. d. Dexedrine will manage the inflammation that causes the snoring.

ANS: C Central nervous system stimulants such as dextroamphetamine (Dexedrine, Dextrostat) may be prescribed to manage excessive daytime sleepiness. This medication has no affect on cataplexy, apnea, or snoring. Apnea and snoring are not symptoms of narcolepsy.

3. A pediatric patient has been diagnosed with obstructive sleep apnea (OSA). Which statement would the nurse use as a basis for explaining the etiology of this disorder? a. Melatonin is not being released in sufficient quantity. b. This condition is often due to adenotonsillar hypertrophy. c. Children have a high ratio of REM sleep that can result in frequent gasping. d. This can be related to a sleep position which compromises chest movement.

ANS: B When OSA is found in children, it is usually the result of adenotonsillar hypertrophy, craniofacial abnormalities, and neuromuscular conditions, all of which result in airway obstruction during sleep. There is no research on OSA related to melatonin insufficiency, dreaming, or a particular sleep position.

4. Which outcome is appropriate for an adult patient recently diagnosed with primary insomnia? a. Demonstrate an understanding of the cerebral stimulants prescribed. b. Recognize that the prescribed flurazepam (Dalmane) can be used for up to 2 months. c. Demonstrate the proper use of continuous positive airway pressure (CPAP) ventilation. d. Recognize physical and psychosocial stressors that exacerbate the sleep disturbance.

ANS: D The patient should identify physical and psychosocial stressors that exacerbate the sleep disturbance in order to attempt successful self-management of the problem. Neither stimulants nor CPAP therapy are prescribed for this disorder. The duration of flurazepam therapy is considerably shorter.

5. A 10-year-old is diagnosed with somnambulism as a result of frequent episodes of sleepwalking. Which topic should be included when considering patient and family education?

a. Medication therapy seldom prescribed for this disorder b. Safety issues such as sleeping in the ground level bedroom c. The likely connection between sleepwalking and narcolepsy d. The need for short-term cognitive and behavioral therapy ANS: B Safety is a primary concern when managing sleepwalking since injury is quite likely as a result of the patients inability to be aware of danger. Drugs that suppress stages 3 and 4 sleep, such as benzodiazepine hypnotics, have been used for the management of this disorder. There is no research to support a connection between this disorder and narcolepsy. This disorder is not treated with either of these therapies.

6. Which patient statement would support a diagnosis of a circadian rhythm sleep disturbance? a. I just started on the night shift at work. b. My mother was seriously depressed for years. c. I wake up gasping for breath, and it is really scary. d. I dont think I drink any more than my buddies do.

ANS: A The shift worktype of circadian sleep disorder is usually the result of night shift work or frequently rotating shift work. Depression, breathing problems, and drinking indicate other types of sleep disturbances.

7. Which physical assessment finding is supportive of a diagnosis of obstructive sleep apnea? a. Barrel chest b. Raccoon eyes c. Enlarged nasal nares d. Large neck circumference

ANS: D Persons with obstructive sleep apnea often have a large neck circumference that appears to be related to pressure being applied to the trachea. Neither an enlarged chest nor enlarged nostrils would cause the airway obstruction associated with this disorder. Blackened eyes are related to trauma or allergies.

8. When the family of a child diagnosed with a nightmare disorder asks the nurse about prognosis, the nurse replies with the knowledge that: a. The disorder is frequently self-limiting in children. b. If the child is obese, it is likely the nightmares will continue. c. High doses of diazepam (Valium) are needed to cure the disorder. d. With the use of antipsychotic medication, the disorder will not worsen.

ANS: A A child who is experiencing nightmares usually outgrows the disorder as he or she ages.

Medications are not generally prescribed for this disorder. There is no research to support a correlation between obesity and nightmares.

9. Which of the statements made by the patient would be most indicative of dyssomnia? a. I think I am seeing things when I wake up. b. My wife says I snore and even stop breathing. c. I go to sleep okay but then wake up several times at night. d. My wife says I sit straight up in bed at 2 AM and then say strange things.

ANS: C The dyssomnia known as insomnia is characterized by a predominant complaint of difficulty initiating or maintaining sleep. Snoring is a characteristic of obstructive sleep apnea. The other options are seen in narcolepsy.

10. A patient with obstructive sleep apnea (OSA) is being discharged. What patient statement indicates the need for further teaching? a. I hope to lose some weight. b. My antidepressants seem to be helping. c. I will try the oral appliance that the doctor suggested. d. A glass of wine at bedtime will help relax my airways.

ANS: D Health care providers usually discourage patients with this disorder from using sedating substances such as alcohol, because these types of sedatives often exacerbate the problem by relaxing the airway, thus increasing the risk of longer apneic episodes throughout the night. The remaining options are all positive strategies to help with OSA. 11. Which statement indicates to the nurse that a patient requires additional education regarding appropriate sleep hygiene? a. I will try to avoid daytime napping. b. Relaxing music may help relax me for sleep. c. Exercising before bed will make me good and tired. d. I need to cut back on my four daily cups of coffee.

ANS: C Avoiding physical exercise or mental stimulation just before bedtime will usually support healthy sleep patterns. The remaining options are all good sleep hygiene practices.

12. A patient tells the nurse, I take herbal products like melatonin and valerian to help sleep.

Which response will the nurse make to the patient? a. My aunt uses them, and they help her a lot. b. Studies show they are ineffective as sleep aids.

c. They can cause serious side effects and should be avoided. d. Be aware that these products are uncontrolled, so preparations vary.

ANS: D Herbal products (e.g., melatonin, valerian) are not regulated by the U.S. Food and Drug Administration, and preparation concentrations may vary. It is not appropriate to give advice based on personal anecdote. There has not been systematic evaluation of the products, so there is no proof to support statements regarding effectiveness or severity of side effects.

13. Which intervention will best assess a narcoleptic patient for a commonly recognized comorbid psychiatric disorder? a. Observing for signs of self-mutilation b. Observing the patient for ritualistic behaviors c. Asking, Do you consider yourself to be depressed? d. Asking, Do you rely on alcohol to function socially?

ANS: C Research supports a link between insomnia and major depression.

MULTIPLE RESPONSE 1. An adult patient diagnosed with insomnia is prescribed the antihistamine, diphenhydramine.

Which side effects does the nurse educate the patient about? Select all that apply a. Urinary retention b. Blurred vision c. Rhinorrhea d. Dry mouth e. Diarrhea

ANS: A, B, D Such drugs as Sominex and Unisom contain diphenhydramine, which is an antihistamine that has both sedative and anticholinergic effects (e.g., dry mouth, blurred vision, constipation, nasal congestion, urinary retention) and prescribed for insomnia. Rhinorrhea and diarrhea are not side effects of the anticholinergics.

2. During the assessment interview, a patient tells the nurse he has sleep problems. Which question will assess for the use of substances that affect the quality of sleep? Select all that apply. a. Do you follow a low-fat diet? b. Are you a big coffee drinker? c. Do you indulge in an evening alcoholic drink? d. Have you been prescribed an opiate-based analgesic? e. Are you currently taking antianxiety medication?

ANS: B, C, D, E Examples of substances that influence sleep includes alcohol, stimulants such as caffeine, sedatives such as opiates, and antianxiety medications. Fats are not thought to influence sleep.

3. Which suggestions would be included when educating a patient concerning the management of a circadian rhythm sleep disorder? Select all that apply. a. Darken the bedroom. b. Go to sleep at the same time each night. c. Keep the bedroom environment calm and serene. d. Initially, retire 30 minutes earlier than usual. e. Take a low-dose over-the-counter sleep aid.

ANS: A, B, C, D

The primary aim when managing a circadian rhythm sleep disorder is positively affected by establishing regularity in the sleep-wake cycle by synchronizing sleep-wake patterns with typical daily schedules, identifying and managing external environmental factors that interfere with sleep, and encouraging the patient to sleep earlier than the previously established pattern. Sleep aids are not recommended.

4. Which notations should be included in a sleep journal? Select all that apply. a. Any regular bedtime rituals b. Things that assist with sleep c. Time when patient went to bed d. Things that interfere with sleeping e. Foods eaten at dinner or last meal ANS: A, B, C, D Information about when the patient went to bed, sleep rituals, aides, and barriers to sleep should be included, but unless foods have been identified as an aid or barrier to sleep, they need not be included.

5. Which comorbid conditions have been associated with sleep deprivation? Select all that apply. a. Depression b. Hypertension c. Anxiety disorders d. Gastric reflux disease e. Coronary artery disease ANS: A, B, C, E Sleep deprivation is associated with mood disorders such as depression and anxiety as well as stress-related medical conditions such as coronary artery disease and hypertension. There is currently no research to support a connection with gastric reflux disease.

Chapter 17: Normal Sexuality and Sexual Dysfunctions MULTIPLE CHOICE 1. Which of these individuals is experiencing a symptom of the DSM-IV-TR diagnosis sexual aversion disorder? a. The patient who has genital pain associated with intercourse b. The patient who avoids genital sexual contact with a partner c. The patient who has absence of desire to engage in sexual activity d. The patient who has delayed orgasm following sexual excitement ANS: B Aversion disorder is characterized by avoidance of genital sexual contact with a partner.

Orgasmic disorder, male or female, is characterized by delayed orgasm following sexual excitement. Hypoactive sexual desire disorder is characterized by absence of drive for sexual activity. Dyspareunia refers to genital pain associated with intercourse.

2. A patient who has a sexual disorder mentions to the nurse, I dont know why I bother looking for help. They dont know much about sex problems. Which statement best describes the evolution of research on sexuality and should serve as the basis for the nurses response? a. Increased knowledge about sexual dysfunction has been available since the late 1960s. b. Masters and Johnson were the first persons to explore the area of sexual dysfunction. c. Kaplan was instrumental in identifying the need for psychoanalysis in treating sexual dysfunction. d. Sigmund Freud, a sexologist, based his work on scientific data from studying human sexual behavior.

ANS: A

In 1966, research conducted by Masters and Johnson described exactly what happens to the body during erotic stimulation. Since then, there has been considerable research concerning the subject of sexuality and sexual dysfunction. Kaplan identified the need for using behavioral techniques in treating sexual disorders. Freud did not base his work on scientific data. Freud, Newton, and Ellis preceded Masters and Johnson in studying sexual dysfunction.

3. A patient who is being treated at the community health clinic complains of lack of sexual desire and mentions the problems this is causing in her marriage. Which of the following data is likely related to her sexual dysfunction? a. Being an adopted only child b. Taking an antidepressant medication c. Growing up in a dysfunctional family d. Living in an isolated area in the country ANS: B Antidepressants, especially SSRIs, are known to decrease sexual desire. The other options are not known to be closely related to development of sexual dysfunction.

4. When a patients wife asks the nurse about fetishism, which example could the nurse give as part of an explanation? a. Being sexually aroused only by touching female shoes b. Standing on the street corner exposing genitals to others c. Feeling sexually attracted to a 10-year-old child who lives next door d. Achieving sexual pleasure from rubbing against a stranger in an elevator ANS: A Fetishism refers to using various objects, not individuals, for sexual arousal. Exposing genitals refers to exhibitionism. Rubbing against a stranger is termed frotteurism. Being sexually attracted to children is an example of pedophilia.

5. Which assessment question will be most informative when interviewing a Hispanic female who reports having a sexual aversion? a. In your culture is the female expected to be subservient? b. How old were you when you first became sexually active? c. What are your religious beliefs regarding sexual intercourse? d. When did you first begin experiencing pain during intercourse?

ANS: C Many religions place restrictions on sexual behavior that is other than procreative and this can result in sexual dysfunction. Although female roles and sexual history can play a role in sexual disorders, they are not frequently viewed in the development of sexual aversion. Painful sexual intercourse is not a symptom of sexual aversion.

6. A sexual history begins with the nurse asking the patient when she experienced her first menstrual period. What is the basis for beginning the assessment with this type of question? a. Medical history is the initial focus of all history assessments. b. Female sexual dysfunction has its roots in pre-pubescent experiences. c. Females are more comfortable discussing physical issues than emotional ones. d. To minimize embarrassment, the history is begun with nonthreatening questions.

ANS: D The sexual history is an important aspect of the assessment but the questions can be embarrassing. It is suggested that the interview begin with the least awkward topic and then working toward more difficult and personal topics. There is no proof that the remaining options are true.

7. What is the basis of the nurses response when a husband reports that, Our problem is that my wife never initiates sex?

a. Initiation of sex is generally viewed as the males role. b. Communication between partners is vital to satisfying sex. c. Men often enjoy sex that is initiated by their female partners. d. Some women may become aroused only after they experience foreplay.

ANS: D Research as shown that in longer-term relationships, women did not initiate sex as often; the desire for sex was generated after they were aroused accounting for this womans apparent lack of sexual interest. The remaining options are not directly related to sexual interest.

8. Which comment would support the sexual diagnosis of dyspareunia? a. I experience genital pain during intercourse. b. I do not enjoy sexual intercourse and try to avoid it. c. I cannot maintain adequate lubrication during intercourse. d. My perineal muscles contract at the wrong times during intercourse.

ANS: A Genital pain is a manifestation of dyspareunia. Ineffective muscle contractions are consistent with female sexual arousal disorder. Avoiding sex is consistent with hypoactive sexual disorder.

Insufficient lubrication is consistent with vaginismus.

9. Which patient statement shows achievement of an expected outcome for a patient being treated for a paraphilic disorder who is receiving Depo-Provera injections? a. The vaginal pain issue is almost totally resolved. b. I dont have those sexual fantasies nearly as often now. c. Sex is more pleasurable now that Im getting the injections. d. I havent had a problem maintaining an erection since I started the medication.

ANS: B

Depo-Provera given intramuscularly once a week has been prescribed with some success for patients with paraphilic disorders provides external control that helps patients develop their own internal controls to avoid relapses by lowering the frequency and intensity of inappropriate sexual thoughts and fantasies. The remaining options do not relate to paraphilic disorders.

Because of the drugs effects and side effects, the patient must give written consent before the drug can be administered initially. The patient can withdraw consent at any time.

10. Which assessment question demonstrates knowledge of possible risk factors for the development of a paraphilic disorder? a. When were you first diagnosed with schizophrenia? b. Are you aware of a family history of obsessive-compulsive disorder? c. When did you begin relying on printed pornography as a sexual stimulant? d. Why do you find it difficult to take your prescribed antianxiety medication?

ANS: C Use of pornography during childhood and adolescence has been shown as a risk factor for the development of inappropriate sexual thinking and behaviors in adulthood. The remaining options have not been associated with being risk factors for this disorder.

11. Which of these statements reflect achievement of discharge criteria for a patient receiving inhospital treatment for a paraphilic disorder? a. My wife is willing to attend counseling with me. b. The medication Im taking has helped me be less anxious. c. I hope I will be able to know what causes me to think this way. d. This injection I take will help me reach a pleasurable climax again.

ANS: A Identification of members of a personal support systems shows achievement of a generally stated discharge criteria. The medication prescribed for this type of disorder is not directed towards

managing anxiety or improving performance. The patient should be aware of triggers and causes of behavior prior to discharge.

12. A patient admits to fondling his 3-year-old and 5-year-old nieces. Which statement best indicates that the patient lacks an understanding of the impact of this behavior? a. There is absolutely nothing wrong with me. b. My babysitter used to do the same things to me. c. Their mother is going to hate me and its your fault. d. The children always want me to hold them in my lap.

ANS: B Exhibiting a lack of empathy or ability to express regret is a clear sign of distorted thoughts and lack of insight regarding the effects on the children. The other options show denial and poor insight in general.

13. Which finding would the nurse expect to assess in a 17-year-old patient who has been diagnosed with Klinefelters syndrome? a. Elevated sperm count b. Decreased secretion of FSH c. Gynecomastia in a teenage male d. Hyperplasia of penis and scrotum ANS: C Having gynecomastia (enlarged breasts) at the time of puberty is a characteristic finding in individuals with Klinefelters syndrome. Aspermatogenesis, an abnormally low sperm, count is an expected finding. FSH level is expected to be elevated. Penile and scrotal changes are not an expected finding.

14. Which topic should be addressed when providing medication information to a patient prescribed Depo-Provera injections for a sexual disorder?

a. Nutritional supplementation to offset weight loss b. Techniques to minimize exposure to viral infections c. Ability to self-monitor for elevated diastolic blood pressure d. Safety measures to protect against injuries related to manic activity ANS: C Common side effects include weight gain, increased blood pressure, and fatigue. The nurse may suggest a dietary consultation to help the patient maintain a healthy weight and decrease the possibility of weight gain. There is no reason to expect an impaired immune system.

15. Which question would enable the nurse to assess for cognitive distortions during an interview with a patient diagnosed as having pedophilia? a. Is there a family history of sexual dysfunction? b. Were you sexually abused as a child or adolescent? c. How do you think the child felt being your sexual partner? d. Will you be willing to take medication to treat your disorder?

ANS: C If the patient does not respond with a statement showing empathy for the child, cognitive distortion is present. Similarly, if the patient uses denial or rationalization as he or she discusses the disorder, the nurse can assess the presence of cognitive disorder. The other options, although valid questions, do not assess for cognitive distortion.

16. A patient approaches a clinic nurse in the waiting room and states, Id like to talk with you about a sexual problem Im having. Which response demonstrates an understanding on the nurses initial responsibility to this patient? a. Offering, Go ahead if you like. I have time to listen. b. Suggesting, Would you prefer speaking to a sex therapist?

c. Saying, Lets go into my office where theres more privacy. d. Asking, What type of sexual dysfunction are you experiencing?

ANS: C To facilitate a therapeutic nurse-patient alliance, preserve patient confidentiality, and minimize embarrassment, the nurse initially ensures a private and quiet space for the discussion. The nurse should not attempt to suggest another person to talk with the patient since the patient has identified the nurse and assessment is a nursing responsibility. Questions should initially be of a nonthreatening nature.

17. Which intervention should the nurse suggest when a couple expresses the concern that, Neither of us is interested in sex at the same time. a. Scheduling a sex date at a time you both agree upon b. Encouraging role playing to help minimize self-consciousness c. Exploring new stimulation techniques to renew interest in sex d. Learning communication techniques that facilitate open expression of feelings ANS: A Teaching couples to schedule sexual experiences at agreed upon times will help them focus on sex at the same time. The other options although valid do not address the issue of the timing of mutual interest.

18. A patient is receiving Depo-Provera. He drinks two to three beers a day, smokes, vacations in hot sunny climates, and is slightly overweight. The nurse knows that essential patient teaching should include the fact that: a. It is vital to use a sunscreen consistently. b. Smoking may increase the risk for deep vein thrombosis. c. Drinking alcohol could cause delusions and hallucinations. d. Losing weight is essential for efficacy of the medication.

ANS: B Smoking may increase the risk for deep vein thrombosis. There are no alerts about alcohol, sunscreens, or losing weight with this medication.

MULTIPLE RESPONSE 1. Which interventions would a nurse include in the teaching plan for a patient diagnosed with a sexual dysfunction? Select all that apply. a. Teach breathing techniques to encourage relaxation during sex. b. Suggest positive imaging to improve body self-acceptance during sex. c. Educate the patient regarding the affects of hormones on sexual functioning. d. Instruct the patient on the use of progressive touch to facilitate sexual pleasure. e. Suggest an external relaxant such as alcohol to promote self-confidence related to sex.

ANS: A, B, C, D All the options with the exception of the use of external relaxants to promote self-confidence are appropriate. Alcohol will provide a false sense of confidence and can negatively affect ones ability to perform sexually.

2. Which topics should be included in a discussion on risk factors for developing a sexually oriented dysfunction? Select all that apply. a. Diabetes b. Depression c. Chronic pain d. Gastric ulcers e. Alcohol consumption ANS: A, B, C, E

All the options reflect conditions that have known risk factors for sexual dysfunction disorders with the exception of gastric ulcers. Currently there is no known connection between the disorders.

Chapter 18: Gender Dysphoria 1. A new staff nurse tells the clinical nurse specialist, I am unsure about my role when patients bring up sexual problems. The clinical nurse specialist should give clarification by saying, All nurses: a. qualify as sexual counselors. Nurses have knowledge about the biopsychosocial aspects of sexuality throughout the life cycle. b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality. d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples.

ANS: B The basic education of nurses provides information sufficient to qualify the generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy requires additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors. Additional education is necessary. A registered nurse may provide basic information about sexual function, but complex questions may require referral.

2. A nurse is performing an assessment for a 59-year-old man who has hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? a. Sexual dysfunction may result from use of prescription medications for management of hypertension.

b. Such questions are an indirect way of learning about the patients medication adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.

ANS: A Some of the drugs used to treat hypertension can interfere with normal sexual functioning and lead to sexual disorders. Hypertension itself can lead to acquired erectile dysfunction. It would not be appropriate or necessary to use such inquiries as a lead-in to other sexual health topics.

Sexual dysfunction, while stressful, does not cause hypertension.

3. An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, I havent had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I dont know if my heart is strong enough. Which nursing diagnosis applies? a. Deficient knowledge related to faulty perception of health status b. Disturbed self-concept related to required lifestyle changes c. Disturbed body image related to treatment side effects d. Sexual dysfunction related to self-esteem disturbance ANS: A Patients who have had a myocardial infarction often believe sexual intercourse will cause another heart attack. The patient has completed the rehabilitation, but education is needed regarding sexual activity. These patients should receive information about when sexual activity may begin, positions that conserve energy, and so forth. The scenario does not suggest selfconcept or body image disturbance.

4. Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should: a. develop an understanding of human sexual response.

b. assess the patients sexual functioning and needs. c. acquire knowledge of the patients sexual roles. d. clarify own personal values about sexuality.

ANS: D Before one can be helpful to patients with sexual dysfunctions or disorders, the nurse must be aware of his or her own feelings and values about sex and sexuality. Nurses must keep their personal beliefs separate from their patient care in order to remain objective, professional, and effective. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. The other options are indicated as well, but self-awareness must precede them to provide the best care.

5. A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, Without the red teddies, I am not interested in sex. The nurse can assess this as consistent with: a. exhibitionism.

c. frotteurism.

b. voyeurism.

d. fetishism.

ANS: D To be sexually satisfied, a person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality. Frotteurism involves deriving sexual pleasure from rubbing against others surreptitiously.Exhibitionism is the intentional display of the genitalia in a public place. Voyeurism refers to viewing others in intimate situations.

6. While performing an assessment, the nurse says to a patient, While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now? The purpose of this question is to: a. identify areas of sexual dysfunction for treatment. b. determine possible homosexual urges.

c. introduce the topic of masturbation. d. identify sexual misinformation.

ANS: D Misinformation about normal sex and sexuality is common. Lack of knowledge may affect an individuals sexual adjustment. Once myths have been identified, the nurse can give information to dispel the myth.

7. A woman tells the nurse, My partner is frustrated with me. I dont have any natural lubrication when we have sex. What type of sexual disorder is evident? a. Genito-Pelvic Pain/Penetration Disorder b. Female Sexual Interest/Arousal Disorder c. Hypoactive Sexual Desire Disorder d. Female Orgasmic Disorder ANS: B One feature of female sexual interest/arousal disorder relates to inability to maintain physiologic requirements for intercourse. For women, this includes problems with lubrication and swelling.

The patients description does not meet criteria for diagnoses in the distracters.

8. The male manager of a health club placed a hidden video camera in the womens locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is: a. homosexuality.

c. pedophilia.

b. exhibitionism.

d. voyeurism.

ANS: D Voyeurism is achieving sexual pleasure through the viewing of others in intimate situations, such as undressing, bathing, or having sexual relations. A homosexual individual would be interested

in watching members of the same sex, and homosexuality is not typically associated with voyeurism. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with children.

9. A woman consults the nurse practitioner because she has not achieved orgasm for 2 years, despite having been sexually active. This is an example of: a. Paraphilic Disorder. b. Female Orgasmic Disorder. c. Genito-Pelvic Pain/Penetration Disorder. d. Female Sexual Interest/Arousal Disorder.

ANS: B The persistent inhibition of orgasm is a form of sexual dysfunction called female orgasmic disorder. Genito-pelvic pain/penetration disorder applies to painful intercourse. The patient has not indicated that her interest in sexual activity is diminished, so female sexual interest/arousal disorder does not apply. Paraphilic disorder is not applicable.

10. An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? a. Defensive coping

c. Ineffective sexuality pattern

b. Sexual dysfunction

d. Disturbed sensory perception, tactile

ANS: B Sexual dysfunction is the most appropriate nursing diagnosis for a patient who is experiencing a problem affecting one or more phases of arousal. This is the primary problem reported by this patient. Ineffective sexuality pattern, since it is due to sexual dysfunction, is secondary to the absence of orgasms. The patient has not indicated she does not become aroused, just that she

cannot achieve orgasm. Disturbed sensory perception may be part of the etiology, but the problem is sexual dysfunction. There is no evidence of defensive coping.

TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity 11. An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful? a. No complaints related to sexual function; to return next week. b. Patient reports achieving orgasm last week; seems very happy. c. Reports satisfaction with sexual encounters; feels partner is supportive. d. Reports achieving orgasm occasionally; relationship with partner is adequate.

ANS: C Human sexuality, sexual expression, and expectations related to sexuality vary tremendously from person to person and across cultures. Therefore, the best indication of satisfactory treatment is that the patient is satisfied with what has been achieved. In this instance, Patient reports satisfaction with sexual encounters; feels partner is supportive best indicates that the patient is satisfied, and both presenting issues are progressing in a positive manner. Achieving orgasm once or occasionally may or may not represent satisfactory progress to the patient. No complaints does not necessarily mean that satisfaction exists.

12. Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? a. Homosexual

c. Seeks access to children

b. Ritualistic behaviors

d. Self-confident professional

ANS: C

Persons with pedophilic disorder usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilic disorder.

13. A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patients sexual practices? a. Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern? b. Sexual health can reflect a number of medical problems, so Id like to ask if you have any sexual problems you think we should know about. c. Its your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please? d. I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment.

ANS: A Explaining that sexual practices vary helps reduce patient anxiety about the topic by normalizing the full range of sexual practices so that whatever his situation, the patient can feel comfortable sharing it. Its your business of course implies the nurse does not have a valid reason to seek the information and in effect suggests that the patient perhaps should not answer the question. It might be helpful makes the information seem less valid or important for the nurse to pursue and, again, could discourage the patient from responding fully. Asking if the patient has any sexual problems that staff should know about is not unprofessional, but it is a very broad question that may increase a patients uncertainty about what the nurse wants to hear, thus increasing his anxiety. Defining or giving an example of sexual problem would make this inquiry more effective.

14. A man says, I enjoy watching women when I am out in public. I like to go to places where I can observe women crossing their legs in hopes of seeing something good. Which statement about this behavior is most accurate?

a. It is a sexual disorder. The behavior is socially atypical. It could disrupt relationships and could be insulting to others. b. It is not a sexual disorder. These events occur in public, where those he observes do not have a reasonable expectation of privacy. c. It is not a sexual disorder. Because it occurs in public areas, this behavior does not hurt others or involve intrusion into the personal space of those observed. d. An action is or is not a sexual disorder depending on applicable local laws, so whether this meets the definition of a sexual disorder depends on the location.

ANS: A A sexual disorder is defined as an activity that is socially atypical, has the potential to disrupt significant relationships, and may result in insult or injury to others. The behavior described constitutes a sexual disorder (voyeurism). Although laws vary, an act does not have to be illegal to constitute a sexual disorder. The fact that the behavior occurs in a public setting could have a bearing on whether it is illegal, but not on whether it is considered to be a sexual disorder.

15. A parent who is very concerned about a 3-year-old son says, He likes to play with girls toys.

Do you think he is homosexual or mentally ill? Which response by the nurse most professionally describes the current understanding of gender identity? a. A childs interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood. b. Its difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult. c. The research is incomplete, but many boys play with girls toys and turn out normal as adults. d. I am sure that whatever happens, he will be a loving son, and you will be a proud parent.

ANS: A

The parents inquiry is really two questions: (1) whether the childs behavior suggests an increased risk of developing mental illness and (2) what the childs future sexual preference will be. The psychiatric disorder that most directly addresses gender preferences and cross-gender activities is gender identity disorder. Pointing out that cross-gender activities are not necessarily related to gender identity and not likely to be carried into adulthood is supported by current research.

Saying the child will grow up to be normal implies that to be homosexual is to be abnormal, which reflects a cultural perspective that most professionals would believe to be inappropriate to share in a professional setting. Research provides information about the relationship between cross-gender interests in childhood and adulthood, so a comment that research is incomplete is not entirely accurate. Stating that the child is a wonderful boy the father will be proud of, whatever happens, evades the parents question and suggests that parental bonds should not be affected by gender issues. The nurse has a professional obligation to maintain an objective, therapeutic relationship.

16. Which statement about paraphilic disorders is accurate? a. Paraphilic behavior is controllable by willpower, but most persons with these disorders fail to do so. b. Persons with paraphilic disorders rarely experience shame and are not distressed by their acts. c. Persons with paraphilic disorders prey primarily on female children between the ages of 12 and 15 years. d. Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon.

ANS: D Paraphilic disorders are uncommon; however, because persons with these disorders repeatedly enact behaviors associated with their disorders, paraphilic acts are relatively common. The majority of victims of pedophiles are males in early adolescence; those pedophiles who prefer females usually prefer prepubescent children. Some persons with paraphilic disorders experience shame and are at higher risk for suicide due to the stigma, shame, and embarrassment. Biological and psychological drives underlying paraphilic behavior can be very strong and often are not

controllable by willpower alone. Persons with paraphilic disorders have difficulty controlling their behavior, even when very motivated to do so.

17. A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coachs arrest? a. Determine the nature and extent of the coachs sexual disorder. b. Assess the coachs potential for suicide or other self-harm. c. Assess the coachs self-perception of problem and needs. d. Determine whether other children were harmed.

ANS: B Pedophiles and other persons with paraphilic disorders can be at increased risk of self-harm associated with the guilt, shame, and anger they feel about their behavior and its effect on their families, victims, and victims families. They also face considerable losses, such as the end of their careers or the loss of freedom to imprisonment. Thus, safety is the priority issue for assessment. Determining the nature and extent of the patients disorder and related patient perceptions would be appropriate but not the highest priority for assessment. Investigating whether other victims exist is a matter for law enforcement rather than health care personnel. See relationship to audience response question.

18. An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult: a. consistently avoids schools and shops at malls only during school hours. b. indicates sexual drive and enjoyment from sex have decreased. c. reports an active and satisfying sex life with an adult partner. d. volunteers to become a scout troop leader.

ANS: A

One strategy for avoiding acting on inappropriate urges is to avoid environments and circumstances that evoke those urges; for a pedophile this would include avoiding all situations that would likely result in contact with children. Pedophilic disorder is persistent; elimination of fantasies about children would be unrealistic. A person who volunteers to lead a scout troop is placing himself/herself around children. A diminished sex drive or a healthy sex life with an appropriate partner does not necessarily reduce the desire for sexual contact with children.

19. A patients medical record documents sexual masochism. This patient derives sexual pleasure: a. from inanimate objects. b. by inflicting pain on a partner. c. when sexually humiliated by a partner. d. from touching a non-consenting person.

ANS: C Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.

20. A man with hypospadias tells the nurse, Intercourse with my new bride is painful. Which term applies to the patients complaint? a. Delayed ejaculation b. Erectile dysfunction c. Premature ejaculation d. Genito-pelvic pain/penetration disorder ANS: D This sexual pain is genito-pelvic pain/penetration disorder and may occur in men or women. The individual feels pain in the genitals during intercourse. Erectile or ejaculation problems are not evident. See relationship to audience response question.

21. A man who regularly experiences premature ejaculation tells the nurse, I feel like such a failure. Its so awful for both me and my partner. Select the nurses most therapeutic response. a. I sense you are feeling frustrated and upset. b. Tell me more about feeling like a failure. c. You are too hard on yourself. d. What do you mean by awful?

ANS: A Using reflection and empathy promotes trust and conveys concern to the patient. The distracters do not offer empathy, probe, and offer premature reassurance.

22. A man who reports frequently experiencing premature ejaculation tells the nurse, I feel like such a failure. Its so awful for both me and my partner. Can you help me? Select the nurses best response. a. Have you discussed this problem with your partner? b. I can refer you to a practitioner who can help you with this problem. c. Have you asked your health care provider for prescription medication? d. There are several techniques described in this pamphlet that might be helpful.

ANS: B The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurses role.

23. A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with boys who are athletic

d. Intense urges to watch his parents have sex ANS: A An individual with gender dysphoria feels at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender dysphoria.

24. A patient approaches the nurse in the clinic waiting room and says, I want to talk to you about a sexual matter. The nurse can best facilitate the discussion by: a. saying, Lets go my office. b. responding, I want to help. Go ahead; Im listening. c. telling the patient, Lets schedule another appointment. d. offering to sit in a corner of the waiting room with the patient.

ANS: A A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. The distracters block communication.

MULTIPLE RESPONSE 1. A nurse assesses a patient diagnosed with pedophilic disorder. Which findings are most likely?

Select all that apply. a. Childhood history of attention deficit hyperactivity disorder (ADHD) b. A poorly managed endocrine disorder c. History of brain injury d. Cognitive distortions e. Grandiosity

ANS: A, C, D Attention deficit hyperactivity disorder (ADHD) in childhood, substance abuse, phobic disorders, and major depression/dysthymia are strongly associated with paraphilic disorders.

Errors in thought make it seem acceptable for deviant and destructive sexual behaviors to occur.

Patients who have experienced head trauma with damage to the frontal lobe of the brain may display symptoms of promiscuity, poor judgment, inability to recognize triggers that set off sexual desires, and poor impulse control. Endocrine problems are not associated with pedophilic disorder. Self-confidence is lacking; therefore, grandiosity would not be expected.

Chapter 19: Disruptive, Impulse Control, and Conduct Disorders MULTIPLE CHOICE 1. A 16-year-old diagnosed with a conduct disorder has been in a residential program for 3 months. Which outcome should occur before discharge? a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b. The adolescent identifies friends in the home community who are a positive influence. c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d. The adolescent experiences no anger and frustration for 1 week.

ANS: A The adolescent and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The adolescent will continue to experience anger and frustration. The adolescent and parents must continue with family therapy to work on boundary and communication issues. It is not necessary to separate the adolescent from the family to work on these issues. Separation is detrimental to the healing process. While it is helpful for the

adolescent to identify peers who are a positive influence, its more important for behavior to be managed for an adolescent diagnosed with a conduct disorder.

2. A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the court, We cant manage our teenager. The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescents behavior? a. Attention deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Intermittent explosive disorder d. Conduct disorder ANS: D Conduct disorders are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. Criteria for ADHD and PTSD are not met in the scenario.

3. A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic? a. Planned ignoring

c. Neutrally permit refusals

b. Establish firm limits

d. Coaxing to gain compliance

ANS: B Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teens thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, ignoring, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.

4. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all attention on my brother, whos perfect in their eyes. Which type of therapy might promote the greatest change in the adolescents behavior? a. Family therapy

c. Play therapy

b. Bibliotherapy

d. Art therapy

ANS: A Family therapy focuses on problematic family relationships and interactions. The patient has identified problems within the family. Play therapy is more appropriate for younger patients. Art therapy and bibliotherapy would not focus specifically on the identified problem.

5. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all attention on my brother, whos perfect in their eyes. Which nursing diagnosis is most applicable? a. Disturbed personal identity related to acting out as evidenced by prostitution b. Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents c. Ineffective coping related to inappropriate methods of seeking parental attention as evidenced by acting out d. Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another ANS: C The patient demonstrates a failure to follow age-appropriate social norms and an inability to problem solve by using adaptive behaviors to meet lifes demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient never mentioned hopelessness or disturbed personal identity. The problem relates to the patients perceptions of parental behavior rather than the actual behavior.

6. A 12-year-old has engaged in bullying for several years. The parents say, We cant believe anything our child says. Recently this child shot a dog with a pellet gun and set fire to a neighbors trash bin. The childs behaviors support the diagnosis of: a. attention deficit hyperactivity disorder. b. intermittent explosive disorder. c. defiance of authority. d. conduct disorder.

ANS: D The behaviors mentioned are most consistent with criteria for conduct disorder, for example, aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. The behaviors are not consistent with attention deficit and are more pervasive than defiance of authority. See related audience response question.

7. An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. a. Ignore the childs behavior. b. Send the child to time-out. c. Accompany the child to the gym and shoot baskets. d. Role-play a more appropriate behavior with the child.

ANS: C The childs behavior warrants an active response. Redirecting the expression of feelings into nondestructive age-appropriate behaviors, such as a physical activity, helps defuse the situation here and now. This response helps the child learn how to modulate the expression of feelings and

exert self-control. This is the least restrictive alternative and should be tried before resorting to a more restrictive measure. Role-playing is appropriate after the childs anger is defused.

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

ANS: C Setting limits uses clear, sharp statements about prohibited behavior and guidance for performing a behavior that is expected. The incorrect options represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the childs developing self-control that may be ineffective.

9. The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the childs plan of care will be provided by an advanced practice nurse rather than a staff nurse? a. Leading an activity group

c. Formulating nursing diagnoses

b. Providing positive feedback

d. Dialectical behavioral therapy (DBT)

ANS: D The advanced practice nurse role includes individual, group, and family psychotherapist; educator of nurses, other professions, and the community; clinical supervisor; consultant to professional and nonprofessional groups; and researcher. Dialectical behavioral therapy (DBT) is an aspect of psychotherapy. The distracters describe actions of a nurse generalist.

10. Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, Id rather stay in my room and listen to music. Its easier than thinking about what is happening in my family. Which nursing diagnosis is most applicable? a. Chronic low self-esteem related to role within the family b. Decisional conflict related to compliance with school requirements c. Ineffective coping related to adjustment to changes in family relationships d. Disturbed personal identity related to self-perceptions of changing family dynamics ANS: C Depression is often associated with impulse control disorder. The correct nursing diagnosis refers to the patients dysfunctional management of feelings associated with upcoming changes to the family. The teen displays self-imposed isolation. The distracters are not supported by data in the scenario.

11. A child known as the neighborhood bully says, Nobody can tell me what to do. After receiving a poor grade on a science project, this child secretly loaded a virus on the teachers computer. These behaviors support a diagnosis of: a. conduct disorder. b. oppositional defiant disorder. c. intermittent explosive disorder. d. attention deficit hyperactivity disorder.

ANS: B Oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Loading a virus is a vindictive behavior in retribution for a poor grade. Persons with conduct disorder are aggressive against people and animals; destroy property; are deceitful; violate rules; and have impaired

social, academic, or occupational functioning. There is no evidence of explosiveness or distractibility.

12. An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurses initial action to defuse the situation? a. Say to the child, Tell me how youre feeling right now. b. Take the child swimming at the programs pool. c. Establish a behavioral contract with the child. d. Administer an anxiolytic medication.

ANS: B Redirecting the expression of feelings into nondestructive, age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert selfcontrol. This is the least restrictive alternative and should be tried before resorting to measures that are more restrictive. A shouting child will not likely engage in a discussion about feelings. A behavioral contract could be considered later, but first the situation must be defused.

13. Parents of an adolescent diagnosed with a conduct disorder say, We dont know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?

Which therapy is likely to be helpful for these parents? a. Parent-child interaction therapy (PCIT) b. Behavior modification therapy c. Multi-systemic therapy (MST) d. Pharmacotherapy ANS: A In parent-child interaction therapy (PCIT), the therapist sits behind one-way mirrors and coaches parents through an ear audio device while they interact with their children. The therapist can

suggest strategies that reinforce positive behavior in the adolescent. The goal is to improve parenting strategies and thereby reduce problematic behavior. Behavior modification therapy may help the adolescent, but the parents are seeking help for themselves. Multi-systemic therapy is much broader and does not target the parents need.

14. An adolescent diagnosed with an impulse control disorder said, I just want to die. I spend all my time getting even with people who have done wrong to me. When asked about a suicide plan, the adolescent replied, Ill jump from the bridge near my home. My father threw kittens off that bridge, and they died because they couldnt swim. Rate the suicide risk. a. Absent

c. Moderate

b. Low

d. High

ANS: D The suicide risk is high. The child is experiencing feelings of hopelessness and helplessness. The method described is lethal, and the means to carry out the plan are available.

15. An adolescent diagnosed with conduct disorder has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication.

The nurse anticipates the health care provider will prescribe which type of medication? a. Second-generation antipsychotic

c. Calcium channel blocker

b. Anti-anxiety medication

d. Beta-blocker

ANS: A Medications for conduct disorder are directed at problematic behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms. Second-generation antipsychotics are likely to be prescribed. Beta-blocking medications may help to calm individuals with intermittent explosive disorder by slowing the heart rate and reducing blood pressure. Calcium channel blockers reduce blood pressure but are not used for persons with impulse control problems. An anti-anxiety medication will not assist with impulse control.

16. An adolescent was recently diagnosed with oppositional defiant disorder. The parents say to the nurse, Isnt there some medication that will help with this problem? Select the nurses best response. a. There are no medications to treat this problem. This diagnosis is behavioral in nature. b. Its a common misconception that there is a medication available to treat every health problem. c. Medication is usually not prescribed for this problem. Lets discuss some behavioral strategies you can use. d. There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you.

ANS: C The parents are seeking a quick solution. Medications are generally not indicated for oppositional defiant disorder. Comorbid conditions that increase defiant symptoms, such as attention deficit hyperactivity disorder, should be managed with medication, but no comorbid problem is identified in the question. The nurse should give information on helpful strategies to manage the adolescents behavior.

17. An adolescent diagnosed with a conduct disorder stole and wrecked a neighbors motorcycle.

Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescents reaction? a. Serotonin dysregulation and increased testosterone activity impair ones capacity for remorse. b. Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules. c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. d. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.

ANS: C

Adolescents with conduct disorder have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the amygdala. This reduction may be related to aggressive behavior and deficits of empathy. The less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. People with intermittent explosive disorder may have differences in serotonin regulation in the brain and higher levels of testosterone. Neuron destruction in the hippocampus is associated with memory deficits. The occipital lobe is involved with visual stimuli but not the processing of emotions.

18. Which assessment findings support a diagnosis of oppositional defiant disorder? a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior. b. Exhibits involuntary facial twitching and blinking; makes barking sounds. c. Violates others rights; cruelty toward people or animals; steals; truancy. d. Displays poor academic performance and reports frequent nightmares.

ANS: A Oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. The distracters identify findings associated with conduct disorder, anxiety disorder, and Tourettes syndrome.MULTIPLE RESPONSE 1. A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patients history support the suspected diagnosis? Select all that apply. a. Family history of mental illness b. Allergies to multiple antibiotics c. Long history of severe facial acne d. Father with history of alcohol abuse e. History of an abusive relationship with one parent ANS: A, D, E

Parents who are abusive, rejecting, or overly controlling cause a child to suffer detrimental effects. Other stressors associated with impulse control disorders can include major disruptions such as placement in foster care, severe marital discord, or a separation of parents. Substance abuse by a parent is common. Acne and allergies are not aspects of the history that relate to the behavior.

2. What are the primary distinguishing factors between the behavior of persons diagnosed with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? Select all that apply.

The person diagnosed with: a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from loved ones. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

ANS: B, E Persons diagnosed with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas persons with conduct disorder frequently behave in ways that do violate the rights of others and age-appropriate societal norms.

Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are seen in persons with autism spectrum disorders.

3. A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because: (select all that apply) a. it is a vital component of implementing a behavior modification program. b. a therapeutic alliance is the first step in a nurses therapeutic use of self. c. the adolescent has demonstrated resistance to other authority figures. d. acceptance and trust convey feelings of security for the adolescent.

e. adolescents usually relate better to authority figures than peers.

ANS: B, D Trust is frequently an issue because the adolescent may never have had a trusting relationship with an adult. Trust promotes feelings of security and is the basis of the nurses therapeutic use of self. Adolescents value peer relationships over those related to authority. Rewards for appropriate behavior are the main component of behavior modification programs.

Chapter 20: Substance Use and Addictive Disorders MULTIPLE CHOICE 1. When asked, What causes alcoholism? the nurses response will be based on the fact that: a. The response to alcohol is a result of a brain-based disorder. b. Alcoholism is believed to be an allergic response to the alcohol. c. Every individual has the same susceptibility for developing alcoholism. d. It is a physical response to alcohol but its etiology is not fully understood.

ANS: A It has been determined that alcoholism is not an allergy but rather it is recognized as a partial brain-based disorder that some brains are more susceptible to than others.

2. Which patient response would support the conclusion that the patient has moved into the dark side of a narcotic addition? a. Ive been abusing drugs for at least 10 years. b. Drugs makes me feel good; that why I use them. c. I dont like the way I feel when I dont use drugs. d. Drugs are something that I can either take or leave

ANS: C During beginning use (the light side), the feel good effects are dominant. As the individual becomes habituated to the drug, tolerance and withdrawal symptoms develop; this constitutes the dark side. The remaining options do not describe effects of drug use.

3. A substance use disorder (SUD) is a likely comorbid mental illness in which patient? a. The soldier diagnosed with posttraumatic stress disorder b. The teenager demonstrating symptoms of poor impulse control c. The older adult diagnosed with early stage Alzheimers disease d. The new mother exhibiting symptoms of postpartum depression ANS: A Posttraumatic stress disorder creates a risk for substance use or relapse. A total of 30% to 60% of persons with SUDs meet the criteria for comorbid posttraumatic stress disorder. The remaining options have not shown such a prevalence of comorbid relationship with SUDs. 4. Which group would be the target population for educational material on the dangers of binge drinking? a. Full-time college students b. Blue-collared young adults c. Older widows and widowers d. High school juniors and seniors ANS: A The highest prevalence of binge and heavy drinking is among young adults between the ages of 18 and 25 years, with the majority being full-time college students.

5. Which social factor has the greatest impact on the changing nature of alcohol abuse treatment?

a. Development of new pharmaceutical treatment options b. Dramatic increase of alcoholism among young adult males c. Raising cost of both inpatient and outpatient treatment programs d. Womens substance abuse only recently acknowledge by society ANS: D The existence of an alcohol abuse problem among women has only been recently recognized and this has dramatically affected treatments and services being provided. Although the other options are true, they do not have the impact on treatment modalities as much as the correct option.

6. Which assessment data poses the greatest risk for injury in a patient who abuses alcohol? a. Takes a baby aspirin each morning b. Uses over-the-counter antihistamines for seasonal allergies c. Has been taking a tricyclic antidepressant for more than 2 years d. Took a narcotic for 1 week to manage postdental surgery pain ANS: C Tricyclic antidepressants are strictly contraindicated with alcohol consumption because of their potential effect on cardiac function. Although aspirin increases bleeding times and antihistamines and narcotics increase sedation, the outcome of combining alcohol and these drugs is not as dangerous as that of the correct option.

7. If an individual is admitted with a diagnosis of Wernicke-Korsakoffs syndrome, the nurse would expect to assess: a. Peptic ulcer b. Vivid illusions c. Cognitive deficits d. Auditory hallucinations

ANS: C Wernicke-Korsakoffs syndrome includes a severe form of amnesia and an inability to learn new skills which reflects a cognitive impairment. The other options are not associated with the syndrome.

8. Which sociological aspect, vital to relapse prevention, is greatly affected when a patient is found to have a dual diagnosis of psychosis and alcoholism? a. Ability to afford the cost of outpatient services b. A supportive, reliable, accessible support system c. Protection from both physical and emotional abuse d. Access to reasonable housing and employment opportunities ANS: B Often individuals with this type of diagnosis have lost their support systems as a result of chronic mistreatment of their family and friends and an inability to maintain and recognize the importance of this aspect to their treatment plan. Although the remaining options impact relapse prevention, they are generally available when the patient is being supported appropriately.

9. Which nursing intervention best demonstrates an understanding of the relationship between confirmed intravenous drug abuse and specific infections? a. Screening the patient for hepatitis B virus (HBV) b. Assessing the patient for potentially infected injection sites c. Determining if the patient has ever been tested for human immunodeficiency virus (HIV) d. Evaluating the patients understanding of the increased risk for developing sexually transmitted diseases ANS: A

Injecting drug users have one of the highest HBV rates among all risk groups and account for at least half of all new HCV cases, so screening for such infections demonstrates that the nurse understands the severity of the problem. Although the other options reflect potential infection risks, they are not as commonly seen in patients with this diagnosis.

10. Which assessment data would bring into question a patients statement that, I have only a few drinks on special occasions.? a. History of treatment for glaucoma b. Fasting serum blood glucose level of 182 mg/dL c. Patient reports numbness in hands and feet bilaterally d. Red rash observed over neck, shoulders, and upper chest ANS: C Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake.

Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking causing the nurse to question the patients statement. The remaining options do not reflect symptomology generally associated with alcoholism.

11. Which intervention has priority when a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs? a. Asking the staff member to explain their suspicious behavior b. Adjust the staff members assignment to minimize patient contact c. Providing the staff member with material regarding alcohol abuse and treatment d. Reporting the staff members suspicious behavior to the nursing supervisor on duty ANS: D It is a professional obligation to report suspected impaired practice. The remaining options do not have prior in this situation since the concern is patient safety.

12. Which nursing intervention demonstrates an understanding regarding the primary form of substance use disorder among older adults? a. Assessing the patients hands and feet for the presence of both numbness and tingling b. Having the patient, describe your relationship with you adult children, coworkers, and friends. c. Asking, Please identify for me all the medications both prescribed and over the counter you regularly take. d. Evaluate the patients understanding of the possible health risks that alcohol and medication abuse has on ones health ANS: C Misuse of prescription medications is the most common form of drug abuse among older adults.

This population is especially vulnerable because of the multiple drugs that are often prescribed for medical conditions. The remaining options do not help identify the presence of multiple medications.

13. Which assessment demonstrates the nurses understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium? a. Determining the patients age and gender b. Evaluating the patients food and fluid intake over the last 48 hours c. Observing the patient for fine tremors of the hands, especially the fingers d. Determining the amount of caffeine the patient ingested in the last 24 hours ANS: D Some people who ingest large amounts of caffeine develop delirium. The remaining options are not relevant to caffeine ingestion or the abuse of any other substance.

14. Which protocol should guide the nurse responsible for administering pharmacologic interventions for a patient who is experiencing alcohol intoxication?

a. Medication interventions are based on the presence of withdrawal symptoms. b. Medications are prescribed at appropriate intervals for at least one full week. c. Symptoms are managed with medications for only the initial 24 hours of hospitalization. d. Medications are introduced to treat grand mal seizures that may accompany withdrawal symptoms.

ANS: A The course of intoxication is usually self-limiting to approximately 24 hours, after which withdrawal symptoms can occur for a time period unique to each patient. Treatment is directed by the symptoms the patient is experiencing, which generally emerge during the withdrawal stage. Seizures are among several serious symptoms that can occur during the withdrawal stage.

15. A patient recently discharged from an alcohol rehabilitation program is brought to the hospital in a state of prostration with severe throbbing headache, tachycardia, a beet-red face, dyspnea, and continuous vomiting. The patients significant other states the patient got sick about 15 minutes after drinking a glass of wine. The nurse should be guided in assessment by the suspicion that the patient: a. Is having a stroke b. Has alcohol intoxication c. Is reacting to disulfiram (Antabuse) d. Is exhibiting symptoms of cross-dependence ANS: C The alcohol deterrent drug, Antabuse, commonly prescribed in recovering alcoholic treatment, causes this reaction when taken in combination with alcohol. Alcohol intoxication, stroke, and cross-dependence do not present with the listed prostration symptoms.

16. Which question is most appropriate when assessing a patient who is exhibiting symptoms of a systemic infection including a fever of unknown origin?

a. Are you an intravenous drug user? b. Have you been told that you drink too much alcohol? c. Have you been diagnosed with an acute bacterial infection before? d. Are you familiar with an infection of the heart called endocarditis?

ANS: A Intravenous drug users are at risk for subacute bacterial endocarditis and other circulatory compromise created by foreign substances introduced during the process of intravenous use.

Regardless of the setting, nurses need to ask about intravenous drug use whenever a patient presents with fever of unexplained origin. Assessing the patients knowledge related to bacterial infections and endocarditis will not address the possible cause of the fever. Alcohol consumption is not relevant in this situation.

17. Which observation seen in a teenage patient supports the suspicion of anabolic steroid abuse? a. Lack of facial hair b. Ritualized hand washing c. Stealing and hiding a magazine belonging to another patient d. Throwing a chair when told it was time to turn off the television ANS: D For all individuals abusing anabolic steroids, extreme mood swings occur, and these may be accompanied by violent behaviors. Obsessive-compulsive behaviors and stealing are not generally associated with this disorder. The increased hormone presence would result not in a lack, but rather an increase, in facial hair.

18. A patients wife has chronic alcoholism, and the husband is concerned about the possibility that their children may develop the disease. He asks the nurse what the risk is. The nurses best response is:

a. The risk for developing alcoholism is increased if there is a family history of alcoholism. b. Studies have confirmed that individuals with dependent personality traits are at high risk for this disease. c. Cultures that include alcohol as part of the ritualized behavior have a higher rate of alcoholism. d. Twin studies have indicated that the environment of a person is more important than the biologic influences of parents.

ANS: A Problems with alcohol increase with the number of relatives with alcoholism. No unique personality profile is prone to addiction. Ritualized use of alcohol does not predispose to alcoholism and twin studies indicate a significant genetic contribution to susceptibility to alcoholism.

19. Which observation best supports the patients success with achieving long-term sobriety? a. Asking a family member to, get rid of all the alcohol before I come home b. Identifying all the problems alcoholism has caused the family over the years c. Being able to discuss the importance of attending a support group for alcoholics d. Promising to, stop the drinking so I can be a good parent and raise a good child ANS: B One of the most prominent factors that leads an individual to recovery is the patients recognition that substance use has caused or influenced his or her lifes problems and interrupted his or her functioning. The remaining options lack that element of self-reflection.

20. Which principle of recovery is the basis of the nurses response when a patient relapses and is hospitalized for alcohol detox treatment? a. Alcoholism requires a lifelong commitment to control. b. Most people who are serious about treatment achieve sobriety.

c. Relapsing is an expected occurrence for the patient diagnosed with alcohol abuse. d. Rehabilitation generally involves several relapses before true sobriety is achieved.

ANS: D Sobriety is the goal of complete abstention from drugs, alcohol, and addictive behaviors.

Sobriety often involves several attempts, and many patients relapse 9 or 10 times before achieving and sustaining sobriety. This information is the basis for the physical and emotional support provided by the nurse. Although citing that a relapse is not a failure but an expected part of the recovery process, this option does not include the needed information of the frequency of the possible relapses. The remaining options are not focused on relapsing.

21. Which assessment observation is the best support for a patients diagnosis of alcoholism? a. Reporting, I messed up three marriages. b. Testing positive for hepatitis B virus (HBV) c. Admission that, I drink more than I should. d. A positive response to three items on the CAGE test ANS: D The CAGE questionnaire is a well-validated screening instrument. A positive response to two of the four items of the CAGE questionnaire indicates a potential problem with alcoholism.

Although the remaining options are recognized red flags for possible alcoholism, they lack the selectivity of the screening tool.

22. Which factor has the greatest negative impact on the use of laboratory serum alcohol results in determining legal intoxication? a. The variable time it takes to metabolize alcohol in the body b. States differs greatly in their definitions of legal intoxication c. Legal issues with securing consent for the test from an impaired patient

d. The relatively short period of time alcohol can be detected in the blood ANS: D The major disadvantage of blood alcohol testing is the narrow window of time for the detection of drugs in the blood stream. Although the variability of individual metabolism rates may be considered a factor, they are stable enough to allow for testing timetables. The legal issues related to consent and the definition of legal intoxication limits does not impact the reliability of the test itself to determine intoxication.

23. Which intervention will the nurse caring for a patient suspected of phencyclidine (PCP) abuse implement based on an understanding of the medications unique properties? a. Assessing for chronic renal failure b. Focusing attention on providing patient safety c. Implementing suicide precautions immediately d. Monitoring for delayed development of psychotic symptoms ANS: D Phencyclidine (PCP) is a hallucinogen, but it has its own set of CNS reactions. PCP has a long duration of action that can result in delayed psychotic symptoms. Chronic renal failure would not be immediately observable. Patient safety is a nursing responsibility regardless of the diagnosis.

Self-harm is not generally a characteristic of this type of substance abuse.

24. Which outcome would be appropriate for the detoxification phase of treatment for alcoholism? a. Adequate dietary protein intake b. Re-connection with family and support system c. Identification of triggers that cause alcohol abuse d. Control over emotions resulting in aggressive behavior

ANS: A When implementing any plan, patient safety and health are always the first priorities, so the nurse focuses on nutritional support, including providing a protein-rich diet. The remaining options are outcomes reserved for the later stages of the recovery process.

25. Which intervention will the nurse plan for when managing the detoxification of a patient diagnosed with chronic alcoholism? a. Low-protein diet to minimize risk of kidney failure b. Seclusion to help manage aggression towards others c. Transporting patient to scheduled 12-step support group meetings d. Administering Ativan (lorazepam) to manage alcohol withdrawal symptoms ANS: D During the process of detoxification, the nurse gives enough of a drug (or one to which the person has cross-tolerance) to relieve the withdrawal symptoms. Benzodiazepines like lorazepam (Ativan) have a cross-tolerance with alcohol, so they are used to manage withdrawal symptoms.

The detoxification diet would be high in protein. Seclusion would not be initiated before less severe attempts to manage the behavior failed. Attending a support group would not be appropriate for the detoxification stage of rehabilitation.

MULTIPLE RESPONSE 1. Which behaviors would demonstrate a strong possibility for successful rehabilitation for a patient with a substance abuserelated diagnosis? Select all that apply. a. States that, I promise Ill never use drugs again. b. Has shown ability to use effective coping mechanisms c. Expresses an understanding of the severity of their addiction d. Plans to associate with old friends only when they arent drinking e. Demonstrates an interest in staying involved in an appropriate support group

ANS: B, C, E The correct options show an understanding of the disease process and examples of needed skills as well as the commitment to maintain control over their addiction. The remaining options reflect promises but not true insight into the severity of their problem and the effects needed to manage it successfully.

2. A nurse engaged in primary prevention for substance abuse among adolescents could advise parents to (select all that apply): a. Watch for signs of depression. b. Help the teen anticipate pressures. c. Be a role model for effective coping skills. d. Support the teens interest in hobbies and sports. e. Require academic tutoring when grades begin to drop.

ANS: B, C, D The correct options are proactive and focus on preventing the problem although the remaining options intervene once there are indications that the problem may exist.

3. When suspicious of possible fetal alcohol syndrome, which assessment findings would support this diagnosis? Select all that apply. a. Webbed toes b. An enlarged head c. Super sensitive hearing d. A flattened bridge of the nose e. Symptoms of a septal heart defect ANS: A, D, E

The correct options are characteristics of FAS but one would not include hearing loss or a small head in children with this disorder.

4. A teen says to the school nurse, Huffing is harmless. There are no reasons not to sniff inhalants. The nurse can reply knowing that (select all that apply): a. Such behavior can result in irreversible hearing impairment. b. There has been minimal research done on the effects in teens. c. Long-term use can result in poor short- and long-term memory. d. Irreversible kidney damage is often observed with even casual use. e. Research indicates both central nervous system and bone marrow damage.

ANS: A, C, E Research as shown that even teens who engage in sniffing high concentrations on inhalants often experience hearing loss, CNS and bone marrow damage, and impaired cognitive function.

Kidney impairment is often seen as reversible.

Chapter 21: Neurocognitive Disorders MULTIPLE CHOICE 1. A patient diagnosed with moderate dementia consistently appears to be distorting the truth resulting in his wife asking, What should I do when he lies to me about unimportant things?

Upon what rationale should the nurses response be based? a. Changing the topic provides diversion. b. Delusions should be confronted to clarify thinking. c. Ignoring memory deficit avoids catastrophic reactions. d. This isnt lying but rather a way to fill in the memory gaps.

ANS: D

Confabulation is not lying but rather a method for filling in the memory gaps. Ignoring, using confrontation, and changing the topic would not be as useful as gently reorienting.

2. The nurse is to perform a complete assessment of a patient in her home, using the Mini-Mental State Examination (MMSE) as one component. When the nurse arrives, the patient is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The patient is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be which of the following? a. Ask the husband to make an appointment to bring his wife to the clinic for testing. b. Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room. c. Do not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family. d. Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled.

ANS: D Testing the patient in her home under quieter, less distracting circumstances is the best solution.

Asking the husband to leave is likely to increase the patients anxiety and alter test results. Use of the MMSE is an integral component of the assessment and must not be deleted. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.

3. A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing intervention is supported by this diagnosis? a. Encouraging fluids to minimize constipation b. Frequently assessing both visual and auditory hallucinations c. Scheduling frequent changing of position to prevent skin breakdown d. Dimming the lights to help control eye discomfort resulting from cataracts ANS: C

Because of inactivity, hypoactive delirium patients are more likely to develop further complications, including decubiti that could be minimized by frequent repositioning. The remaining options identify interventions that are not generally a result of this diagnosis.

4. Which of the following should the nurse use as a basis for explaining the etiology of Alzheimers disease to the family of a patient with this disease? a. It is a secondary dementia indicated by loss of recent memory and disorientation to time and place. b. It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence of a beta-amyloid protein in the neurons resulting in senile plaques. c. It is a secondary dementia that is treatable with analysis of the diet and removal of toxic substances from the diet and environment. d. It is a primary dementia characterized by stepwise decreases in cognitive abilities. It is irreversible but treatable with antihypertensive medications.

ANS: B This option provides accurate information about Alzheimers disease. Alzheimers disease is not a secondary dementia nor is it treated with antihypertensive medications.

5. Which outcome is realistic for a patient with stage 1 Alzheimers disease? a. Caregiver will assume role of decision maker for patient to reduce stress. b. The patient will maintain the highest possible functional level to preserve autonomy. c. Arrangements will be made for appropriate long-term placement to minimize risk of injury. d. The patient will retain full physical functioning through cognitive and occupational therapies.

ANS: B This outcome addresses health maintenance (i.e., maintaining an optimal functional level as determined by present capacity). Although long-term placement may be an option, it is not

necessarily appropriate during this stage. Patients in stage 1 are often able to make simple decisions. Continuing to make decisions gives the patient a sense of control. Although a patient in stage 1 does not appear markedly deteriorated, some diminution of function may be present.

6. The home care nurse is visiting a patient who was discharged to home after a procedure at an ambulatory surgical center. The patient lives alone in a senior retirement community. The nurses assessment documents mild dysphasia. The patient repeatedly asks, Why is there a bandage on my arm? and is not able to state the appropriate day and year. Appropriate planning for the patient should include: a. Assessing diet and meal preparation, assessing environment for safety problems, referral to a dementia program b. Attending English class to improve speech, transferring finances to a conservator, employing an aide to help with medications c. Arranging Meals on Wheels, attending speech therapy, relocation to a skilled nursing facility if no improvement in 1 month d. Arranging an appointment at a geriatric assessment program, OT referral for swallowing therapy, teaching to manage public transportation ANS: A Further assessment is appropriate before making changes in the living environment. Enrolling in a dementia program will provide stimulation and help the patient maintain intellectual skills.

English classes will not improve speech. The other plans might have relevance, however. The remaining sets of options are either irrelevant or beyond the patients abilities.

7. A patient diagnosed with Alzheimers disease has a catastrophic reaction during an activity involving simultaneous playing of music and working on a craft project. The patient starts shouting no, no, no and rushes out of the room. The nurse should: a. Discontinue the activity program since it upsets the patients. b. Follow the patient, reassure her, and redirect her to a quieter activity. c. Isolate the patient until she is calm, and then direct her back to the activity. d. Give the patient prn antianxiety medication and restrict her activity participation.

ANS: B These actions will restore safety and self-esteem. Isolation will decrease self-esteem and may increase confusion. It is only one patient that is distressed, not the entire group. Behavioral interventions should be attempted prior to administering medication.

8. Which behaviors would indicate that a therapeutic activity program for a patient with Alzheimers disease had been successful? a. Accurate recent memory, positive emotional response, and increased verbal expression b. Increased attention span, verbal expression of remote memory, and positive emotional response c. Positive use of perseveration, reduction in use of habitual skills, and improved abstract reasoning d. Positive emotional response, ability to remember multiple steps, and accurate recent memory ANS: B These are all observations that would indicate that a therapeutic activity program has kept the patient functioning at the highest level of which he is capable. The behaviors described in the other options are not realistic expectations for this patient.

9. A patient has been diagnosed with dementia secondary to cerebral disease. The family members note the patient has not been as sharp as he once was and that he has developed urinary incontinence and a gait disturbance. Which pathophysiology can cause such symptoms? a. Normal pressure hydrocephalus b. Vitamin B12 deficiency c. Hepatic disease d. Tuberculosis ANS: A

Normal pressure hydrocephalus is a disorder characterized by dementia, gait disorder, and urinary incontinence. Dilation of ventricles in the absence of increased CSF is a prominent manifestation. Early urinary incontinence is not seen in the disorders listed in the other options.

10. When asked about the prognosis for a patient diagnosed with a dementia secondary to normal pressure hydrocephalus the nurse replies: a. Unfortunately the prognosis is for a downhill course ending in death. b. There will be good days and bad days for the rest of the patients life. c. The symptoms generally remit after a shunt is inserted to drain fluid. d. Well try our very best, but only time will tell how successful we are.

ANS: C By relieving the cause, the symptoms of secondary dementias are largely reversible. The statements reflected in the other options do not reflect this fact.

11. Which statement by an adult child concerning the behaviors of their parent supports the diagnosis of Alzheimers disease? a. Mom forgot to pay her utility bills last month. b. Mom isnt as interested in keeping a neat house as she was. c. Mom doesnt seem interested in going out with friends anymore. d. Mom refuses to stop driving even though her reaction time is very slow.

ANS: A Increased forgetfulness, particularly that involving former routine activities (such as bill paying), is symptomatic of Alzheimers disease. The other options do not indicate cognitive deficit.

12. The daughter of an older patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of holding her prisoner. Which nursing diagnosis would be appropriate for this patient?

a. Powerlessness b. Defensive coping c. Ineffective coping d. Disturbed thought processes ANS: D Paranoid thinking is common in patients with dementia. Inability to correctly interpret environmental clues and to think logically leads to delusional thinking as the patient tries to make sense of a confusing world. The remaining options are not supported by the data in the scenario.

13. The daughter of an elderly patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of stealing her money.

The nurse assesses the patients stage of Alzheimers disease as stage: a. 1 b. 2 c. 3 d. 4 ANS: B In stage 2, memory and cognitive deficits are worsening. The patient is less able to make sense of a confusing world and makes faulty interpretations resulting in paranoid delusional thinking.

The patient in stage 1 does not usually have delusions. The patient in stage 3 often is unable to communicate meaningfully. There is no stage 4 of Alzheimers disease.

14. An elderly patient was well until 12 hours ago, when she reported to her family that in the middle of the night she awakened to see a man standing at the foot of her bed. There is no evidence that this situation ever happened. This series of events supports which possible diagnosis?

a. Delirium b. Anxiety c. Paranoia d. Dementia ANS: A Delirium is a disturbance of consciousness and cognition that develops over a short period. It is secondary to a medical condition. The scenario does not fit the disorders mentioned in the remaining options.

15. A patient diagnosed with delirium has become agitated and fearful. Which nursing intervention should the nurse implement to help prevent a catastrophic response? a. Interact with the patient on an adult-to-child level. b. Place the patient in a safe, nonstimulating environment. c. Ask the patient to explain what is causing the agitation and fear. d. Be prepared to apply physical restraints to minimize the patients risk for injury.

ANS: B The safety of a patient with delirium is of primary importance. Symptoms of delirium fluctuate and may worsen, especially at night. The greater the patients confusion and disorientation, the greater the possibility for self-harm. The patient should be treated as an adult; to do otherwise is demeaning. Asking for an explanation is inappropriate, because delirious patients cannot formulate rational answers. Patients are never restrained unless all other less restrictive measures have failed.

16. A patient has been diagnosed with Alzheimers disease, stage 1. The nurse would expect to help the family plan measures to assist the patient with: a. Perseveration b. Recent memory loss

c. Catastrophic reactions d. Progressive gait disturbances ANS: B Recent memory loss is the only symptom listed in the options that would be expected in stage 1 Alzheimers disease.

17. An elderly patient with dementia has a nursing diagnosis of self-care deficit: bathing, hygiene. She lives alone and the nursing assessment proves reason to believe she has forgotten how to perform hygiene and bathing activities. Which intervention is most appropriate for this patient? a. Bathe daily with reminders. b. Bathe twice weekly with assistance. c. Patient will be provided with in-home nursing care. d. Patient will be transferred to an assisted living facility.

ANS: B Bathing twice weekly would be a realistic goal. Assistance should be provided, both to prevent falls and to regulate shower temperature. The elderly are advised not to bathe daily because it is too drying to their skin. The remaining options are not supported by the information given in the scenario.

18. Which situation would be most likely to serve as a trigger to a catastrophic reaction in a patient with stage 2 Alzheimers disease? a. Participating in singing Happy Birthday to another patient at dinner b. Being scolded by an aide for spilling a glass of milk c. Listening to Big Band music from the 1940s d. Eating cupcakes in the activities room

ANS: B Catastrophic reactions are overexaggerated negative emotional responses initiated as a result of a perceived failure at a task or change in the environment. Being scolded by the aide presents a situation that would clearly be frustrating to the patient.

19. Which theory of etiology of Alzheimers disease, suggested by current research, might the nurse use to help a family understand that this disorder is not of psychosocial origin? Alzheimers disease is associated with: a. Abnormal serotonin reuptake b. Prion infection of gray matter c. -Amyloid protein deposits in the brain d. Excessive acetylcholine in the frontal cortex ANS: C The prevailing theories of etiology of Alzheimers disease include the following: angiopathy and blood-brain barrier incompetence; neurotransmitter and receptor deficiencies of acetylcholine; abnormal proteins, specifically -amyloid and their products; and genetic defects. Neither serotonin nor prions are implicated as problems in Alzheimers disease.

20. The nurse is administering donepezil (Aricept) to a patient with stage 1 Alzheimers disease.

Based on this drugs mechanism of action, the nurse will seek evidence of improvement in the patients: a. Social behaviors b. Existing delusions c. Ability to tolerate stress d. Ability to remember recent events ANS: D

Donepezil is a cholinesterase inhibitor that increases the concentration of acetylcholine.

Acetylcholine is needed for intact memory and for learning. This medication is not prescribed for the conditions identified in the remaining options.

21. A patient with dementia is unable to name ordinary objects. Instead, he describes the function of each item (e.g., the thing you cut meat with). The nurse assesses this as: a. Apraxia b. Agnosia c. Aphasia d. Amnesia ANS: B Agnosia is the failure to identify objects despite intact sensory function. Apraxia is the inability to carry out purposeful, complex movements and use objects properly. Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). Amnesia is inability to remember a significant block of information.

22. Which intervention has highest priority for a patient with stage 3 Alzheimers disease? a. Cutting the patients food into bite size pieces b. Providing fluids to the patient every hour while awake c. Demonstrating to the patient how to put toothpaste on the brush d. Assisting the patient in signing a birthday care for a granddaughter ANS: B The severe dementia characteristics of stage 3 renders the patient incapable of independently meeting hydration and nutrition needs. These needs are basic to life, so they are of highest priority. The remaining options are not applicable for such an impaired patient.

23. A patient was admitted to a dementia unit after persistently wandering away from home.

Which intervention will best address this patients risk for injury?

a. Place the patient in a geriatric chair with a tray across the lap. b. Provide one-to-one supervision when the patient is ambulatory. c. Reinforce verbal explanation to the patient concerning the dangers of wandering. d. Activate alarm system that will alert staff to the patients attempt to open the door.

ANS: D Electronic alarms allow patients freedom of movement although still preventing them from wandering off the unit. One-to-one supervision is not necessary in an environment designed as a dementia unit. The geriatric chair would be an unacceptable form of restraint for this patient. The patient would not be capable of processing the verbal explanation.

24. A patient with moderate dementia does not remember her sons name. The son repeatedly questions the mother asking, Do you know my name? The mother invariably becomes agitated.

The nurse can most effectively intervene by explaining to the son: a. Your mother is angry with you and is punishing you by forgetting who you are.

Be patient and shell get over it. b. Your mothers dementia is preventing her from retaining information even for short periods of time. She senses your distress and becomes agitated. c. You will need to reorient your mother often during your visits with her. With reinforcement, she may be able to begin to recall who you are. d. Because you both become so distressed, it might be better if you come to see your mother less frequently and stay for only shorter periods of time.

ANS: B When a patient with dementia is presented with a demand that exceeds their capacity to function, the demand creates a high level of stress. Showing anxiety and disapproval adds even greater stress. The son should be counseled to make every attempt to demonstrate positive responses to his mother. The other options are not effective interventions.

25. The wife of a patient with moderate to severe dementia tells the nurse, Im exhausted. He wanders at night instead of sleeping, so I get no rest. Im afraid to leave him during the day, so I have to take him with me wherever I go. The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome for this teaching would include: a. Experiences less stress indicated by improved sleep patterns b. Feels comfortable leaving the patient in the care of others occasionally c. No longer experiences resentment concerning the need to care for the patient d. Feels at peace with the decision to admit the patient to an appropriate care facility ANS: A Stress reduction allowing for better rest is an appropriate outcome. The other options are not necessarily appropriate nor will they result in improvement for the caregiver.

26. A teenager is admitted to the ED after being alternately hyperalert and difficult to arouse.

The symptoms started within the last few hours, during which time he became disoriented, confused, and delusional. These symptoms support the diagnosis of: a. Amnesia b. Delirium c. Dementia d. Depression ANS: B The symptoms are indicative of delirium. The other options are not supported by the scenario.

MULTIPLE RESPONSE 1. Which interventions provided by the caregiver will help ensure effective care for the patient diagnosed with dementia? (Select all that apply)

a. Taking the patients blood pressure regularly b. Being alert to ways the patient might be hurt c. Keeping the patient on a predictable schedule d. Assuming responsibility for meeting the patients needs e. Providing the patient with nonstimulating, private time ANS: B, C, E These interventions take responsibility for areas in which the patient is incapable of providing self-care and addressing the special needs this patient has. Taking the blood pressure is not necessary unless there is a medical condition that requires doing so. Although the patients ability to provide self-care will deteriorate, independence should be encouraged as appropriate.

2. For which medication will the nurse prepare material for the family of a patient diagnosed with mild to moderate Alzheimers disease? (Select all that apply.) a. Tacrine (Cognex) b. Donepezil (Aricept) c. Haloperidol (Haldol) d. Rivastigmine (Exelon) e. Galantamine (Razadyne) ANS: A, B, D, E The only drug that is not generally prescribed for Alzheimers disease is Haldol.

Chapter 22: Personality Disorders MULTIPLE CHOICE 1. When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial personality disorder, the nurse recognizes that which nursing diagnosis would be pertinent to his care? a. Risk for self-mutilation b. Disturbed personal identity c. Impaired social interaction d. Social isolation ANS: C The patient with antisocial personality disorder is impulsive, manipulative, and dishonest.

Patients with this disorder are frequently involved in illegal matters. Self-mutilation and disturbed identity are more appropriate for patients with borderline personality disorder. Social isolation would apply more readily to Cluster A disorders.

2. Which observation is supportive of a diagnosis of avoidant personality disorder? a. Talks about my three failed marriages b. Cries loudly whenever requests are denied c. Fears criticism from others, including staff d. Shows no remorse when accidentally breaking another patients bracelet ANS: C Symptoms suggesting an avoidant personality disorder include fear of rejection, avoidance of relationships, and censorship of expression of thoughts and feelings because of fear of a negative reaction. Borderline personality disorder presents with unstable interpersonal relationships, labile affect, and complaints of emptiness. Patients with histrionic personality disorders are overly

dramatic, manipulative, and attention-seeking. Patients with schizoid personality disorder are indifferent to and lack concern for interpersonal contacts.

3. Which behavior is supportive of a diagnosis of dependent personality disorder? a. Perceives personal behavior to be embarrassing b. Believes they are incapable of functioning independently c. Tends to exaggerate the potential dangers of ordinary situations d. Demands excessive attention from others whenever in a group situation ANS: B The dependent person must rely on others to make decisions and assume responsibility of major areas of his or her life. Low self-esteem and exaggeration are seen in avoidant personality disorder. Attention seeking is seen in narcissistic personality disorder.

4. When planning care for a patient with antisocial personality disorder, which consideration has greatest importance? a. Addressing the demand for constant attention b. Teaching coping skills related to frustration tolerance c. Identifying behaviors related to well-developed superegos d. Managing the manipulative behaviors resulting from a charming persona ANS: D Patients with antisocial personality disorder are described as charming because of their ability to size up and manipulate others. Narcissistic patients demand constant attention. Patients with histrionic personality disorder do not tolerate delay of gratification or frustration. Patients with personality disorder have poorly developed superegos.

5. When a patient diagnosed with borderline personality disorder experiences the death of a beloved parent, which characteristic response will the nurse anticipate?

a. Denies the death for a protracted period of time b. Exhibits several different psychotic thought processes c. Expresses extreme anger and rage by burning the parents clothes d. Becomes uncharacteristically helpful and attends to the funeral arrangements ANS: C If a significant person in the patients life dies, the patient with borderline personality disorder cannot mourn but often exhibits one or more of the six constituent states that include anger and rage. The other options are not characteristically seen as mourning behaviors in individuals with this diagnosis.

6. A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without selfinjury. A priority nursing diagnosis for this patient is: a. Anxiety b. Risk for self-mutilation c. Risk for other-directed violence d. Ineffective coping ANS: B Patients with borderline personality disorder frequently engage in self-mutilation in an attempt to manage chaotic feelings. The important clue to this diagnosis is that the patient is having difficulty tolerating feelings without self-injuring. There is no data to support anxiety or ineffective coping. The risk is greater for violence toward self.

7. Which outcome has priority for a patient with borderline personality disorder being discharged from an outpatient treatment environment? a. Patient demonstrates control over self-destructive impulses. b. Patient can identify symptoms that indicate a need for psychotherapy.

c. Patient demonstrates an understanding of the importance of medication compliance. d. Patient actively participates in a community 12-step group related to relevant care.

ANS: A The patients ability to control self-destructive impulses has priority over the other options because doing so will affect patient safety.

8. A patient who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this patient? a. Anxiety related to a new environment as evidenced by isolation and not talking with peers b. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others c. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers d. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others ANS: C This nursing diagnosis relates directly to her symptoms and their underlying pathology. Data are not present to support the other options.

9. The nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a patient believed to be exhibiting characteristics of a personality disorder? a. These patients are generally experiencing chronic depression and are severely impaired socially. b. A high stimulus environment will cause the patient to exhibit exacerbated behaviors that are loud and attention seeking.

c. The patient is easily intimidated and may become so withdrawn that the assessment will be difficult if not impossible to complete. d. This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the patient feels threatened.

ANS: D Individuals with these disorders are often withdrawn, defensive, guarded, and impulsive, and may demonstrate an escalation of anger or make hostile or threatening comments. The remaining options are specific to certain types of personality disorders.

10. When facilitating change in the behavior of a patient diagnosed with a personality disorder, which intervention will have the greatest impact on success? a. Collaborating with the patient when establishing treatment goals b. Educating the patient to the importance of complying with treatment interventions c. Evaluating the patients understanding of the etiology of the prescribed medications d. Conducting regular assessments so the treatment can be changed when necessary ANS: A When planning interventions with a patient who has a personality disorder, it is important to recognize that the person has disturbed values that do not reflect the views held by the general population. Because of these disturbances, the nurse needs to collaborate with the patient regarding the goals that are identified during treatment. The remaining options although appropriate will not be attainable if the patient does not recognize the interventions as being useful and personally applicable.

11. A patient with antisocial personality disorder yells, Shut up about that, or Ill punch you in the nose! and shakes his fist at another patient in a group meeting after the patient speaks negatively of illicit drug use. The nurse quickly determines that the patient is at risk to act violently against others as evidenced by his aggressive behavior, verbal threats, and a history of impulsivity.

Which is the best approach for the nurse to use?

a. Secluding the patient to protect the other patients and staff b. Putting the patient in restraints to protect the entire milieu c. Exploring alternate ways to handle frustrating topics in the group d. Telling the patient to leave the group until he can behave appropriately ANS: C Discussing angry feelings in a group setting that is focused on exploring alternative problemsolving options will both distract the patient from angry feelings and help to focus energy on constructive activities. Seclusion and restraints are not necessary until verbal interventions prove unsuccessful. Making the patient leave the group is not an approach that will lead to meaningful learning.

12. A patient with borderline personality disorder is having difficulty with memories of sexual abuse and reports vague, generalized pains, menstrual problems, and headaches that severely impact her ability to function independently. Which collaborative consult will have the greatest impact on the patients health and wellness? a. Occupational therapist exploring ways to reduce stress b. Neurologist to evaluate the patients reports of headaches c. Acupuncturist exploring ways to reduce the generalized pain d. Gynecologist to assess the patients dysmenorrheal symptoms ANS: A An occupational therapist can determine ways to increase adaptive functioning and independent living skills. Groups on stress reduction, self-awareness, and feelings are often co-led by occupational therapists. Although appropriate, the remaining options are all a result of unmanaged stress.

13. Which intervention will best ensure a nonjudgmental evaluation of a patients noncompliance with the treatment plan for management of his antisocial behaviors?

a. Re-evaluating the patients understanding of the goals of the prescribed treatment plan b. Asking questions that focus on his perception of why he can follow his treatment plan c. Expressing concern about the patients long-term prognosis if his noncompliance continues d. Re-assessing the patient for changes that may require the revision of his current treatment plan ANS: B The nurse asking questions to determine possible reasons for the outcome criteria not being met would exhibit a nonjudgmental approach to this patients assessment interview. While appropriate, the remaining options are not nonjudgmental in nature.

14. The nurse counsels a mother to allow her 2-year-old child to keep a blanket that he uses to comfort himself. The basis for this counseling is: a. Sullivans theory of good me b. Freuds developmental theory c. Mahlers theory of object relations d. Kernbergs conceptualization object constancy ANS: C Mahlers theory of object relations suggests that the child at this age has a beginning sense of object constancy and can use a representation of the mother for comfort. The child may use a blanket or other object to remind himself of the mother. The other theories mentioned are not as clearly related as Mahlers.

15. Which behavior supports the failure to successfully achieve the oral stage of Freuds psychosexual stages of development? a. An adults excessive dependency on parents

b. A history of multiple, simultaneous sex partners c. A need to ritualistically turn the lights off repeatedly d. A lack of guilt when responsible for mistreating others ANS: A Individuals who have difficulty with the oral stage are often dependent. The other options reflect behavior not grounded in this stage.

16. A patient with borderline disorder tells the nurse, Its hard to figure out who I am. Sometimes Im sexually attracted to women and sometimes to men. The nurse using Freudian concepts can analyze this as a developmental problem related to: a. Lack of separation-individuation b. Isolation of affect during latency c. Impaired development of sexual identity during the phallic stage d. Overdevelopment of latency stage traits related to control issues ANS: C According to Freud, identifying ones sexual identity takes place during the phallic stage of development. When sexual identity is not clearly established, the individual may express confusion in sexual preference. The other options do not relate to information given in the scenario.

17. The patient tells the nurse, I thought my doctor understood me completely. Now, I hate him!

He doesnt understand me at all. The nurse assesses the patients description of feelings about the physician as evidence of the use of: a. Splitting b. Dissociation c. Isolation of affect

d. Projective identification ANS: A Splitting is the inability to synthesize the positive and negative aspects of self and others. It manifests as idealization and devaluation. Definitions of the other defenses listed do not fit the description of the behavior in the scenario.

18. The nurse conducts milieu therapy based on the understanding that: a. Therapy is grounded in the milieu routine. b. The milieu is a substitute for the patients family. c. Staff represents the authority within the milieu. d. The milieu provides realistic community interactions.

ANS: D The purpose of milieu therapy is to recreate a community setting on these units so that the patient is able to interact with other patient peers to identify and problem-solve issues that occur when relating to others. The milieu does not replace the patients family. The remaining options are not true.

19. A patient with a borderline personality disorder tells the nurse, My doctor tells me theres something wrong with the hard wiring of my brain, and thats why Im so impulsive and get so many mood swings. He said hes going to prescribe some medication. Being aware of current practice guidelines, the nurse will prepare a teaching plan for: a. Lithium (Lithobid) b. Fluoxetine (Prozac) c. Lorazepam (Ativan) d. Haloperidol (Haldol) ANS: B

Fluoxetine is an SSRI. SSRIs are the medications of choice for patients with personality disorder who have affect dysregulation and impulsivity. SSRIs have a low incidence of side effects.

Lithium may be used in instances of severe mood disorder. Lorazepam is used to help manage high anxiety, while haloperidol is prescribed in cases of violent behavior.

20. Which self-reflective intervention is most appropriate for the nurse to engage in when managing care for patients who exhibit characteristics of personality disorders? a. Reinforcing the therapeutic boundaries between the nurse and patient as often as needed b. Requesting a temporary transfer to a medical unit periodically to help minimize burn-out c. Frequently self-assessing for biases and prejudices that result in patient care that is compromised d. Arriving at a personal decision regarding the use of both chemical and physical restraints to assure milieu safety.

ANS: A Patients with personality disorders have difficulty relating to others. As a consequence, these individuals have difficulty defining boundaries between themselves and others. Part of nursing care is to define boundaries within the therapeutic relationship in order to develop safe, patientcentered therapeutic relationships. The use of chemical and/or physical restraints is determined by institutional policies, not personal decision. The remaining options are appropriate for all patient care, not specifically care of patients with personality disorders.

21. Which statement correctly describes the schizotypal personality disorder? a. Psychotic behavior will require a long hospitalization. b. There may be misinterpretation of events but not psychosis. c. There is greater personality disorganization than in schizophrenia. d. The patient will be outgoing, actively seeking interactions with others.

ANS: B

Patients with schizotypal personality disorder may have problems thinking and accurately perceiving events, but symptoms of psychosis such as delusional thinking and hallucinations will be absent. Personality disorganization is greater in schizophrenia. Psychosis will require longer hospitalization. Patients with schizotypal personality disorder are not generally outgoing and social.

22. A psychiatric technician remarks to the nurse, That patient with dependent personality disorder is so clingy! The response by the nurse that will be helpful to the technician is: a. I think everyone feels that way. Its difficult to have someone clinging. b. Patients with personality disorders have little regard for the rights of others. c. The patient fears having to function independently without direction from someone else. d. The patient is so preoccupied with perfection and structure that shes afraid to do anything at all.

ANS: C Patients with dependent personality disorder have an all-encompassing need to be taken care of.

This need causes submissive, clinging behaviors. By helping the technician understand that the patients behavior is need-based rather than purposely annoying, the technician will be better able to respond with empathy and care. Validating the remark shows neither acceptance nor empathy for the patient. The remaining options do not provide accurate learning for the technician.

23. Which behavior is of particular concern to the nurse when managing the care of a patient diagnosed with a personality disorder? a. Reporting a staff member for wanting to hurt me b. Shoplifting two candy bars from the hospitals gift shop c. Asking much more frequently to be allowed to smoke a cigarette d. Refusing for three days to either bathe or change into clean clothing ANS: B

Patients with personality disorders often exhibit self-destructive behaviors that result in getting themselves in trouble with the law, such as shoplifting. The remaining options are not generally considered characteristic behaviors of the patient diagnosed with a personality disorder.

24. Which intervention will provide the most information regarding a patients self-perception of their role in their environment? a. Asking the patient to keep a journal about things they enjoy doing b. Observing the patient interact with family members at a unit picnic c. Encouraging the patient to discuss the successes they have experienced d. Helping the patient select appropriate, attractive clothing for family visitation day ANS: B How the patient interacts within the family system and the role that the patient takes (e.g., victim, placater) will offer the nurse the most insight into the patients self-perception. The other options are focused on assessing and/or affecting self-esteem.

25. A psychiatric technician mentions to the nurse, All these patients with Axis II problems! It makes me wonder how so many mothers could have been such poor parents and messed up their kids so badly! The response by the nurse that helps put the development of personality disorders into perspective is: a. Parenting is the responsibility of fathers, too, so dont blame only mothers. b. Personality disorder is often related to sexual abuse that occurs without parental knowledge. c. There is some evidence to suggest a biologic component to personality disorders. d. Peer interactions may be more important in child development than parental involvement.

ANS: C

Tests show that schizotypal and schizoid disorders may reflect neurointegrative or neurochemical dysfunction and that affective dysregulation found in a number of personality disorders may be a function of serotonin abnormalities and may be implicated in impulsivity, aggression, and suicidal tendencies. The other options are either untrue or unhelpful.

26. Which behavior is supportive of a histrionic personality disorder? a. Withholding of feelings and low self-esteem b. Insistence on others conforming to own methods c. Engaging in impulsive acts like unprotected sex d. Initial charm dissolving into coldness and blaming others ANS: C Impulsive sexual activities are characteristic of histrionic personality disorder. Low self-esteem is more indicative of avoidant behaviors. Inflexible methods are usually seen in obsessivecompulsive personality disorders. Alternating between charming and blaming describes some behaviors commonly seen in antisocial personality disorders.

27. A patient with a personality disorder asks the nurse, Is it true I have an inherited brain disorder? The nurse replies, knowing that: a. There is proof that personality disorders are inherited. b. All persons with personality disorders display brain abnormalities. c. Individuals with personality disorders manifest some biological markers. d. Individuals with personality disorders show an error in brain glucose metabolism.

ANS: C There is a need for more research relating genetics and brain dysfunction to personality disorders. Although there are some biologic markers, none of the other options are true.

MULTIPLE RESPONSE

1. Which assessment data is supportive of a diagnosis of antisocial personality disorder? Select all that apply. a. Was reprimanded to a juvenile correction facility at age 14 b. Mother reports characteristic behaviors as early as age 7 c. Is below age-appropriate norms for both weight and height d. Patient states, I dont like school and skip whenever I feel like it. e. Has been admitted to a drug rehabilitation program twice in 4 years ANS: A, B, E Patients diagnosed with antisocial personality disorder have a history of conduct disorders before the age of 15 years, prison or juvenile detention experiences, and substance abuse. There is no research that supports the remaining options as being characteristic of this disorder.

2. When implementing Freuds theory of human psychosexual development, the nurse observes for behaviors that are characteristic of successful completion of stages that include (select all that apply): a. Anal, where self-confidence is formed b. Oral, where the ability to trust is developed c. Latency, where a person learns inner control d. Adjustment, where developmental failures are re-addressed e. Phallic, where the ability to interact with others is grounded ANS: A, B, C, E Freuds stages of psychosexual development include in order of completion: oral, anal, phallic, latency, and genital. There is no adjustment stage in Freuds theory.

Chapter 23: Emergency Psychiatric Medicine MULTIPLE CHOICE 1. Which patient statement is representative of those seen in Phase 2 of the crisis response regarding financial problems? a. I cant get evicted and live on the street; Id kill myself first. b. I need to get drunk and forget about money problems for a little while c. I need to figure out a way to get enough money to meet my rent this month. d. Ive always been able to rely on my mother but she wont give it to me this time.

ANS: B Phase 2: Previous coping and problem-solving strategies fail to relieve the stressor. Phase 1: The individual is exposed to a stressor. Phase 3: Resources from within and outside of the individual are mobilized to resolve the problem and to alleviate the discomfort caused by the stressor. Note that people may drop out of situations in numerous ways, including selfmedication with alcohol. Phase 4: The absence of crisis resolution leads to major disorganization such as self-injurious behavior.

2. Which event has the potential for causing a situational crisis? a. Losing ones faith in God b. Losing a job after 10 years c. Leaving home to attend college d. Retirement from teaching school ANS: B A situational crisis occurs when a specific, external event, such as job loss, disturbs ones psychologic equilibrium. The other options would be considered internal (subjective) crises.

3. Which patient statement made by a spouse is representative of those seen in Phase 3 of the crisis response regarding the death of a loved one? a. I dont know what Ill do to fill my days now. b. Life isnt worth living if I have to live alone. c. Prayer doesnt seem to give me the peace it has in the past. d. Maybe going and spending time with my daughter will help.

ANS: D Phase 3: Resources from within and outside of the individual are mobilized to resolve the problem and to alleviate the discomfort caused by the stressor. Phase 1: The individual is exposed to a stressor. Phase 2: Previous coping and problem-solving strategies fail to relieve the stressor. Phase 4: The absence of crisis resolution leads to major disorganization such as selfinjurious behavior.

4. Which patient response demonstrates that the patient whose home was destroyed by a fire is coping with the disaster? a. Agreeing to see a grief counselor b. Stating, At least no one was hurt in the fire. c. Addressing the details regarding the rebuilding of the house d. Stating, I knew things were going along too well to be true.

ANS: C Coping does not imply mastery over the crisis; rather, it is the process that is used to respond to the crisis and find resolution. Working on rebuilding the home is an example of this process. The remaining option show varying degrees of attempting to justify or minimize the crisis.

5. Which factor will have the greatest impact on a patients ability to effectively respond to the loss of a spouse?

a. The age of the patient b. The years they were married c. How the patient has handled other deaths d. Availability of an effective support system ANS: C An individuals interpretation of the crisis is based to a large degree on previous outcomes to similar situations such as experiencing another death crisis. The remaining options do not have the same degree of influence as does the correct option since they are not an example of previous experience.

6. What is the basis for a 1-month crisis intervention follow-up for individuals who have survived a major hurricane? a. Symptomology of acute stress disorder can occur within a month of experiencing the trauma. b. The patient generally has had time to reflect on the trauma and is now ready to discuss its impact. c. Medications prescribed to help manage the initial anxiety caused by the trauma will need to be re-evaluated. d. Private insurance carriers require professional mental health follow-ups when initial counseling has occurred.

ANS: A An acute stress disorder (ASD) may manifest when a person is in crisis. ASD is an anxiety disorder that is characterized by a cluster of dissociative and anxiety symptoms that occur within 1 month of a major traumatic stressor. Although the patient may now be receptive to counseling, there is no reason to believe this will happen within a month. The remaining options are not necessarily true.

7. What intervention has highest priority when a patient diagnosed with acute stress disorder (ASD) reports difficulty sleeping and is observed to have an exaggerated startled response 6 weeks after the trauma occurred? a. Short-term therapy will be suggested. b. Antianxiety medication will be prescribed. c. The patient will be scheduled for a consult at the sleep patient. d. The patient will be assessed for possible posttraumatic stress disorder (PTSD).

ANS: D If symptoms of ASD persist for more than 1 month, an assessment for other diagnoses may also be considered, such as posttraumatic stress disorder (PTSD). The remaining options do not address the issue of a more complex diagnosis and would be treating only isolated symptoms.

8. Several school-age children injured in a school bus accident were brought to the ED. Family members and friends paced back and forth in the waiting room. Members of the crisis team were called in for the primary purpose of: a. Waiting with the families and friends b. Facilitating understanding and providing support c. Determining the level of individual family coping d. Assisting the medical team with the physical injuries ANS: B A crisis team is able to provide immediate emotional support to friends and families who are distressed over the event and the state of victims, and they are able to facilitate understanding of the event by teaching. The remaining options do not reflect the function of crisis intervention teams.

9. Which behavior is observed in the honeymoon stage of a communitys adjustment to a severe flood?

a. Individuals unselfishly share the limited resources. b. The communitys shopping mall and theater reopen. c. A community rally is held to show support for the rebuilding of the town. d. Individuals protest the governments plan to distribute flood recovery funding.

ANS: C The honeymoon phase occurs 1 week to 3 to 6 months after the event, when feelings of community sharing and high social attachment exist demonstrated by a community rally. The heroic phase occurs immediately after the event, and it is a time of altruism and heroic behavior in the community such as selfless sharing. The disillusionment phase occurs 2 months to 1 to 2 years after the event, and it is characterized by feelings of disappointment, anger, resentment, and bitterness regarding the expectations of support that were not met and often demonstrated through examples of community protest. The reconstruction phase occurs 2 months to 1 to 2 years after the event, when physical and emotional reinvestment take place as community resources are re-established.

10. A worker has recently been involved in assisting with the cleanup from a flood that washed away many homes in his area and caused loss of life. Which crisis intervention would assist the worker in dealing with the traumatic experience? a. Arranging for his minister to meet with him b. Suggesting he be admitted to a mental health facility c. Providing him the opportunity to talk about the experience d. Encouraging him to leave the area in order to forget the experience ANS: C The worker needs to be able to express his feelings and deal with the pain associated with the crisis event. Nurses can help facilitate understanding of the event by listening and teaching. The remaining interventions are not considered crisis interventions.

11. A patient who survived a tornado is without shelter and food, has lost his car, and has learned that several friends sustained injuries. To tailor intervention to the patients needs, the nurse would make it a priority to: a. Offer antianxiety medication. b. Explore earlier life experiences. c. Explain computer-based crisis therapy. d. Arrange for an agency to provide shelter and food.

ANS: D Maslows hierarchy of need theory suggests that survival needs should be met first. Thus arranging for food and shelter takes precedence over other concerns.

12. A new nurse mentions, I can understand a situational crisis upsetting a persons equilibrium, but I dont understand how something positive, like getting married or having a baby, can precipitate a crisis. To explain, the mentor should answer, You need to think of a crisis as a(n): a. Threat to survival. b. Threat to the familiar. c. Opportunity to learn. d. Psychiatric disorder.

ANS: B By viewing a crisis as a threat to the norm, it is possible to understand why even positive events, such as winning the lottery, may provoke a crisis. Crises are not considered discrete psychiatric disorders nor are they opportunities to learn. Crises are not always threats to ones physical survival.

13. At the crisis center a staff nurse tells the nurse clinician, The patient is dealing with an internal crisis situation. Which situation would qualify as a trigger for that designation?

a. Job loss b. Marital breakup c. Death of a friend d. Loss of religious faith ANS: D Internal (subjective) crises are threats to a persons well-being that are not so obvious to the outside observer. Some are associated with phase-of-life events. Loss of faith in a supreme being would exemplify an internal crisis. The other options are considered external (situational) crises.

14. Which behavior is observed in the disillusionment stage of a communitys adjustment to a devastating hurricane? a. Individuals opening their homes to those without shelter. b. Nearby communities provide clothing and food for victims. c. The community remembers the event with a rally in its newly rebuilt park. d. State leaders attend a community meeting to discuss why funding is slow to arrive.

ANS: D The disillusionment phase occurs 2 months to 1 to 2 years after the event, and it is characterized by feelings of disappointment, anger, resentment, and bitterness regarding the expectations of support that were not met and often demonstrated through examples of community protest meetings. The heroic phase occurs immediately after the event, and it is a time of altruism and heroic behavior in the community such as selfless sharing. Thereconstruction phase occurs 2 months to 1 to 2 years after the event, when physical and emotional reinvestment take place as community resources are re-established.

15. Which clinical picture can the nurse expect to see most frequently among patients who have been in a bus-train collision and derailment?

a. Elation and hyperactivity b. Denial of the incident and suspicion c. Shock, numbness, confusion, and disorganization d. Highly emotional displays, such as begging for help ANS: C Common immediate responses to a traumatic event include shock, numbness, denial, dissociative behavior, confusion, disorganization, indecisiveness, and suggestibility. The other options contain behaviors that may be observed, but they are far less common than the behaviors given in the correct option.

16. To plan effectively for an individual who is in crisis, the nurse must have an understanding of: a. Methods to establish rapport b. Family counseling techniques c. The meaning of the crisis event to the individual d. Posttraumatic stress disorder treatment modalities ANS: C Knowing the meaning to the individual is crucial, since the mitigating circumstances and support a patient has may reduce the impact of the crisis event. For example, a property loss is likely to be of greater concern to someone with few financial resources than to someone who is wealthy or fully insured. Establishing rapport should occur prior to the planning stage. An understanding of family counseling techniques is not necessary. Crisis intervention may not depend on information about posttraumatic stress disorder.

17. Which nursing intervention is vital to the effective management of a psychiatric emergency resulting from a patients experience of extreme despair? a. Suicide precautions

b. Introduction to a support group c. Introducing new coping mechanisms d. Assessment for obsessive-compulsive rituals ANS: A A psychiatric emergency involves a sudden and serious psychological disturbance that results in a behavioral state that requires intervention to prevent a life-threatening or psychologically damaging consequence. Despair is often associated with the patients attempt at self-harm and so suicide precautions are vital to emergency management in the situation. Obsessive-compulsive behavior is not generally seen as a response to despair. The remaining interventions would not be considered during emergency management.

18. Which patient statement assures the nurse that the patients immediate psychiatric emergency has been resolved? a. Will I ever be able to go back to my family and job? b. I dont ever want to feel so out of control ever again. c. Will you please ask the doctor if I can have a pill for my nerves? d. I will let you know if I start feeling the need to hurt myself again.

ANS: D The primary factor that distinguishes a psychiatric emergency from other types of crises and medical emergencies is the presence or threat of danger to the self or others. When the patient expresses the willingness to alert the staff when such feelings are occurring there is reason to believe the immediate emergency has past. The other options do not exhibit such a sense of willingness on the patients part.

19. Which patient has the greatest risk for the development of a psychiatric emergency? a. The schizophrenic older adult living on the streets b. The anorexic young adult hospitalized for treatment

c. The orphaned teenager who lives with grandparents d. The teenager who has a problem with authority figures ANS: A Populations at high risk for psychiatric emergencies include those with chronic mental pathologies, such as chronic schizophrenia, because their emotional stability can be easily disrupted. The other patients lack that element of emotional and cognitive fragility and have a responsible support system.

20. The crisis nurse working with law enforcement is called to assist at a scene where an overtly psychotic individual is threatening officers with a handgun. He shouts that aliens dressed like police are pursuing him and he has to get away. The priority intervention is: a. Evaluate the patient for recent substance use. b. Ensure the patients safety and develop rapport. c. Screen for the level of psychiatric care needed. d. Assist the patient to make sense of the experience.

ANS: B Patients who feel threatened should be assured of their safety so that rapport building can take place. When rapport has been developed, the nurse may be able to convince the individual to give up any weapons. The patient is not capable of understanding the experience at this point in the scenario. Although relevant, the remaining options do not have the priority of the correct option since they depend upon a therapeutic nurse-patient rapport.

21. Which patient behavior assures the nurse that the primary goal of crisis intervention has been achieved by a patient who experiencing extreme mania? a. The patient has resumed a healthy sleep pattern. b. The patient has asked that their family be allowed to visit. c. The patient demonstrates an understanding of manic behaviors.

d. The patient is compliant with the medication therapy prescribed.

ANS: A The goal of crisis intervention is to return the individual to their precrisis level of functioning.

Resuming healthy sleep patterns would indicate that the crisis had been resolved. The remaining options fail to demonstrate a return to normal or precrisis function or behavior.

22. Which statement is the basis for the combination of both interactive therapy and antidepressant medication for a patient whose chronic depression resulted in a suicide attempt? a. Therapy is seldom effective when not supported with appropriately prescribed medications. b. The suicide attempt was the deciding factor in determining the need to prescribe an antidepressant. c. Patients are more willing to attend therapy sessions when they are prescribed medications to manage acute symptoms. d. Research has shown that a combination of therapy and medications achieve expected outcomes more effectively than single interventions.

ANS: D In general, when medications are indicated, the combination of medication and interactive therapy is more effective than either modality alone. The remaining options are not true statements.

MULTIPLE RESPONSE 1. Which statements are the basis for making counseling available to grade-school children who have experienced the violent death of a classmate? Select all that apply. a. It is vital to foster each childs sense of psychologically safety. b. The fear of the unknown circumstances of the classmates death will serve to increase their own anxieties.

c. Counseling will provide mental health professionals with the opportunity to address all the childrens concerns. d. The more appropriate information the children are given about their classmates death, the better they will be able to understand why the death occurred. e. Although the children may not be capable of understanding the information they are given, the interaction with mental health providers will minimize their anxieties.

ANS: A, B, D Strategies to enhance a sense of psychological safety for children in crisis include talking with the child about the crisis or trauma in terms that he or she can understand. The more information that the child can be given about who, what, where, why, and how the crisis occurred, the easier it is for the child to make sense of the situation. Fear of the unknown will make a traumatized child more anxious and symptomatic. Although is may not be possible to address or resolve all of the concerns, listening to the child, without necessarily having good answers to his or her questions, can be very therapeutic.

2. Which nursing interventions are implemented when using the ACT model to manage a patient who has experienced a physical assault while visiting a vacation resort? Select all that apply. a. Assessing the patients need for medical attention b. Performing a cultural assessment c. Arranging for a social service consult d. Offering to notify the patients family e. Requesting a visit by the hospital clergy ANS: A, B, C, D The components of ACT include assessment for immediate medical needs as well as a cultural assessment in order to provide culturally sensitive care. Facilitating connection to support systems such as family and social services will help meet the patients need for physical and emotional support. Requesting a clergy visit should not be done without the first securing the patients consent.

3. Which assessment observations will be most influential in determining whether a patient exhibiting signs of alcohol intoxication who was brought to the emergency room by friends will be involuntarily admitted for psychiatric evaluation? Select all that apply. a. The patients earlier contact with a crisis hotline b. Expressing a desire, to just drive myself home c. Patients admission that, I dont want to keep living like this. d. Uncooperative and disrespectful behavior towards the hospital staff e. Announcing that, my girlfriend will pay for leaving me for my best friend.

ANS: C, E The decision to admit this patient involuntarily is based on whether the person poses a danger to himself or herself, including sharing thoughts or threats of suicide, sharing a suicide plan, or actively using a weapon or situation to injure himself or herself; and/or whether the person poses a danger to others as evidenced by threatening another, brandishing a weapon, or displaying erratic or unpredictable behavior. The remaining options do not fulfill either of these conditions.

4. Which situations would increase an individuals risk for ineffective coping related to stress?

Select all that apply. a. Being over 65 years of age b. Being unmarried and female c. Having been adopted as an infant d. Having a history of chronic back pain e. Being diagnosed with both depression and hypertension ANS: D, E Risk factors may limit an individuals ability to cope or problem solve during stressful life events or situations. These may include the presence of concurrent or multiple biopsychosocial stressors, such as depression and hypertension, as well as chronic physical or psychological pain.

The other options are not known to negatively impact an individuals ability to cope or problem solve.

5. Which characteristic makes a stressful event a crisis situation? Select all that apply. a. The event was not expected. b. The patient felt emotional or physically threatened. c. The event resulted in physical trauma to the patient. d. The patient showed immediate signs of anxiety or panic. e. The patient has little or no social support system to rely upon.

ANS: A, B Crises have defining characteristics that include being unexpected and creating the perceptions of threat. The other options are not necessary characteristics of a crisis situation.

Chapter 24: Complementary and Alternative Medicine in Psychiatry MULTIPLE CHOICE 1. A patient who experiences panic attacks when he is alone at home has been instructed in the use of meditation techniques. The technique can be evaluated as having proved most useful when the patient explains to a friend that meditation: a. Is easy to learn b. Provides me with a sense of control c. Can be implemented at any time and place d. Can be mastered by anyone, young or old ANS: B

When implemented effectively, meditation has wide-ranging effects that include a sense of control over ones situation. All the remaining options are correct but they lack the connection to a patients sense of well-being and control.

2. A patient reports little change in her blood pressure even though she has been doing the biofeedback exercises stating that, The machine has not been successful. The nurse will observe the next session being aware that: a. There are several different components that need to be mastered in order to achieve successful biofeedback results. b. The machine is a critical component of biofeedback during all phases and its response needs to be monitored by a professional. c. A patients relaxation skills need to be excellent because muscle responses play a large role in determining the success of biofeedback. d. The patients mood and emotional stability affects ones ability to alter physiological results and thus affect positive results from biofeedback.

ANS: A With biofeedback, a patient can learn to gain conscious control over bodily responses thought to be beyond voluntary command. Listening to the monitoring device makes the patient aware of whether or not the mental exercises, breathing, or other techniques being used are effective. The machine is only needed early in therapy. Muscle relaxation and emotions have a role to play but are not the only significant factors to be considered.

3. The nurse when entering the room to find a terminally ill child laughing at an old The Three Stooges movie decides to postpone a scheduled treatment. This intervention is based on the knowledge that humor: a. Has been shown to have a positive effect on patients and staff alike b. Can foster positive changes on several physiological systems and functions c. Allows the patient to implement therapeutic denial to best manage the situation d. May help the very young who are unaware of the seriousness of their situations

ANS: B Research has shown humor may have positive effects on cognitive ability, heart and respiratory rates, blood pressure, muscle tension, and pain. Humor does have the effects reflected in the remaining options but none would be the basis for postponing a treatment.

4. The nurse describes in a balanced and neutral manner traditional medicine options that are available to treat a patients health problems. The patient thanks the nurse and shares that he prefers to continue treatment with acupuncture and Ayurvedic medicine. The nurse encourages the patient to carefully consider his choices and tells him that the staff is available if needed. The nurses response demonstrates: a. Understanding of patient rights b. Lack of concern for the patients well-being c. Respect for the patients health care choices d. Inability to confront the patient about his inappropriate health choices ANS: C After receiving all relevant, current information, patients have the right to make their own decisions about health care. This response shows respect for the patients right to make such a choice and the nurses understanding of the philosophy of holistic nursing. Although an understanding of patient rights is vital, it is not the best description of the nurses response. The nurse must remain objective and empathetic but may not interfere with the patients choices.

There is no need for confrontation.

5. Which nursing response best describes alternative therapies to a patient? a. They are not widely used in hospitals or reimbursed by insurance. b. They are often considered quackery and of little real value to those who use them. c. They are widely researched and can take their place with allopathic medicine. d. They are more effective if used as preventive measures than if used for cure.

ANS: A Alternative therapies are treatments and health care practices that are not widely taught in Western medical schools, not generally used in Western hospitals, and not generally reimbursed by health insurance. There are valuable forms of alternative therapies. Alternative therapies have not been widely researched. No evidence supports the statement regarding preventive measures.

6. When a patient asks for an example of an alternative or complementary therapy, the nurse would correctly identify: a. ECT b. Acupuncture c. Response prevention d. Classic conditioning ANS: B Acupuncture is considered an alternative or complementary therapy coming to Western health care from traditional oriental medicine. Options a, c, and d are considered allopathic therapies.

7. Which alternative treatment could the nurse suggest that would be appropriate for the patient whose health-illness beliefs equate illness with bodily imbalance? a. Naturopathy b. Acupuncture c. Foot reflexology d. Chiropractic adjustment ANS: B The purpose of acupuncture is to activate qi and achieve balance when imbalance exists.

Naturopathy focuses on self-healing. Reflexology focuses on relief of tension. Chiropractics provides manual adjustments of bones and joints to correct alignment problems.

8. A desired outcome for a patient who uses ginkgo biloba for improved cerebral circulation would be that the patient will: a. Experience elevated mood. b. Recall information accurately. c. Remain relaxed under stress. d. Eat smaller helpings at meals.

ANS: B This herb is said to improve mental alertness, improve blood flow, and reduce the effects of aging. Many use it to improve memory. This herb does not elevate mood, modify appetite, or reduce stress.substance instead of a prescription antidepressant. The herbal preparation that could be suggested for its antidepressant effects is: a. Valerian b. Echinacea c. Saw palmetto d. St. Johns wort ANS: D St. Johns wort is an herb often used to treat mild depressive symptoms. Valerian is considered an anxiolytic. Saw palmetto is used to treat benign prostatic hyperplasia. Echinacea is used to boost immunity.

10. The nurse is planning care for an anxious patient receiving antidepressant medication. Which alternative therapy could the nurse incorporate in the care plan without being concerned about untoward interactions? a. St. Johns wort b. Homeopathy

c. Ginseng d. Yoga ANS: D Yoga and meditation are accepted alternative or complementary therapies for patients with anxiety disorders. Patients report relaxation with use of yoga. There are no untoward side effects of drug-herb interactions with the use of yoga. Untoward effects are possible with ingestion of herbal medicines or homeopathic remedies.

11. The nurse asked by a patient to contrast conventional Western medicine with alternative therapy would correctly respond, Conventional medicine focuses on curing symptoms, whereas alternative therapy is concerned with: a. culture-bound illnesses. b. building healer prestige. c. healing the total person. d. the importance of science.

ANS: C Healing the whole person is the focus of most alternative therapy. Unifying themes among these therapies are the persons inherent recuperative ability, the importance of self-esteem, and the influence of spiritual and emotional beliefs on health. Culture-bound illnesses are not the whole focus of alternative therapies. Alternative therapy is patient-centered. Pure science is not the focus of alternative therapy; in fact, most alternative methods have not been researched.

12. Which statement made by a nurse discussing alternative and conventional therapies supports the holistic philosophy that mind-body interrelationships influence wellness? a. The development of lung cancer is strongly influenced by environmental factors. b. Alternative therapy is often less expensive than conventional medical treatment.

c. Widowed persons have higher death rates than married people of the same age have. d. Personal values and misconceptions are barriers to use of alternative therapy in the Western world.

ANS: C The minds influence on the body is suggested by the statistics that married individuals live longer. It is hypothesized that the sense of security and benefits of companionship from marriage may be protective against disease. The other statements are true, but have no bearing on mindbody relationships.

13. During assessment, the patient tells the nurse that she eats a natural food/high vitamin diet, exercises 30 minutes daily, uses meditation and yoga techniques for stress reduction, and takes prescribed antihypertensive medication. The nurse would assess that number of CAM therapies the patient uses as: a. Four b. Three c. Two d. One ANS: A CAM therapies include diet, exercise, yoga, and meditation. Only the prescribed antihypertensive medication would be considered conventional medical treatment.

14. The fundamental belief of nurses that will foster use of a holistic nursing model to promote wellness is which of the following? a. Health care requires a partnership between patients and nurses. b. Nurses must monitor environmental influences on patient health. c. Wellness promotion centers on health teaching by professional nurses.

d. The publics awareness of useful alternative therapies must be enhanced.

ANS: A Holistic care requires patient participation as an equal partner in the process if healthy outcomes are to be achieved. Environmental influences are important, but the central belief concerns partnership. Health teaching is important in wellness promotion but is not the central concept of holistic nursing. Public awareness is not a belief central to holistic nursing.

15. An impact the popularity of alternative therapy has on the nursing application of therapeutic interventions is that nurses: a. Must be taught such intervention techniques b. Need to possess understanding of herb-drug interactions c. Will need in-depth courses to effectively use bio-electromagnetics d. Will adopt the approach of regularly using more manual healing methods ANS: B Herbal preparations are presently in common use. Nurses must include assessment of herbal use and be cognizant of herb-drug interactions in order to provide safe, effective care. There is no support for any of the remaining options.

16. The nurse planning care for an Asian-American patient who plans to use Oriental medicinal dietary principles will need to understand that hot and cold substances are an integral part of therapy. The substances used are: a. Served iced or steaming hot b. Determined by yin and yang characteristics c. Selected by native shamans who divine patient needs d. Often disrupt conventional Western medical therapy ANS: B

Many Oriental patients believe illness is due to imbalance of yin and yang. Herbal mixtures are prescribed according to their yin or yang characteristics (hot or cold) in order to rebalance yin and yang. Hot and cold properties do not refer to thermal properties in this case. Divining by shamans is not part of the Oriental medical tradition. For the most part, the substances used are not disruptive of conventional therapy but are complementary.

17. When statement best answers a patients request for an explanation of how homeopathy works? a. It cures by using tiny amounts of known poisons. b. It purges foreign substances from the persons body. c. It controls illness symptoms by using medication. d. It uses substances to stimulate the body to heal itself.

ANS: D Substances are given that produce reactions that correspond to existing symptoms. The rationale is to follow the bodys lead to effect a cure. The substances used are not necessarily poisonous or purgatives. Homeopathic medicines are not prescription medications nor are they given for controlling symptoms.

18. Which point should the nurse include when teaching about concurrent use of alternative and prescription medicines? a. Health care providers need to know when the patient is using both. b. Health care provider cultural incompetence on this topic is relatively high. c. Most nursing actions are consciously directed towards fulfilling holistic goals. d. It is usually dangerous to combine these two types of patient-focused therapies.

ANS: A Only when the provider has accurate information about all therapies in use can safe, effective care be provided. The provider cannot function with incomplete assessment information. New

standards for cultural competency exist and are generally observable. It is not universally true that nurses focus on holistic goals because many actions are designed to alleviate symptoms.

Alternative and conventional therapies can be effectively used together.

19. What nursing activity is directed towards addressing a major goal identified by Healthy People 2010? a. Monitoring the urinary output of an older postsurgical patient b. Educating a pregnant woman about the benefits of breastfeeding c. Providing free depression screenings for single, teenage mothers d. Providing a patient who has had several teeth extracted with a liquid diet ANS: C One of the major goals for Healthy People 2010 was to eliminate health disparities. Providing depression screening for an identified underserved population would be an example of such focus. Although appropriate, the remaining options do not address that stated goal.

MULTIPLE RESPONSE 1. Which health promotion activities address the statistical indicators of a healthy population as stated by Healthy People 2010? Select all that apply. a. Promoting a weight loss contest among hospital employees b. Conducting a stress reduction seminar for college students c. Discussing safe sex practices with older adults at a seniors center d. Providing information on cooking for children with allergies to wheat e. Organizing a walking group that meets at the mall three times a week ANS: A, B, C, E

Statistical indicators of a healthy population include evidence of physical activity, a reduction in obesity, responsible sexual behavior, and improved mental health. Management of allergies does not directly apply to any stated indicator.

Chapter 25: Other Conditions that May be a Focus of Clinical Attention MULTIPLE CHOICE 1. An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patients history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patients history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication.

2. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night ANS: D

This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient ANS: D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.

4. Which change in the brains biochemical function is most associated with suicidal behavior? a. Dopamine excess

c. Acetylcholine excess

b. Serotonin deficiency

d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide.

The other neurotransmitter alterations have not been implicated in suicidality.

5. A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents

c. Giving away sweaters

b. Excessive crying

d. Staying alone in dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level.

c. suicide potential.

b. mood disturbance.

d. level of anxiety.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness

c. Risk for suicide

b. Social isolation

d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day.

c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, We should have seen this coming. We did not do enough. The parents reaction reflects: a. guilt.

c. shame.

b. denial.

d. rescue feelings.

ANS: A The parents statements indicate guilt. Guilt is evident from the parents self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents?

ANS: B The nurse must assess the patients access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patients

safety. The information in the other questions may be important to ask but are not the most critical.

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not in any way attempt to harm or kill myself. d. I will not kill myself until I call my primary nurse or a member of the staff.

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks I am not going to harm myself, I am going to kill myself or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan.

Implementation

13. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan.

c. establish rapport with the patient.

b. encourage expression of anger.

d. determine risk factors for suicide.

ANS: C This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, I am considering committing suicide. a. Im glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to keep you safe. c. Bringing up these feelings is a very positive action on your part. d. We need to talk about the good things you have to live for.

ANS: C The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as You have a lot to live for. It uses the patients ambivalence and sets the stage for more realistic problem solving.

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment

c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt.

Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?

a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me.

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patients suicide as being a way to fix everything but does not say it outright.

18. A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you became depressed.

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are very important and which are less important.

ANS: D

The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

20. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social support ANS: C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness.

c. elation.

b. sadness.

d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk.

Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

22. Which statement by a depressed patient will alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help.

b. I have no one to turn to for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I cut myself last time.

ANS: B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk.

Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

23. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

ANS: B Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care.

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. Genetics are associated with suicide risk. Monitoring and support are important.

b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins.

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

25. Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate ANS: D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

MULTIPLE RESPONSE 1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply.

a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male ANS: A, B, D Whites have suicide rates almost twice those of non-whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

2. Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arms-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patients eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; no silver or glassware orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arms-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arms length at all times would allow enough time to

interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

3. A college student is extremely upset after failing two examinations. The student said, No one understands how this will hurt my chances of getting into medical school. The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event ANS: A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, No one can understand, can be seen as recent lack of social support. Terminating access to ones social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

Chapter 26: Physical and Sexual Abuse of Adults MULTIPLE CHOICE 1. A young child is being evaluated in the Emergency Department for injuries her mother reports resulted from a fall down the stairs. Which of these findings indicates that physical abuse may be a chronic problem for the child? a. The mothers description of the child as being clumsy b. Several fractures revealed on x-ray in varying degrees of healing c. Clinging to her mother as she attempted to leave the examining room d. Struggling with the staff when attempts to obtain a blood specimen were made ANS: B Unhealed fractures indicate both numerous injuries and that medical intervention was not sought at the time of injury. Although unkind, the mothers description of the child is not reason to believe chronic abuse has occurred. The remaining options reflect normal behavior, especially if pain or separation is suspected.

2. A child was admitted to the childrens unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse? a. Family therapy b. Play therapy c. Individual communication with the nurse d. Role-play with other children on the unit ANS: B

Play helps communicate and release feelings about the childs problems. A child may have difficulty expressing feelings verbally. Family therapy may be useful, but it is not designed for releasing feelings. Role-playing is more effective with older children or adults.

3. The nurse is leading a support group for women who have experienced interpersonal violence.

When a patient asks about the characteristics of the perpetrators of interpersonal violence, the nurse accurately responds that they are: a. Usually under the influence of alcohol b. Most often someone the victim knows c. A stranger to the victim in most cases d. Often in a psychotic state during the act ANS: B Statistics show that interpersonal violence is usually committed by someone the victim knows.

Drugs and alcohol are not necessarily involved. The victim usually knows the perpetrator. The perpetrators are aware of what they are doing.

4. Which nursing intervention will assist a patient being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence? a. Allowing the patient to initiate the topic of violence b. Speaking with the patient in the absence of her husband c. Providing a safe, nonintimidating, and supportive environment d. Interviewing her in the presence of another healthcare professional ANS: C Providing a safe environment is the first step in assisting a patient who is a victim of domestic violence. Including others in the conversation may increase anxiety and reluctance to disclose.

Isolating the husband is assumed in providing a safe, nonintimidating environment. The patient may not disclose without prompting by the nurse.

5. A patient admits to having been battered by her live-in boyfriend several times over the past 2 years. She states to the nurse, We plan to get married next June, and I think things will be better then. He is always so sorry afterward, that I think I can trust him to change. Which intervention should be included in the patients teaching plan? a. Discourage her hope that the battering will end after they are married. b. Assist her in enrolling in a class to learn techniques of self-defense. c. Assist her in developing an emergency plan, because the pattern of violence is likely to continue. d. Emphasize that the battering pattern usually remains the same in frequency and severity over time.

ANS: C Developing an emergency plan is critical for any battered woman. The battering is not likely to cease unless the batterer seeks help but stating that fact is not therapeutic by itself. This will not stop the violence, although it might afford her some protection. Violence usually increases over time.

6. The nurse in the Emergency Department is taking a history from a family accompanying a child with suspicious traumatic injuries. The nurse should: a. Be open, concerned, and honest. b. Obtain information as covertly as possible. c. Avoid responding to hints that abuse has occurred. d. Separate the family from the child during the interview.

ANS: A The nurse serves as a role model for the parents and the child. Being open and honest and showing appropriate concern for the child is the most appropriate approach. Direct questioning is necessary to obtain the history. Concerns about the possibility of abuse must be addressed in a sensitive manner. The family will be able to remain with the child during history taking. It is helpful for the nurse to observe family interactions.

7. When an elderly patient is brought into the Emergency Department by family members who reported a fall the nurse became suspicious that the patient had suffered physical abuse. The patient denied that she had been abused. Her denial is most likely based on her: a. Feeling that she deserved the physical abuse b. Strong belief that nothing could be done to help her c. Lack of trust that the situation could ever be changed d. Fear of the possibility of being removed from her family ANS: D Fear of being separated from family and institutionalized is a powerful motive that keeps elders from revealing abuse. The other options may be factors in some cases but they are not primary motivators of silence.

8. A nurse planning a group to help batterers learn more effective ways to cope would teach participants that the key component in wife battering is: a. Their need for the batterer to control b. The role of alcohol in the pattern of abuse c. History of psychotic or paranoid behavior d. Failure of the woman involved to assert herself ANS: A The batterer uses violence as a means of controlling his partner to meet his own needs. Alcohol use is not the root cause of spousal abuse. There are no data to support mental illness as a factor in abusive relationships. Assertive behavior may result in increased abuse.

9. The nurse caring for a school-age child who has been sexually abused by a close family member demonstrates an understanding of communication barriers in this situation by: a. Realizing that repeated questioning by others will occur

b. Assuring the child that the story they are telling is believed c. Reinforcing that the child will not be in trouble with the police d. Promising to tell only those who need to know about the incident ANS: B Fear of being blamed or of being disbelieved is a powerful motivator of silence. When the child fears that there will be no support, there is no reason to disclose the abuse. The other options are much more remote.

10. The nurse is considering making a child abuse or neglect report to protective services. To make the report, the nurse needs to: a. Have strong evidence that the abuse/neglect has occurred. b. Obtain the supervisors permission to make the report. c. Notify the parents of the intent to file the report. d. Have suspicions that the abuse has occurred.

ANS: D Suspicions are all that are required by state mandatory child abuse and neglect reporting laws.

The agency bears the burden of collecting evidence. As a mandated reporter, the nurse does not need anyones permission to make the report. Only a suspicion is required. Parent notification is unnecessary.

11. A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife but insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority? a. Identifying community resources to decrease the caregivers stress b. Establishing patient rights and consequences of abuse and monitoring c. Providing stress management techniques for both of the caregivers

d. Educating the caregivers on the aging process and how to cope with it ANS: B Securing the patients safety is the priority for care. This option sets forth expectations for the family and establishes the fact that the patients state will be monitored. The other options are appropriate interventions but are not the highest priority.

12. To provide nursing care to abused children and their families, the nurse must first: a. Recommend removal of the children from the family. b. Complete a comprehensive physical and mental assessment. c. Refer each case to the appropriate social worker for follow-up. d. Examine personal feelings regarding the trauma of child abuse and neglect.

ANS: D Self-examination is required in order for the nurse to be objective and therapeutic in providing care. Although important, an assessment is not the initial step in this situation. Removal is not always recommended. A social service referral may not be required, depending on the situation.

13. According to statistical research data, which of these children currently being followed by the pediatric nurse practitioner is at the greatest risk for fatal abuse? a. A child who is 2 years old and has cerebral palsy b. A child who is 5 years old and has chicken pox c. A child who is 8 years old and has appendicitis d. A child who is 11 years old and has a fractured humerus ANS: A At highest risk for fatal abuse are children under 3 years of age and those with disabilities. The remaining options do not present children meeting the criteria.

14. A patient has been physically abused by her boyfriend frequently since moving in together.

During her last discussion with the nurse, the patient stated, I probably should not keep going back to him, because he continues to abuse me. The nurse is aware that the final decision to leave a batterer is: a. Usually a gradual process that occurs over time b. Likely to occur after the victim suffers a serious injury c. More likely if the patient has approval from her family d. Made when the batterer gives her permission to do so ANS: A The victim usually moves slowly when making the decision to leave the batterer because of many self-imposed constraints and many environmental factors that must be considered. It is unlikely that a batterer will give permission for the victim to leave. The remaining options are not supported by current research.

15. A patient has been chronically battered by her husband since they were married. Until now she had avoided dealing with her situation, but she now expresses a desire to deal with the problem since the attacks are occurring more frequently. Which outcome is realistic for the patient? a. Setting a goal date for divorcing her husband b. Verbalizing an awareness of her increasingly dangerous situation c. Citing possible ways she may have contributed to the abusive episodes d. Employing methods of retaliating in order to gain experience being assertive ANS: B Because the abuse has been long-term and is increasing in intensity, the patient needs to state her awareness of being in danger. When the patient accepts this fact, she may be increasingly ready to make further plans to extricate herself. The victim is not at fault for abuse. Setting a divorce

date is not practical because she has not begun to pursue litigation. Retaliation is not an effective means of resolving the problem.

16. The nurse who sees a number of battered elderly females each year decides to put together a set of guidelines for nurses. An appropriate guideline to include would be to: a. Make protective services aware of the abuse. b. Take at least two photographs of each trauma area. c. Begin the interview by asking the least sensitive questions. d. Assess for the presence of sexually transmitted diseases.

ANS: C During the assessment and when taking the womans history, it is recommended that in all cases the nurse begins with the least sensitive questions and gradually progress to the more sensitive ones. The remaining options may be appropriate but depend on the circumstances.

17. A nurse planning teaching for a parent group concerned with preventing family violence can discuss the fact that exposure to violence in the media: a. Desensitizes people to the violence around them b. Has no effect on the increase of violence in society c. Broadens the viewers knowledge about world happenings d. Helps to distinguish appropriate behaviors from inappropriate behaviors ANS: A Violence in the media has been shown to desensitize people to environmental violence.

Desensitization to violence results in people being apathetic about the violence going on around them. The remaining options are not true statements.

18. Which symptom reported by an adult patient, who was sexually abused as a child, reflects the diagnosis of posttraumatic stress disorder (PTSD)?

a. A history of substance abuse b. Refusing to go to public places from which escape may be difficult c. Seeking advice and guidance prior to making any significant decision d. Ruminating easily concerning the abuse with friends and acquaintances ANS: A Substance abuse to help manage the unpleasant symptoms is characteristic of PTSD. Being uncomfortable in certain locations refers to agoraphobia. Seeking extensive support characterizes a dependent person. Ease in talking about the experience is uncharacteristic of PTSD. 19. While planning care for a preschool child who has been physically and sexually abused, the nurse includes play therapy because it assists the child to: a. Learn adaptive behaviors through acting. b. Express feelings that cannot easily be verbalized. c. Act out aggression in a sociably acceptable manner. d. Interact with other children in the appropriate age group.

ANS: B Abused children, especially young children, are unable to put feelings into words as they describe events. Play therapy affords the tools through which the child can access and work through feelings. The other options are not purposes of play therapy.

20. A new nurse asks the experienced nurse, Why did you ask about culture when it was obvious you needed to focus on the battering? The experienced nurse should respond: a. Its just a habit I got into awhile ago. b. It helps me focus on whether to do a complete physical assessment. c. Culture is a determinant of how women interpret and respond to violence. d. If I know more I can refer her to a shelter that caters to her cultural group.

ANS: C Understanding the womans culture not only helps understand how the woman will view and respond to violence but also is essential to developing an effective treatment plan. Some ethnic women are isolated and would not be able to seek assistance from police or community agencies.

The remaining options are made-up responses and have no basis in theory or practice.

21. The experienced nurse assessing a battered woman patient uses many open-ended questions during the interview. The rationale for this is that: a. The woman will feel more in charge of the interview. b. Patients cant refuse to answer when sensitive information is being probed. c. The questions are direct and easily understood by the anxious individuals. d. Such questions allow for simple yes or no answers when the patient is upset.

ANS: A Open-ended questions reflecting what the woman is disclosing give the patient the sense of being in control of the interview, and she is likely to reveal more than when direct questions are used exclusively. Open-ended questions are not easily answered yes or no. Open-ended questions are indirect. Patients can refuse to answer any question, so this is not an acceptable rationale.

22. The nurse is interviewing a patient who presents with a dislocated shoulder and demonstrates signs of anxiety although relying on her partner for answers. Although the partner is out of the room, which question is most important to ask? a. Have you been with your partner long? b. Are you being abused by your partner? c. Shall I notify the police that you would like to press charges? d. Have you ever been physically or emotionally hurt by someone?

ANS: D

When the victim is alone, the nurse must seek information about abuse. Phrasing the question to avoid use of such terms as abuse or battered is essential. These terms are too emotionally charged, and patients often respond in the negative. The length of the relationship is not a priority. Asking to call the police is premature.

23. A woman whose husband physically abuses her mentions to the nurse, Someday Ill have to leave him. Which of the following would be the nurses best response? a. Yes, you should, before he harms you badly. b. Could we talk about developing a safety plan? c. Are you afraid of what your family will say? d. I dont know why you would stay with him.

ANS: B It is well known that the woman is at high risk for being killed or seriously injured when she leaves the abuser. Having a safety plan lowers the risk and makes leaving a less nebulous idea.

The patient must make up her own mind. Asking about the familys response sidesteps the issue of safety. The patient needs empowerment, not criticism.

24. The nurse is planning care for a battered woman who has mentioned, Someday Ill have to leave him. Which outcome should the nurse include in the plan of care for this patient? a. Patient will leave husband for a safe environment within 3 weeks. b. Patient will verbalize awareness of the dangerousness of her situation. c. Patient will state that she feels strong enough to return to the situation. d. Patient will state that she feels more relaxed after consultation with nurse.

ANS: B This is a realistic outcome for a patient who is beginning to consider leaving the abusive situation. Setting a timeline is premature. Feeling relaxed is more related to a problem of anxiety than to abuse. Returning is not an outcome that is in the patients best interest.

25. A patient who has been battered by her partner sobs, It was my own fault. Which of the following would be the priority response by the nurse? a. Why do you think he does it? b. What did you do to deserve this? c. No one has the right to abuse another. d. Tell me about when you were growing up.

ANS: C The patient must understand that as a human being she has the right not to be abused. Victims of abuse should be given this information in a respectful way to counteract their feelings of guilt and shame. Asking about behaviors suggests that the patient had a role in provoking the battery.

Asking why sidesteps the real issue. Enquiring about her childhood continues to look at factors within the patient.

26. The care plan for a battered woman will be most successful if the nurse: a. Empowers the patient to make her own decisions b. Develops the plan and presents it to the woman c. Obtains photo evidence of the battery for use in court d. Has a family conference and mediates among the parties ANS: A The nurses attitudes, values, and choices cannot be imposed upon the patient. The nurse must empower the patient to make her own decisions. Empowerment will help the patient develop strength to make growth-producing decisions independently. The remaining options would be counterproductive or have no bearing on the success of the care plan.

27. A teenage boy has been periodically beaten by his father. The boy tells the nurse, Hell pay for this one way or another. The nurse treating his contusions should assess for behaviors suggesting:

a. Aggression b. Depression c. Regression d. Withdrawal ANS: A Research suggests that children who are abused are at high risk for antisocial behavior and associated aggressive behaviors for a period of at least 2 years after the battering incident. The boys remark is not consistent with any of the other options.

28. A patient in her early teens who is being treated for irritable bowel syndrome has just disclosed that she has been the victim of child abuse for 8 years. For what other condition should the nurse assess this patient? a. Schizophrenia b. Agoraphobia c. Posttraumatic stress disorder d. Obsessive-compulsive disorder ANS: C The state of chronic hyperarousal caused by the abuse is the basis for three common outcomes of childhood abuse: PTSD, depression, and irritable bowel syndrome. The conditions mentioned in the other options are not related to child abuse.

29. Which statement regarding the various types of child offender is correct? a. The physical offender lacks remorse, although the sexual offender usually shows guilt and shame. b. The physical offender has diverse characteristics, although the sexual offender has lack of remorse.

c. The physical offender has a mature ego, although the sexual offender has a rigid, overdeveloped superego. d. The physical offender has poor self-esteem and unrealistic expectations of children, although the sexual offender has diverse characteristics.

ANS: D The child physical offender often is assessed as having poor self-esteem, poor impulse control, unrealistic expectations of children, immaturity, and minimal external supports. The child sexual offender has diverse characteristics, with no profile becoming apparent. The child sexual offender often does not show remorse for the acts.

30. A toddler was brought to the hospital with a broken humerus and upper arm bruising. The childs father states that he shook the child while disciplining him to teach him to be quiet. An appropriate family-related nursing diagnosis is: a. Anxiety related to physical abuse b. Powerlessness related to inability to keep child quiet c. Impaired parenting related to unrealistic expectations for child d. Risk for impaired parenting related to harsh disciplinary methods ANS: C This diagnosis is supported by data in the scenario. Violence has occurred, so a risk diagnosis is not appropriate. The remaining diagnoses are not supported by data.

31. An experienced nurse correctly notes that an important factor in assessing survivors of childhood sexual abuse is to be aware that they often experience long-term symptoms most closely resembling DSM-IV-TR criteria for: a. Adjustment disorders b. Schizophreniform reaction c. Posttraumatic stress disorder

d. Obsessive-compulsive personality disorder ANS: C Although childhood sexual abuse produces a wide variety of long-term sequelae, the most common psychosocial problems are PTSD, self-damaging behavior, mood disturbances, interpersonal problems, and sexual difficulties. The other options are rarely noted.

32. An elderly patient who lives with her daughter, son-in-law, and their three children reveals that her daughter sometimes slaps her when she does not move fast enough or spills things. The daughter states, I have so much to do that I become frustrated when my mother cant move fast enough or causes me extra work. The nurse caring for the mother could appropriately suggest: a. Moving the mother to an adult ambulatory care facility b. Employing an aide to provide care and stimulation for the mother c. Enrolling in a therapeutic group that addresses stress management d. Reading the elder law of the state to learn the penalties for elder abuse ANS: C The daughter has many stressors and has few external supports. Enrolling in a stress management group would provide support as well as teach new adaptive coping strategies. Being required to read the law is threatening. The remaining options are premature.

33. After being raped, a woman was told by her aunt, Im not surprised that happened to you. You always dress to show off your figure. The victim states, I cant believe that people can think that way. The rape crisis nurse correctly hypothesizes that the patient is: a. Being revictimized by society b. Overly sensitive to others views c. Overreacting to not resisting more strongly d. Unaware of the normalcy of male sexual aggression

ANS: A Victim blaming is common following a rape. Instead of blaming the rapist, many individuals lack knowledge and empathy and revictimize the woman. Rape education programs can be helpful in changing attitudes. The other options are hypotheses that continue to place blame on the victim.

34. Which of the following would be an appropriate outcome for a patient diagnosed with rapetrauma syndrome? a. Patient will sleep 8 hours without medication by week 6 of therapy. b. Patient will develop better self-esteem by week 8 of therapy. c. Patient will accept nurses word that her reactions are normal. d. Patient will verbalize that recovery may never happen totally.

ANS: D Rape trauma victims require time to process what has happened to them and to reorganize their lives, just as an individual who is grieving must do. The remaining options are not realistic nor therapeutic.

Chapter 27: Psychiatry and Reproductive Medicine ____ 1. Pete has recently been admitted to the hospital and is being treated for bipolar disorder.

When you go to check in on him, he tells you that he is feeling very drowsy and has been vomiting. He is also running a fever. You suspect that Petes problem is caused by: A. Anxiety over his new surroundings after being admitted to the hospital for treatment.

B. Side effects of the lithium therapy he is receiving.

C. A hospital-acquired viral infection.

D. Food poisoning. ____ 2. Your manic patient is being discharged on lithium. Which of the following would NOT be in the teaching plan?

A. Blood levels must be closely monitored.

B. Continue to take lithium even when your manic symptoms are resolved.

C. Restrict fluids while taking this drug.

D. Contact your doctor if you experience side effects rather than stopping the drug. ____ 3. Which of the following is true about lithium?

A. It is available in multiple formulations, including IV and suppository.

B. It is generally discontinued for 2 weeks prior to any major surgery.

C. It is used on a prn basis when the patient feels anxious.

D. None of the above ____ 4. Nurse Arlene recognizes that the focus of environmental (MILIEU) therapy is to: A. Control the environment to bring about a positive behavior change.

B. Allow the patient freedom to decide whether they want to participate in activities.

C. Use role-play to meet their personal needs.

D. Use natural medicines rather than drugs to control behavior. ____ 5. During electroconvulsive therapy (ECT), the patient is monitored carefully before and after the procedure. The nurse assisting with this procedure is aware that monitoring is necessary because the patient may suffer from: A. Euphoria.

B. Immediate alertness after the procedure and sleepy later in the day.

C. Urine retention.

D. Seizure activity. ____ 6. Lynn, the LPN/LVN, is providing care for a patient diagnosed with depression. The patient is not responding to any of the medications ordered. The nurse foresees this patient may be a candidate for: A. Neuroleptic medication.

B. Short-term seclusion.

C. Psychosurgery.

D. Electroconvulsive therapy. ____ 7. When teaching Mary, who has depression, about foods to avoid while taking phenelzine (Nardil), which of the following would Audrey LPN include?

A. Peanut butter B. Fresh fish C. Salami D. Soup

____ 8. When developing a care plan for Ms. Smith, who was diagnosed with schizophrenia and is receiving haloperidol, which of the following medications would Nurse Janet expect to administer if the patient developed extrapyramidal side effects (EPS)?

A. Olanzapine (Zyprexa) B. Paroxetine (Paxil) C. Benztropine mesylate (Cogentin) D. Lorazepam (Ativan) ____ 9. Nurse Maryse invites a recently discharged patients family to attend an outpatient support group. This type of program would most likely help the family with which of the following issues?

A. Learning from others in the same situations B. Gaining insight into why they feel guilty C. Recognizing the clients weakness D. Managing the clients financial concern and problems ____ 10. Linda says that she feels confused and anxious. In addition, Linda feels unorganized and states, It is as not bad as it seems. What phase of crisis is Linda experiencing?

A. Precrisis B. Impact C. Adaptive D. Postcrisis ____ 11. Andrea, the charge nurse, spoke to the director of nursing about one of the staff nurses having a crisis. The nurse suggested a crisis intervention group to the staff nurse. Crisis intervention groups are successful because: A. The crisis intervention worker is a psychologist and understands the presenting behavior patterns.

B. They supply a workable solution to the patients problem.

C. The patient is encouraged to share with others about personal problems.

D. The patient is assisted to develop new insights and return to the precrisis phase. ____ 12. Which of the following best explains why tricyclic antidepressants (TCA) are used cautiously with the elderly population?

A. Central nervous system effects B. Cardiovascular system effects C. Gastrointestinal system effects D. Serotonin syndrome effects ____ 13. Which of the following drugs indicates the patient is toxic with a serum level of 1.5 mEq/L? A. Lithium B. Ritalin C. Tofranil D. Buspar ____ 14. The patient taking lithium should understand that the following could affect fluid and sodium levels and increase the chances of becoming toxic: A. Muscle weakness.

B. Lithium level of 0.7.

C. Dehydration.

D. Hypertension. ____ 15. A patient being medicated with haloperidol for over 4 weeks has started to display symptoms of involuntary movements of the mouth that resemble chewing. Of the following extrapyramidal adverse reactions, the client is showing signs of:

A. Dystonia.

B. Akathisia.

C. Drug-induced Parkinsonism.

D. Tardive dyskinesia.

____ 16. A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurses teaching about this medication?

A. I dont need to see my doctor for a new prescription when this runs out.

B. I need to keep my appointment this week for a blood test to monitor my white blood cells.

C. I can have a martini with this medication.

D. I dont need to come into the clinic for a few months if I dont have side effects

____ 17. A patient is admitted to the Mental Illness and Chemical Abuse unit. The patient has been placed on a 1:1. After reviewing the clients progress notes, the nurse notes that the admission was voluntary. The nurse would expect which of the following: A. The patient will be angry at being forced to be on the unit.

B. The patient was given an informed consent.

C. The patient may not leave the unit without a court order.

D. The patients wife has signed the consent form for admission. ____ 18. While doing a 24-hour chart check, the LPN/LVN notes a patient was admitted to a mental health unit on an involuntary status. The nurse becomes aware that this type of admission could be because the patient attempted to do the following:

A. Presented harm to self.

B. Scheduled this admission.

C. Signed an informed consent.

D. Looked at several facilities prior to this admission. ____ 19. The desired outcome from humor therapy is: A. The patient will feel accepted.

B. The patient will have increased feelings of depression.

C. The patient will demonstrate a more positive outlook.

D. The patient will be discharged sooner. ____ 20. Counseling is a field that requires licensing. This licensing is providing by: A. The municipality.

B. The office C. The state.

D. There are no regulations for counselors. ____ 21. The ABCs of rational-emotive therapy (RET) are: A. Acting, believing, concise.

B. Able, belief, consequences.

C. Activating, belief, consequence.

D. Awareness, believing, conclusions. ____ 22. Dr. Albert Ellis, who developed the theory of RET, thought that people teach themselves to be ill. He used the following terminology: A. Musturbation and awareness.

B. Awfulizing and musting.

C. Musturbation and awfulizing.

D. Realizing and supersizing. ____ 23. When observing a patient receiving tricyclic antidepressant therapy, ________________would bring attention to the nurse that the patient was undergoing anticholinergic effects.

A. Urine retention and changes in blood glucose B. Respiratory depression C. Delirium D. Cardiac arrhythmias Completion Complete each statement.

24. A therapeutic environment in mental health terminology is called a ________________.

25. The drug category _______________ blocks dopamine receptors and is a major treatment for schizophrenia.

26. The drug category _______________________________ increases the availability of serotonin, which is decreased in the brains of depressed individuals.

27. The form of therapy that focuses on the cause of the problem, originated from Sigmund Freud, is _____________________.

28. The category of medication that promotes alertness, diminishes appetite, and combats narcolepsy and attention deficit hyperactivity disorder is __________________.

29. The act of purging or purification of emotions is known as ____________________.

30. The movie about Patch Adams represents this type of therapy: __________ __________.

31. This type of intervention might be used for states of extreme emotional or physical turmoil in which the patient feels out of control of self: ______________ _______________.

32. A patient consents to be hospitalized for psychiatric treatment. This is a _______________ _________________________ admission.

33. The patient in what type of therapy gains knowledge that there are others with similar problems? _____________________ 34. The category of drugs that treat manic phase of bipolar disorder are called _______________.

Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 35. Commonly used typical antipsychotic agents are (select all that apply): A. Thorazine.

B. Stelazine.

C. Prolixin.

D. Risperdal.

E. Haldol. ____ 36. Which of the following should be included in patient teaching about antidepressants (select all that apply)?

A. Medications take 1 week to become effective.

B. Encourage patients to continue taking the medication.

C. Not all antidepressant medications have to be tapered gradually.

D. Patients dont have to be monitored for suicidal ideations.

E. If it is an MAOI antidepressant, the patient should avoid foods containing the amino acid tyramine.

____ 37. Which of the following may affect African Americans seeking to comply with medical or mental health treatment (select all that apply)?

A. Usually receive treatment from primary health care provider rather than a mental health specialist B. More likely to receive substandard treatment C. Approximately 20% to 30% of this group do not have health insurance.

D. Tend to be more receptive to taking medications that any other group ____ 38. The following medications are used for treatment in mental health disorders (select all that apply): A. Antipsychotics.

B. Antibiotics.

C. Antifungals.

D. Stimulants.

E. Mood stabilizers. ____ 39. Which of the following items should be included when providing patient teaching about monoamine oxidase inhibitor (MAOI) antidepressants (select all that apply): A. Avoid foods containing the amino acid tyramine.

B. Have blood levels screened weekly for leukopenia.

C. Need sun exposure at least 1 hour a day.

D. Dont take prescribed or over-the-counter medications without consulting the physician. ____ 40. Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemble those used for general anesthesia (select all that apply): A. Monitors the patients vital signs before and after the procedure.

B. Medicate prior to procedure if ordered.

C. Educate patient and patients family.

D. Consent is not required.

E. The patient may be slightly confused after the procedure. ____ 41. Patients who practice Judaism may have concerns about the following (select all that apply): A. Dietary selection.

B. Having tests scheduled between sundown Friday and sundown Saturday.

C. Tests scheduled between sundown Saturday and sundown Tuesday.

D. Meeting with the shamans.

E. Meeting with the imam.

Other 42. Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for general anesthesia. The nurse should follow these steps for this procedure (place in the order they will occur): _____ A. Monitor the patients vital signs before the procedure. _____ B. Medicate as prior to procedure if ordered. _____ C. Educate patient and patients family. _____ D. Check a signed consent. _____ E. Monitor the patients vital signs after the procedure.

Answer Section MULTIPLE CHOICE 1. ANS: B

These are common early warning signs of toxicity, so further investigation is needed right away.

KEY: Integrated Processes: Nursing Process: Analysis | Content Area: Mental Health: Pharmacology | Cognitive Level: Application | Client Need: Physiological Integrity: Pharmacological and parenteral therapies: Adverse effects/contraindications/side effects/interactions 2. ANS: C Dehydration promotes lithium toxicity.

KEY: Integrated Processes: Nursing Process: Analysis | Content Area: Mental Health: Pharmacology | Cognitive Level: Application | Client Need: Physiological Integrity: Pharmacological and parenteral therapies: Adverse effects/contraindication/side effects/interactions 3. ANS: D All of these responses are incorrect about lithium.

KEY: Integrated Processes: Nursing Process: Analysis | Content Area: Mental Health: Pharmacology | Cognitive Level: Comprehension | Client Need: Physiological Integrity: Pharmacological and parenteral therapies: Medication administration 4. ANS: A Environmental (MILIEU) therapies aim to provide safety and a therapeutic environment.

KEY: Integrated Processes: Caring | Content Area: Mental Health: Therapy | Cognitive Level: Knowledge | Client Need: Psychosocial Integrity: Therapeutic Environment 5. ANS: D ECT does have some side effects, which can be unpleasant. The patient will need to be monitored.

PTS: 1

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health | Cognitive Level: Synthesis | Client Need: Physiological Integrity: Reduction of Risk Potential: Therapeutic Procedures 6. ANS: D Electroconvulsive therapy is an effective treatment for those experiencing severe depression that is not helped with medication.

PTS: 1 KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Physiological Integrity: Therapeutic Procedures 7. ANS: C Foods containing the amino acid tyramine should be avoided. MAOIs block the metabolism of tyramine, resulting in an increase of norepinephrine. Aged and processed meats are an example.

A hypertensive crisis may occur.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Application | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications/Side Effects/Interactions 8. ANS: C Extrapyramidal side effects from haloperidol (Haldol) should be treated with benztropine mesylate (Cogentin) because of its anticholinergic properties.

PTS: 1 KEY: Integrated Processes: Nursing Process: Implementation | Content Area: Mental Health: Pharmacology | Cognitive Level: Comprehension | Client Need: Physiological Integrity:

Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications/Side Effects/Interactions 9. ANS: A In a group treatment modality, the members realize there are others with similar problems.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Synthesis | Client Need: Psychosocial Integrity: Support Systems 10. ANS: B In this phase the person acknowledges feeling stress but minimizes its severity.

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: crisis | Cognitive Level: Analysis | Client Need: Psychosocial Integrity: Stress Management 11. ANS: D A crisis intervention group helps patients determine their stressors. Patients are assisted in developing new coping techniques or modifying their current coping mechanisms.

12. ANS: B The TCAs affect norepinephrine as well as other neurotransmitters and thus have significant cardiovascular side effects. Therefore, they are used with caution in elderly clients who may have increased risk factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any patient taking a TCA and are not particular to an elderly person.

PTS: 1 KEY: Integrated Processes: Nursing Process: Analysis | Content Area: Mental Health: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Adverse Effects/Contraindications/Side Effects/Interactions 13. ANS: A

When the drug lithium cannot be cleared and excreted by the kidney, toxicity can occur. A 1.5 toxicity lithium level is considered mild.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Comprehension | Client Need: Physiological Integrity: Adverse Effects/Contraindications/Side Effects/Interactions 14. ANS: C Dehydration is a major trigger for lithium toxicity. Monitor the patients vital signs, and fluid intake and output.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Comprehension | Client Need: Physiological Integrity: Fluid and Electrolyte Imbalances 15. ANS: D Protrusion of the tongue and movements of the mouth are the common symptoms of tardive dyskinesia.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Application | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Adverse Effects/Contraindications/Side Effects/Interactions 16. ANS: B Clozapine can cause bone marrow depression; therefore, frequent blood counts are necessary to monitor the patients WBCs. This drug needs to be taken regularly and should not be discontinued abruptly.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Application | Client Need: Psychosocial Integrity 17. ANS: B

The informed consent from the patient is an indication that the patient has volunteered for care.

KEY: Integrated Processes: Communication and Documentation | Content Area: Legal | Cognitive Level: Analysis | Client Need: Safe and Effective Care Environment: Management of Care: Client Rights 18. ANS: A The patient is confined to the facility due to being a harm to himself or herself. The goal is to maintain patient safety.

KEY: Integrated Processes: Communication and Documentation | Content Area: Mental Health: Legal Considerations | Cognitive Level: Analysis | Client Need: Safe and Effective Care Environment: Management of Care: Client Rights 19. ANS: C A positive response to humor can bring about improvement in outlook and neurochemical changes to improve mood.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Therapeutic Communication | Cognitive Level: Analysis | Client Need: Psychosocial Integrity: Mental Health Concepts 20. ANS: C Each state has specific requirements for licensing of counselors.

KEY: Integrated Processes: Teaching/Learning | Content Area: Legal | Cognitive Level: Application | Client Need: Safe and Effective Practice: Legal Rights and Responsibilities 21. ANS: C The rational-emotive therapy proposes that people teach themselves to be ill because of the way they think about a situation. The theory proposes ways of rethinking situations.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Implementing Behavioral Interventions/Mental Health Concepts 22. ANS: C Dr. Ellis believed there was no musts and shoulds. He often used the words in Response C to demonstrate how we teach ourselves to have problems.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Therapeutic Communication 23. ANS: A Anticholinergic effects include hypotension, lethargy, weight gain, urine retention, blurred vision, dry mouth, constipation, and changes in blood glucose.

KEY: Integrated Processes: Nursing Process: Assessment | Content Area: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Adverse Effects/Contraindications/Side Effects/Interactions COMPLETION 24. ANS: milieu The milieu can have an effect on behavior, thus making it a therapeutic environment.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Therapeutic Environment | Cognitive Level: Knowledge | Client Need: Physiological Integrity: NonPharmacological Comfort Interventions 25. ANS: antipsychotics

Antipsychotics are major tranquilizers. Antipsychotic agents block both serotonin and dopamine.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Medication administration 26. ANS: antidepressants Used in the treatment of depression, anxiety, obsessive disorders, and impulse-control disorders, antidepressants increase the availability of serotonin.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Medication Administration 27. ANS: psychoanalysis Psychoanalysis focuses on the problem, which is buried somewhere in the unconscious. Freud believed it had something to do with poor parent-child relationships.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Mental Health Concepts 28. ANS: stimulant These drugs directly stimulate the central nervous system.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Comprehension | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Expected Actions/Outcomes

29. ANS: catharsis Catharsis assists in the elimination of a complex problem by bringing it to consciousness and affording it expression.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Mental Health Concepts 30. ANS: humor therapy Studies have shown that the effects of smiles, hugs, and humor can have a beneficial effect on ones outlook and even biochemical processes.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Therapeutic Communication 31. ANS: crisis intervention Crisis is a state of psychological disequilibrium. The person in crisis is at risk for physical and emotional harm. Crisis intervention strategies provide a structured way to help the person crisis return to at least pre crisis level of functioning.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Crisis Intervention 32. ANS: voluntary

Voluntary admission means the patient has given informed consent to seek care in the facility.

The informed consent means that the patient has been made aware of his or her behaviors, the implications of the behaviors, and expectations from the treatment.

KEY: Integrated Processes: Teaching/Learning |Content Area: Legal | Cognitive Level: Comprehension | Client Need: Psychosocial Integrity: Mental Health Concepts/Safe and Effective Care Environment: Management of Care: Legal Rights and Responsibilities 33. ANS: group therapy There are various types of group therapy; some are short-term or they can be long-term. All types of group therapy emphasize the sharing of feelings and experiences of the group members.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Knowledge | Client Need: Psychosocial Integrity: mental health concepts 34. ANS: mood stabilizers Mood stabilizers work biochemically to control manic behavior and include lithium as well as some anticonvulsants.

KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Expected Actions/Outcomes MULTIPLE RESPONSE 35. ANS: A, B, C, E The typical antipsychotic agents treat the positive symptoms of schizophrenia and are generally the older agents.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Expected actions/outcomes 36. ANS: B, E The nursing considerations for all antidepressants are the same. Patients taking antidepressants should be reminded it takes 2 to 3 weeks to become effective, they should not be discontinued abruptly, and MAOIs require a special diet.

37. ANS: A, B, D Community education can modify attitude. Emphasis should be placed on talking about problems. This assists in early diagnosis, which is crucial.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Cultural Diversity | Cognitive Level: Analysis | Client Need: Health Promotion and Maintenance: Health and Wellness 38. ANS: A, D, E These medications control symptoms, helping the patient feel more comfortable emotionally.

These medications are usually used in connection with some other type of therapy.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Pharmacology | Cognitive Level: Knowledge | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies: Expected Actions/outcomes 39. ANS: A, D MAOI antidepressants can precipitate a hypertensive crisis in the presence of tyramine. Caution should be used with other medication interactions as well.

40. ANS: A, B, C, E The nurse should prepare the patient for ECT in a manner similar to that for general anesthesia.

Under general anesthesia, the patient should sign consent, the vital signs need to be monitored before and after the procedure, and the patient should be educated about the procedure and the expected outcome.

PTS: 1 KEY: Integrated Processes: Teaching/Learning | Content Area: Mental Health: Treatment | Cognitive Level: Application | Client Need: Physiological Integrity: Reduction of Risk Potential: Potential for complications of diagnostic tests/treatments/procedures 41. ANS: A, B These responses reflect practices of Judaism.The Sabbath is from sundown Friday to sundown Saturday. Kosher diet may be preferred.

OTHER 42. ANS: A: 3 B: 4 C: 1 D: 2 E: 5 The patient/family should receive information regarding the procedure first. After the patient teaching has occurred, then the patient will be able to sig

Chapter 28: Psychotherapies MULTIPLE CHOICE 1. Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals? a. Administering the prescribed medications accurately b. Interacting effectively with members of the health care team c. Being aware of all the patient related therapeutic modalities d. Evaluating patient behaviors to reward economic tokens appropriately ANS: D The primary role of the nurse who is involved in behavioral therapy is to assess and identify the patients problem behaviors in collaboration with the multidisciplinary team. A token economy is a system of behavior reinforcements in which patients earn tokens by performing predetermined desired behaviors. The remaining options are generalized responsibilities that are relevant to any therapy format.

2. A new nurse asks the mentor, How can I be sure Im developing a therapeutic environment for my unit? The mentor uses as a basis for the response the fact that a therapeutic milieu is characterized by: a. Rigid adherence to timelines and unit routine b. Relaxation of boundaries when doing so is accepted by all c. The focus of the staff is directed to the most critically disturbed patients d. Specific patient-centered goals are established mutually by patient and staff ANS: D Factors that determine the therapeutic effectiveness of the social environment includes the presence of two-way communication between the patients and the members of the

multidisciplinary team for purposes of goal setting. In a therapeutic relationship, boundaries are established early and maintained throughout and although adherence to routine is important, there is room for adjustment when it benefits the therapeutic nature of the milieu. Although short-term attention may require focus on the patient in crisis, attention of the staff is equally shared.

3. To plan care for a patient with a psychiatric disorder, the nurse keeps in mind that the primary nursing role related to therapeutic activities is: a. Assisting the patient in accomplishing the activity b. Ensuring that the patient will comply with the rules of the activity c. Ensuring that the patient can accomplish the activity in a timely manner d. Providing a support system for the patient if they fail to complete the activity ANS: A The nurses role in therapeutic activities is that of a professional observer and participant who works with the therapist to enhance the patients capabilities and functioning within the parameters of the assigned activity. Assuring accomplishment, compliance, or providing failure support are not nursing roles.

4. Which statement would the nurse use to describe the primary purpose of boundaries? a. Boundaries define responsibilities and duties to ones self in relation to others. b. Boundaries determine objectives of the various working stage of the relationship. c. Boundaries differentiate the assumed roles of both the nurse and of the patient. d. Boundaries prevent undesired material from emerging during the interaction.

ANS: A Boundaries are the social, physical, and emotional limits of the interaction. As such, they serve to define the responsibilities and duties of the nurse in relation to the patient. Objectives and

roles are determined during the orientation stage. Emergence of undesired material may be a significant issue for the patient.

5. Which action will best facilitate the development of trust between a nurse and patient? a. Responding positively to the patients demands b. Following through with whatever was promised c. Clarifying with the patient whenever there is doubt d. Staying available to the patient for the entire shift ANS: B Being consistent in keeping ones word implies that the nurse is trustworthy and does what is agreed upon. Being responsive to demands may not be therapeutic. Instead, the patient will need to learn new techniques for meeting needs. Clarification is important but is not the best method for promoting trust. Trust is better served by shorter contacts at agreed-upon intervals.

6. Which statement best defines the nurses initial role as the patients source of help in addressing interpersonal problems? a. Ill work with your doctor to help you get better. b. Ill be working with you to help solve your marital troubles. c. Your medications will help you feel better as soon as they take effect. d. You will be expected to attend the group activities while you are here.

ANS: B This statement clearly specifies the nurses purpose as a helping professional, and establishes the relationship as therapeutic, rather than social. The nurse has independent functions and does not work exclusively with the doctor. Identifying only medication overlooks the contributions of staff and the therapeutic milieu. Giving information is appropriate, but this statement does not define the nurses role as resource.

7. The nurse is determining whether the patients needs could be best met in a task or a process group. The decision is based on the understanding that a task group focuses on: a. Content issues b. The here and now c. Communication styles d. Relations among the members ANS: A Content-oriented groups focus on goals and tasks of the group. Thus a task-oriented group would focus on content issues. Process groups focus on interpersonal relationships. Communication styles are not relevant to describing task-oriented groups. Here and now refers to dealing with issues that are taking place at the present time.

8. The treatment team was engaged in planning how group therapy could be included as a part of the structured daily activities of the unit. A new team member asked, Why is it so important to include group therapy for the patients? The most accurate response would be based on the assumption that: a. Hidden agendas frequently surface in group sessions. b. Some persons do not relate well on an individual basis. c. Group therapy is far more cost-effective for the patients. d. Psychopathology has its source in disordered relationships.

ANS: D A key assumption of group therapy is that psychopathology has its source in disordered relationships. It follows that individuals will behave in the group as they do in other settings, so group provides an opportunity to help individuals develop more functional relationships. Ability to relate is not relevant to group work. It is dealt with in one-to-one therapy. Hidden agenda is not a reason to offer group therapy. Cost-effectiveness is not an assumption about the reason group therapy is effective.

9. Which patient would the group co-leaders determine is demonstrating Yaloms therapeutic factor termed universality? a. Patient A, who states he realizes he is not the only person who has a problem with loneliness b. Patient B, who displays dysfunctional interaction patterns learned in his family of origin c. Patient C, who states he finally feels a strong sense of belonging d. Patient D, who openly expresses his anger about his work ANS: A Universality is the factor that refers to understanding that one is not unique, that others share thoughts, reactions, and discomforts like your own. Dysfunctional interaction refers to corrective recapitulation of the family group. A strong sense of belonging provides an example of cohesiveness. Display of anger is an example of catharsis.

10. A nurse, leading an inpatient group dealing with womens issues, identifies a patient who is assuming the role of aggressor. Which behavior characterizes this role? a. Attempting to manipulate others b. Mediating conflicts and disagreements c. Criticizing the contributions of others d. Seeking a position between contending sides ANS: C An aggressor acts in negative ways, displaying hostility, attacking the group, or criticizing the members. Seeking a position between contending sides describes the compromiser. Mediating conflicts and disagreements describes the harmonizer. Attempting to manipulate others describes the dominator.

11. Which statement by a 16-year-old is considered as positive evidence that the familys involvement in therapy is moving them towards effective functioning?

a. My dad has finally stopped giving me advice on how to live my life. b. I stopped playing football since practice required me to be away from home so often. c. Since my mother quit her job, she is more available to keep the home running smoothly. d. Eating dinner with my parents on Sunday nights has helped us be more aware of each others needs.

ANS: D This statement shows the family has made an effort to improve communication and deal with alienation without any one member bearing complete responsibility. Withdrawing from the team suggests he felt solely responsible for the family problem. Quitting the job suggests the mother saw herself as responsible; however, being home does not guarantee unification. A lack of advisement suggests withdrawal of the father from participation in family matters.

12. In response to the nurses statement, Tell me about your family, the patient became silent and displayed nonverbally that he is uncomfortable. Which statement by the nurse reflects sensitivity to the patient? a. Im so sorry. I didnt realize your family was a problem for you. b. Learning to express negative feelings will assist you in getting well. c. Perhaps you can talk about your feelings to the physician next time you meet. d. That seems to be a difficult subject for you. We can discuss when you are ready.

ANS: D This response acknowledges the situation, is respectful, and allows the patient to choose when to refocus the therapeutic interaction. Referring to the family as a problem is not sensitively worded. Offering false reassurance implies that feelings are negative. Suggesting postponing the discussion represents avoidance of dealing with the patients feelings.

13. When sharing her feelings about separating from a therapy group, the patient stated, I feel a bit sad and empty that I wont be seeing you folks again. What is the most accurate evaluation of the patients statement? a. It indicates regression and her lack of readiness to terminate. b. Unconsciously, she is hoping she will be permitted to continue the group. c. She is demonstrating normal feelings associated with termination of therapy. d. She needs further evaluation by her therapist to determine readiness to terminate.

ANS: C The patient is expressing feelings of sadness over the loss of the therapeutic group relationships that have been helpful to her. Such feelings are considered normal, just as they are considered normal when the nurse-patient relationship terminates. The feelings expressed are normal, not regressive. No hidden meaning is present; the patient openly expressed genuine feelings. Further evaluation is not needed.

14. A patient asks the nurse manager to help resolve a situation between her and another patient.

Which action would best support the patients feelings of safety when experimenting with new ways of being? a. Encouraging the patient to report the incident to the other patients physician b. Intervening on the patients behalf and sorting out the incident with the other patient c. Suggesting that the patient ignore the situation since the other patient was probably not aware of her behavior d. Offering to be present and help the patient discusses her feelings about the incident with the other patient ANS: D Offering to be with the patient affords her a safe nonthreatening opportunity to assume responsibility for meeting her own needs assertively by encouraging skills that affect positive communication. Intervening removes the responsibility from the patient. Ignoring supports

passive behavior. There is no need to bring in another person. The patient is capable of addressing the problem herself.

15. A patient tells the nurse, I really like you. Youre the only true friend I have. The patients remarks call for the nurse to revisit the issue of: a. Trust b. Safety c. Boundaries d. Countertransference ANS: C The patients remarks call for the nurse to remind the patient of the parameters of the nursepatient relationship. The remark would also give the nurse the opening to go on to discuss the matter of friendship. The patients remarks do not suggest the need to deal with trust, safety, or countertransference.

16. By the end of the orientation phase, which outcome can be identified for a newly admitted patient? The patient will demonstrate: a. Ability to problem solve one issue b. Trust in at least one nurse on the unit c. Positive transference with a staff member d. Ability to ask for help in meeting needs ANS: B Establishing trust in the nurse is a fundamental task of the orientation phase of the relationship; thus it is an appropriate outcome to identify. When trust is present, the patient is free to focus on the work and tasks of therapy. The ability to problem solve is an outcome appropriate for the working phase. Positive transference would not be an identified outcome. The ability to ask for help would not be an identified outcome for the orientation phase.

17. The patient and the nurse have agreed on problems to be addressed during a short course of outpatient therapy. At the beginning of the appointment, the patient states, Id like to work on the issue of relationships today. Which assessment can be made? a. Nurse-patient roles have not been clearly delineated. b. The nurse should suggest several alternative behaviors. c. The patient must be able to manage emotions before continuing. d. The relationship is moving from orientation to working phase.

ANS: D Once the patient and nurse have collaborated to define and prioritize problems, the relationship moves from orientation to working phase. The remaining options have no relevance to the scenario since there is no reference to roles, alternative behaviors, or managing behaviors.

18. A nurse and patient are entering the termination phase in the group experience. An important nursing intervention will be to: a. Encourage the group to describe goals for change. b. Inquire whether the group needs more time to accomplish goals. c. Assist the group to explore alternative coping strategies for problems. d. Discuss feelings about leaving the group and the support found with the group.

ANS: D Healthy termination is facilitated when the group and nurse express reactions to termination. The nurse serves as a role model by being open and genuine as the feelings about the losses incurred with ending are discussed. On a positive note, accomplishments and growth are acknowledged and the transfer of safety and trust to the group members is accomplished. Describing goals is accomplished in the orientation phase. Accomplishing goals is part of the working phase in a relationship that does not have a strict time limit. Exploring alternative coping strategies would be part of the working stage.

19. A patient attending group therapy mentions, In the beginning, I was so sick that everyone had to help me. For the last few days, its felt good to be able to give something back to the group.

This statement can be assessed as an example of Yaloms factor of: a. Altruism b. Harmonizing c. Cohesiveness d. Imitative behavior ANS: A Altruism refers to the experience of being helpful to others and is clearly what the patient is displaying in the scenario. The other factors are not applicable.

20. During the first family therapy session, the mother of a child being treated for truancy and emotional outbursts asks the nurse, Why are you bothering to ask the rest of us questions? My son is the one with the problems. The best response for the nurse would be: a. Well get more accurate information if the entire family is involved. b. It may seem strange to you, but well get better results doing it this way. c. When one family member is sick, the whole family system is sick as well. d. Every family members perceptions are very important to the total picture.

ANS: D This response orients the family to the idea that each persons opinion will be valued. Having the family present for assessment prepares them for working together to identify family issues, identify outcomes, and solve problems. It may or may not be true that this will result in accurate information. Getting better results doesnt convey the real reason. Referring to the family as sick is pessimistic and conveys a threatening message.

21. A novice mental health nurse shares that, Ill never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time. The best response for the nurses mentor would be: a. Perhaps youll want to rethink your transfer to this unit if youre really uncomfortable. b. Your comments make a point about scarce resources. Ill ask the treatment team to review our position on activities. c. Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks. d. Managed care has cost us activities therapists. Activities are necessary to give patients something to do, so we have to fill in.

ANS: C Nurses who engage in co-leadership of therapeutic activities recognize that each activity contributes to outcome attainment. During activities, patients practice skills needed in life situations, process emotions, and give and receive validation and feedback. Suggesting a rethink is not supportive of the nurse. The remaining options do not acknowledge the value of activities therapy.

22. What is the primary reason for the nurse to have an understanding of the various types of activity and adjunct therapies? a. The nurse chooses the most cost-effective therapy group. b. The nurse is expected to encourage patients involvement in the therapies. c. The nurse is responsible for placing the patient in the appropriate group. d. The nurse needs to be supportive of the treatment team members who direct these therapies.

ANS: B The nurse must interpret to patients and others that the purpose of activity therapies is to increase patient awareness of feelings and behaviors and to minimize pathology and promote mental

health. Although they are important, supportiveness, encouragement, and economics are not the primary reason.

23. Which activity therapy should the nurse recommend to the treatment team to assist the patient to relieve tension and achieve increased body awareness? a. Psychodrama b. Music therapy c. Dance therapy d. Recreation ANS: C The large movements involved in dance therapy would enable the patient to relieve tension and move with greater body awareness and freedom. The other options will not promote body awareness.

24. To effectively plan care for a patient, the nurse will understand that activity and adjunct therapies may be more useful in some situations than verbal therapies because adjunct therapies: a. Are readily available in the treatment setting b. Do not require specific training or expertise to facilitate c. Provide the patient the opportunity to use ego-protective mechanisms d. Allow the patient to express feelings on multiple levels at the same time ANS: D A patient is able to express feelings on the emotional, physical, and symbolic levels during activity therapy, whereas verbal therapies are limited to one dimension. The primary facilitator of the selected therapy is required to have formal education and supervised experience. Adjunct therapy does not provide this opportunity, which would be considered nontherapeutic. Treatment settings are not always readily available.

25. A patient is scheduled to attend an occupational therapy group to work on the identified goal of recognizing and using more effective coping techniques. What measure can the nurse use to continue to support the patients attainment of this goal after he returns to the unit? a. Isolating him from more seriously ill patients b. Praising him for positive behavioral changes c. Avoiding setting limits that would increase his anxiety level d. Permitting him to make mistakes prior to intervening on his behalf ANS: B Recognizing and pointing out positive changes provides encouragement to continue pursuing change. The remaining option would not achieve the nurses goal of supporting the patients use of effective coping techniques.

26. How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group? a. Offer to dance with the patient. b. Ask the patient if this is the first dance he has attended. c. Sit with the patient away from the group. d. Encourage another patient to ask him to dance.

ANS: A If trust has been established, the patient may feel safe enough to dance with the nurse. If trust has not yet been established, the patient will see the nurses invitation as demonstrating respect and reaching out to him. Either way, the action will encourage participation. The nurse should not make another patient responsible for this patients participation. The remaining options do not encourage participation.

27. When leading a therapeutic group, the nurse demonstrates an understanding of the need to act as the groups executive when:

a. Restating rules when a new member joins b. Being available to orient the new members c. Helping a member defuse the anger they are experiencing d. Working with a member to help improve their communication skills ANS: A Executive functioning refers to monitoring and attending to group rules and procedures. Caring demonstrates expressions of kindness. Meaning attribution includes accepting of feelings, although emotional stimulation would reflect working communication skills.

28. When another patient serves as alter ego during an outpatient group session, the nurse documents that the group had been engaged in: a. Role-playing b. Psychodrama c. Cognitive therapy d. Consensus building ANS: B Psychodrama uses spontaneous dramas to act out emotional problems to promote health through development of new perceptions, behaviors, and connections with others. Others in the group take the role of significant others. Role-playing and cognitive therapy do not use the technique of alter egos. Consensus building is not a form of therapy.

29. The nurse is collecting the paintings from the patients after the art session is over. After art therapy, a patient hands the nurse a paper that consists of several black scribbles. Which statement demonstrates the nurse understands the goals and objectives of the therapy? a. Do you want to complete your painting? b. I see that you dont take this very seriously.

c. Can you tell me what happened to prompt such work? d. Thank you. Ill put this away in a safe place for you.

ANS: D Art therapy is used to help resolve conflicts and promote self-awareness. The nurse should not comment on the quality of the art or the patients talents, but rather treat the project with respect and value. The work is simply each patients self-expression. The other options make judgments about the work or the patients willingness to participate.

30. When asked, Why do you go to music therapy every morning at 10? The nurse explains that the nurses role in music therapy as: a. Fostering and encouraging performance talent b. Teaching patients about various styles of music c. Noting patient verbal and nonverbal expression of feelings d. Selecting and playing numbers that will reduce anxiety and stress ANS: C A goal of music therapy is to promote expression and social connection. The nurse should observe and document expression of feelings as they occur. The observations may be used later, as a basis for further consideration by the nurse and patient. The other options do not reflect aspects of the nurses role in music therapy.

31. When a novice nurse asks why the unit has a multidisciplinary approach to therapeutic activities, the nurse should explain that multidisciplinary collaboration: a. Produces a higher level of insurance reimbursement b. Reduces the incidence of aggressive behavior by patients c. Produces quicker results and earlier discharge to the community d. Produces better outcomes than when only one perspective is used

ANS: D Broader input in problem identification and resolution enhances patient outcomes. The remaining options are either untrue or irrelevant.

32. When a patient asks the nurse, How can jolting me with an electrical shock possibly do me any good? the answer most reflective of current biologic theory would be: a. ECT must sound like a very frightening treatment alternative to you. b. ECT produces a change in brain chemistry that results in improved mood. c. ECT interrupts brain impulses that are causing hallucinations and delusions. d. ECT provides you with external punishment so you can stop punishing yourself.

ANS: B Current theory regarding use of ECT is that the electrical stimulus causes electrochemical changes within the brain, resulting in increased availability of neurotransmitters at the synapses and improvement of mood. To suggest that the treatment is frightening does not answer the patients question. The treatment is not appropriate for hallucinations or delusions. The remaining option is not appropriate or founded in psychiatric therapy.

33. Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment? a. Ill be so glad when this treatment is over. b. Will I remember having this treatment? c. Did eating some crackers cause any problems? d. Im so tired of being depressed; I dont think I can go on.

ANS: C Because the patient is to receive general anesthesia and has orders to remain without food or liquids (NPO), the nurse should notify the physician immediately. The introduction of food into the stomach could result in aspiration of stomach contents during treatment. An expression of

hopelessness related to depression would be reason to continue with the treatment. The other options offer no contraindication to treatment.

34. The physician has ordered atropine 0.5 mg intramuscularly (IM) for a patient to be administered 30 minutes prior to ECT. The rationale for use of this medication is that it reduces secretions and: a. Protects against vagal bradycardia b. Improves the scope of convulsive activity c. Reduces the need for recovery room staff d. Prevents incontinence of bladder and bowel ANS: A Atropine is used for its ability to prevent vagal bradycardia associated with the electrical stimulus. The other options are neither relevant nor true.

35. Which statement by a patient who has given informed consent for ECT confirms that the patient understands the side effects of this treatment? a. I wont remember the pain. b. It will take several weeks before I feel good again. c. My short-term memory loss will be only temporary. d. I will be at increased risk for developing epilepsy later.

ANS: C Temporary impairment of recent memory is an expected side effect that occurs to some degree during the course of ECT. The other options suggest the patients understanding of treatment and side effects is flawed.

36. In the ECT treatment preparation period the morning of treatment, the nurse should: a. Adequately hydrate the patient.

b. Assess the patients cognitive function. c. Have the patient exercise for 10 minutes. d. Ensure that the patient produces a urine sample.

ANS: B Patient assessment is advisable to provide a baseline against which changes resulting from ECT can be measured. Although taking vital signs and performing other preparatory tasks, the nurse can assess orientation, immediate memory, thought processes, and attention span. The other options are interventions the nurse should not undertake.

37. Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient: a. With severe dementia b. With delirium tremens c. Recovering from conscious sedation d. Recovering from general anesthesia ANS: D The patient who has ECT receives a short-acting IV anesthetic and a skeletal muscle relaxant.

Thus care is most similar to the patient recovering from general anesthesia. The nurse will assess vital signs, quality of respirations, presence or absence of the gag reflex, level of consciousness, orientation, and motor abilities during the post-treatment period.

38. A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT) asks her mentor, What sort of memory impairment is present after several ECT treatments? The best response for the mentor would be: a. Its hard to say. Treatment affects everyone differently. b. Usually the patient has severe difficulty remembering remote events.

c. Patients have mild difficulty remembering recent events, like what was eaten for breakfast. d. Both recent and remote memory is affected, producing profound confused, cognitive states.

ANS: C Most patients experience transient recent memory impairment after electroconvulsive therapy (ECT). The cognitive deficit becomes more pronounced as the number of treatments increases.

When the course of treatments is completed, cognitive deficit generally improves to the pretreatment level. The other options are incorrect.

39. About an hour after the patient has ECT, he complains of having a headache. The nurse should: a. Notify the physician stat. b. Administer an as needed (prn) dose of acetaminophen. c. Take the patient through a progressive relaxation sequence. d. Advise going to activities to expend energy and relieve tension.

ANS: B Post-ECT headache is common. Most physicians routinely write an as needed (prn) order for a headache remedy. Notifying the physician is unnecessary, because this is an expected side effect.

Options c and d would not be as useful as medication in this instance.

40. For which patient is the nurse most likely to need to schedule a pre-ECT workup and teaching? a. Patient A, who is newly diagnosed with dysthymic disorder b. Patient B, who has melancholic depression that responded well to ECT 2 years ago c. Patient C, who was unresponsive to a 6-week trial of SSRI antidepressant therapy

d. Patient D, who has depression associated with diagnosis of inoperable brain tumor ANS: B Indications for ECT include patients with major mood disorders; patients who have responded to ECT in the past; patients who are unresponsive to antidepressants or unable to tolerate their side effects; and patients who are acutely suicidal or in danger of fluid and electrolyte imbalance related to inability to eat due to depression, severe mania, or severe catatonia. Patients with dysthymia are not candidates for ECT. The patient has not run out of medication options when prescribed only an SSRI. Patients with space-occupying lesions of the brain are not candidates for ECT. 41. Which intervention will the nurse implement in the first half hour after the patient has received ECT? a. Continually stimulate patient to respond, using physical and verbal means. b. Continue bagging patient to improve respiratory function until patient is responsive for 10 minutes. c. Reorient as necessary to time, place, and person as level of consciousness improves. d. Encourage walking and eating breakfast as quickly as possible.

ANS: C Patient memory is likely to be impaired in the immediate post-ECT period. Reorientation will be necessary to help the individual return to a functional state. Continual stimulation is not necessary. Bagging is unnecessary. The patient may be allowed to rest and recover at his own pace.

42. What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more scheduled? a. Safety

b. Trust attainment c. Therapeutic activities d. Boundary maintenance ANS: A To feel safe, patients need to know what is expected of them in their role as patients. The patient receiving ECT often has impaired recent memory and may become confused about the milieu and expectations. The nurse will need to reorient and reteach the patient with cognitive deficit.

Options b, c, and d will require attention but not to the same extent as safety.

MULTIPLE RESPONSE 1. Which behaviors are reflective of legitimate phases of a groups development? Select all that apply. a. Stating the goals of the group b. Establishing who will assume the leadership role c. Inviting family members to attend and provide their input d. Feeling safe enough to discuss painful personal situations e. Showing concern about assuming personal responsibility for life ANS: A, B, E All groups progress through the phases of development that are governed by group dynamics and include orientation where goals are identified, conflict where leadership is determined and tested, cohesion where a sense of safety is achieved, and termination where discharge concerns are acted out and addressed. Family input may not necessarily be introduced unless it was a defined goal of the group.

Chapter 29: Psychopharmacological Treatment MULTIPLE CHOICE 1. The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics: a. Remain in the system longer b. Act more quickly to reduce delusions c. Produce fewer extrapyramidal effects d. Are risk free for neuroleptic malignant syndrome (NMS) ANS: C Atypical antipsychotics produce less D2 blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quickly to reduce delusions. The atypicals are not risk free for NMS. 2. The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a: a. 30 mm Hg decrease in blood pressure reading b. Respiratory rate of 24 respirations per minute c. Temperature reading of 104 F d. Pulse rate of 70 beats per minute ANS: C Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate.

3. A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms? a. Decreased dopamine at receptor sites b. Blockade of histamine c. Cholinergic blockade d. Adrenergic blocking ANS: C Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation.

4. Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)? a. Grimacing and lip smacking b. Falling asleep in the chair and refusing to eat lunch c. Experiencing muscle rigidity and tremors d. Having excessive salivation and drooling ANS: A TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine.

5. When the nurse realizes that a patient diagnosed with schizophrenia is not taking the prescribed oral haloperidol (Haldol), which intervention would promote medication compliance? a. Instructing the patient to have friends monitor his medications

b. Beginning administration of haloperidol (Haldol) decanoate c. Writing instructions in detail for the patient to follow d. Changing haloperidol to an atypical antipsychotic ANS: B Haloperidol decanoate is a depot medication, given intramuscularly every 2 to 4 weeks. It is unknown whether the patient has a support system. The patient probably received education, including written instructions prior to discharge. Changing to another classification of medication would not necessarily improve compliance.

6. When asked how tricyclic antidepressants affect neurotransmitter activity, the nurse should respond that they: a. Decrease available dopamine. b. Increase availability of norepinephrine and serotonin. c. Make available increased amounts of monoamine oxidase. d. Increase the effects of the chemical gamma-aminobutyric acid.

ANS: B Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of norepinephrine and serotonin available. Decreasing dopamine is the action of typical antipsychotic medication. Increasing monoamine oxidase is not the action of tricyclics.

Benzodiazepines, not tricyclics, increase the effects of GABA. 7. A severely depressed patient has been prescribed clomipramine (Anafranil). For which medication side effects should the patient be monitored? a. Excess salivation and drooling b. Muscle rigidity and restlessness c. Polyuria and coarse hand tremors

d. Orthostatic hypotension and constipation ANS: D Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces constipation. Mild tremors and urinary retention may occur. Drooling and excessive salvation may occur with SSRIs. Muscle rigidity and restlessness may occur with antipsychotics.

8. Which of these statements made by a patient taking the MAOI phenelzine (Nardil) would warrant further instruction? a. I often forget to wear sunscreen when I go outside. b. I need to restrict the amount of sodium in my diet. c. I should not use over-the-counter cold medications. d. I usually order liver and onions when my wife and I eat out.

ANS: D MAOIs require patients to observe a tyramine-free diet to prevent hypertensive crisis. Liver is a food that contains large amounts of tyramine. The remaining options have no relevance for MAOI therapy.

9. Which patient complaint should receive priority from a patient who is taking the MAOI tranylcypromine (Parnate)? a. I havent had a bowel movement in 2 days. b. Will you take my temperature? I feel too warm. c. I get a headache when I drank several cups of coffee. d. My legs get stiff when I sit in the chair for any length of time.

ANS: C Hypertensive crisis may occur if a patient taking a MAOI ingests certain food containing tyramine or drugs that cause blood pressure (BP) elevation. Headache is a warning sign of

hypertensive crisis. The nurse should assess BP and inquire about other symptoms of hypertensive crisis. Stiffness is not related to MAOI therapy. Elevated temperature is not an initial sign of hypertensive crisis. Constipation is not a sign of hypertensive crisis.

10. Sertraline (Zoloft) has been prescribed for a patient with symptoms of a major depression.

Which factor was probably most important in the physicians decision to use an SSRI? a. Good side-effect profile b. Less expense for the patient c. Increase in medication compliance d. Rapid rate of absorption from the GI tract ANS: A Compared to other antidepressant medication groups, SSRIs have the best side-effect profile.

SSRIs are more costly. No studies have shown that SSRIs result in better compliance. These drugs are absorbed slowly from the GI tract.

11. Which statement made by a patient who will be maintained on lithium following discharge will require further instruction by the nurse? a. I will have my blood work done regularly. b. When I get home, I may go on a salt-free diet. c. I have learned not to restrict my intake of water. d. I understand some people gain weight on lithium.

ANS: B This statement shows that the patient does not understand the relationship between lithium and sodium. The patient must be taught that changing dietary salt intake will affect lithium levels.

Adding salt can cause lower levels; reducing salt can result in toxicity. The remaining options reflect correct information regarding lithium therapy.

12. To educate a patient regarding what to expect following the administration of a benzodiazepine, the nurse must understand that benzodiazepines: a. Have a rapid onset of peak action b. Reduce availability of GABA c. Generally diminish the activity of GABA d. Interact with serotonin to increase availability ANS: A Benzodiazepines do have a more rapid onset. There is no effect on the availability or function of GABA. Benzodiazepines do not diminish GABA activity; they enhance it.

13. A patient prescribed alprazolam (Xanax) for symptoms of anxiety shares with the nurse that, Im concerned about getting off this medication. Upon which fact will the nurse base the response to the patients concern? a. Long elimination half-life will result in a manageable withdrawal treatment plan. b. Rapid absorption and distribution to brain cells make withdrawal more difficult to manage. c. Sensitivity of the mesencephalic reticular activating system makes addiction unlikely. d. The combination of medication with an antidepressant often positively impacts withdrawal.

ANS: B In general, shorter-acting benzodiazepines are more difficult to taper and potentially cause more problems with withdrawal. The remaining options are neither true nor relevant.

14. Which patient outcomes would be most applicable for the patient who has been taking benzodiazepines? Patient will state: a. That there are specific foods to avoid while on this medication

b. An understanding of how to increase medication dosage c. That alcohol is a substance to avoid while on the medication d. An understanding that he or she can return to work while on this medication ANS: C Combining a benzodiazepine with alcohol or other CNS depressant is potentially fatal. No food restrictions exist. Dosage should not be changed without consultation with the physician. Patients may return to work unless experiencing sedation. In this case, they would be cautioned not to operate machinery.

15. Which person with mania is the least likely candidate to receive lithium? The patient who is: a. Six weeks pregnant b. Recovering from a hysterectomy c. Taking hormone replacement therapy d. Displaying symptoms of postpartum depression ANS: A Lithium is contraindicated during pregnancy because of teratogenic effects. The remaining options would not be contraindicative to lithium therapy.

16. An individual with poststroke depression is receiving an SSRI. What is the rationale for giving the medication at breakfast and again at midday? a. Prevent insomnia b. Prevent toxic reactions c. Decrease afternoon sleepiness d. Give an opportunity to monitor behavior closely ANS: A

CNS stimulants may cause insomnia if given late in the day. Toxicity is a result of excessive medication in the system, not when it is administered. The drowsiness resulting from SSRI use would not be minimized if taken as described. There is no expectation that resulting behaviors will need to be so closely monitored.

17. A patient who has received lithium for 3 weeks to control acute mania has the following symptoms: coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion. The priority nursing action should be to: a. Administer prn Cogentin to relieve the symptoms. b. Provide reassurance that the symptoms are transient. c. Obtain a stat lithium level; hold lithium pending results. d. Assist the patient to decrease the sodium in their daily diet.

ANS: C The symptoms the patient is experiencing are consistent with moderate lithium toxicity. The nurse should hold lithium, obtain a stat lithium level, and notify the physician. Cogentin is inappropriate; the symptoms are not EPS. The nurse may reassure the patient but cannot suggest that the symptoms will resolve over time. Minimizing salt would worsen lithium toxicity.

18. A patient with rapid cycling bipolar disorder is not responding well to lithium. The patient tells the nurse, It feels as though Ill never get well. I get better, and then I get worse. The reply that is based on knowledge of current therapy would be: a. Youre feeling very discouraged arent you? b. Its not all bad, is it? Sometimes you like being high. c. Another drug, valproic acid, is proving effective for rapid cycling. d. If your kidneys hold out, the lithium will eventually control the symptoms.

ANS: C

Valproic acid is a first-line agent for the treatment of bipolar disorder. It is particularly effective with rapid cycling. The other options are not responsive to the question stem, which asks for knowledge of current therapy.

19. Which statement by a patient with generalized anxiety disorder for whom lorazepam (Ativan) is prescribed as needed (prn) suggests the patient understands the purpose of the medication? a. I can talk with my therapist more easily after my medication takes effect. b. I wonder if I will have to take this medication for the rest of my entire life. c. Im embarrassed and dont want anyone to know Im on this kind of medication. d. Im going to ask for my prn dose so I can sleep instead of worrying about my kids.

ANS: A The patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist. The remaining options show questions and inappropriate use of the medication.

20. A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks. He drools, has hand tremors, and walks with a shuffling gait. The nurse would correctly attribute these behaviors to: a. Akinesia b. Tardive dyskinesia c. Pseudoparkinsonism d. Neuroleptic malignant syndrome ANS: C These are symptoms of pseudoparkinsonism associated with dopamine blockade. Tardive dyskinesia occurs after long-term therapy. The remaining options are not associated with the symptoms mentioned.

21. What intervention will the nurse request for a patient reporting gastrointestinal side effects related to valproate therapy? a. Mild laxative b. Low-fat diet c. Oral antacid d. Histamine-2 antagonist ANS: D Indigestion, heartburn, and nausea are common side effects of valproate therapy. The administration of a histamine-2 antagonist such as famotidine (Pepcid) is sometimes helpful. The other options would have no impact on the complaint.

22. A patients serum lithium level is reported as 1.9 mEq/L. The nurse should immediately: a. Restrict sodium and fluid intake. b. Assess for signs and symptoms of toxicity. c. Seek to have the patient transferred to ICU. d. Notify the patients physician immediately.

ANS: B A serum lithium level this high suggests that the patient may be experiencing symptoms of lithium toxicity. Clinical assessment is essential to determine what, if any, signs and symptoms are present. After the clinical assessment has been made, the nurse can provide the physician with a complete picture. Restricting sodium and fluids would raise the serum level. Transferring may not be necessary and would require a physicians order.

23. To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic drug therapy, the nurse would look for improvement in: a. Affective mobility

b. Positive symptoms c. Self-care activities d. Cognitive functioning ANS: B Typical antipsychotic medications produce improvement in the positive symptoms of schizophrenia such as hallucinations and delusions. Negative symptoms and cognitive functioning tend to show less improvement.

24. During a psychiatric emergency, IM ziprasidone (Geodon) is administered to an assaultive patient. During the next 2 hours, it is of primary importance that the nurse assess for: a. Tardive dyskinesia b. Anticholinergic effects c. Orthostatic hypotension d. Pseudoparkinsonism ANS: C The side effect most likely to appear is orthostatic hypotension related to alpha1 receptor blockade preventing peripheral blood vessels from automatically responding to positional change. Anticholinergic effects are of lesser concern. The remaining options are less likely to occur at this point in therapy.

25. A patient who began haloperidol (Haldol) therapy 24 hours ago tells the nurse that he feels jittery and unable to sit or stand still. The nurse can hypothesize that this report is related to: a. Dystonia b. Akathisia c. Serotonin syndrome d. Neuroleptic malignant syndrome

ANS: B Akathisia, an extrapyramidal side effect, is characterized by restlessness, inability to sit still, and the need to pace. It usually occurs early in the course of treatment with a typical antipsychotic drug. The symptomology is not related or seen in the other options.

26. When reviewing the medications being taken by an elderly patient diagnosed with Alzheimers disease, the nurse should consult with the patients physician when noting a prescription for: a. Risperidone (Risperdal) b. Fluphenazine (Prolixin) c. Lorazepam (Ativan) d. Sertraline (Zoloft) ANS: A Patients with dementia-related psychosis who were treated with atypical (second-generation) antipsychotics such as Risperdal were at an increased risk of death as compared with patient taking a placebo. The other medications are not currently known to have that risk.

27. When a patient for whom haloperidol has been prescribed tells the nurse, Im burning up and my muscles are stiff and sore, the nurse suspects neuromuscular malignant syndrome and recognizes the possibility that the physician may order: a. Olanzapine (Zyprexa) b. Benztropine (Cogentin) c. Venlafaxine (Effexor) d. Dantrolene (Dantrium) ANS: D Dantrolene, a direct-acting skeletal muscle relaxant, is a drug often used to treat NMS. The other drugs mentioned would have no therapeutic effect on NMS.

28. A patient with schizophrenia is seen in the ED in an acutely agitated state resulting from threatening auditory hallucinations. The patients medical record indicates he has had severe dystonic reactions to parenteral administration of typical antipsychotic medication. The nurse can anticipate that the physician will order: a. Ziprasidone (Geodon) b. Fluphenazine (Prolixin) decanoate c. Clozapine (Clozaril) d. Paroxetine (Paxil) ANS: A This atypical antipsychotic comes in an injectable form and is effective in controlling agitated and assaultive behaviors. Fluphenazine (Prolixin) decanoate is a typical antipsychotic. Clozapine (Clozaril) is used only for refractory schizophrenia. Paroxetine (Paxil) is an SSRI. 29. A patient whose schizophrenia has been refractory to treatment with other medications has been placed on clozapine (Clozaril). The priority discharge teaching should include: a. Keep salt intake the same from day to day. b. Maintain a strict tyramine-free daily diet. c. Report for weekly blood tests for CBC level. d. Use sunblocking agents when out of doors.

ANS: C Clozaril has the potential to cause agranulocytosis; hence the need for weekly blood draws for CBCs for the first 6 months of therapy and every other week after that point. The other options are not relevant to Clozaril therapy. Salt intake refers to lithium therapy, tyramine to MAOI therapy, and sunblocking to phenothiazine therapy.

30. The nurse must notify the physician of the need to suspend treatment for a patient receiving clozapine (Clozaril) when the weekly WBC monitoring shows:

a. WBCs below 2000/mm3 and absolute neutrophils below 1000/mm3 b. WBCs below 2500/mm3 and absolute neutrophils below 1500/mm3 c. WBCs below 3000/mm3 and absolute neutrophils below 2000/mm3 d. WBCs below 3500/mm3 and absolute neutrophils below 2500/mm3 ANS: A Counts at this level indicate the presence of leukopenia. Agranulocytosis is a possible side effect of Clozaril therapy for which the patient is closely monitored. The other levels are high enough to be considered safe.

31. A patient receiving haloperidol urgently calls to the nurse and reports that his eyes have rolled upward and he cannot redirect his gaze. The nurse contacts the physician to seek an order for: a. Fluphenazine (Prolixin) b. Citalopram (Celexa) c. Benztropine (Cogentin) d. Risperidone (Risperdal) ANS: C The nurse should recognize the patients problem as dystonia and know the treatment is IM administration of an antiparkinsonian drug, such as benztropine, or an antihistamine, such as diphenhydramine (Benadryl), for which a physicians order is necessary. Fluphenazine (Prolixin) would worsen the condition. The remaining options would not be useful.

32. An appropriate outcome for trihexyphenidyl (Artane) therapy used in conjunction with high potency typical antipsychotic medication therapy is that the patient will: a. Demonstrate a brighter mood b. Be less sedated and drowsy

c. Display fewer movement disorder symptoms d. Display decreased anticholinergic symptoms ANS: C Trihexyphenidyl is used to treat extrapyramidal symptoms, such as pseudoparkinsonism. The other options are not expected outcomes of administration of this medication.

33. An atypical antipsychotic has been prescribed for an elderly patient. The nurse developing the patients care plan includes: a. Scheduling weekly WBC counts b. Teaching about a tyramine-free diet c. Requesting that a daily laxative be included d. Teaching fall prevention strategies to both the patient and family ANS: D Orthostatic hypotension is a possible side effect due to alpha-adrenergic blockade. The nurse should teach the patient about changing position slowly and using handrails when walking to prevent falls. The remaining options are not related to antipsychotic medications.

34. The nurse notes that a patient who has been receiving paroxetine (Paxil) for symptoms of major depression begins to behave in a confused and elated manner with the presence of restlessness, muscle jerking, and diaphoresis. The nurse should assess these symptoms as probable: a. Neuroleptic malignant syndrome b. Anticholinergic blockade c. Serotonin syndrome d. Dystonia ANS: C

These are symptoms of serotonin syndrome, a condition that requires medical intervention. The other options are not associated with SSRI therapy.

35. When following up on SSRI medication side effects, the nurse will need to make specific inquiries about: a. Anticholinergic symptoms b. Alpha-adrenergic blockade c. GI tract symptoms d. Sexual dysfunction ANS: D SSRIs often cause sexual dysfunction, a symptom patients may be reluctant to bring up voluntarily. Patients readily bring up the side effects mentioned in the other options.

36. A patient taking SSRIs mentions to the nurse that his current medication causes fewer side effects than the tricyclic antidepressant he took several years earlier. The nurse understands that SSRIs advantage is due to: a. Inhibiting both serotonin and norepinephrine uptake b. Selectively inhibiting dopamine uptake c. Blocking only serotonin reuptake d. Making more GABA available ANS: C TCAs inhibit the reuptake of both norepinephrine and serotonin, producing more side effects than SSRIs that selectively block only serotonin reuptake. SSRIs do not affect dopamine or GABA availability.

Chapter 30: Brain Stimulation Methods Multiple Choice 1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurses rationale for this procedure?

A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medication-induced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain.

2. Immediately after electroconvulsive therapy, in which position should a nurse place the client?

A. On his or her side to prevent aspiration B. In semi-Fowlers position to promote oxygenation C. In Trendelenburgs position to promote blood flow to vital organs D. In prone position to prevent airway blockage ANS: A The nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment.

3. A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred?

A. During ECT a state of euphoria is induced.

B. ECT induces a grand mal seizure.

C. During ECT a state of catatonia is induced.

D. ECT induces a petit mal seizure.

ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression.

4. A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention?

A. Suicide assessment must continue throughout the ECT course.

B. Antidepressant medications are contraindicated throughout the ECT course.

C. Discourage expressions of hopelessness throughout the ECT course.

D. Encourage a high-caloric diet throughout the ECT course.

ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom.

Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations.

5. After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, I cant even remember eating breakfast, so I want to stop the ECT. Which is the most appropriate nursing reply?

A. After you begin the course of treatments, you must complete all of them.

B. Youll need to talk with your doctor about what youre thinking.

C. It is within your right to discontinue the treatments, but lets talk about your concerns.

D. Memory loss is a rare side effect of the treatment. I dont think it should be a concern.

ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the clients concerns so that the nurse can provide needed information.

6. Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, Im not hungry and just want to stay in bed and sleep. On the basis of this information, which is the most appropriate nursing intervention?

A. Allow the client to remain in bed.

B. Encourage the client to join the milieu to promote socialization.

C. Obtain a physicians order for parenteral nutrition.

D. Involve the client in physical activities to stimulate circulation.

ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed.

7. A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a clients electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication?

A. Robinul decreases anxiety during the ECT procedure.

B. Robinul induces an unconscious state to prevent pain during the ECT procedure.

C. Robinul prevents severe muscle contractions during the ECT procedure.

D. Robinul decreases secretions to prevent aspiration during the ECT procedure.

ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT procedures to decrease secretions and prevent aspiration.

8. A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred?

A. Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT. B. Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration.

C. Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious.

D. Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure.

ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously a short-acting anesthetic such as thiopental sodium (Pentothal).

9. A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action?

A. The nurse notifies the clients physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room.

C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m.

D. The nurse increases the clients fluid intake to facilitate the digestive process.

ANS: A A client who is scheduled for ECT procedures is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment.

10. A client who is learning about electroconvulsive therapy (ECT) asks a nurse, Isnt this treatment dangerous? Which is the most appropriate nursing reply?

A. No, this treatment is side-effect free.

B. There can be temporary paralysis, but full functioning returns within 3 hours of treatment.

C. There are some risks, but a thorough examination will determine your candidacy for ECT. D. Transient ischemic attacks (TIAs) can occur but are rare.

ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment.

11. A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve?

A. The client will verbalize an understanding of the need for moving slowly after treatment.

B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment.

C. The client will continue adequate tissue perfusion 1 hour after treatment.

D. The client will verbalize an understanding of common side effects of ECT. ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored.

12. A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the clients lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply?

A. The cuff has to be placed on the leg because both arms are used for intravenous fluids.

B. The cuff functions to prevent succinylcholine from reaching the foot.

C. The cuff position gives a more accurate blood pressure reading during the treatment.

D. The cuff is placed on the leg so that arms can easily be restrained during seizure.

ANS: B A blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent.

13. A client states, My doctor has told me I am a candidate for electroconvulsive therapy (ECT).

Where will the treatment take place, and how much time would this entail? Which is the most accurate nursing reply?

A. Clients typically receive ECT in their hospital room, daily for 1 month.

B. Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting.

C. Clients typically receive an unlimited number of treatments, in the hospital procedure room.

D. Clients typically receive two to three treatments, in either an outpatient or inpatient setting.

ANS: B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures. Treatments are usually administered every other day, three times per week.

Treatments are performed on either an inpatient or outpatient basis, depending on the need for client monitoring.

14. A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. Which information should a nurse include when teaching about the potential side effects of this procedure?

A. You may experience transient tangential thinking.

B. You may experience some memory deficit surrounding the ECT. C. You may experience avolution for the remainder of the day.

D. You may experience a higher risk for subsequent seizures.

ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure.

15. When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize?

A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT. 16. A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would impact the feasibility of this treatment option?

A. Because the client is extremely suicidal, ECT is an appropriate option.

B. Because antidepressant medications have been ineffective, ECT is a good alternative.

C. Because informed consent is required for ECT, cognitive deficits could preclude this option.

D. Because of the clients cognitive deficits, a signed consent is waived.

ANS: C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the clients level of competency and, if necessary, the judge would appoint a guardian.

Multiple Response 17. A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply.

A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression, acute mania, and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions.

18. Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply.

A. Electrocardiographic records

B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results ANS: A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the clients physician. The client must be medically cleared prior to ECT. 19. During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply.

A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated.

20. Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply.

A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy.

Chapter 31: Child Psychiatry Test Bank MULTIPLE CHOICE 1. Which complaint is representative of anxiety in a 6-year-old child? a. I worry that my dad will get hurt at work. b. I get a stomach ache when its my weekend at my dads house. c. I cant sleep when I stay at Grandmas because I worry about my mom. d. Im not going to sports camp because I dont like being away from my friends.

ANS: A Developmental differences exist with regard to the symptoms of anxiety. Children between the ages of 5 and 8 years old most commonly report unrealistic worry about harm to their parents.

Between the ages of 9 and 12 years, children report excessive distress during times of separation.

Adolescents typically report somatic complaints.

2. Which of the following meets the DSM-IV-TR criteria for moderate mental retardation? a. Requires constant one-on-one supervision and total physical care b. Advanced as far as the sixth grade and works at a warehouse every day and supports himself c. Advanced as far as the second grade and provides her own personal care with supervision d. Attends the local community college for developmental English and math courses ANS: C Individuals diagnosed as having moderate mental retardation acquire some communication skills, but rarely advance academically beyond the second grade. With supervision they can

provide for their own personal care. Persons requiring constant supervision and total physical care would be considered profoundly retarded. Persons achieving elementary or above learning skills would be considered mildly retarded.

3. The nurse is assessing a child with autism. Which of the following behaviors would the nurse expect to observe? a. Referring to their imaginary friend, Skipper b. Asking to telephone my friends on the weekends c. Repeating, milk, milk, milk, milk until given a drink d. Is insistent that a dim light be left on in the bedroom at night ANS: C Stereotyped and repetitive use of language or idiosyncratic language is one of the characteristic behaviors seen in autism. The remaining options are normal characteristics of a child in various developmental stages.

4. Which behavior best supports the diagnosis of attention-deficit/hyperactivity disorder in an 8year-old child? a. Cries when separated from his mother or father b. Refuses to pick up toys as instructed by his parents c. Is fascinated with spinning and moving toys and objects d. Can concentrate on school work for only very short periods of time ANS: D Experiencing difficulty concentrating on tasks is a hallmark for ADHD. Crying is a characteristic of separation anxiety. Disobedience as described may represent oppositional behavior. Focusing on repetitious motion is characteristic of autism.

5. Which behavior is most characteristic of a conduct disorder?

a. Frequently getting up and interrupting while being read to b. Only apologizes for hitting a friend to avoid being punished c. Finds it difficult to spend the night away from family members d. Becomes extremely agitated when the television is turned off ANS: B Children or adolescents with conduct disorder generally do not empathize with other peoples feelings and are unconcerned with others situations or needs. They exhibit uncaring behavior, but they will often express words of guilt or remorse because they have learned that it reduces or prevents punishment. ADHD is often characterized by hyperactivity. Separation anxiety is often responsible for a childs resistance to spending time away from home. Autism can be the cause of exaggerated responses.

6. Which assessment finding should be considered a high risk factor for adolescent suicide? a. Being sexually abused b. Having experienced panic attacks c. Being mildly cognitively impaired d. Having a diagnosis of type 1 diabetes ANS: A Suicide risk factors include a history of sexual abuse. There is no current research to support a strong relationship between suicide attempts and any of the other options.

7. Planning for a patient with Aspergers disorder will be facilitated if the nurse understands that this disorder is different from autism. The nurse will base care on knowledge that Aspergers disorder is characterized by: a. Repetitive patterns of behavior b. Age-appropriate language development

c. Stereotypic movements and speech patterns d. Obsession with objects that move in a spinning motion ANS: B Communication will be facilitated knowing that a patient with Aspergers disorder has no clinically significant delays in language or cognitive function. The remaining options are characteristics of both disorders.

8. Which behaviors would support a diagnosis of oppositional-defiant disorder? a. Exhibits involuntary facial twitching and blinking and makes barking sounds b. Negative, hostile, and spiteful toward parents and blames others for misbehavior c. Displays high anxiety when away from parents, has nightmares, and fears being kidnapped d. Violates others rights, is cruel to people or animals, lies and steals, and is truant from school ANS: B Children with oppositional defiant disorder argue with adults, actively defy adults requests, deliberately annoy adults, and refuse to take responsibility for their behaviors. Lying, stealing, and animal cruelty describes a child with conduct disorder. Being afraid of being kidnapped describes a child with separation anxiety. Facial twitching is associated with Tourettes disorder.

9. Which childs history is a risk for developing a reactive attachment disorder? a. Father is a chronic alcoholic b. Was born with a congenital cardiac disorder c. Experienced head trauma at age 7 months of age d. Spent first 12 months of life in an Asian orphanage ANS: D

Reactive attachment disorder is a disorder that occurs in some children who are institutionalized.

10. Which intervention will best help a teenager manage aggressive behavior? a. Administering prescribed medication as ordered b. Supporting the patients interest in writing poetry c. Reenacting situations that may trigger aggression d. Providing information on anger management techniques ANS: C Role-play situations that trigger aggressiveness explore and reinforce alternative methods of coping. The other options although appropriate lack the opportunity to reflect on the triggers and practice the coping skills.

11. Which intervention will best help a child manage hyperactive behavior? a. Arranging for the child to play basketball 4 times a week b. Allowing the child to play a favorite video game as a reward c. Using a favorite food and beverage to distract the child d. Placing the child in a low stimulation environment for 30-60 minutes ANS: A Redirect disruptive behavior with recreational activities to channel excess energy. The remaining options will have little positive effect on the childs energy level.

12. The nursing diagnosis that would be universally applicable for children with autistic disorder would be: a. Risk for constipation related to odd eating habits b. Chronic low self-esteem related to negative social feedback c. Impaired social interaction related to inability to relate to others

d. Disturbed thought processes related a neurological dysfunction ANS: C Children with autistic disorder display profoundly disturbed social relationships. Essentially, they lack social reciprocity. They seem aloof and indifferent to others and prefer inanimate objects to people. The remaining options are not necessarily true of this mental illness.

13. A childs diagnosis of conduct disorder is supported by the fact that: a. The childs mother is a chronic alcoholic. b. The child engages in ritualistic behaviors. c. A brain scan shows structural abnormalities. d. There is a family history of respiratory disorders.

ANS: B Conduct disorder occurs more frequently when a biologic parent has alcohol dependency. There is no research to support a connection between a conduct disorder and any of the remaining options.

14. Which intervention will best help minimize parental guilt in the family of a child diagnosed with a psychiatric disorder? a. Helping them to develop realistic expectations for their child b. Educating them on the need to provide the child with boundaries c. Providing them with information regarding locally available services d. Encouraging them to use respite care periodically to allow for downtime ANS: A Teach the parents about the patients disorder to minimize their guilt related to causing or caring for the child. The remaining options although appropriate do not focus on the potential for self guilt.

15. Which behavior demonstrates that a child is achieving appropriate management of separation anxiety? a. Earned two As, three Bs, and one C this report card period b. Falls asleep with a parent sitting outside the bedroom door c. Sleeps on a chair in the parents bedroom rather than in their bed d. Reports having only a little stomach ache during breakfast on school days ANS: A Children with separation anxiety disorder demonstrate academic difficulties resulting from a refusal to attend school or frequent absences resulting from somatic illnesses. The other options show continued behaviors seen with this disorder.

16. A 15-year-old has been diagnosed with major depression and admitted to the adolescent unit.

Which behavior would the nurse expect to observe in this patient? a. Discussing repeated run-ins with the law b. Being manipulative and callous towards others c. Blaming adults for his admission to the adolescent unit d. Reporting decreased enjoyment of school-related activities ANS: D Anhedonia, the absence of pleasure, is a common manifestation of depression. Legal behavior and manipulative and uncaring behavior are characteristic of conduct disorder. Seeing adults as the root of their problems is common in conduct disorder and oppositional-defiant disorder.

17. When discussing depression and suicide with parents of teenagers, the nurse is accurate in reporting that the most common method used in late adolescent suicide is: a. Hanging b. Firearms

c. Oral poisoning d. Drug overdose ANS: B Statistics show the use of firearms is the most commonly used method of committing suicide among adolescents. With this in mind, the nurse could counsel parents about the importance of keeping firearms locked away from teens. The other options are less-often used methods for attempting suicide.

18. Planning safety interventions for a teenager with a history of self-injurious behavior is based on what research-based information? a. Teenagers rarely entertain the idea of suicide. b. Suicides can occur accidentally as a result of self-injurious behaviors. c. Self-injury is always viewed as a risk factor for future suicidal attempts. d. Assessment for suicidal ideations is a vital component of this childs care.

ANS: B Self-injurious behavior is not suicidal behavior and is not viewed as a risk factor for suicidal ideations or attempts, but some teenagers accidentally commit suicide in the process. Teenagers are acting on suicidal thoughts at an alarming rate.

19. Which statement made by a teenage male hospitalized after a failed suicide attempt is most concerning to the nurse? a. My uncle shot himself but he didnt die. b. I dont know why I get so depressed and want to die. c. The gun I got for my birthday is my most prized possession. d. I hope I dont ever get depressed enough to try and hurt myself again.

ANS: C

Factors associated with suicidal behaviors include access to firearms providing the teenage patient with the opportunity and means to harm himself if he again becomes depressed. Although the remaining options represent possible risk factors, none provide insight into opportunity and means.

20. The mother of a child describes her childs annoying behavior as not being able to sit still or to stop jerking his arms when told to. Which disorder does the nurse suspect? a. Tourettes disorder b. Oppositional-defiant disorder c. Pervasive developmental disorder d. Attention-deficit/hyperactivity disorder ANS: A The parent describes simple motor tics that are involuntary behaviors and characteristic of Tourettes disorder. The child is not being defiant because he has no control of the tics. Although the child displays repeated motor behaviors, they are unrelated to hyperactivity because they are not generalized and occur only sporadically. These involuntary tics are not seen in pervasive developmental disorders such as autism.

21. Which response is most therapeutic when a parent whose child is diagnosed with Tourettes disorder voices concerns that their childs facial contortions are merely acts of defiance? a. Your child isnt defiant but rather mentally ill. b. What makes you think he is doing that out of defiance? c. I think with the use of some behavior modification techniques, he can learn to control the facial tics. d. Your sons behavior is likely due to a neurological dysfunction that causes those involuntary facial tics.

ANS: D

Tourettes disorder is most often thought to be a genetic neurologic disorder whose characteristic behaviors are involuntary in nature. Referring to the child as mentally ill is not a true description of the situation. Asking the parent to further discuss the idea that the tics are an act of defiance is inappropriate since that is not true. Behavioral modification is not effective on involuntary behaviors.

22. Which description is characteristic of an impulsive child? a. Pacing and speaking in a very loud, disruptive voice b. Frequently talking about hearing voices telling him what to do c. Running out into the street regardless of frequent instruction to look both ways first d. Having a difficult time concentrating on reading since his attention is easily diverted ANS: C Running into the street is an example of impulsive behavior because it is clearly taking action before considering consequences. Hyperactivity refers to such things as increased pace and volume of activity. Thought disorders include such perceptual dysfunction as auditory hallucinations. Distractibility is characterized by poor concentration.

23. Which intervention would qualify as primary prevention of violent behaviors in children and adolescents? a. Forbidding the child to continue friendships with violent peers b. Limiting exposure to violence on TV, video, and computer games c. Seeking counseling for a child who has been experimenting with drugs d. Showing a unified approach to parenting when dealing with a violent child ANS: B

Studies suggest that an obsession with violence in video games, movies, music, and writings increases aggressiveness in children and adolescents. The other options are relevant only after the risk for violence has been established.

24. A friend says to a nurse, I am not going to get vaccines for my baby. I hear that vaccines cause autism. The nurses best reply is: a. The exact cause of autism is not really known b. Its believed that autism is really a result of birth trauma. c. There is no conclusive evidence to connect autism to vaccinations. d. Please tell me more about where you got that information about autism?

ANS: C There is no research to connect autism to a reaction to vaccinations or to birth trauma. The exact cause of autism remains undetermined but that response doesnt address the patients statement nor does asking the patient to give additional information regarding their original statement.

25. A 5-year-old girl on a behavior modification program is admitted to the unit. The nurse would expect to participate in which activity based on this approach? a. Firmly challenging the childs irrational thoughts b. Including the child in the creation of a behavioral contract c. Family therapy with every member present for each session d. Play therapy with dolls representing every member of the family ANS: B Behavior modification includes constructing a contract that outlines behavioral changes that is a result of the input of therapists, family and the child. Family therapy, play therapy, and thought challenging are not generally used with a behavior modification program.

26. A mother asks why the whole family needs to meet with the therapist because it is her teenage stepdaughter who has the substance abuse problem. The nurse replies with the knowledge that: a. Mothers usually have insight into their childrens problem. b. The parents are responsible for changing the teens behavior. c. The family will probably use behavior modification with the teen. d. Sometimes the teenaged patient is actually acting out family dynamics.

ANS: D It is important to remember that children will often act out the underlying family dynamics or family psychopathology. Mothers may not have an understanding of the problems their children are experiencing. Behavior modification is not typically a treatment for teen substance abuse.

The teen is responsible for changing personal behavior.

MULTIPLE RESPONSE 1. The parents of a child diagnosed with ADHD ask the nurse what current medications are available for their child. The nurse should list which of the following medications? (Select all that apply.) a. Methylphenidate (Concerta) b. Zolpidem (Ambien) c. Dextroamphetamine (Adderall) d. Atomoxetine (Strattera) e. Haloperidol (Haldol) ANS: A, C, D Ambien is a sleeping medication and not typically used to treat ADHD. Haldol is an antipsychotic that is not specified for use for ADHD. The other medications are sometimes used for ADHD.

Chapter 32: Adulthood 1. A student nurse visiting a senior center says, Its depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion. The student is expressing: a. reality.

c. empathy.

b. ageism.

d. vulnerability.

ANS: B Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student.

2. A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include? a. Pain assessment techniques for older adults b. Psychosocial stimulation for those who live alone c. Preparation of psychiatric advance directives in the elderly d. Ways to manage disinhibition in elderly persons with dementia ANS: A The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.

3. Select the best comment for a nurse to begin an interview with an elderly patient. a. I am a nurse. Are you familiar with what nurses do? b. Hello. I am going to ask you some questions to get to know you better.

c. You look comfortable and ready to participate in an admission interview. Shall we get started? d. Hello. My name is _______ and I am a nurse. How you would like to be addressed by staff?

ANS: D The correct opening identifies the nurses role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.

4. Which information is most important to obtain during assessment of an older adult diagnosed with a mental disorder? a. Functional ability and emotional status b. Chronological age and sexual function c. Economic status and sources of income d. Developmental history, interests, and activities ANS: A Information related to functional ability and emotional status provides an overview of patient problems and abilities. It guides selection of interventions and services to meet identified needs.

The distracters reflect information of relevance, but are not of highest priority.

5. A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important? a. Complete a neurological assessment. b. Determine whether the patient can hear as the nurse speaks.

c. Suggest that the patient lie down in a darkened room for a few minutes. d. Administer medication to relieve the patients pain before continuing the assessment.

ANS: B Before proceeding with any further assessment, the nurse should assess the patients ability to hear questions. Impaired hearing could lead to inaccurate answers.

6. Which statement about aging provides the best rationale for focused assessment of elderly patients? a. The elderly are usually socially isolated and lonely. b. Vision, hearing, touch, taste, and smell decline with age. c. The majority of elderly patients have some form of early dementia. d. As people age, thinking becomes more rigid and learning is impaired.

ANS: B Only the key is a true statement. It cues the nurse to assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging.

7. A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively. a. Would you say your mood is often sad? b. Are you having any trouble with your memory? c. Have you noticed an increase in your alcohol use? d. Do you often experience moderate to severe pain?

ANS: A

Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood.

8. A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 G sodium diet, Restraint as needed, Limit fluids to 1800 mL daily, Continue antihypertensive medication, Milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should: a. question the fluid restriction. b. question the order for restraint. c. transcribe the prescriptions as written. d. assess the residents bowel elimination.

ANS: B Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.

9. An elderly patient must be physically restrained. Who is responsible for the patients safety? a. The nurse assigned to care for the patient b. Unlicensed assistive personnel who apply the restraint c. Family member who agrees to application of the restraint d. Health care provider who prescribed application of restraint ANS: A Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the

application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes.

10. A new nurse asks, My elderly patient has Lewy body disease. What should I do about assessing for pain? Select the best response from the nurse manager. a. Ask the patients family if they think the patient is experiencing pain. b. Use a visual analog scale to help the patient determine the presence and severity of pain. c. There are special scales for assessing patients with dementia. Lets review how to use them. d. The perception of pain is diminished by this type of dementia. Focus your assessment on the patients mental status.

ANS: C Lewy body disease is a form of dementia. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.

11. An advance directive gives legally binding direction for health care interventions when a patient: a. has a new diagnosis of cancer. b. is diagnosed with Parkinsons disease. c. is unable to make decisions for self because of illness. d. diagnosed with amyotrophic lateral sclerosis is unable to speak.

ANS: C

Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinsons disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.

12. A patient asks, What advantage does a durable power of attorney for health care have over a living will? The nurse should reply, A durable power of attorney for health care: a. gives your agent authority to make decisions during any illness if you are incapacitated. b. can be given only to a relative, usually the next of kin, who has your best interests at heart. c. can be used only if you have a terminal illness and become incapacitated. d. cannot be implemented until 30 days after the documents are signed.

ANS: A A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individuals agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individuals behalf.

13. A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patients needs? a. Adult day care program

c. Partial hospitalization

b. Skilled nursing facility

d. Group home

ANS: A

A day care program provides recreation and social interaction as well as supervision in a safe environment. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A group home is inappropriate and would not meet the patients needs.

14. A 79-year-old white male tells a nurse, I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing. The nurse should analyze this comment as: a. normal pessimism of the elderly.

c. a call for sympathy.

b. evidence of risks for suicide.

d. normal grieving.

ANS: B The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.

15. In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurses priority is to determine whether which nursing diagnosis applies to this patient? a. Risk for suicide related to recent deaths of significant others b. Anxiety related to sudden and abrupt lifestyle changes c. Social isolation related to loss of existing family d. Spiritual distress related to anger with God ANS: A The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No

defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patients social isolation is important, but the risk for suicide has higher priority.

16. When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value? a. Evidence of spasticity or flaccidity b. The patients level of motor activity c. Medications the patient has recently taken d. Level of preoccupation with somatic symptoms ANS: C Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.

17. An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, Its awful to be old. Every day is a struggle. No one cares about old people. Select the nurses best response. a. Everyone here cares about old people. Thats why we work here. b. It sounds like youre having a difficult time. Tell me about it. c. Lets not focus on the negative. Tell me something good. d. You are still able to get around, and your mind is alert.

ANS: B The nurse uses empathetic understanding to permit the patient to express frustration and clarify her struggle for the nurse. The distracters block communication.

18. A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization? a. Remotivation

c. Psychotherapy

b. Activity group

d. Reminiscence (life review)

ANS: A Remotivation therapy helps to resocialize regressed and apathetic patients by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies related to the topic. Group leaders give members acceptance and appreciation. Group psychotherapy would not be effective for this patient. An activity group does not address the patients problem.

19. A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who: a. consumes 1 glass of wine nightly with dinner. b. began drinking alcohol daily after retirement and says, A few drinks keep my mind off my arthritis. c. drank socially throughout adult life and continues this pattern, saying Ive earned the right to do as I please. d. abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA).

ANS: B Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.

20. A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment. a. Are there any things going on in your life that would cause you to consider suicide? b. What are your beliefs about a persons right to take his or her own life? c. Do you think you are vulnerable to developing a depressed mood?

d. If you felt suicidal, would you tell someone about your feelings?

ANS: B This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth.

The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.

21. A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, I get lonely and drink a little to help me forget. Select the nurses most therapeutic intervention. a. Assess whether this patient is drinking and driving. b. Advise the person not to drink alone because the risks for injury increase. c. Teach the person about risks for alcoholism and suggest other coping strategies. d. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.

ANS: D This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.

22. Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depression. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient. a. Behavioral health home care

c. Partial hospitalization

b. A skilled nursing facility

d. A halfway house

ANS: C Partial hospitalization will provide services the patient needs as well as give supervision and meals to the patient while the daughter is at work. Home care would not provide socialization.

The patient does not need the intensity of a skilled nursing facility. A halfway house provides 24-hour care and usually expects involvement in off-campus programs.

23. A patient living in community housing for the elderly says, I dont go to the senior citizens club. They play cards and talk about the past because thats all they can do. The nurse analyzes these remarks to represent: a. failure to achieve developmental tasks. b. thinking associated with ageism. c. hypercritical behavior. d. paranoid thinking.

ANS: B Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of ageism as younger individuals. The other options are not substantiated by the information given in the scenario.

24. A nurse plans a staff education program for employees of a senior living community. Which topic has priority? a. Late-onset schizophrenia

c. Dementia

b. Depression and suicide

d. Delirium

ANS: B Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence.

25. An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful? a. Ask questions that can be answered with yes or no. b. Ask clear, simple questions using concrete language. c. Use silence often and let the patient take the lead. d. Use open-ended, indirect questions.

ANS: B Communication with individuals who have schizophrenia might be difficult because of the individuals various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed. The nurse needs more information than yes or no questions will provide.

26. An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled Ativan and one labeled lorazepam, both of which are to be taken BID. There are also bottles labeled hydrochlorothiazide, Inderal, and rofecoxib, each to be taken once daily. Which conclusion is accurate? a. Rofecoxib should not be taken with Ativan. b. Lorazepam interferes with the action of Inderal. c. The patient should not self-administer medication. d. Lorazepam and Ativan are the same drug, so the dose is excessive.

ANS: D Lorazepam and Ativan are generic and trade names for the same drug, creating an accidental misuse situation. The patient needs medication education and help with proper, consistent labeling of bottles; there is no evidence that the patient cannot self-administer medication. The other distracters are not factual statements.

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

ANS: A Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The distracters may be relevant but are not the highest priority.

28. A nurse and social worker co-lead a reminiscence group for eight elite-old adults. Which activity is appropriate to include in the group? a. Mild aerobic exercise b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in todays newspaper ANS: B Elite-old adults are persons 100+ years of age. They were young people during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

29. A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group? a. Mild aerobic exercise b. Singing a song from World War II c. Discussing national leadership during the Vietnam War

d. Identifying the most troubling story in todays newspaper ANS: C Young-old adults are persons 65 to 75 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

MULTIPLE RESPONSE 1. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? Select all that apply. a. Failure of the elderly to receive necessary medical information b. Development of public policy that discriminates against the elderly c. Staff shortages because caregivers prefer working with younger adults d. The perception that elderly consume a smaller share of medical resources e. More ancillary than professional personnel discriminate with regard to age ANS: A, B, C Because of societys negative stereotyping of the elderly as having little to offer, some staff persons avoid working with older patients. Staff shortages in long-term care are common.

Elderly patients are often provided less information about their conditions and fewer treatment options than younger patients are because some health care staff members perceive them as less able to understand. This problem exists among both professional and ancillary personnel. Public policy discriminates against programs for the elderly. Anger exists because the elderly are perceived to consume a disproportionately large share of medical resources.

Chapter 33: Geriatric Psychiatry Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. An 85-year-old patient is admitted to the hospital with the diagnosis of cerebrovascular accident and depression. The symptom that is unrelated to depression would be?

A. Crying and refusing to perform task B. Answering I forgot to questions C. Having positive self-esteem D. Neglecting ADLs ____ 2. The Omnibus Budget Reconciliation Act (OBRA) provides standards of care for which of the following: A. Very young B. Older adults C. Those who have certain intellectual communication difficulties D. Those without medical insurance ____ 3. In the elderly, administering medication is a great concern for the nurse since these patients are more prone to side effects. The primary cause of this is: A. Altered circulation and renal function B. Accelerated gastrointestinal system C. Enlarged Lymph nodes D. Musculoskeletal system weakness Completion

Complete each statement.

4. The federal act that establishes the standards of care for older adults is known as the Omnibus Budget ______________ Act. 5. Major concerns of the elderly living alone in their home are: (Name 2) ____________________________________________ Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 6. When assessing the elderly for depression, the nurse may find that a depressed person over 70 years of age without a medical diagnosis, may have the following symptoms of depression (select all that apply): A. Aches B. Pains C. Constipation D. One-sided weakness E. Sleep disturbances Answer Section MULTIPLE CHOICE 1. ANS: C The patient may suffer from depression as a result of limitations produced by the stroke. The patients cerebrovascular event also will have an impact on the patient and his family. Depression can be evidenced by sadness, confusion, and lack of self-care.

2. ANS: B

OBRA provides regulations for proper assessment of the elderly; for this reason, registered nurses have to provide the initial physical assessment.

3. ANS: A LPNs/LVNs are accountable for medications administered to their patients. It is important to know the side effects of all medications distributed. Document and report any signs of toxicity.

The elderly are more likely to have side effects when there is altered metabolism through the kidneys and liver as well as altered circulatory function.

PTS: 1 COMPLETION 4. ANS: Reconciliation The Omnibus Budget Reconciliation Act (OBRA) ensures that proper assessment of elderly people will be provided in the health care facility and in the home.

5. ANS: Safety, quality of life, support system, access to medical care, financial support, emotional support The elderly remaining in the home have a greater chance of remaining healthier longer.

Integrated Process: Caring | Content Area: Mental Health: Aging | Cognitive Level: Application | Client Need: Health Promotion and Maintenance: Aging Process MULTIPLE RESPONSE 6. ANS: A, B, C, E These symptoms can be confused with other conditions, such as electrolyte imbalance, drug reactions, and dementia. Observation and documentation by the practical nurse can assist the

physician in ruling out a medical diagnosis. The elderly are more likely to have physical symptoms with depression.

Chapter 34: End of Life Issues MULTIPLE CHOICE 1. Which physical disturbance is commonly assessed in patients experiencing acute grief? a. Hypersomnia b. Increased appetite c. Tightness in the chest d. Cardiovascular problems ANS: C Chest discomfort is common with the bereaved person. Anorexia is more common. There is no research to support the connection with cardiovascular involvement. Insomnia is more frequent than sleepiness.

2. When differentiating between bereavement symptoms and depression, the nurse will base the formulation on knowledge that in bereavement: a. Suicide thoughts are common. b. Symptoms remit and exacerbate. c. Guilt feelings are overwhelming. d. Psychomotor retardation is obvious.

ANS: B Acute exacerbations are common especially around holidays and significant milestones. The remaining options are more common with depression.

3. A grief support group is held at the local community center to assist persons who are dealing with issues of loss. Which remark by one of the members would the nurse interpret as indicating unresolved feelings of guilt? a. I know that my husband had a good life. b. It seems I miss my son more as time goes on. c. I am still wishing I had gotten help to him sooner. d. The Christmas season is always a sad time for me.

ANS: C Unresolved guilt reflects that the person should have done more. Expressing peace with a situation indicates closure on the husbands life. Missing indicates continued grieving but not guilt. Reflection on difficult times is not guilt.

4. A young woman had just learned of the accidental death of her husband. She begins to cry and states, Its not fair! How could he do this to me? This remark is assessed as: a. A plea for help b. An explosive episode c. An expression of anger d. Fear of making decisions alone ANS: C The remark indicates anger that her husband died on purpose. She is not asking for help nor is there data to support an explosive response. She is not stating fear.

5. Family and friends rush to offer support to a friend who has lost her teenage son. Which of these persons, through an intended act of kindness, may contribute to prolonging the womans grief? a. The physician who prescribed antianxiety agents

b. The nurse who offered to spend the night at her home c. The next-door teenager who provided care for the sons pet d. The accountant who assisted with stabilizing their financial affairs ANS: A Frequent use of anxiolytic medications can mask grief. The other options are usual offers of assistance.

6. When a hospitalized patient dies, his wife stares blankly at the nurse and states, It cant be. The nurse assesses this as indicating: a. Despair and protest b. Shock and disbelief c. Anger and hostility d. Disorganization and confusion ANS: B Shock and disbelief are often the first responses to a death, followed by protest and despair. The wifes statement does not indicate confusion or anger.

7. When asked, the nurse explains that grief work refers to: a. Establishing new methods of coping with stress b. Evaluating progress made toward accepting the loss c. The means by which one moves through the grief process d. Actively seeking assistance to cope with the loss experiences ANS: C Grief work is moving through the stages of grief. The remaining options can be components of grief work.

8. A teen is grieving the loss of her pet dog. She states to her mother, I miss my dog so much, but I know that if I start crying, I will never stop. The teen is expressing a fear of: a. Losing control over her emotions b. Appearing emotionally immature c. Embarrassing herself by crying in public d. Losing the support of her friends and family ANS: A The teens statement that she will never stop indicates a control concern. The statement does not indicate embarrassment, immaturity concerns, or lack of support.

9. During a grief-processing group, an elderly patient stated, For the first time since my husband died, Im having more good days than bad. This statement suggests that the patient has: a. Replaced old memories with new ones b. Reached the phase of reestablishment c. Completed her grief work successfully d. Determined she is ready to terminate the support group ANS: B Reestablishment is the gradual decrease in symptoms. There are not enough data to support the remaining options.

10. A patient returned from attending the service memorializing his wife, who died after a sudden illness. Although those around him were visibly saddened, he smiled and remained in control. He refused support from friends, stating, I can handle anything that comes my way. The patients behavior is an example of _____ grief. a. Normal b. Inhibited

c. Distorted d. Conflicted ANS: B The statement indicates inhibited grief that is characterized by minimal emotional expression of grief. There is not enough data to support conflicted grief, which involves ambivalence in the relationship with the departed. Distorted grief is not one of the standard types, and normal grief is not characterized by this behavior.

11. Which person would the nurse assess as experiencing chronic sorrow? a. The mother of a child diagnosed with asthma b. The father of an adult son who is a schizophrenic c. The daughter whose father experienced a hip replacement d. The wife whose husband has recently requested a trial separation ANS: B The only situation that presents as a long-term, chronic loss is having a child with a chronic disorder like schizophrenia. The other situations are resolving or at least hopeful for recovery.

12. A patient is being seen for symptoms of insomnia and significant weight loss that has occurred during the 2 months since her husbands death. What is the purpose of the query, Describe how it has been for you since your husband died? a. To display an attitude of concern and sympathy to the patient b. To learn whether the patient has a significant support system c. To rule out factors that may interfere with diagnosing her illness d. To determine the risk for pathologic grief and the need for grief therapy ANS: D

The question is a common assessment question to determine the grief work that has been done.

The query does not ask about support systems or specific factors, and the query is more than a display of concern.

13. A nurse plans care based upon the fact that anticipatory grief: a. Is associated with a high risk for depression b. Is associated with fewer expressions of guilt c. Prevents development of symptoms of depression d. Requires a longer period of time to effect resolution ANS: A Pre-mourning or anticipatory grief is associated with a high risk for depression or family withdrawal from the patient. It is normative and does not necessarily require a longer period of resolution or indicate fewer guilt expressions. It does not prevent depression.

14. A woman whose abusive husband was killed in an automobile accident 3 years earlier continues to idealize him and repeatedly talks about their wonderful relationship. Which outcome is most appropriate for the patient? Patient will: a. Enlist the emotional support of both family and friends. b. Keep a daily journal recording memories of time spent with her husband. c. Read information on the affects of physical abuse and the support groups available to her. d. Express both positive and negative feelings about her husband and their life together.

ANS: D Chronic grief involves unresolved issues in a relationship with the person who died. In this case, a more realistic expression of their life together is needed. The remaining options are appropriate but do not address the primary need to establish realistic memories of the relationship.

MSC: NCLEX: Psychosocial Integrity 15. During a bereavement group, one of the members states, I should have been the one to die.

My husband had so much to offer. The member was expressing: a. An intention to commit suicide b. Ambivalence and low self-esteem c. Unresolved anger toward her husband d. A need for attention from group members ANS: B The statement suggests low self-esteem. There is no mention of suicidal ideation. This is not simply an attention-getting statement. The statement does not imply anger.

16. The community health nurse is visiting a patient diagnosed with dysfunctional grieving since the death of his wife and child over a year ago. Which actions should the nurse implement first? a. Promote interaction with others. b. Assess risk of self-directed violence. c. Facilitate expression of feelings related to the loss. d. Determine the degree of ambivalence toward the loss.

ANS: B Safety issues would be the priority in cases of depression and dysfunctional grief. The remaining options are appropriate actions after risk is assessed.

17. An adult patient shares that, When my mother died when we were children, I never saw my father show any emotion. What do you think will happen with those unexpressed feelings?

Which response is most appropriate? a. Pent-up emotions may lead to depression or other disorders.

b. Your father probably has worked through his grief by this time. c. Maybe you can teach him how to best express his own feelings. d. If feelings are not effectively expressed, the person can become suicidal.

ANS: A Inhibited expression of grief can lead to depression. It cannot be assumed that the grieving process has been completed. The adult child should not be made to feel responsible for counseling the father. Unexpressed feelings do not necessarily lead to suicidality.

18. An elderly couple who lived in the same home for the past 50 years have moved into an adult retirement center in a nearby town. Changes in lifestyle such as this couple is experiencing should alert the nurse to the possibility of: a. Acute grief b. Traumatic grief c. Chronic sorrow d. Adventitious crisis ANS: A Adjustment to life cycle transitions may initiate acute grief. This could be a situational crisis but not an adventitious crisis. There are no indications that this will become chronic and lacks the magnitude needed to result in traumatic grief.

19. A teenage boy has lost his best friend as a result of a hunting accident. His parents report that he is eating and sleeping very little and expresses little interest in school. They are concerned that he talks about the accident repeatedly. These behaviors are generally seen as: a. Expressing responsibility for his friends death b. Attempts to avoid dealing with his pain c. Expressions of a normal grief reaction

d. Indications of a risk for self-harm ANS: C The teen is displaying normal grief responses. He is not avoiding his pain but rather expressing it various ways. There are no data to support that he feels responsible. He has not expressed suicidal ideation.

20. An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed with terminal cancer would be that the patient will: a. Continue to be emotionally involved with the dying spouse b. Develop protective mental mechanisms to allay the pain of spousal loss c. Not voice threats of physical violence that is either self or others directed d. Agree to stay at home and care for the spouse with appropriate assistance ANS: A Some families who are experiencing anticipatory grieving withdraw prematurely from the ill member, so this is an important outcome. There are no protective mechanisms to prevent loss experiences. Anticipatory grieving does not imply violence. A contract to stay home and care for the spouse even with assistance is not helpful.

21. Which patient would the nurse determine to be at highest risk for dysfunctional grief? The patient: a. Whose 16-year-old daughter was raped and killed while going on an errand for the patient b. Whose 86-year-old mother, with whom she has shared her home, died after a long illness. c. Who attended a support group and had been assisted by hospice to care for her terminally ill husband d. Who attended a bereavement group, where she learned to express feelings after the deaths of her twin daughters

ANS: A The traumatic nature of the death makes this patient at highest risk. The death of the mother was of an elderly person and expected. The remaining options involve patients involved with hospice or support groups that lessen the likelihood for dysfunctional grief.

22. Which intervention will the nurse planning care for a patient with acute grief implement? a. Providing information about the grief process b. Encouraging dependence on the nurse for support c. Suggesting utilization of community resources in a few weeks d. Advising the patient to minimize contact with nonfamily members ANS: A Patient education is always helpful. Limiting contact with support is not helpful. Postponing use of resources and encouraging dependence on the nurse are unhelpful and therefore incorrect.

23. The nurse determines that the most effective point of intervention for bereavement is: a. Promotion of mental and spiritual health across the life span b. At the time a newly discovered loss is impending c. Immediately after the loss has occurred d. When requested by the patient ANS: A Effective health promotion before stress and loss regardless of age is most helpful. The remaining options provide help around the time of loss, which is helpful but not as effective as long-term help throughout a persons life.

24. The nurse counseling a patient with acute grief would assess the patient for: a. Severe depressive symptoms

b. Conflicted and unresolved issues c. Increased arousal and hypervigilance d. Preoccupation with the image of the deceased ANS: D Acute grief can involve images of the deceased. Acute grief does not include severe depression or conflicted issues. Hypervigilance is a PTSD symptom.

25. Which person has the greatest potential for developing dysfunctional grief? a. A teen who has always been one of the popular kids b. A widow who regularly states, I really loved my deceased wife c. A woman whose husband died as a result of a sudden, traumatic injury d. An adult who has dealt with the loss of several family members over the years ANS: C A sudden separation could increase risk for dysfunctional grieving. An extensive social support network and a loving relationship do not predispose to dysfunctional grief. Appropriate grief work in the past would not increase the risk for dysfunction.

26. The common element seen in every type of bereavement is: a. Bereavement is a predictable process that is a result of loss. b. The individual has experienced the loss of something of importance. c. Acute depression is generally experienced by all who grieve for a loss. d. The course of the grieving will be determined by the seriousness of the loss.

ANS: B

Each type of loss means that something meaningful has been taken away, whether it is physical, psychological, social, or symbolic. The remaining options are not true statements regarding bereavement.

27. Which statement best explains how a mother of several children should prepare to help them cope with the loss of a dear aunt? a. Children are resilient and simply need love as they grieve. b. People regardless of age or gender experience stages of grief. c. Each child will grieve in a unique way and on their own timetable. d. Extreme reactions are more commonly observed in the young griever.

ANS: C No two people regardless of age will grieve the same way, even in the same family. Each persons grief has unique characteristics and a timetable all its own. It is not necessarily true that young grievers experience severe reactions to loss and require only love during this experience.

Although most individuals do experience the various stages of grief, that information is not the most instructive for the mother.

MULTIPLE RESPONSE 1. The patients daughter was murdered while they were customers in a local bank. Which statements would support the patients diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply: a. I feel numb, like a robot going through the motions of existing. b. Im so nervous and jump at the slightest noise. c. I have not slept very well at all since I lost her. d. I cant stop reliving the last time I saw her alive. e. Id love nothing better than to kill that murderer.

ANS: A, B, C, D

The traumatic nature of the murder and the patients symptoms of hypervigilance, intrusive thoughts, and numbness indicate PTSD. Homicidal thoughts are not generally associated with PTSD. Chapter 35: Public Psychiatry MULTIPLE CHOICE 1. In addition to excellent assessment skills and keen insight into human behavior, what additional ability is most critical to effective community mental health nursing? a. Attention to economical nursing practice b. Willingness to advocate for the patient c. Familiarity with local patient-focused resources d. Working relationship with community medical professionals ANS: C The role of the community mental health nurse is to help the patient to maintain his or her highest level of functioning and independence within the community. It is critical for the nurse to be familiar with the available community resources and community networks, so they can work with the multidisciplinary treatment team to help patients and their families adjust to the community. The remaining options are appropriate but are not unique to community mental health nursing and its role in facilitating the patients ability to live and function as a member of a community.

2. What factor had the greatest impact on the limited success of the deinstitutionalization of the mentally ill population? a. The initiative was never funded by the federal government. b. The mentally ill population found it too difficult to function autonomously. c. Community support systems were unprepared to provide the required services. d. The communities were biased against having the mentally ill living among them.

ANS: A During deinstitutionalization, federal dollars were designated for community mental health facilities; however, the enacted legislation was never funded. The effects of the other options would have been directly related to the lack of sufficient funding.

3. What is the primary event that results in many eccentric individuals being initially diagnosed with a psychiatric disorder? a. They commit a crime and are incarcerated. b. They become both homeless and destitute. c. They are unable to meet their own physical needs. d. There is proof that they are a danger to themselves or others.

ANS: D The family may describe the persons behavior as odd or eccentric without realizing or being willing to admit that the family member has a psychiatric illness that needs professional help.

The family generally seeks treatment for the ill member when the behavior becomes irrational, threatening, assaultive, or self-destructive. Although the remaining options are characteristic of mental illness, they are generally not sufficient to warrant a mental illness diagnosis.

4. To best respect the mentally ill patients rights, no restricting intervention can be implemented without: a. First securing the patients informed consent b. Proof that the patient is a danger to self or others c. Initially attempting to secure the patients cooperation d. Securing an order from the patients psychiatric care provider ANS: B Mentally ill persons who are disturbed or actively psychotic are not required to obtain psychiatric treatment unless they are a threat to themselves or others. In cases where safety is a concern,

informed consent is not required and actions can be approved by the care provider postintervention.

5. Which nursing intervention by a community mental health nurse demonstrates an understanding of the potential health risks that psychotropic medications present? a. Discussing the risk of food interactions when taking buspirone (BuSpar) b. Monitoring the blood glucose levels of a patient prescribed risperidone (Risperdal) c. Stressing the importance of using alprazolam (Xanax) only as a short-term therapy d. Evaluating a patients understanding of the possible weight gain resulting from escitalopram oxalate (Lexapro) therapy ANS: B The onset of type 2 diabetes is one of the less known side effects of commonly used antipsychotic medications. Diabetes associated with psychotropic medications has been demonstrated to be more frequent with risperidone (Risperdal).

Weight gain is a possible side effect of the antidepressant escitalopram oxalate (Lexapro). Drugs used to treat anxiety, including buspirone (BuSpar), have known food interactions such as grapefruit. Benzodiazepines, like alprazolam (Xanax), are prescribed for depression and anxiety but should not be used on a long-term basis.

6. Which behavior engaged in by a patient diagnosed with both schizophrenia and hepatitis C presents the community mental health nurse with the greatest need to share information ordinarily protected by the patients right to confidentiality? a. Engaging in unprotected sex b. Wearing the uniform of a police officer c. Expressing a real hatred for the government d. Stealing clothing and food from stores in the neighborhood

ANS: A Legal and ethical issues continually challenge community mental health nurses. Nurses need to be aware of state laws that mandate patient confidentiality while sharing necessary information about a patient. For example, a nurse who learns this patient is engaging in high-risk sexual behavior needs to report such findings to the appropriate professionals in order to protect the public. The other options, although problematic, do not have this level of seriousness regarding the good of the general public.

7. Regarding freedom-of-choice care systems, what information must the patient receive regarding the criteria for terminating treatment of a patient with mental health disorders? a. Patients inability to pay for the services b. Aggressive behavior on the part of the patient c. Facility finds it uneconomical to provide the treatment d. Patients noncompliance with an appropriate treatment plan ANS: D Freedom-of-choice systems have experienced some common problems with patient care resulting in many agencies choosing not to develop treatment options for severe mental disorders because they disagree with the premise of freedom of choice. Both the provider and the patient have the freedom to make decisions; however, treatment providers in these systems have the right to refuse to treat anyone whose symptoms make that person resistant to accept treatment.

The remaining options are not considered as criteria for treatment termination regarding freedom of choice.

8. Which interview question demonstrates cultural competency when conducting an admission interview for a Jewish patient being admitted for severe depression? a. Is there a history of depression in your family? b. Do you find comfort in your religious beliefs? c. Has been being Jewish contributed to your depression?

d. How has your family responded to you since you have been depressed?

ANS: D Every cultural group has traditions and beliefs about the acceptance of mental illness and the ability and willingness to trust health care providers. Members of the Jewish community generally view severe mental illness as a stigma. The other options do not directly address this culturally stigma.

9. Which intervention demonstrates cultural competency regarding the care provided an African American who is experiencing depression after the death of a child? a. Providing information regarding local grief support groups b. Assessing the patients ability to understand the grief process c. Encouraging family members to be present when discharge planning is discussed d. Consulting with the patient before discussing treatment plans with her adult children ANS: A African Americans are more likely to rely on family and religious groups for support. The remaining options are appropriate for all patients regardless of cultural considerations.

10. What understanding is the most critical to the delivery of effective culturally-congruent nursing care to the mentally ill patient? a. Willingness to learn about the cultural beliefs of the affected population b. Consciousness of the role cultural beliefs play regarding the acceptance of mental health nursing interventions c. Attentiveness to the individuals expression of cultural beliefs and reliance on the culture for various support d. Awareness of the biases the culturally diverse population experiences when experiencing mental illness

ANS: B Understanding the cultural beliefs about mental illness and being sensitive to diverse ethnic and cultural groups is a critical goal for community mental health nurses since this has an immense impact on the planning and acceptance of nursing interventions. The other options, although impactful, lack the direct relationship to the patients willingness to accept and comply with mental health treatment 11. Which activity best reflects the role of the mental health nurse case manager? a. Advocating for the patient in all aspects of care b. Attending to the patients physical and emotional needs c. Acting as the leader of a patients multidisciplinary care team d. Assuming responsibility for maintaining the patients mental health records ANS: C Case management facilitates and promotes the coordination of patient care, thereby minimizing the fragmentation of treatment which is a major factor in the relapsing of the patients symptomology. The other options are roles of the case manager but they lack the attention to the basic concept of integrated, focused, and supervised care of the patient.

12. Which statement supports the fact that a patient diagnosed with chronic schizophrenia who is being prepared for placement in an adult family home understands the unique expectations of such an arrangement? a. Ill have a safe, clean place to live. b. Im excited about having a bedroom of my own. c. I will help wash dishes and sweep floors but I like doing that. d. I cant wait to live my life like I want to and make my own decisions.

ANS: C

Adult family homes (supportive housing programs) provide a quieter and more personal living arrangement for patients who need supervision. The patient becomes a part of the family structure and is expected to fit into the normal routines of the household performing routine tasks of daily living when appropriate. The patient may not have a private bedroom and will have only the independence they are capable of managing effectively and safely. Any placement is intended to ensure a clean, safe place to live.

13. Which intervention demonstrates the community mental health nurses understanding of the potential risks that home visits present? a. Calling ahead to make an appointment to visit b. Being sure to have access to a telephone during the actual visit c. Asking family members to describe the patients recent behavior d. Taking a small gift to give to the patients family during the visit ANS: C It is crucial that the nurse who is planning a home visit evaluate the potential risks of that visit before beginning the actual interventions. Risk evaluation always includes the patients history, especially current emotional and behavioral status. Calling ahead to make an appointment is standard procedure and is more directed towards respect than safety. Having access to a telephone is good practice but has little impact on minimizing risk. It is not recommended to set the expectation that the family will receive a gift with each visit.

14. Which action provides the nurse with evidence that a Hispanic patient diagnosed with schizophrenia 10 years ago is likely to continue to benefit from social support after being discharged for a psychotic break? a. The patients brother and sister-in-law offer suggestions concerning the support they can provide after discharge b. The patients mother expresses an understanding of the need for compliance with the treatment plan c. The familys religious leader visits the patient regularly and suggests part-time employment at the church

d. Friends of the patient offer to provide transportation to and from therapy sessions that the patient is scheduled to attend ANS: A Racial and ethnic differences play a significant role in the familys response to mentally ill members. Some cultural groups are protective of the ill individual, whereas others soon become exhausted and emotionally drained with the care, dependency needs, and symptoms of the ill person. The familys continued involvement in the patients care is the most positive example of continued support. The other options are positive but lack the element of long-term active involvement with the patient.

MULTIPLE RESPONSE 1. Which intervention is considered an essential element of a community nurses mental health home visit? Select all that apply. a. Documenting the patients current level of function b. Evaluating the patients compliance with the plan of care c. Ensuring that the patients family is supportive of the patient d. Assessing the patients ability to understand their condition e. Determining whether the patient has access to prescribed medication ANS: A, B, D, E The psychiatric nurses visit needs to include psychiatric evaluation, medication compliance, health teaching, crisis intervention, and documentation. It would not be possible for the nurse to ensure the familys support regardless of its impact on the patients prognosis.

Chapter 36: Forensic Psychiatry and Ethics in Psychiatry MULTIPLE CHOICE 1. What is the primary expected outcome when a victim of a violent crime is initially attended to by a forensic nurse? a. Their physical injuries will be assessed and treated. b. The evidence of the assault from their body will be preserved. c. The legal system will be provided with evidence of the crime. d. Their long-term emotional health will be of primary concern.

ANS: B Forensic nurses fill a gap where the health care system interacts with the legal system by meeting the needs of victims and perpetrators of violent crimes through enhanced quality of care and preventive services. Observation, documentation, preservation, and notification are critical for determining the legal outcomes of cases that involve violence. Although it is true that the legal system is supported, that is not the focus of care in these cases. The remaining options are not responsibilities unique to the forensic nurse.

2. Which therapeutic outcome has resulted from the introduction of the specialized SANE nurse? a. ED staff are no longer involved in the care of rape victims. b. Retraumatizating of the rape victim has been decreased greatly. c. The rights of both the rape victim and the rapist are preserved. d. The rape victim is assured quality physical and mental healthcare.

ANS: B The specialized attention of these nurses has addressed the long-standing issue of retraumatizing victims. The ED staff may still be involved in the physical care of the victim. The focus is not on

the rights of the potential rapist. The physical and mental health needs of the victim are not the sole responsibility of the SANE nurse.

3. When providing care to an assault victim, the forensic nurse will initially: a. Notify the police that an assault has occurred. b. Assess the individual for any resulting physical trauma. c. Bag all clothing to preserve any relevant evidence. d. Determine whether the victim as been sexually assaulted as well.

ANS: B It is the role of the forensic nurse to immediately assess the assault victim for evidence of acute physical injuries. The remaining options do not have the priority that the individuals physical health needs demand.

4. Which intervention demonstrates the SANE nurses unique attention to the assessment of a sexual assault? a. Conducting the assessment in the most private exam room b. Not directly questioning the patient about the attack or the attacker c. Identifying that the patient is showing signs of anxiety by withdrawing d. Meticulously assessing the patient for signs of any resulting physical trauma ANS: C Throughout the physical examination, the SANE nurse will be attuned to the victims mental status and monitor him or her for signs and symptoms of anxiety, panic, and grief. The event and the assailant are topics that must be discussed. The remaining options identify interventions that are considered a nursing responsibility and not unique to the role of the SANE nurse.

5. To best address the assault victims psychosocial needs, the forensic nurse: a. Warns the family that the patient will likely be suicidal

b. Suggests that the family provide continuous supervision of the patient for at least 30 days c. Encourages the patient to discuss medication therapy with the physician prior to discharge from the ED d. Provides education to both the patient and the family regarding the signs of posttraumatic stress disorder (PTSD) ANS: D These patients are at extreme risk for PTSD, depression, and anxiety disorders, making education on such topics vitally important to their mental health. Although the patient may become depressed and have an increased risk for suicide, it is not true that the patient is likely to attempt such an act nor is it necessary to provide constant supervision. If such was needed, the patient would be hospitalized. The need for medications will be determined by the physician.

6. Which nursing intervention demonstrates an understanding of the coping mechanisms often used by individuals who are not receiving formal treatment for their symptoms of postassault anxiety and stress? a. Providing smoking cessation materials b. Discussing the importance of safe sex c. Assessing for the abuse of marijuana d. Monitoring for weight gain since the assault ANS: C Rather than being engaged in formal treatment, 67% of a studys participants reported the use of illicit substances, mainly marijuana. The primary purpose for this substance use is to aid in numbing the victim from the effects of intrusive thoughts and to allow victims to self-medicate for the treatment of insomnia and irritability. Although some individuals will use cigarette smoking, sexual promiscuity, and eating as coping mechanisms, they do not appear to have the affects that marijuana has on managing the symptoms of anxiety and stress.

7. A patient, brought into the ED by family members who reported a fall, shares that the injury was actually a result of physical abuse. The patient tells the nurse that this is to be kept confidential because, that is my right. The nurse tells the patient that: a. It is a patient right but it was intended to protect patients. b. Nurses are required by law to report all incidents of abuse. c. The report will not mention the patients admission that abuse has occurred. d. The abuser needs to be stopped before they go on to really cause the patient harm.

ANS: B Releasing patient information in the context of a criminal act, such as physical abuse, is exempt from confidentiality standards and laws, because the release of this information is for the protection of the victim; it is used to investigate the crime and potentially to apprehend the perpetrator. Although the remaining options are true, those statements do not adequately address the patients remarks.

8. Based on the importance of recognizing all the important elements for their role as part of the assaulted patients context or environment of care, the nurse will: a. Keep the family well informed of the patients status and plan of care. b. Document the patients statement for the purpose of future legal proceedings. c. Provide the staff with a detailed shift change report including the patients state of mind. d. Notify the local police with updates concerning the patients health status and verbal statements.

ANS: A It is pertinent for nurses to adopt a family-centered approach that encompasses family members in caring interventions so that they are recognized as part of the patients context or environment.

Providing effective shift change information is an expectation regardless of the nature of the

care. The remaining options would be considered standard practice in cases involving violence as a crime and not related to the plan of care.

9. When preparing an educational session for urban adolescents concerning the personal impact of violence in their communities, the nurse includes information on: a. The need to report all incidences of violence to the local police b. How depression and anxiety can result from living in a violent environment c. The role of drug and alcohol abuse in the making of a violent neighborhood d. The role that neighborhood police officers play in the management of violence ANS: B Witnessing a violent crime and having knowledge of a violent crime in the family or community are considered precursors to posttraumatic illness. In addition to demonstrating symptoms of PTSD, adolescents who live in poor urban neighborhoods are more likely to be exposed to multiple incidents of violence during their adolescence, which is strongly linked to major depression and anxiety disorders, particularly among women. Although substance abuse does play a role in community violence, this option lacks the personal connect of the correct option, at least in this scenario. The remaining options do not relate to the personal but rather the communal impact of violence.

10. The nurse demonstrates an understanding of the physical effects of posttraumatic stress disorder (PTSD) when implementing which intervention for a patient who was abducted and assaulted three months ago? a. Regular evaluations for suicidal thoughts b. Explaining the need for appropriate use of a rescue inhaler c. Providing reinforcement for the patients new exercise program d. Evaluating the patients understanding of the proper use of analgesic medications ANS: D

The presence of PTSDparticularly among those who have been exposed to violent crimesdemonstrates a heightened risk for negative health outcomes that include cardiac disease, intestinal problems, and chronic pain as common disorders found in patients with PTSD. Although suicide and stress certainly have a physical impact, they are considered psychiatric disorders. Respiratory issues are more related to anxiety disorders.

11. Which intervention should be given highest priority when attempting to gain the trust of the members of an urban family whose child has been violently assaulted and is in critical condition? a. Discussing the family needs with the childs multidisciplinary care team b. Constantly assuring them that their child is receiving quality nursing care c. Encouraging and respecting their right to ask questions about their child and the childs care d. Keeping them updated on the health and emotional status of their child during each shift ANS: C Assuring the family that you are not hiding facts from them will best assist in establishing a trusting relationship and can be facilitated by respecting and encouraging them to ask questions that will be answered honestly by the staff. The remaining options are appropriate but lack the interaction between nurse and family that the correct option possesses.

12. When encouraging healthy coping mechanisms for a group of parents attending a workshop for families who have lost children to violent crimes, the nurse focuses on: a. Discussing how the fathers are attempting to accept the death b. Providing the fathers with information on the value of crying c. Discussing the problems that occur when women suppress their feelings d. Encouraging the mothers to adopt a rigorous exercise plan to help manage grief ANS: A

A study of parental coping showed that mothers preferred to use emotion-focused coping, whereas fathers preferred coping mechanisms that focused on restraint, acceptance, and suppression.

13. Which intervention is considered a responsibility of the forensic nurse working within the correctional prison system? a. Counseling inmate families b. Identifying postdischarge community resources c. Providing health care services to the prison staff d. Protecting the legal rights of the inmates while incarcerated ANS: B The nurse may identify and provide community linkages for inmates after discharge. The remaining options are not considered the responsibility of the forensic nurse when working in the correctional prison setting.

14. Which nursing intervention will best improve an inmates likelihood of not re-offending and thus not returning to the correctional system? a. Frequently screening inmates for mental health disorders b. Providing mandatory inmate focused anger management workshops c. Providing as needed (prn) medications for inmates with a history of depression d. Working with the families to prepare them for the inmates scheduled release ANS: A More than 250,000 incarcerated offenders are believed to have been diagnosed with or will develop a major mental illness while in the prison system. Without proper treatment and intervention, these offenders are at higher risk for violence recidivism, which is the criminal behavior of an offender after being released from incarceration. Frequent screenings for mental health disorders and the resulting treatment will have the greatest impact on this situation. PRN,

as needed, treatment of mental disorders is not within the nurses scope unless covered by standing orders. Attention to anger management is appropriate but not as impactful as the correct option. Working with families is not a typical responsibility of a nurse in the prison environment.

15. Which intervention demonstrates that the nurse understands the risk factors for the commission of violent crimes? a. Reinforcement of anger management skills b. Substance abuse rehabilitation counseling c. Community focused depression screenings d. Counseling for adult victims of child abuse ANS: B In addition to major mental illnesses, a common issue that is seen in prison and offender populations is substance addiction. Substance abuse and addictionparticularly involving alcoholare strongly correlated with the commission of violent crime in the United States.

Although the remaining options have varying degrees of impact on violent crime, none are as important as the correct option.

Chapter 37: World Aspects of Psychiatry MULTIPLE CHOICE 1. To include a cultural focus in patient care planning, which belief about faith will the nurse incorporate? Faith is a: a. Belief of body and mind b. Manner of expressing spirituality c. Use of spiritual resources without empiric proof d. Search for the sacred, transcendent, or universal ANS: C Faith is the ability to draw on spiritual resources without having physical and empiric proof.

Body and mind refer to psychosomatic concepts. A manner of expressing spirituality refers to religion. A search for the sacred, transcendent, or universal refers to spirituality.

2. A culturally diverse patient refuses to participate in a group because of the presence of a person who can put spells on. The nurse recognizes a priority need to explore this patients: a. Economic status b. Home environment c. Health-illness beliefs d. Educational background ANS: C Culture influences beliefs about health and illness, including causes of illness. What the nurse might label as delusional might be a culturally determined belief about illness causation. The other assessments do not relate to the situation as directly.

3. An Asian-American patient diagnosed with depression explains to the nurse that eating two specific foods will restore the balance of hot and cold and she will be cured. The nurse should: a. Explain that foods cannot cure mental disorders. b. Arrange for the patient to talk with the dietitian. c. Change the subject to focus on medication compliance. d. Accept that cultural beliefs about illness die slowly.

ANS: B Culturally determined beliefs about health and illness should be respected. If there are no contraindications to the patient eating the foods mentioned, the nurse should facilitate obtaining them. Attempt to explain the flaw in the patients belief is an attempt to negate culturally determined beliefs. Changing the subject does not address patient concerns. Assuming that the belief is inflexible suggests the patients beliefs have no merit.

4. When working with a patient newly emigrated from Asia who has been assessed as having xenophobia, the nurse could anticipate making the assessment that the individual: a. Resists sharing food with others b. Would be reluctant to ride an elevator c. Is unlikely to talk with nonfamily members d. Fears the consequences of going out of doors ANS: C Xenophobia is defined as a morbid fear of strangers. The xenophobic individual would not necessarily resist sharing food (fear of germs), riding in elevators (fear of closed spaces), or going out of doors (fear of open spaces).

5. The nurse plans to use pamphlets to teach a newly immigrated Vietnamese patient about diabetes mellitus. Before initiating this education, the priority information for the nurse to obtain is the patients:

a. Ability to read and understand English b. Readiness and ability to learn this material c. Previous knowledge and interest in the subject d. Willingness to participate and follow instructions ANS: A Pamphlets are useful only if the patient can read and understand the language in which the material is written. The other options are secondary to this priority concern.

6. A nurse is planning to incorporate a culturally sensitive focus in her nursing care. Which of these underlying principles concerning cultural heritage will be included? a. A group is formed from among individuals who share similar ancestral origins. b. A condition of belonging to a group is that all members share a unique heritage. c. Learned patterns of behavior and thinking are shared by members of a cultural group. d. The classification of humans into cultural groups is generally based on physical characteristics.

ANS: C Cultural heritage is learned patterns of behavior and thinking shared by a particular group that is transmitted over time to other members. Ancestral origins, a similar heritage, and physical characteristics may be shared traits but alone do not constitute cultural heritage.

7. A patient diagnosed with paranoid schizophrenia is describing religiously-based delusions that other patients find offensive. Which nursing intervention will the nurse implement to provide a therapeutic milieu? a. Engaging the delusional patient in prayer in order to redirect the problematic behavior b. Explaining to the delusional patient that such talk is offensive to some of the milieu and will not be allowed

c. Asking for the pastoral counselor to visit the unit and talk with both the delusional patient as well as the rest of the milieu d. Removing the delusional patient from the milieu when staff is unable to successfully refocus the conversation to a non-religious topic ANS: C Occasionally, individuals with serious mental disorders experience delusions that are spiritual or religious in nature. Certified pastoral counselors are skilled with regard to counseling patients and consulting with staff about these problems, and they assist the health care team in ways that address the particular concerns of individual patients. Challenging or debating the truth of a persons delusions is not therapeutic, and spiritual delusions are no exception. Engaging in spiritual or religious practice with individuals on a psychiatric unit is also inappropriate.

Removing the patient from the milieu is seldom therapeutic and done only to maximize milieu safety.

8. A patient confides to the nurse that she feels guilty about the poor relationship she had with her mother-in-law, who is now deceased. The patient tells the nurse that she is sure God will punish her for this and that she needs to confess her sins to someone. Which of the following is the best response by the nurse? a. Would you like to speak to the chaplain when he comes later today? In the meantime, we could talk about your relationship with your mother-in-law. b. It sounds as if you need to talk about this. Lets sit down in a private area. Id like to know more about your relationship with your mother-in-law. c. We all have trouble with our in-laws occasionally. God doesnt punish us for that. d. Whats done is done. We need to focus on your positive qualities.

ANS: A The patient has identified a specific spiritual problem that a chaplain would be equipped to handle, so a referral is appropriate. The nurse, in the meantime, is equipped to discuss relationship issues. Offering to talk about the relationship without addressing the patients expressed spiritual needs is not therapeutic. Suggesting that the patients relationship issues are

not uncommon minimizes the patients feelings. Attempting to refocus the patient dismisses the patients needs.

9. A patient is dealing with the loss of a spouse. Which response shows an understanding of the role spirituality plays in the management of grief? a. Hes in a better place; my faith tells me that is true. b. I find that my faith is stronger now that Im alone. c. Im told that a sense of spiritual connection will help me go on with life. d. My faith helps me deal and gives me renewed hope; I rely on it to help me heal.

ANS: D Spirituality allows one to cope with these feelings by providing a sense of hope and meaning to experiences that would otherwise be crippling. Spirituality is often a key component in the healing process, and it is an integral part of the patients treatment plan. The remaining options do not as directly deal with the patients personal loss and the progression to healing.

10. The nurse identifies a patient as being in spiritual distress. Which patient statement supports this nursing diagnosis? a. Ive never felt so alone before in my entire life. b. I dont know if I could get through this without faith in God. c. Ive always relied on my faith in God but now I feel Ive been abandoned. d. Why do bad things happen to good people? Ive always been a good person.

ANS: C Spiritual distress is a nursing diagnosis that is defined as a disruption in the value and belief systems that pervades the persons state of being and that transcends the physical and psychosocial self. Feeling abandoned when one has always relied on faith is an indication of spiritual distress. Feeling alone and questioning why something has occurred is not necessarily

spirit based, and not an indication of spiritual distress. Questioning ones ability to manage an emotion without ones faith is a testimony to the faith, not an expression of despair.

11. Assessment of interpersonal relationships of Asian and Asian-American patients is dependent on the nurses understanding that the culture of these patients is identified as high context and will therefore value: a. Privacy; family is not routinely included in health discussions b. Their right to make independent decisions about their care c. Sharing their opinions and wishes with healthcare team d. Their role and place in their family structure ANS: D Asian and Asian-American patients have been socialized into high-context cultures in which there is collective identity, group decision making, emotional dependence, deference to those of higher status and age, and use of indirect language to communicate. The remaining options are characteristic of low-context cultures.

12. Which communication behavior would be considered uncharacteristic for a patient from a high-context culture? a. Little direct eye contact b. Use of global messages c. Use of nonverbal symbolization d. Arguing points with the physician ANS: D Arguing to get a point across is more characteristic of the communication of a person from a low-context culture. A person from a high-context culture would not be expected to dispute a person with authority. The person from a high-context culture would be expected to use global communication and nonverbal symbolization but to make little direct eye contact.

13. An Asian-American patient is referred to the mental health clinic. He has many somatic complaints for which no physical basis has been found. The patient tells the nurse that he does not believe this clinic can help him. Based on knowledge of the beliefs common to this culture, what can the nurse hypothesize about the patient? a. Because of the cultural stigma attached to mental illness, he may be expressing psychological distress via somatic symptoms. b. Acculturation has occurred because feelings of hopelessness are alien to his native culture. c. Suicide is not a present danger because suicidal impulses are rarely associated with feelings of helplessness among Asian-American patients. d. The patient has rejected both family care and traditional healing methods in favor of health care practices of the new culture.

ANS: A The following facts are known about beliefs commonly held by members of this culture: there is a stigma attached to mental illness; mental illness is often described in somatic terms; members of this culture come into treatment late and often have feelings of hopelessness upon entry into the system; families tend to care for their members with mental illness; and traditional healing has usually been tried and failed before the patient attempts to access the mental health system.

14. The nurse determines which patient is at the greatest risk for a spiritual crisis? a. A patient, whose religion opposes the use of blood products, has a severely bleeding ulcer b. A single parent who must decide to terminate life support for a terminally ill child c. A newlywed whose spouse has died in an automobile accident caused by a drunk driver d. A patient who denies the need for spiritual support when given the diagnosis of terminal cancer ANS: A

A spiritual crisis may occur when religious or spiritual beliefs conflict with a necessary procedure or a treatment protocol, such as permitting a blood transfusion. Although the remaining options all present with a serious emotional situation, there is no evidence to support that the patients beliefs are being challenged.

15. The nurse believes that a patient is exhibiting internal locus of control related to spiritual development. Which patient statement supports this conclusion? a. Praying gives me tremendous comfort. b. I pray because my church says that prayer is the way to God c. I will ask that my fellow church members pray for me to get better. d. My mother prayed daily and she was such a good and kind person.

ANS: A During development, ones sense of faith, meaning moral values, and judgment moves from an external locus of control to an internal locus of control. An example of such internal control is the expressed feeling of comfort derived from prayer. The remaining options reflect external locus of control since each is an expression of how beliefs about prayer are provided by others; church doctrine and the faith of others.

16. A novice nurse has identified impaired verbal communication for an older Asian patient who recently immigrated to the United States based on the patients reluctance to maintain eye contact and engage in a conversation with staff. In order to assure that the diagnosis is appropriate, the nurse manage asks: a. Have you asked the patient why communication is difficult for them? b. Could you be misdiagnosing common shyness for a communication issue? c. Have you noticed the patient communicating differently with family when they visit? d. Do you think the patients cultural traditions have a part to play in their communication behaviors?

ANS: D

Misunderstanding occurs when the nurse fails to take into account culture-specific interaction patterns. Silence, infrequent eye contact, shame, fear, and language barriers all affect a patients ability to interact. In light of the patients cultural diversity, the other options are less likely to be pertinent.

17. As a nurse assesses culture factors with patients, the subculture that poses the greatest risk to a patients mental health is: a. Poverty b. Female gender c. Advanced age d. Cultural ethnicity ANS: A Many people in poverty suffer discrimination and stigma which places them at risk for depression and other anxiety-related illnesses. The other subcultures do not present with the same or greater degree of risk.

MULTIPLE RESPONSE 1. The nurse is addressing the possibility that a family of newly emigrated Hispanics may experience cultural shock. Which statements are truisms concerning this cultural adaptation issue? Select all that apply. a. Most primitive cultures embrace the lifestyle of the industrialized ones. b. It may take generations for family members to become acculturated. c. The most resistant to adaptation are children and young adults. d. Typical responses include fear and distrust of strangers. e. Family members are at high risk for anxiety disorder.

ANS: B, E

Many immigrants experience culture shock, a sudden or violent disturbance of emotions that involves a sense of anxiety, fear, and distrust. Children and young adults usually adapt to their new surroundings more quickly. It takes approximately three generations or longer for members of a minority group to integrate into the dominant cultural environment.

2. A nurse works in a mental health clinic serving many Southeast Asian individuals. Which statements by the nurse would validate a striving toward cultural competence? Select all that apply. a. Its a challenge to plan treatment that is culturally congruent. b. My dream is to be accepted by the Southeast Asian patients I care for. c. There is so much to learn about the Southeast Asians and their problems. d. Psychiatric care tends to be similar for those of Southeast Asian cultures. e. I always try to be sensitive to the uniqueness of my culturally diverse patients.

ANS: A, B, C, E Culturally competent health care requires the development of interpersonal skills, communication skills, and awareness and sensitivity to the uniqueness of individuals. It is also an ongoing process, because each new encounter presents the opportunity to gain additional knowledge and skills. Psychiatric care should be tailored to the individual and not to cultural.

3. A patients cultural background is identified as being sociologically low context. Which nursing interventions would be appropriate for such a patient? Select all that apply. a. Asking the patient to contribute suggestions to include in the care plan b. Providing the patient with privacy during visits with their religious leaders c. Instructing the patient on how to select foods within their prescribed diet plan d. Waiting to provide medication education until family members are visiting e. Facilitating the family in assuming responsibility for the patients physical needs ANS: A, B, C

Behaviors and communication styles of cultural societies referred to as low context (individualistic) are those in which people care for themselves. Low-context societies emphasize thinking and values that are centered on the individual: autonomy, individual initiative, the right to privacy, and emotional independence. Facilitating family in assuming responsibility for the patients physical and educational needs is not compatible with the characteristic needs of the low-context society.

4. Guidelines for communicating with a patient whose ability to speak and understand English is questionable include (select all that apply): a. Use interpreters whenever possible. b. Allow sufficient time for patient to formulate response. c. Recruit a family member as an interpreter whenever possible. d. Use nonverbal communication whenever it is considered appropriate. e. Maintain eye contract if such interaction is accepted by the patients culture.

ANS: A, B, D, E Interpreters are preferred to translators since they are trained to decode the message behind the patients verbal response. The patient needs time to formulate their responses especially if they are attempting to speak in English. Nonverbal communication is a good source of information when effectively interpreted. Eye contact when accepted by the patients culture encourages interaction and allows for interpretation of nonverbal communication. Family members should not be used if other options are available since they are not always objective in their translations.

5. A patient experiencing depression over the loss of a loved one shares that, Im not a religious person but I need something to help me cope with this. The nurse shows an understanding to the need for an outlet for the expression of emotions when (select all that apply): a. Asking, Does dancing make you feel good? b. Encouraging the patient to talk about the feelings c. Offering to arrange for a consult with the music therapist

d. Asking, Can you think of ways to express your emotions in a healthy way? e. Suggesting the patient draw a picture of what it feels like to experience such a loss ANS: A, C, E Religious practices are often beneficial for patients, but for those who do not have a formal religion, other spiritual interventions are useful. Group therapies that encourage patients to extend themselves and to find meaning in life are helpful. In addition, several other creative forms of expression such as art, music, and dance therapy often address patients spiritual needs.

Although the other options are not inappropriate, they do not provide interventions but rather reflect assessment questions.