TEST BANK for Psychiatric Nursing 7th Edition by Keltner Norman & Steele Debbie. ISBN 9780323185790

Chapter 01: Me, Meds, Milieu MULTIPLE CHOICE 1. Select the best description of nursing practice in the psychiatric setting. a. The nurse primarily serves in a supportive role to other members of the team. b. The multidisciplinary approach eliminates the need to clearly define the

responsibilities of nursing. c. Clearly differentiated nursing actions have been identified that distinguish nursing

from other professions. d. Although professional role overlap exists, nursing offers unique contributions to

psychotherapeutic management.

ANS: D

Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Psychiatric social workers do not have expertise in physical care. Ideally, all team members support each other.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

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2. The primary element required to match individual patient needs with appropriate services is

proper: a. planning. b. evaluation. c. assessment. d. implementation.

ANS: C

Proper assessment is critical for being able to determine the appropriate level of services that will provide the patient with optimal care at the lowest cost. The decision tree for the continuum of care establishes this fact.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

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3. An adult with paranoid schizophrenia is hospitalized. This patient has frequent auditory

hallucinations and walks about the unit, muttering. To use psychotherapeutic management effectively, it is most important for the nurse to: a. understand the disease process of schizophrenia. b. minimize contact between this patient and other patients. c. administer PRN medication before interacting with the patient. d. use behavior modification to decrease the frequency of hallucinations.

ANS: A

An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 1-2 MSC: NCLEX: Safe, Effective Care Environment

4. A depressed adult is hospitalized after a suicide attempt. The patient receives an

antidepressant medication, is closely supervised, attends a variety of group therapies and activities, watches television during free time, and talks to visitors in the evening. Which additional intervention is needed in the patient’s care? a. Milieu therapy b. Adequate drug therapy c. Increased contact with significant others d. Meaningful communication with nursing staff ANS: D

Two of the three elements of psychotherapeutic management are present: psychopharmacology and milieu management. There is no evidence that the psychotherapeutic nurse–patient relationship exists. Maintaining contact with significant others is not considered an element of the psychotherapeutic management model.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 1-2

TOP: Nursing process: Planning

5. A patient attends outpatient programs at a community mental health center and meets with the

primary nurse regularly. Last week, the patient’s haloperidol (Haldol) dose was reduced from 5 mg to 2 mg daily to decrease side effects. The nurse will need to monitor changes in: a. the activity schedule at the center. b. the nature of the patient’s symptoms. c. attention given to the patient by other staff. d. balance among psychotherapeutic management elements.

ANS: B

It will be necessary for the nurse to assess for exacerbation of the patient’s symptoms of psychosis as well as for an amelioration of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 2 MSC: NCLEX: Physiologic Integrity

6. Which guideline should a nurse use when applying the components of psychotherapeutic

management to the care of a patient with mental illness? a. The nurse’s role in milieu management is secondary to that of social work. b. Omitting any one component usually will result in less effective treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse–patient relationship is the most important aspect of treatment.

ANS: B

The three components listed as choices a, c, and d above work together to provide the best treatment outcomes. When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients’ needs govern the application of the components and permit judicious use.

DIF: Cognitive level: Applying REF: pp. 1-2 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

7. Which statement most accurately describes a nurse’s role regarding psychopharmacology?

The psychiatric nurse: a. frequently makes decisions regarding administration of PRN medications. b. might adjust a medication dose if a patient is not responding positively. c. administers medications but is not responsible for monitoring drug effectiveness. d. should refer a patient’s questions about drug side and adverse effects to the psychiatrist.

ANS: A

Nursing assessment and analysis of data might suggest the need for PRN medication as patient anxiety increases or psychotic symptoms become more acute. The nurse is the health team member who makes this determination. Nurses are responsible for monitoring drug effectiveness as well as administering medication. Nurses should assume responsibility for teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages of medications unless they have prescriptive privileges.

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8. A nurse considers environmental aspects of milieu management while planning care for a

newly admitted patient. Which element has the highest priority? a. Norms b. Safety c. Balance d. Structure ANS: B

Milieu management provides a proactive approach to care. Safety overrides all other dimensions of the milieu.

DIF: Cognitive level: Analyzing REF: 2 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

9. When the treatment team in an inpatient psychiatric unit institutes a new unit schedule that

provides for all patients to be involved in activities continuously throughout both the day and early evening, which element of milieu management needs reflection and reconsideration? a. Norms b. Balance c. Limit setting d. Environmental modification ANS: B

The situation described suggests a milieu in which patients have no time for planned therapeutic encounters with staff; hence, it is a milieu lacking balance. Environmental modification is not a core element of milieu management. Data are insufficient to permit the student to choose either the component of norms or limit setting.

DIF: Cognitive level: Analyzing REF: p. 2 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

10. During an interaction with a patient, a nurse encourages the patient to express feelings,

identify stressors, and review coping strategies. These nursing interventions relate most to the use of: a. risk assessment. b. behavior modification. c. therapeutic communication. d. environmental manipulation.

ANS: C

A nurse uses therapeutic communication techniques as part of the therapeutic nurse–patient relationship. Being therapeutic does not imply that the nurse is providing therapy, a formal, structured process. Risk assessment has a different purpose related to provision of an appropriate level of care. Environmental manipulation is more related to milieu management than to therapeutic use of self.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 2 MSC: NCLEX: Psychosocial Integrity

11. During the risk assessment phase of care for a psychiatric patient, the nurse will: a. b. c. d.

make an initial assessmenNt.URSINGTB.COM confirm the patient’s problem. assess potential dangerousness to self or others. determine the level of supervision needed for the patient.

ANS: C

Risk assessment involves looking at dangerousness to self or others, the degree of disability, and whether or not the individual is acutely psychotic to determine the feasibility of community-based care versus hospital-based care. Risk assessment usually follows the initial assessment. Confirmation of the patient’s problem is not part of the risk assessment protocol.

Arranging entry into the mental health system will follow risk assessment if the patient is assessed as needing service.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 2-3 MSC: NCLEX: Safe, Effective Care Environment

12. Risk assessment for a patient shows these findings: schizophrenia but not acutely psychotic at

the moment; not a danger to self or others; lives in parents’ home. Which decision regarding placement on the continuum of care is appropriate? a. Hospitalize the patient. b. Discharge the patient from the system. c. Refer the patient to outpatient services. d. Refer the patient to self-help resources in the community.

ANS: C

Referral should be made to the least restrictive, most effective, and most cost-conscious source of services. Because the patient is not a danger to self or others, hospitalization is not needed. However, follow-up as an outpatient would be more appropriate than referral to a self-help group, in which structure might be lacking, or discharge from the system.

DIF: Cognitive level: Analyzing REF: pp. 2-3 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

13. A patient tells the nurse, “This medicine makes me feel weird. I don’t think I should take it

anymore. Do you?” The most effective reply that the nurse could make is based on the psychotherapeutic management model component of: a. psychopathology. b. milieu management. c. psychopharmacology. d. therapeutic nurse–patient relationship.

ANS: C

Concerns about medication voiced by patients require the nurse to have knowledge about psychotherapeutic drugs to make helpful responses. The nurse–patient relationship component is based on use of self. Milieu management is concerned with the environment of care.

Psychopathology provides foundational knowledge of mental disorders but would be less relevant in framing a response to the patient than knowledge of psychopharmacology.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 2 MSC: NCLEX: Physiologic Integrity

14. A patient tells the nurse, “This medication makes me feel weird. I don’t think I should take it

anymore. Do you?” Select thN eU nuRrsSe’Is N beGsT t rB es. poCnO seM. a. “I wonder why you think that.” b. “Tell me how it makes you feel.” c. “One must never stop taking medication.” d. “You need to discuss this with your psychiatrist.”

ANS: B

As part of the psychopharmacology component of psychotherapeutic management, the responsibility of the nurse is to gather data about patients’ responses to medication and to be alert for side and adverse effects of the medication. The other responses are tangential to the real issue.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: 2 MSC: NCLEX: Physiologic Integrity

15. The spouse of a patient with panic attacks tells the nurse, “I am afraid my husband has a

permanent disorder and will have many hospitalizations in the future. I wonder how I will be able to raise our children alone.” The nurse’s reply should be based on knowledge of: a. psychopathology. b. milieu management. c. psychopharmacology. d. nursing relationship therapy.

ANS: A

An understanding of psychopathology will enable the nurse to communicate reassurance to the spouse regarding the treatment of panic attacks in an outpatient setting.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 2 MSC: NCLEX: Psychosocial Integrity

16. Which observation during morning rounds should receive a nurse’s priority attention? a. Breakfast is late being served. b. A sink is leaking, leaving water on the bathroom floor. c. The daily schedule has not been posted on the unit bulletin board. d. A small group of patients is complaining that one patient turned down the TV

volume.

ANS: B

Safety is the component of therapeutic milieu management that takes priority over the other components. A patient could be injured if he or she slipped and fell. The other problems do not pose a threat to patient safety.

DIF: Cognitive level: Analyzing REF: p. 2 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

17. A community mental health nurse assesses a person with a psychiatric disorder on an initial

visit. The nurse should refer this person to services on the care continuum that: a. are the least costly. b. are the least restrictive. c. offer psychoeducation. d. promote rapid symptom stabilization.

ANS: B

The concept of least restrictive treatment environment preserves individual rights to freedom.

Many patients are healthy enough to receive community-based treatment. Hospitalization is reserved for short periods when patients are assessed as being a danger to self or others. Cost is a consideration but is of lesser concern than safety. All facets of the continuum should offer psychoeducation as needed by patients and families. Some aspects of the care continuum are more concerned with a patient’s need for symptom stabilization than others (e.g., hospitals versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a need for some patients, so it is not a correct answer.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 2-3 MSC: NCLEX: Safe, Effective Care Environment

18. An acutely psychotic patient is restricted to an inpatient unit. Which milieu element has been

adapted? a. Norms b. Balance c. Therapy d. Psychopathology ANS: B

Balance refers to negotiating the line between dependence and independence. The more psychotic the individual, the less independence he or she can usually handle safely. Unit restriction with careful supervision by staff helps compensate for lack of patient judgment.

Norms refers to behavioral expectations for patients. Therapy is provided by advanced-practice nurses or others with advanced education. Psychopathology is not considered an environmental element.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 1-2 MSC: NCLEX: Safe, Effective Care Environment

19. When inpatient psychiatric care is not indicated, an individual with schizophrenia who has a

history of medication noncompliance should be referred to which service? a. Primary care b. Outpatient counseling c. Apartment residential living d. A group home with 24-hour supervision ANS: D

Although inpatient hospitalization is unnecessary, the individual requires an environment in which medication compliance can be fostered. In this case, the group home would provide the best alternative. The other options do not provide adequate supervision.

DIF: Cognitive level: Analyzing REF: pp. 2-3 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

20. A patient with bipolar disorder has stabilized and is being discharged from the hospital. The

patient will live independently at home but lacks social skills and transportation. Which referral would be most approN prU iaR teS ? INGTB.COM a. A group home b. A self-help group c. A day treatment program d. Assertive community treatment (ACT) ANS: D

Assertive community treatment (ACT) provides intensive supervision, which includes assistance with medications and transportation that would support the goal of minimizing future hospitalizations. A group home is unnecessary, because the patient will reside at home.

A day treatment program would provide a therapeutic program directed toward symptoms, but the patient’s symptoms have stabilized so this service is not indicated. A self-help group would not provide the intensity of service this patient needs.

DIF: Cognitive level: Analyzing REF: p. 4 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

21. A patient with long-standing bipolar disorder comes to the mental health center. The patient

says, “I lost my job and home. Now, I eat in soup kitchens and sleep at a shelter. I am so depressed that I thought about jumping from a railroad bridge into a river.” Which factor has priority for the nurse who determines the appropriate level of care? a. Long-standing bipolar disorder b. Risk for suicide c. Homelessness

d. Lack of income ANS: B

Risk assessment shows the patient to have suicidal thoughts, and a plan for the suicide that is highly lethal, executable, and with low potential for rescue. The other factors do not have as great an effect on the determination of the level of services needed.

DIF: Cognitive level: Analyzing REF: pp. 2-3 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

22. When explaining risk assessment, the nurse would indicate that the highest priority for

admission to hospital-based care is: a. safety of self and others. b. confusion and disorientation. c. withdrawal from harmful substances. d. medical illness complicating a psychiatric disorder.

ANS: A

The highest priority is safety. In the other situations, threats to safety might or might not exist.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 2-3 MSC: NCLEX: Safe, Effective Care Environment

23. What explanation about the unit milieu would be most important for the nurse to give to a

newly admitted patient? a. “Your behavior will be carefully monitored during your hospital stay.” b. “Unit activities will help you cope with immediate needs and stressors.” c. “You will be given enougNh mRediI catiG on tB o. brC ing M your symptoms under control.”

U S N T d. “I will be gathering information about you to plan your care and your discharge.”

ANS: B

This choice best reflects the purpose of milieu management in psychotherapeutic management. Stating that behavior will be monitored creates suspicion. Discussing medication administration is a psychopharmacology issue and is not pertinent to unit milieu.

Stating that assessment will take place is not directly related to milieu.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 1-3 MSC: NCLEX: Psychosocial Integrity

24. Referral to a psychiatric extended-care facility would be most appropriate for which of the

following patients? a. An adult with generalized anxiety disorder b. A severely depressed 70-year-old retiree c. A patient with personality disorder who frequently self-mutilates d. A severely ill person with schizophrenia who is regressed and withdrawn ANS: D

Extended care often serves those with severe and persistent mental illness and those with a combination of psychiatric and medical illnesses. Patients with anxiety disorders can be referred to outpatient services. Severely depressed patients would need more intensive care, as would a self-mutilating individual.

DIF: Cognitive level: Analyzing REF: p. 6 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Analysis

MULTIPLE RESPONSE 1. What data should a nurse analyze when deciding to refer a patient with a psychiatric disorder

to community-based care? Select all that apply. a. Need for PRN medication b. Severity of the patient’s illness c. Need for structured formal therapy d. Presence of suicidal or homicidal ideation e. Amount of supervision required by the patient ANS: B, D, E

The decision tree for the continuum of care calls for the assessment of severity of the illness, the presence or absence of suicidal or homicidal ideation, whether or not the disability is so great that the patient is unable to provide for his or her own basic needs, and the amount of supervision required for patient safety. The frequency of need for PRN medication and the need for structured formal therapy are not considerations mentioned in the decision tree.

DIF: Cognitive level: Applying REF: p. 2 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

2. Which scenarios demonstrate that a nurse is functioning within the scope of psychotherapeutic

management? The nurse (select all that apply) a. structures meaningful unit activities. b. administers electroconvuN lsivR e theIrapG y. B.C M U S N O c. encourages a patient to express feelingT s. d. interprets the results of psychological testing. e. assesses a patient for medication side effects.

ANS: A, C, E

Electroconvulsive therapy is a medical treatment and, therefore, should be administered by a physician. Psychological testing is interpreted by a psychologist. All other scenarios are within the scope of practice of the nurse.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 1-2 MSC: NCLEX: Safe, Effective Care Environment

Chapter 02: Historical Issues MULTIPLE CHOICE 1. A person says, “Now that many state hospitals are closed, patients with psychiatric problems

are free in our community. It is not safe for me.” The nurse’s reply should be based on knowledge that: a. depressed patients are nonviolent. b. state hospitals are no longer needed. c. major depression is very prevalent. d. bizarre behavior is viewed as sensational.

ANS: C

Four of the top medical disorders causing disability are psychiatric disorders (i.e., major depression, schizophrenia, bipolar disorder, and alcohol abuse). The other options are not true statements.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 9 MSC: NCLEX: Psychosocial Integrity

2. Select the most accurate characterization of treatment of the mentally ill prior to the Period of

Enlightenment. a. Large asylums provided custodial care. b. Care for the mentally ill was more compassionate. c. Care focused on reducing stress and meeting basic human needs. d. Patients were banished from communities or displayed for public amusement.

ANS: D

N R I G B.C M U S N T O

In the 1700s it was common practice for caretakers to display mentally ill patients for the amusement of the paying public. The creation of large asylums took place during the Period of Enlightenment. Mental illness was first studied during the Period of Scientific Study.

Dealing with stress and meeting basic needs are concerns of the modern era.

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REF: p. 10 MSC: NCLEX: Safe, Effective Care Environment

3. What concerns were shared by society during both the Period of Enlightenment and the Period

of Community Mental Health? a. Moving patients out of asylums b. Studying brain structure and function c. Meeting basic human needs humanely d. Providing medication to control symptoms ANS: C

The use of asylums signaled concern for meeting basic needs of the mentally ill, who in earlier times often wandered the countryside. With deinstitutionalization, many patients who were poorly equipped to provide for their own needs were returned to the community. The current system must now concern itself with ensuring that patients have such basic needs as food, shelter, and clothing. Studying brain structure and function is more a concern of modern times, as is the provision of medication.

DIF: Cognitive level: Applying REF: pp. 10-11 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

4. A key factor motivating passage of the Community Mental Health Centers Act in 1963 was

that mentally ill individuals had been: a. hospitalized only if they demonstrated violent behavior. b. geographically isolated from family and community. c. discharged before receiving adequate treatment. d. used as subjects in pharmacologic research.

ANS: B

State hospitals were often located a great distance from the patients’ homes, making family visits difficult during hospitalization. The Community Mental Health Centers Act in 1963 served as the impetus for deinstitutionalization, allowing patients and families to receive care close to home. Admission only for behavior that endangers self or others is more consistent with current admission criteria. Early discharge rarely occurred before the community mental health movement. Unethical pharmacologic research was not a major issue leading to community mental health legislation.

DIF: Cognitive level: Understanding REF: p. 13 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

5. Freud’s contribution to psychiatry that most affects current psychiatric nursing is: a. the challenge to look at humans objectively. b. recognition of the importance of human sexuality. c. theories about the importance of sleep and dreams. d. discoveries about the effeN ctU ivR enSeI ssNoG fT freBe.aC ssO ocM iation.

ANS: A

Freud’s work created a milieu for thinking about mental disorders in terms of the individual human mind. This called for therapists to look objectively at the individual, a principle that is basic to nursing. The correct answer is the most global response. Freud’s theories of psychosexual development are an aspect of holistic nursing practice, but not the entire focus.

Free association is not a pivotal issue in nursing practice.

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REF: p. 12 MSC: NCLEX: Psychosocial Integrity

6. The greatest impact in the care of the mentally ill over the past 50 years has resulted from

progress and improvement in which area? a. Self-help groups b. Outpatient therapy c. Psychotropic drugs d. Patients’ rights awareness ANS: C

The advent of psychotropic drugs allowed patients to normalize thinking and feeling. As psychosis diminished, the individual became accessible for psychotherapeutic interventions.

Hospital stays were shortened. Hospital milieus improved. Though important, none of the other choices has had such a significant impact.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 12

TOP: Nursing process: Evaluation

7. An adult with schizophrenia is discharged from a state mental hospital after 20 years of

institutionalization. When planning care in the community, which premise applies? This patient is likely to: a. independently find support services to aid transition from hospitalization to community. b. adjust smoothly to the community if provided with sufficient support services. c. self-administer antipsychotic medications correctly if provided with education. d. need crisis or emergency psychiatric interventions from time to time.

ANS: D

Patients with serious mental illness are rarely considered cured at the time of hospital discharge. Decompensation is likely from time to time, even when good community support is provided. The emergency room may become a first-line resource in the continuum of care designed to prevent rehospitalization. Unfortunately, transitional services are not always readily available. Adjustment to a community environment after long institutionalization is often a slow process.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 15

TOP: Nursing process: Planning

8. A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient’s

insurance form. Which resource should the nurse use to discern the criteria used to establish this diagnosis? a. The Diagnostic and Statistical Manual of Mental Disorders (DSM) b. Nursing Diagnosis ManuN alURSINGTB.COM c. A psychiatric nursing textbook d. A behavioral health reference manual ANS: A

The DSM gives the criteria used to diagnose each mental disorder. The distracters do not contain diagnostic criteria for mental illness.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 17-18 MSC: NCLEX: Safe, Effective Care Environment

9. A shift in the psychiatric nursing focus during the community mental health period of the

1960s resulted in: a. disillusionment with the high numbers of people seeking treatment. b. focusing more attention on complications associated with substance abuse. c. spending more time providing services to persons with serious mental illness. d. shifting focus away from the most acutely ill and to persons with a perceived greater potential for improvement.

ANS: D

The community mental health movement brought with it a broadening of areas of concern to the psychiatric nurse. It became acceptable, even desirable, for psychiatric nurses to focus on what was called the worried well, as opposed to providing care for acutely ill psychotic individuals. Neither disillusionment with the numbers seeking treatment nor providing more services to those with severe mental illness occurred.

DIF: Cognitive level: Understanding REF: p. 16 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

10. An adult with serious mental illness is being admitted to a community behavioral health

inpatient unit. Recognizing current trends in hospitalization, this patient is likely to: a. comply readily with the prescribed treatment. b. have a clear understanding of the illness. c. display aggressive behavior. d. stabilize within 24 hours.

ANS: C

Compared with patients of the 1960s and 1970s, today’s patients are likely to display more aggressive behavior. This understanding is critical to making astute assessments that lead to planning for the provision of safety for patients and staff. Treatment compliance, understanding of the illness process, and discharge against medical advice are possible issues with which the nurse might deal, but these are less relevant when admission assessment is performed.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 14 MSC: NCLEX: Safe, Effective Care Environment

11. When a nurse working in a wN eU ll-R chSilI dN clG inT icBa. skC sO aM parent’s address, the parent responds, “My

children and I are homeless.” The nurse can assess this response as: a. a common occurrence, because 1 out of 50 children are homeless. b. a signal to investigate the possibility that the parent has severe mental illness. c. evidence of child abuse or neglect that should be reported to social service agencies. d. unusual because most homeless individuals have severe mental illness or substance abuse problems.

ANS: A

The current belief is that the homeless are people (including entire families) who have been displaced by social policies over which they have no control. One out of 50 children is homeless. Although homelessness might be associated with serious mental illness, it might also be the result of having a weak support system and of social policies over which the individual or family has no control. Clinic users come from all socioeconomic backgrounds.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment 12.

REF: p. 16 MSC: NCLEX: Psychosocial Integrity

Which individual should the nurse assess as having the highest risk for homelessness? a. An older adult woman with mild dementia who resides in an assisted-living facility b. An adult with serious mental illness and no family c. An adolescent with an eating disorder d. A married person with alcoholism

ANS: B

The adult has both a serious mental illness and a potentially weak support system. Both are risk factors for homelessness. The other individuals have psychiatric disorders but have better established support systems.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 16 MSC: NCLEX: Psychosocial Integrity

13. A former pediatric nurse begins working in a clinic housed in a homeless shelter. The nurse

asks the clinic director, “What topic should I review to improve my effectiveness as I begin my new job?” Which topic should the clinic director suggest? a. Care of school-age children b. Psychiatric and substance abuse assessment c. Communicable disease prevention strategies d. Sexually transmitted disease signs and symptoms ANS: B

It is estimated that significant numbers of the homeless population have a serious mental illness and/or suffer from substance abuse or dependence. Although the other conditions may exist, the numbers are not as significant.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 16 MSC: NCLEX: Psychosocial Integrity

14. Which skill is most important to a nurse working as a member of a community mental health

team that strives to use a seamless continuum of care? a. Case management b. Diagnostic ability c. Physical assessment skills d. Patients’ rights advocacy ANS: A

To effectively use a seamless continuum of care, a nurse must have case management skills with which he or she can coordinate care using available and appropriate community resources. Psychosocial assessment and physical assessment are functions that can be fulfilled by another health care worker. Patients’ rights advocacy is one aspect of case management.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 16 MSC: NCLEX: Safe, Effective Care Environment

15. The broadened scope of psychiatric nursing practice is attributable primarily to: a. increased use of psychotropic drugs. b. opening of community mental health centers. c. legislation that changed nurse practice acts across the country. d. recidivism of seriously mentally ill patients in public mental hospitals.

ANS: B

Community mental health centers were designed and organized to provide services in addition to inpatient hospitalization, thus giving nurses opportunities to practice in a variety of treatment settings (e.g., emergency rooms, partial hospitalization settings, outpatient care) and to have new roles, such as consultant, liaison, and case manager. Increased use of psychotropic drugs is not as important a factor as are community mental health centers.

Legislation changing nurse practice acts broadened the scope of practice for nurse practitioners only by allowing prescriptive privileges. Recidivism is not a relevant factor.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 16 MSC: NCLEX: Safe, Effective Care Environment

16. A patient with mental illness was initially treated in an outpatient setting and then hospitalized

for a week when the disorder became acute. After discharge to a halfway house, this patient’s care was managed by a community mental health nurse. Which inference applies to this community? a. Additional mental health services should be made available for the severely mentally ill. b. A seamless continuum of services is in place to serve persons with severe mental illness. c. Case management services should be expanded to care for acute as well as long-term system consumers. d. There are insufficient data to make a conclusion.

ANS: B

Data are sufficient to suggest that a seamless continuum of service is in place, because the individual is able to move between continuum treatment sources and is given the services of a case manager to coordinate cN are.RDaI ta prGoviB de.dCareM insufficient to warrant any of the other assessments.

U S N T O DIF: Cognitive level: Analyzing REF: p. 16 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

MULTIPLE RESPONSE 1. Which changes in psychiatric nursing practice are directly attributable to events occurring

during the Decade of the Brain? Select all that apply. a. Homeless shelters became practice sites. b. Nurses upgraded knowledge of psychopharmacology. c. Nurses provided psychoeducation to patients and families. d. Nurses viewed psychiatric symptoms as resulting from brain irregularities. e. Nurses were more likely to advocate for patients’ rights related to involuntary commitment.

ANS: B, C, D

Psychobiologic research relating to brain structure and function made it possible for psychiatric nurses to view symptoms as brain irregularities and made it necessary for them to become knowledgeable about psychotropic medications to make appropriate assessments regarding desired outcomes and side and toxic effects of therapy. With hospital stays shortened, it became necessary for nurses to provide psychoeducation to patients and families who would need to monitor outcomes, symptoms of relapse, and side and toxic effects of medication. Homeless shelters became practice sites with the onset of deinstitutionalization.

Advocacy for patients’ rights relating to hospitalization and commitment became an ethical issue before the Decade of the Brain.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 15 MSC: NCLEX: Safe, Effective Care Environment

2. A community mental health nurse works in a mental health services system that is undergoing

change to become a seamless system. To promote integrity of the new system, the nurse should focus on (select all that apply) a. psychopathology. b. symptom stabilization. c. medication management. d. patient and family psychoeducation. e. patient reintegration into the community. f. holistic issues relating to patient care.

ANS: D, E, F

A seamless system of mental health services will require new conceptualizations. Nurses will need to focus more on recovery and reintegration than on symptom stabilization and more on holistic issues such as finances and housing than on medication management. Consumers and N R Irovi GTded B.C M family members will also needUto bSe pN witO h extensive psychoeducation.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 16 MSC: NCLEX: Safe, Effective Care Environment

3. A newcomer to a community support meeting asks a nurse, “Why aren’t people with mental

illnesses treated at state institutions anymore?” What would be the nurse’s accurate responses? Select all that apply. a. “Funding for treatment of mental illness now focuses on community treatment.” b. “Psychiatric institutions are no longer accepted because of negative stories in the press.” c. “There are less restrictive settings available now to care for individuals with mental illness.” d. “Our nation has fewer people with mental illness; therefore, fewer hospital beds are needed.” e. “Better drugs now make it possible for many persons with mental illness to live in their communities.”

ANS: A, C, E

Deinstitutionalization and changes in funding shifted care for persons with mental illness to the community rather than large institutions. Care provided in a community setting, closer to family and significant others, is preferable. Improvements in medications to treat serious mental illness made it possible for more patients to live in their home communities.

Prevalence rates for serious mental illness have not decreased. Although the national perspectives on institutional care did become negative, that was not the reason many institutions closed.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 12-13 MSC: NCLEX: Safe, Effective Care Environment

4. Put these services in order from least to most intensive. a. Day treatment b. Hospitalization c. Scheduled visits at a community mental health center ANS: A, B, C

The continuum of care represents treatment services along a range of intensity.

Hospitalization is the most intensive, progressing to day treatment, and finally to routine visits at a community mental health center.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: 17 MSC: NCLEX: Safe, Effective Care Environment

Chapter 03: Legal Issues MULTIPLE CHOICE 1. Considering that a state uses the M’Naghten Rule when an individual is on trial for a crime,

what would be most important to document for a nurse caring for a patient who will soon be tried on murder charges? a. The patient’s participation in treatment planning b. The patient’s comments about commission of the crime c. Examples of behaviors that support psychiatric diagnoses d. The patient’s perceptions of the need for hospitalization and treatment ANS: B

The M’Naghten Rule states that to be held legally accountable for his or her actions, a person with mental illness must be able to understand the nature and implications of the crime.

Although each of the options refers to data that should be documented, the patient’s comments about the crime would be of most importance to the trial.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 21 MSC: NCLEX: Psychosocial Integrity

2. A patient tells the nurse, “You better take good care of me or I’ll sue you using the precedent

established in Wyatt v. Stickney.” The nurse can interpret this as: a. intellectualization. b. concern about rights to adequate treatment. c. a warning about being coerced into treatment.

NUcha RS I from GTB.C M d. a request for immediate dis rge N the faO cility.

ANS: B

Wyatt v. Stickney was a case in which the court ruled that patients had the right to adequate treatment while hospitalized. Intellectualizing is a defense mechanism. Right to refuse treatment and commitment issues were not the focus of Wyatt v. Stickney.

DIF: Cognitive level: Understanding REF: p. 21 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

3. A patient shouts, “I’m holding you responsible for mistreatment based on Rogers v. Orkin.”

The nurse can conclude that the patient is objecting to: a. loss of privileges to leave the unit. b. inability to make phone calls. c. taking medication. d. hospitalization.

ANS: C

Rogers v. Orkin was a case in which the court ruled that nonviolent patients could not be forced to take medication. It did not have implications related to hospitalization or application of patient privileges.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 21 MSC: NCLEX: Safe, Effective Care Environment

4. To help preserve patients’ rights to freedom from restraint and seclusion, the most important

interventions that the nurse can use are based on which principle? a. Therapeutic management b. Reality-based communication c. Confidentiality of documentation d. Effective use of ancillary personnel ANS: A

Attention to the nurse–patient relationship, the therapeutic milieu, and principles of pharmacologic management can reduce the need for restrictive measures. The other options are important aspects of care but do not relate directly to the use of restraint and seclusion.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 28 MSC: NCLEX: Safe, Effective Care Environment

5. A nurse finds a psychiatric advance directive in the medical record of a patient experiencing

psychosis. The directive was executed during a period in which the patient was stable and competent. The nurse should: a. ensure that the directives are respected in treatment planning. b. review the directive with the patient to ensure that it is current. c. consider the directive only if there is a cardiac or respiratory arrest. d. realize that such directives address only the use of psychotropic medication.

ANS: A

Advance directives for psychiatric care might be given by competent patients. They are considered binding and should be considered in planning treatment. Advance directives address several issues including psychotropic medication. Review is not required. A psychiatric advance directiveNrU elR ateSsIspNeG ciT ficBa. llyCtO oM mental health services, not cardiac or respiratory problems.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 30 MSC: NCLEX: Safe, Effective Care Environment

6. A patient constantly interferes with activities on an inpatient unit. The nurse, speaking in a

loud voice, tells the patient, “If you don’t go to your room immediately, I will give you medication that will make you sleep.” The nurse’s behavior demonstrates: a. assault. b. battery. c. negligence. d. false imprisonment.

ANS: A

Assault is defined as an act that creates a reasonable apprehension of harmful or offensive contact to another without consent of the other. The nurse has threatened the patient. Battery is unwanted touching. Negligence is failure to do what is reasonably prudent under the circumstances. False imprisonment is not evident.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 24 MSC: NCLEX: Safe, Effective Care Environment

7. A patient tells the nurse, “When I get out, I’m going to get even with a lot of people.” With

respect to the nurse’s duty to warn, the nurse should:

a. b. c. d.

take no action on a general threat. notify local law enforcement officials. warn close relatives and significant other. document and discuss the threat with the clinical team.

ANS: D

The Tarasoff ruling specifies that a specific threat to a readily identifiable person or persons must be made. In this situation, the threat is nonspecific. The prudent action is to document and discuss with the clinical team to determine the need for providing a warning to third parties.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 23-24 MSC: NCLEX: Safe, Effective Care Environment

8. A gravely disabled psychiatric patient has a guardian. What is the essential implication for

nursing care? a. The patient can override the guardian’s judgment at any time. b. Guardianship is a legal matter that does not affect clinical care. c. The guardian’s rights apply only to a patient’s financial interests. d. The guardian participates in treatment planning on behalf of the patient.

ANS: D

Guardians make decisions on behalf of the patient and represent the patient in treatment planning meetings. Guardianship affects clinical care, as previously mentioned. The guardian has the right to refuse treatment for the patient. The patient cannot override the guardian’s judgment, because the patient is considered incompetent.

DIF: Cognitive level: UnderstN andiR ng I GREB F:.C p. 26M U S N T TOP: Nursing process: Implementation MSC: NCLEX: Safe, Effective Care Environment 9. A patient tells the nurse, “I still have suicidal thoughts, but don’t tell anyone because I am

supposed to be discharged today.” Select the nurse’s best course of action. a. Have the patient sign a “no suicide” contract. b. Respect the patient’s request related to confidentiality. c. Inform the health care provider and other team members. d. Search the patient’s belongings for potentially hazardous items.

ANS: C

Patient right to confidentiality never includes keeping important clinical information secret, especially information related to patient safety. Patients should be informed that all relevant information will be shared with the health care team. None of the other options sufficiently address the safety issue presented by a patient who expresses suicidal thoughts.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 29-30 MSC: NCLEX: Safe, Effective Care Environment

10. Which situation is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours

of the patient’s admission. b. An advanced-practice nurse recommends that a patient who is dangerous to self

and others be voluntarily hospitalized. c. A patient’s admission status is changed from involuntary to voluntary after the

patient’s hallucinations subside. d. A nurse gives a PRN dose of an antipsychotic drug to a patient to prevent violent

acting out because the unit is short staffed.

ANS: D

A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts.

DIF: Cognitive level: Understanding REF: pp. 22, 24 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

11. A crisis team led by a psychiatric nurse is called to a home because a patient with a history of

paranoid schizophrenia is standing on the lawn shouting, “People are poisoning my water.”

The nurse should advise the police officer to institute procedures for: a. emergency care. b. long-term commitment. c. a probable-cause hearing. d. short-term observation and treatment.

ANS: A

Individuals who are deemed to be dangerous to self, dangerous to others, or gravely disabled can be detained involuntarily for evaluation and emergency treatment for a specified period of time (often for 72 hours). Long-term commitment might be unnecessary. A probable-cause hearing is needed only for short-term observation and treatment.

DIF: Cognitive level: Applying TOP: Nursing process: ImplemNentR ationI

REF: p. 25 M : N G SBC. CCLMEX: Safe, Effective Care Environment

U S N T

O

12. Which individual would be the most likely candidate to have a guardian appointed? a. A patient with panic attacks b. A bipolar patient who refuses medication c. A patient with frequent admissions for drug abuse d. A gravely disabled patient with paranoid schizophrenia ANS: D

Guardians or conservators are appointed by the courts to manage the affairs of mentally ill individuals found to be incompetent and unable to manage their own affairs appropriately. A gravely disabled patient with schizophrenia would be in need of a conservator or guardian, whereas the other individuals would more likely be judged competent.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 26 MSC: NCLEX: Safe, Effective Care Environment

13. An involuntarily admitted inpatient with paranoid schizophrenia repeatedly calls the local

mayor. The patient verbally abuses the person who answers the phone as well as the mayor.

Select the most appropriate initial nursing intervention. a. Allow the patient to continue to use the phone. b. Include the patient in a social skills building group. c. Suspend the patient’s phone privileges temporarily, and document the reason. d. Ask the patient advocate to review the limits of the patient’s rights with the patient.

ANS: C

The nurse should document that the patient’s calls violated the rights of others, thus providing a basis for temporary suspension of the right to make phone calls to the mayor’s office.

Allowing continued calls violates the rights of others. It might require several days for the advocate to meet with the patient.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 29-30 MSC: NCLEX: Safe, Effective Care Environment

14. A nurse in a community mental health center receives a call asking for information about a

patient. Under which condition can the nurse release information to the caller? a. The caller is related to the patient. b. The psychiatrist approves the request. c. The caller is a mental health professional. d. The patient has given written consent for release of information.

ANS: D

Patient information is privileged. Information cannot be released without consent signed by the patient. None of the other conditions is sufficient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 27 MSC: NCLEX: Safe, Effective Care Environment

15. A patient backs into a corner of the room and shouts at the nurse, “Stay away from me.”

Select the best initial nursing intervention in this situation. a. Obtain an order for seclusion. b. Administer a PRN antipsychotic drug. c. Call for assistance to phyN siU caR llySI reN strG aiT nB th.eC paOtiM ent. d. Talk to the patient in a calm, nonthreatening manner.

ANS: D

Verbal intervention provides the least restrictive alternative in this situation. Verbal intervention might halt escalation and prevent the need for medication or the use of restraint or seclusion. Seclusion, restraint, and medication usage are all more restrictive than verbal intervention.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 28 MSC: NCLEX: Safe, Effective Care Environment

16. A patient was restrained after assaulting a staff member. Which nursing measure has priority? a. Monitor the patient every 30 minutes. b. Maintain constant supervision of the patient. c. Administer a sedating medication after applying the restraints. d. Distract the patient at frequent intervals while restraints are in use.

ANS: B

Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred.

DIF: Cognitive level: Analyzing

REF: p. 28

TOP: Nursing process: Implementation

MSC: NCLEX: Safe, Effective Care Environment

17. Which patient should be considered for involuntary commitment for psychiatric treatment? a. A patient who is noncompliant with the treatment regimen b. A patient who sold and distributed illegal drugs c. A patient who threatens to harm self and others d. A patient who fraudulently filed for bankruptcy ANS: C

Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 24 MSC: NCLEX: Safe, Effective Care Environment

18. A patient who is admitted involuntarily with bipolar disorder, manic phase, refuses a

prescribed dose of lithium. The nurse assembles a show of force and intimidates the patient into taking the medication. As an outcome of this action, the patient: a. will experience lessened mania. b. can bring civil suit for assault and battery. c. can sue the hospital for false imprisonment. d. has no recourse, because the medication is in the interest of the patient’s welfare.

ANS: B

A nurse who forces a patient to accept treatment or take medication in a nonemergency situation against the patient’sNwisRhesIcanGbeB fo.uC nd lM iable for assault (threatening) and battery U S N T O (nonconsenting touching) in civil court, even if the nurse had the best interest of the patient in mind. Diminished symptoms of mania are not likely to be related to a single dose of lithium.

The scenario does not describe the conditions of false imprisonment. Actions taken in the best interest of the patient that violate the patient’s rights are cause for civil action.

DIF: Cognitive level: Applying REF: p. 24 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

19. To reduce the risk of a lawsuit based on false imprisonment, mental health nurses must give

the highest priority to which intervention? a. Educating patients about unit protocols b. Providing adequate treatment during hospitalization c. Selecting the least restrictive treatment environment that will be effective d. Ensuring that patients have probable-cause hearings within 24 hours of admission ANS: C

Treating a patient in the least restrictive environment that will be effective lessens the threat of the patient bringing civil suit for false imprisonment. In the least restrictive environment the disruption to patient rights is minimized. Providing information about unit rules and providing adequate treatments are of less immediate importance than ensuring the least restrictive alternative. Probable-cause hearings are necessary only in certain cases.

DIF: Cognitive level: Analyzing REF: p. 24 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

20. How many violations of Medicare and Medicaid guidelines are evident in this documentation?

Patient assaulted nurse in hall at 1730. Staff provided verbal intervention, but patient continued to strike out. Patient placed in seclusion at 1745. Observation instituted at hourly intervals. Order received from physician at 1930. Patient sleeping soundly at 2100. Patient released from seclusion at 2230 and returned to own room. a. Two b. Three c. Four d. Five ANS: D

Constant observation of a secluded individual is necessary, with attention given at frequent intervals for safety and comfort interventions. No mention is made of providing fluids or bathroom privileges. Seclusion requires a written order posted within 1 hour. Seclusion must be terminated when patient behavior permits. If the patient is calm enough to sleep, the need for seclusion should be reevaluated. The patient should be debriefed after the seclusion.

DIF: Cognitive level: Analyzing REF: p. 28 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

21. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol

decanoate (Haldol depot injection) to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, “Stop, stop. I don’t want to take that medicine anymore. I hate the side effects.” Select the nurse’s first action. a. Stop the medication administration procedure and say to the patient, “Tell me more N R I G B.C M about the side effects you’ve having.”

U been S N T O b. Proceed with the injection but explain to the patient that there are medications that may help reduce the unpleasant side effects. c. Say to the patient, “Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about delaying next month’s dose.” d. Notify other staff to report to the room for a show of force, and proceed with the injection, using restraint if necessary.

ANS: A

The nurse, as an advocate and educator, should seek more information about the patient’s decision and should not force the medication. Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. It is not reasonable to promise a reduction in side effects without first discussing them, nor is it appropriate to pressure the patient into taking the medication. The medication cannot be given without the patient's informed consent.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 29 MSC: NCLEX: Safe, Effective Care Environment

22. An example of a breach of a patient’s right to privacy occurred when a nurse: a. released information to the patient’s employer without consent. b. documented the patient’s daily behaviors during hospitalization. c. discussed the patient’s history with other staff during care planning.

d. asked a family to share information about a patient’s behavior prior to admission.

ANS: A

Release of information without patient authorization violates the patient’s right to privacy.

The other options are acceptable nursing practices.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 27 MSC: NCLEX: Safe, Effective Care Environment

23. An adolescent is hospitalized after a violent physical outburst and tells the nurse, “I’m going

to kill my parents, but you can’t tell them.” Select the nurse’s initial response. a. “You’re right. Federal law requires me to keep information private.” b. “Those kinds of threats will make your hospitalization longer.” c. “You really should share this thought with your psychiatrist.” d. “I am required to talk to the treatment team about your threats.”

ANS: D

Breach of nurse–patient confidentiality does not pose a legal dilemma for nurses in these circumstances, because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the patient’s parents of the risk for harm.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 21-23 MSC: NCLEX: Safe, Effective Care Environment

24. A patient’s insurance will not pay for continuing hospitalization at a private facility, so the

family considers transferringNtheRpatI ientG to aBp. ubClicM psychiatric hospital. They express concern U S N T that the patient will “never get any treatment.” Select the nurse’s most helpful reply. a. “Under the law, treatment must be provided. Hospitalization without treatment violates patients’ rights.” b. “That’s a justifiable concern, because the right to treatment extends only to provision of food, shelter, and safety.” c. “Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable.” d. “All patients in public hospitals have the right to choose both a primary therapist and a primary nurse.”

ANS: A

The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals under federal law. The remaining statements do not accurately describe that right.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 22, 30-31 MSC: NCLEX: Safe, Effective Care Environment

25. A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by

a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. What is the basis for this action? a. Information cannot be released without proper authorization. b. There is a duty to warn and protect. c. No action can violate the patient’s confidentiality.

d. Charges of malpractice must be avoided.

ANS: B

It is the health care professional’s duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not considered a violation of confidentiality or an example of malpractice.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 21-23 MSC: NCLEX: Safe, Effective Care Environment

MULTIPLE RESPONSE 1. Which interventions apply to the care plan of a patient being secluded? Select all that apply. a. Seclusion instituted when verbal intervention ineffective in stopping threatening b. c. d. e.

behavior Written medical order obtained within 2 hours Patient debriefed when seclusion discontinued Patient offered bathroom privileges hourly Fluids offered every 4 hours

ANS: A, C, D

The correct interventions meet Medicare and Medicaid guidelines for the psychiatric setting.

Other guidelines exist and should also be observed so that care can be evaluated as safe and effective. Fluids should be offered more often than every 4 hours, and a medical order must be secured within 1 hour.

DIF: Cognitive level: ApplyinN gURSINGRT EB F:.C p. O 28M MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

2. A patient diagnosed with bipolar disorder is admitted involuntarily during a manic phase.

Lithium 300 mg PO t.i.d. is prescribed. The patient refuses the morning dose. What are the nurse’s best actions? Select all that apply. a. Get the prescription changed to an elixir, and administer it in juice. b. Assemble adequate help to force the patient to take the medication. c. Educate the patient about the importance of lithium in stabilizing the mood. d. Allow the patient to refuse the medication, and document the patient’s comments. e. Inform the patient that unit privileges are contingent on taking prescribed medications.

ANS: C, D

Patients have the right to refuse consent to treatment, including medication administration.

The courts have ruled that neither voluntary nor involuntary patients can be forced to take psychotropic medication. Hiding the medication in food or fluids is not ethical. Assembling a show of force implies that forcible administration will occur. Making privileges contingent on medication ingestion is coercion.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 29 MSC: NCLEX: Safe, Effective Care Environment

Chapter 04: Psychobiologic Bases of Behavior MULTIPLE CHOICE 1. When a nurse administers an anticholinergic drug, it is important to assess for symptoms

associated with inhibition of: a. spinal nerve function. b. the central nervous system. c. the sympathetic nervous system. d. the parasympathetic nervous system.

ANS: D

Drugs with anticholinergic properties block parasympathetic function of certain cranial nerves, resulting in dilated pupils, decreased tearing, dry mouth, tachycardia, and a slowed gastrointestinal system. Anticholinergics do not affect spinal nerve function or function associated with the central or sympathetic nervous systems.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 43 MSC: NCLEX: Physiologic Integrity

2. A patient denies hunger despite ingesting fewer than 400 calories daily. The patient’s problem

might be associated with dysfunction of which structure? a. Parietal lobe b. Hypothalamus c. Medulla oblongata d. Reticular activating system I G B.C M ANS: B

NUR S N T

O

Research has shown that the hypothalamus is involved with eating and satiety, so dysfunction might be a factor in anorexia nervosa. Research has not implicated any of the other brain structures listed in anorexia nervosa.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 38 MSC: NCLEX: Physiologic Integrity

3. A patient is recovering from surgery to remove a tumor in the cerebellum. Which assessment

finding is most attributable to this diagnosis? a. The patient complains of limited taste and smell. b. The patient demonstrates poor balance and coordination. c. The patient has limited ability to learn and poor memory. d. The patient has poor emotional control and low motivation.

ANS: B

The cerebellum coordinates muscle synergy and is responsible for the maintenance of equilibrium. The limbic system plays a role in taste, smell, memory, learning, emotional control, and motivation.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 42 MSC: NCLEX: Physiologic Integrity

4. The nurse plans discharge teaching for a patient who experienced a stroke involving the

hippocampus. The nurse should adapt the teaching plan to account for possible problems with: a. visual acuity. b. expressive aphasia. c. short-term memory. d. balance and coordination.

ANS: C

The limbic system is crucial to memory. Damage to the hippocampus, a part of the limbic system, causes problems converting short-term to long-term memory, making learning difficult. Aphasia is a temporal lobe problem. Blindness is an occipital lobe problem. Balance and coordination are affected by damage to the cerebellum.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 38

TOP: Nursing process: Planning

5. A patient diagnosed with split-brain syndrome has damage to which structure of the brain? a. Amygdala b. Hippocampus c. Pyramidal tract d. Corpus callosum ANS: D

The corpus callosum connects the two brain hemispheres. When this communication pathway is severed, split-brain syndrome develops. None of the other structures is implicated in this disorder.

DIF: Cognitive level: UnderstN andiR ng I GREB F:.C p. 35M U S N T TOP: Nursing process: Assessment MSC: NCLEX: Physiologic Integrity 6. A patient reports an inability to sleep because of too much noise and light, even though the

environment is quiet with soft lighting. The nurse knows such reports support dysfunction of which organ? a. Basal ganglia b. Pituitary gland c. Substantia nigra d. Reticular activating system ANS: D

The reticular activating system (RAS) serves as a screen that allows individuals to tune out some stimuli and attend to others. When RAS disruption occurs and the individual is unable to tune out stimuli, the individual is unable to sleep. Lack of sleep can produce psychotic symptoms. The other structures are not involved in perception of sensory stimuli.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 42 MSC: NCLEX: Physiologic Integrity

7. A patient excitedly tells the nurse, “Look what I made in arts and crafts! I did a good job. I

want to make some other things too.” The nurse may conclude that which part of the patient’s nervous system is responsible for processing this reaction? a. Brainstem b. Occipital lobe

c. Limbic system d. Corpus callosum ANS: C

Feelings of pleasure are generated in the brain’s limbic system. The exact mechanisms of generating emotions and motivation, however, are unclear. The other structures are not involved in pleasure or motivation processing.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 39 MSC: NCLEX: Physiologic Integrity

8. The nurse assesses a patient diagnosed with Parkinson’s disease. When will tremors be most

pronounced? a. When sleeping b. When sitting quietly c. When focusing intently d. When reaching for something ANS: B

The tremor of Parkinson’s disease, a disease that affects the extrapyramidal system, is most pronounced when the patient is at rest. In Parkinson’s disease, tremor is absent during sleep and diminished when concentrating or with intentional movement.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 47 MSC: NCLEX: Physiologic Integrity

9. Dysfunction in which structure should lead the nurse to consider institution of fall

precautions? a. Wernicke’s area b. Hippocampus c. Amygdala d. Cerebellum ANS: D

The cerebellum is responsible for the maintenance of equilibrium. When equilibrium is impaired, fall prevention becomes a priority. Problems in Wernicke’s area are associated with impaired comprehension of the spoken word. Problems with the hippocampus or amygdala are associated with impaired memory formation.

DIF: Cognitive level: Analyzing REF: p. 42 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

10. Ventricular enlargement noted in brain studies of patients diagnosed with Alzheimer’s disease

is most likely attributable to: a. narrowing of the subarachnoid space. b. overproduction of cerebrospinal fluid. c. blockage of cerebrospinal fluid outflow. d. brain atrophy associated with cellular degeneration.

ANS: D

In Alzheimer’s disease, when brain cells degenerate, the brain atrophies and the ventricles enlarge to fill the existing space. Planning should consider the fact that the patient has fewer functioning brain cells, thus explaining cognitive symptoms and problems such as incontinence and difficulty in swallowing.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 47

TOP: Nursing process: Planning

11. A patient has disorganized thinking associated with schizophrenia. Neuroimaging studies will

most likely show dysfunction in which part of the brain? a. Temporal lobe b. Cerebellum c. Brainstem d. Frontal lobe ANS: D

The frontal lobe is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 44, 46 MSC: NCLEX: Physiologic Integrity

12. The patient is tense, hypervigilant, and reports, “My heart is racing.” The nurse understands

that the primary neurotransmitter associated with these complaints is: a. serotonin. b. glutamate. c. acetylcholine. d. norepinephrine.

ANS: D

Norepinephrine is a catecholamine. It is released in response to sympathetic stimulation and causes increased heart rate and blood pressure and other symptoms of anxiety. Glutamate, serotonin, and acetylcholine are not associated with sympathetic nervous system stimulation.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 47

TOP: Nursing process: Analysis

13. A patient who experiences frequent panic attacks asks the nurse, “Why does this happen to

me?” The nurse should explain that the problem might relate to a deficit of which brain chemical? a. GABA b. Serotonin c. Dopamine d. Glutamate ANS: A

Gamma-aminobutyric acid (GABA) is a neurotransmitter thought to exert a braking force on anxiety. A GABA deficit is implicated in generalized anxiety disorder and panic attacks. The other options have not been suggested as factors by research studies.

DIF: Cognitive level: Understanding

REF: p. 44

TOP: Nursing process: Implementation

MSC: NCLEX: Physiologic Integrity

14. Although a patient appears to have recovered from a head injury resulting from an auto

accident 3 months ago, the family reports changes in the patient’s personality and behavior.

The nurse should explain that these changes are probably associated with injury to which structure? a. Pons b. Parietal lobe c. Prefrontal area d. Caudate nucleus ANS: C

The prefrontal area is the seat of personality. It is responsible for thought, goal-oriented behavior, and inhibition. The other structures have less significant roles in personality change.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 38 MSC: NCLEX: Physiologic Integrity

15. When assessing a patient, the nurse elicits the Babinski reflex on the left foot. The nurse

knows this response can indicate the existence of: a. an upper motor neuron lesion on the right side. b. an upper motor neuron lesion on the left side. c. a lower motor neuron lesion on the right side. d. a lower motor neuron lesion on the left side.

ANS: A

The Babinski sign is the result of an upper motor neuron lesion on the opposite (contralateral) side of the body. Lower motoNrU neRuS roI nN leG siT onBs. noCrO mM ally result in flaccid paralysis.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 36 MSC: NCLEX: Physiologic Integrity

16. A patient demonstrates visual aphasia. The nurse can project that there is dysfunction in which

cerebral lobe? a. Temporal b. Parietal c. Occipital d. Frontal ANS: A

Temporal lobe lesion of the visual association area would result in visual aphasia, the inability to recognize previously known words. A parietal lobe lesion would involve sensory interpretation or association. An occipital lobe lesion would produce loss of vision. Problems with the frontal lobe would produce motor problems or changes in thought or personality.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 38 MSC: NCLEX: Physiologic Integrity

17. A male patient is diagnosed with mitochondrial encephalopathy. The patient’s daughter asks,

“Since this is a genetic disorder, am I at risk for having it too?” Select the nurse’s best response. a. “Your risk is related to exposure to environmental toxins.”

b. “No, this problem is only passed on by the mother.” c. “You must be feeling very worried.” d. “Your risk is not predictable.”

ANS: B

Mitochondria are passed to the ovum only by the mother, so the patient is not at risk for receiving it from the father. It is important to provide information in response to the daughter’s question.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 47 MSC: NCLEX: Psychosocial Integrity

18. The parent of an adopted infant tells the nurse, “Our baby was abused before the adoption. I

read an article online that said this experience causes problems as a child grows up. What we should be watching for?” Select the nurse’s best response. a. “Early trauma sometimes causes learning difficulties, anxiety, and difficulty handling stress later in life.” b. “Early abuse causes the myelin covering of the nerves to overgrow, which leads to high anxiety and mood instability.” c. “Many individuals who experience early trauma and abuse develop symptoms of schizophrenia.” d. “Your child will be normal. Information in online articles is not reliable.”

ANS: A

Stress increases cortisol levels. Excessive cortisol levels can cause hippocampal atrophy, leading to memory and learning difficulty. Elevated cortisol level is also associated with hypersensitivity of the hypothalamic-pituitary-adrenal (HPA) system, leading to overreaction to stress and possibly a propeN nU sitR yS toIdN epGrT esB si. onCaO ndManxiety. Myelin continues to grow after birth, but overgrowth is not likely as a result of abuse. Stating that the individual is at risk for schizophrenia is incorrect. Online articles may or may not be reliable. The nurse should not give false reassurance about the child’s development.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 48 MSC: NCLEX: Psychosocial Integrity

19. A patient who abuses heroin says, “I have willpower to manage my life in other areas, but I

feel helpless to control my craving for heroin.” The nurse’s response should be based on research findings suggesting that addictive behavior is related to changes in: a. cortisol secretion. b. the substantia nigra. c. mitochondrial DNA. d. the nucleus accumbens.

ANS: D

Research has implicated the nucleus accumbens as having a role in addictive behaviors. The substantia nigra is concerned with dopamine production. Excessive cortisol secretion has its primary effect on the hippocampus. Mitochondrial DNA mutation has not been implicated in addiction risk.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 47 MSC: NCLEX: Psychosocial Integrity

20. The nurse administers a medication that potentiates the action of GABA. Which finding

would be expected? a. Reduced anxiety b. Improved memory c. More organized thinking d. Fewer sensory perceptual alterations ANS: A

Increased levels of GABA reduce anxiety; thus any potentiation of GABA action should result in anxiety reduction. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 44

TOP: Nursing process: Evaluation

21. A nurse could anticipate that the treatment plan for a patient experiencing memory difficulties

might include medications designed to: a. inhibit GABA. b. increase dopamine at receptor sites. c. decrease dopamine at receptor sites. d. prevent destruction of acetylcholine.

ANS: D

Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA is known to affect anxiety level rather than memory.

IpNtoGmTsBa. Increased dopamine would cN auU seRsS ym ssC ocOiaM ted with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson’s disease rather than improving memory.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 44

TOP: Nursing process: Planning

MULTIPLE RESPONSE 1. An individual is experiencing problems associated with speech and communication. Which

cerebral structures are most likely to be involved in this deficit? Select all that apply. a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe e. Basal ganglia ANS: A, D

The frontal and temporal lobes of the cerebrum play a key role in the reception of messages and speech. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement as well as some thoughts and emotions, whereas the parietal lobe is involved with sensory reception.

DIF: Cognitive level: Understanding

REF: p. 38

TOP: Nursing process: Planning

MSC: NCLEX: Physiologic Integrity 2. A patient is diagnosed with severe depression. The nurse will prepare a plan to teach the

patient about medications that improve brain availability of which neurotransmitter? Select all that apply. a. Serotonin b. Dopamine c. Norepinephrine d. Acetylcholine e. Substance P ANS: A, C

Two neurotransmitters believed to be in low concentration at brain synapses of patients with depression are norepinephrine and serotonin. Most antidepressants act to increase availability of one or both of these neurotransmitters. Dopamine is implicated in schizophrenia; acetylcholine is implicated in Alzheimer’s disease. Substance P modulates pain.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: 44

TOP: Nursing process: Planning

Chapter 05: Cultural Issues MULTIPLE CHOICE 1. Culture is defined as a group’s shared: a. race and ethnicity. b. values, beliefs, and norms. c. biologic variations and psychological characteristics. d. patterned behavioral responses that developed over time.

ANS: B

Culture is the internal and external manifestation of a person’s, group’s, or community’s learned and shared values, beliefs, and norms that are used to help individuals function in life and understand and interpret life occurrences. None of the other responses provides an adequate explanation of culture, because all are too narrow in scope.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 50 MSC: NCLEX: Safe, Effective Care Environment

2. A nurse begins work at an agency that provides care to members of a minority ethnic

population. The nurse will be better able to demonstrate cultural competence after: a. identifying culture-bound issues. b. implementing scientifically proven interventions. c. correcting inferior health practices of the population. d. exploring commonly held beliefs and values of the population.

ANS: D

Cultural competence is dependent on understanding the beliefs and values of members of a different culture. A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture. The other options have little to do with cultural competence or represent only a portion of the answer.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 50 MSC: NCLEX: Safe, Effective Care Environment

3. A nurse cares for a first-generation American whose family emigrated from Germany one

generation ago. This patient would probably have which worldview about the source of knowledge? a. Knowledge is acquired through use of affective or feeling senses. b. Knowledge is acquired according to proof of existence. c. Knowledge develops by striving for transcendence of the mind and body. d. Knowledge evolves from an individual’s relationship with a supreme being.

ANS: B

The European-American perspective of acquiring knowledge evolves through acquiring proof that something exists using the personal senses. The distracters describe the beliefs of other cultural groups.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 51 MSC: NCLEX: Psychosocial Integrity

4. The nurse administers medications to a culturally diverse group of patients on a psychiatric

unit. What expectation should the nurse have about pharmacokinetics? a. Patients of different cultural groups may metabolize medications at different rates. b. Metabolism of psychotropic medication is consistent among various cultural groups. c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications. d. It is important to provide patients with oral and written literature about their psychotropic medications.

ANS: A

Cytochrome P-450 enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic medication; hepatic function influences metabolism rates. Information about medication is important but does not apply to pharmacokinetics.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 53 MSC: NCLEX: Psychosocial Integrity

5. A nurse prepares to assess a newly hospitalized patient who moved to the United States 6

months ago from Somalia. The nurse should first determine: a. if the patient’s immunizations are current. b. the patient’s religious preferences. c. the patient’s specific ethnic group. d. whether or not an interpreter is needed.

ANS: D

The assessment depends on cN oU mR mS unIicNatG ioT nB . T.hC eO nuMrse should first determine whether or not an interpreter is needed. The other information can be subsequently assessed when communication is effective.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 54 MSC: NCLEX: Psychosocial Integrity

6. A clinic nurse encounters many patients who request acupuncture, nutritional therapies,

moxibustion, cupping, and coining. The nurse understands that these patients are seeking to restore: a. chi. b. meridians. c. equilibrium. d. divine relationships.

ANS: C

Patients who view illness as disequilibrium or lack of balance may seek alternative therapies to restore balance. Chi is an energy force. Meridians are lines in the body representing body functions. Divine relationships are an aspect of balance, but equilibrium is a broader concept.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 53 MSC: NCLEX: Psychosocial Integrity

7. The nurse can expect the parent of a child with mal ojo (evil eye) to believe that the effects of

the spell can be broken after:

a. b. c. d.

ignoring the child. feeding the child warm foods. looking deeply into the child’s eyes. a root doctor or native healer intervenes.

ANS: D

Individuals who believe in culture-bound illnesses usually also believe that the cure for the illness is found in treatment by a native healer or roots doctor. The parent would not believe that any of the other options are effective.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 53 MSC: NCLEX: Psychosocial Integrity

8. A Hispanic parent says, “An old woman gave my baby the evil eye.” The health care provider

determines that the infant is physically healthy. The most culturally competent intervention would be to: a. tell the parent that the baby is healthy and needs no treatment. b. explain that the evil eye is a superstition and not a cause of illness. c. encourage the parent to immerse the baby in cool water baths daily. d. bring a root doctor into the consultation to restore the baby’s lost soul.

ANS: D

An individual who believes in mal ojo will also believe that Western medicine is ineffective to treat it. This person will believe that because the illness has an unnatural cause, treatment is best conducted by a native healer who can remove the spell. The parent would not view offering no treatment or casting doubt on evil eye as a superstition as helpful, making these options culturally insensitive. A cool water bath could destabilize an infant’s body temperature.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 53 MSC: NCLEX: Psychosocial Integrity

9. A patient of Cuban descent is hospitalized with depression. Which factor is most applicable to

care planning? a. The nurse should confer with the family’s oldest woman, who will serve as the primary decision maker. b. With the patient’s permission, the nurse should consult with family and religious advisors to plan care. c. The plan of care should incorporate use of meditation and contemplation techniques. d. Western medical treatment will be readily accepted by the patient.

ANS: B

Patients of Hispanic cultures often have relational worldviews. Individuals who have a relational worldview usually desire the involvement of family, religious advisors, and even friends during health care visits and the planning of interventions. The patient’s consent is required for this involvement. The other options reflect alternative worldviews.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 53

TOP: Nursing process: Planning

10. A clinic patient comes to an appointment carrying a baby. The nurse notes abrasions on the

baby’s thighs and determines that skin scraping has been used. In an effort to use cultural negotiation, the nurse should: a. encourage using less pressure during scraping to prevent abrasions and infections. b. show the parent how to use moxibustion rather than skin scraping. c. explain that skin scraping does not effectively treat illness. d. caution that the scraped skin can become infected.

ANS: A

Cultural negotiation is the nurse’s ability to work within a patient’s cultural belief system to develop culturally appropriate interventions. Only by suggesting a modification of the technique of skin scraping so as to perform it in a manner that will not cause injury or the potential for infection can the nurse reflect cultural negotiation.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 53 MSC: NCLEX: Physiologic Integrity

11. A Hispanic patient says, “I have no energy and cannot eat. I want to sleep but can’t, because

pain moves around different parts of my body.” A physical examination reveals no pathology.

The nurse should hypothesize that the patient may be experiencing: a. lost soul (susto). b. spiritual distress. c. a broken heart. d. amok.

ANS: A

Loss of one’s soul, a culture-bound illness occasionally seen among Hispanic individuals, produces vague symptoms suN chUaRsSthIoN seGdT esB cr. ibCed. OMWestern medicine regards these as depressive symptoms, but individuals with lost soul speak only of physical symptoms, rather than psychological or emotional disequilibrium. The other options are culture-bound disorders with symptoms different from what is described in this scenario.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 53

TOP: Nursing process: Analysis

12. A Hispanic patient reports symptoms consistent with the cultural phenomena of susto. A

physical examination reveals no pathology, and depression is diagnosed. The effectiveness of selective serotonin reuptake inhibitors (SSRIs) may be increased if combined with: a. care from a traditional healer. b. acupuncture. c. skin scraping. d. moxibustion.

ANS: A

The patient is probably experiencing lost soul, a culture-bound illness. Its symptoms are depressive in nature and might well respond to treatment with an antidepressant. However, because the individual sees the cause as loss of the soul, she will not have faith in medication as a cure. Using a traditional healer to return the lost soul will set the stage for medication to relieve symptoms. The other options are not culturally appropriate.

DIF: Cognitive level: Applying

REF: p. 53

TOP: Nursing process: Planning

MSC: NCLEX: Psychosocial Integrity 13. A Chinese-American infant is seen in a well-baby clinic. The parent reports that the baby is

irritable and not eating well. The nurse notices several skin abrasions on the thighs and upper arms. What is the nurse’s most appropriate initial intervention? a. Ask if the parent has used coining. b. Report the parent for suspected child abuse. c. Assess whether or not the parent desires to harm the child. d. Ask if the parent has taken the child to an acupuncturist.

ANS: A

Recognition of the characteristic marks of coining or skin scraping can keep the nurse from making a culturally insensitive judgment that child abuse is occurring. Coining is used by Asian families to restore equilibrium for babies and small children. The other options would be inappropriate or ineffective.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 53 MSC: NCLEX: Psychosocial Integrity

14. A parent said, “My child had mal ojo, so I did not give her the medicine for an ear infection.”

The nursing diagnosis of noncompliance was documented by the nurse who saw the child last.

A culturally competent nurse would analyze that the situation occurred because of: a. lack of knowledge of therapeutic regimen. b. differences in perceptions of how illness occurs. c. evidence of unconscious hostility toward the child. d. a misunderstanding about the communicability of microbes.

ANS: B

A parent who believes that his or her child’s illness is the result of a spell cast on him or her will not understand the need for giving the child medication on a regular basis for several days. Diagnosing noncompliance will not help resolve the problem. Cultural negotiation and repatterning will be necessary. The other options do not present viable explanations.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 51, 53 Table

15. A psychiatric nurse leads a medication education group for Hispanic outpatients. This nurse

holds an analytic worldview and uses pamphlets as teaching tools. Group sessions are short and concise. After the group session, the patients are most likely to believe that: a. the nurse was uncaring. b. the session was effective. c. the teaching was efficient. d. they were treated respectfully.

ANS: A

Hispanic individuals usually have a relational worldview. Their needs are for learning through verbal communication rather than reading and for having time to chat before approaching the task. An individual with a relational worldview would be unlikely to hold any of the other views.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 51-52

TOP: Nursing process: Evaluation

16. A nurse cares for a Chinese-American patient diagnosed with major depression. After the

nurse reviews the therapeutic regimen with the patient, which action should occur next? a. Verify understanding by asking the patient to restate the information. b. Ask if the patient is willing to follow directions for medications. c. Reinforce cultural norms about eating hot and cold foods. d. Provide the information in written form to the patient.

ANS: A

Many Asians and Asian-Americans believe that questioning an authority figure (nurse) would be disrespectful, so they do not ask for clarification when they do not understand directions for their treatment. Individuals of this culture are usually willing to comply once they understand. Written information may be provided later. Although hot and cold foods might be used by Asian-Americans, there is no evidence that this patient is interested in this therapy.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 51

TOP: Nursing process: Evaluation

17. A nurse is assigned to an outreach program on a Native-American reservation. Which tenet

should the nurse consider when communicating with these consumers? a. Silence is considered a social error. b. Touching is an accepted part of conversation. c. Important topics are always preceded by polite social conversation. d. Rules regarding roles and status are important and must be observed.

ANS: D

Relationships are based on the idea that the Supreme Being is present in each person and that all persons must be valued anNdUtrR eaS teIdN wG itT hB di. gnCity.MThis is particularly true of treatment received by tribal elders, healers, and others perceived to be in positions of importance. The other options are not consistent with the ecologic worldview.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 52

TOP: Nursing process: Planning

18. A nurse is scheduled to interview a new patient, a Muslim college professor from the Middle

East. Which action by the nurse would support cultural competence? a. Serve the patient a cold beverage at the beginning of the interview. b. Review Middle Eastern cultural values before the interview. c. Avoid offering to shake hands with the patient. d. Determine if a translator is available.

ANS: B

Brushing up on Middle Eastern culture would be a sensitive action that might result in a lowering of barriers between the nurse and patient. It would not be necessary to serve beverages during the interview. A translator would probably not be needed if the patient is a college professor. Shaking hands with Middle Easterners is acceptable.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 51-52 MSC: NCLEX: Psychosocial Integrity

19. An African-American patient tells a nurse with a European-American worldview, “There’s no

sense talking. You wouldn’t understand because you live in a white world.” Select the nurse’s best response. a. “Nurses are educated to care for people from all cultures. It is a required component of nursing education.” b. “It would be helpful if you described an example of something you think I would not understand.” c. “Your mental illness is causing you to view me with prejudice. We are all here to help you.” d. “Yes, I do understand. Everyone goes through the same experiences.”

ANS: B

Having the patient speak in specifics rather than globally will help the nurse understand the patient’s perspective. This approach will help the nurse establish rapport with the patient.

False reassurances will not facilitate communication with the patient.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 51 MSC: NCLEX: Psychosocial Integrity

20. A Korean-American patient showed rare eye contact. This nursing diagnosis was formulated:

Chronic low self-esteem related to shame and guilt as evidenced by lack of eye contact.

Interventions were sought to improve the patient’s self-esteem, but after 3 weeks the patient’s eye contact was unchanged. Select the accurate analysis of this scenario. a. The patient’s poor eye contact indicated anger and hostility that did not resolve. b. The nurse should have assessed the patient’s culture before formulating this diagnosis and plan. c. Resolution of shame and guilt cannot be expected to occur in 3 weeks. The nurse N R I G B.C M O should allow more time. U S N T d. The patient’s eye contact should have been directly addressed by role-playing to increase comfort with eye contact.

ANS: B

The amount of eye contact a person engages in is often culturally determined. In some cultures eye contact is considered insolent, whereas in others eye contact is expected and valued. Korean-Americans often prefer not to engage in direct eye contact.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 54

TOP: Nursing process: Evaluation

21. When a Mexican-American woman and nurse interact, the patient often holds the nurse’s

hand or links arms with the nurse. The nurse is uncomfortable with this behavior. Which analysis is most accurate? a. The patient is using touch to make the nurse uncomfortable and manipulate the relationship based on that factor. b. An energy field disturbance has occurred. Touch rebalances the energy between the patient and nurse. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The patient is accustomed to and comfortable with touch, as are members of many Hispanic cultures.

ANS: D

The most likely answer is that the patient’s behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are much less likely.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 51-52

TOP: Nursing process: Analysis

22. At the time of discharge, a patient with a European-American worldview demands copies of

all medical records. Which analysis most accurately explains the patient’s behavior? The patient: a. continues to experience mistrust of the team’s truthfulness. b. is probably planning to see an attorney about poor care. c. values the written evidence of illness and treatment. d. probably wants to edit the records for accuracy.

ANS: C

Members of European-American cultures have analytic worldviews and value information that is written because it lends proof. The distracters offer more remote reasons for the behavior.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 51-52 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. Which questions should the nurse ask to determine an individual’s worldview? Select all that

N R I G B.C M

U S N T O apply. a. “What is more important: the needs of an individual or the needs of a community?” b. “How would you describe an ideal relationship between individuals?” c. “How long have you lived at your present residence?” d. “Of what importance are possessions in your life?” e. “Do you speak any foreign languages?”

ANS: A, B, D

The answers provide information about cultural values related to the importance of individuality, material possessions, relational connectedness, community needs versus individual needs, and interconnectedness between humans and nature. These will assist the nurse to determine whether the worldview of the individual is analytic, relational, community, or ecologic. Other follow-up questions would be needed to validate findings.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 51-52 MSC: NCLEX: Psychosocial Integrity

2. A nurse cares for patients who recently immigrated to the United States. The nurse would

expect patients from which countries to hold relational worldviews? Select all that apply. a. Germany b. Panama c. Mexico d. Ghana

e. France ANS: B, C, D

Persons of Hispanic and African-American cultures often hold relational worldviews. Mexico and Panama are predominantly Hispanic cultures. Ghana is African. Immigrants from Germany and France (European countries) would more likely have analytic worldviews.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 52 MSC: NCLEX: Psychosocial Integrity

Chapter 06: Spiritual Issues MULTIPLE CHOICE 1. The patient says, “I know I’m very sick right now, but I trust that God will make me better.”

Based on this statement, the nurse can assess the patient’s spirituality as being based in: a. theism. b. humanism. c. behaviorism. d. existentialism.

ANS: A

Theism is the only model that suggests that people are inextricably tied to a transcendent being. This view provides hope for a better future. None of the other views have this basis.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 58-59 MSC: NCLEX: Psychosocial Integrity

2. The spouse of a psychiatric patient says, “This mental illness should not have happened. I

tried to teach the importance of professing faith in God and getting converts, but my partner rejected them. Those practices keep me well. It’s the only way to live.” The nurse can assess that the spouse is demonstrating: a. atheism. b. humanism. c. agnosticism. d. sick religiosity.

ANS: D

Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The scenario does not give evidence of any of the other options.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 59 MSC: NCLEX: Psychosocial Integrity

3. A depressed patient expresses feelings of hopelessness, helplessness, and powerlessness. The

patient’s spiritual distress is related to an inability to: a. find meaning and hope through choices. b. develop wisdom in the face of adversity. c. draw strength from a higher power. d. live by higher principles.

ANS: A

Although individuals cannot always choose their circumstances, they always have a choice of attitudes toward their experiences. Without finding meaning, individuals develop hopelessness. None of the other options relates directly to hopelessness.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 59 MSC: NCLEX: Psychosocial Integrity

4. A patient says, “I know I need religion in my life, but I don’t know how to find God. I feel I

have been abandoned.” The nurse should assess for a childhood history of: a. recurrent losses. b. overindulgence. c. lack of nurturing. d. poor school performance.

ANS: C

Loder has hypothesized that early developmental experiences set the stage for later spiritual dynamics. Inadequate nurturing may result in lack of establishment of trust. Later, spiritual issues of abandonment and shame might surface. None of the other options have been advanced as explanations for feelings of abandonment by God. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 59 MSC: NCLEX: Psychosocial Integrity

5. A group of nurses disagrees about whether or not to make spirituality a part of the assessment.

Which statement provides a compelling argument in favor of including spiritual assessment? a. Research clearly demonstrates that spiritual interventions by nurses are a cost-effective practice. b. Accrediting organizations regard spiritual care as a patient right. c. Spirituality is better addressed by nurses than by clergy. d. Prayer consistently improves mental health outcomes.

ANS: B

There is a lack of agreement as to whether or not spiritual care should be a legitimate concern of nurses, despite a large body of research evidence citing its advantages to patients. Among the major deterrents to includNinUgRspSiI ritN uaGl T caB re.iC s tO heMconcern that already overburdened nurses will not find time to perform the assessment. It should be noted, however, that when an accrediting body considers a facet of care to be a right of patients, it will look for evidence of attention to that right. A spiritual assessment documented in the medical record provides such evidence. The other options are of lesser importance when weighed against the standards set by an accrediting agency.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 59-60

TOP: Nursing process: Planning

6. Which statement by a mentally ill patient best exemplifies sick religiosity? a. “Suicide will result in eternal damnation for your soul.” b. “Your illness has nothing to do with insufficient faith.” c. “Questioning God is a common reaction to illness.” d. “Your illness is not related to sin.”

ANS: A

Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The correct option best exemplifies this thinking. The other options are supportive of the patient’s spirituality.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 59 MSC: NCLEX: Psychosocial Integrity

7. A patient diagnosed with schizophrenia says, “I am a reincarnation of Jesus. I can raise the

dead.” The most qualified person for the nurse to refer the patient would be a: a. psychiatric nurse clinician. b. professional chaplain. c. clinical psychologist. d. community minister.

ANS: B

A professional chaplain holds a ministerial degree and has had a year of special study in ministering to individuals with spiritual concerns related to health problems. The other professionals have less knowledge and experience in dealing with the dual problems of mental illness and spiritual concerns.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 62 MSC: NCLEX: Psychosocial Integrity

8. A nurse provides spiritual care for a patient awaiting a liver transplant. The nurse should

anticipate that the patient’s most likely response will be: a. consideration of issues related to own mortality. b. devaluation of prayer and organized religion. c. misinterpretation of medical information. d. clinical depression.

ANS: A

Although each of the options is possible, the most likely response is thinking about what the illness means in terms of lifespan, quality of life, and other mortality issues. The other responses are pathologic and are not seen as frequently.

NURSINGTB.COM REF: p. 61

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

TOP: Nursing process: Planning

9. An African-American caregiver says, “Both of my parents have dementia. I find it so difficult

to care for them because of their disabilities. I get depressed and hopeless thinking about it.

Can you give me any suggestions for coping?” Before making suggestions, the nurse should assess: a. the parents’ stage of dementia. b. the caregiver’s religious ideology. c. whether or not the parents’ medications are helping. d. if financial resources are sufficient to provide a health care aide.

ANS: B

Serious illness of loved ones often presents difficult dilemmas and problems in adjustment for caregivers. It is known that religious activities are important coping mechanisms for many African-American caregivers of older adults. The correct answer is the only option directly concerned with caretaker coping. The foci of the other options are on the parents.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 58 MSC: NCLEX: Psychosocial Integrity

10. A patient diagnosed with schizophrenia, paranoid type, has been suspicious of staff since

admission. The patient visits with a chaplain but then tells the nurse, “Don’t send any more preachers.” What is the most likely reason for the patient’s reaction?

a. b. c. d.

Hostility Distractibility Inability to trust Inability to find meaning in suffering

ANS: C

Individuals with paranoid schizophrenia often have an inability to trust. Inability to trust may be related to inadequate nurturing in infancy and to later difficulty recognizing a connection with God. The other options are less clearly related to issues of paranoia and trust.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 59, 61

TOP: Nursing process: Evaluation

11. A patient tells the nurse, “I make decisions each day that have a positive effect on my life.”

This statement is most closely related to the spiritual construct of: a. making meaning through choices. b. a presence that orders the world. c. higher purpose and principles. d. higher power and achievement.

ANS: A

Frankl advocated that humans find meaning when they commit themselves to something beyond themselves. Making meaningful choices improves an individual’s mental health. The constructs mentioned in the other options have less to do with the individual’s decision making described in the scenario.

DIF: Cognitive level: Understanding TOP: Nursing process: AssessN menR t I

REF: p. 59 M : N G SBC. CCLMEX: Psychosocial Integrity

U S N T

O

12. A patient moans, “God wants me to suffer, but I don’t know why. I feel like an outcast. I

should have never been born.” Which nursing diagnosis applies? a. Potential for enhanced spiritual well-being b. Disturbed personal identity c. Spiritual distress d. Powerlessness ANS: C

Defining characteristics for the nursing diagnosis of spiritual distress are present. They include concern with the meaning of life, anger toward God, questioning the meaning of suffering, conflict about beliefs, and questions about the morality of the therapeutic regimen.

Spiritual distress is more applicable to the patient’s comments than the other diagnoses.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 60 MSC: NCLEX: Psychosocial Integrity

13. A patient diagnosed with schizophrenia complains of demon voices coming through the

television. Which statement by the nurse providing spiritual care would be most comforting to the patient? a. “Rest assured that God will fill your heart with peace.” b. “I am concerned about your spiritual distress.” c. “God will hold you in the palm of His hand.” d. “God knows your every thought.”

ANS: B

The correct answer shows compassion and caring on the part of the nurse and contributes to trust building. The nurse has offered concerns, which reassures the individual that he or she will not be abandoned. The other options each include abstract concepts that are difficult for someone who thinks concretely to interpret correctly. They might even be frightening to patients who think concretely.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 59, 61 MSC: NCLEX: Psychosocial Integrity

14. A patient with major depression shows the nurse a passage in the Bible and says, “How do

you think this verse relates to me?” The nurse is unfamiliar with the verse and unsure how to respond. Select the nurse’s best action. a. Ask the patient, “What do you think the verse means?” b. Invite professional clergy to join the dialogue with the patient. c. Explain to the patient, “I’m not familiar with that passage. It would be better for me not to comment.” d. Say to the patient, “Would you bring that up in the group session? You can get input from several people about what the verse means.”

ANS: B

The correct answer shows that the nurse recognizes personal limits but remains engaged in the interaction with the patient. The distracters reject the patient’s concerns.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 62 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

U Schecked N Tthe box O labeled “No religious affiliation.” What 15.1 On the admission papers, a patient 5 meaning can the nurse draw from this information? The patient: . a. is not religious. b. is probably monotheistic. c. has conventional religious values. d. is probably experiencing spiritual distress.

ANS: B

The correct answer is consistent with the beliefs of 80% of Americans: there is one Supreme Being. The distracters offer misinformation and misinterpretation about the meaning of “No religious affiliation.”

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 58 MSC: NCLEX: Psychosocial Integrity

16. What is the predominant religious tradition in the United States? a. Christian b. Buddhist c. Muslim d. Jewish ANS: A

Christians compose 78% of Americans.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 58 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. A patient says, “I am a Christian.” The nurse understands that Christianity includes which

groups? Select all that apply. a. Judaism b. Mormonism c. Buddhism d. Catholicism e. Greek Orthodox ANS: B, D, E

Christianity accounts for 78% of the U.S. population and includes Protestant, Mormon, Catholic, and some orthodox groups. Judaism and Buddhism are not Christian religions.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 58 MSC: NCLEX: Psychosocial Integrity

2. A new nurse asks the mentor, “How can I help meet patients’ spiritual needs?” Select the

mentor’s best responses. “Patients have reported that what they want most is for a spiritual care provider to (select all that apply): a. be authentic.” b. be respectful.” c. demonstrate caring.” d. speak slowly and concretN ely.R ” I G B.C M e. provide answers to theologU icalS queN stioT ns.”

O

ANS: A, B, C, D

The needs elicited from patients (authenticity, caring, respect) can be seen as caregiver behaviors that enhance trust formation. The need to speak slowly and in concrete terms is important for patients with thought disorders who have cognitive problems that make comprehension slower and abstraction difficult to understand.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 61 MSC: NCLEX: Psychosocial Integrity

3. What information about a patient’s perceptions and values would the nurse obtain by using

questions from the HOPE tool? Select all that apply. a. Healthy spirituality versus sick religiosity b. That which gives the patient hope and meaning in life c. Important personal spiritual practices d. Role of religion in the patient’s life e. Sources of strength and comfort ANS: B, C, D, E

The HOPE questions gather information about sources of hope, strength, comfort, meaning, peace, love, and connection; the role of organized religion for the patient; personal spirituality and practices; and effects on medical care and end-of-life decisions.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 61 MSC: NCLEX: Psychosocial Integrity

Chapter 07: Models for Working with Psychiatric Patients MULTIPLE CHOICE 1. When interacting with patients, it is important for the nurse to recognize that defense

mechanisms: a. keep id impulses from gaining control. b. protect the ego from excessive anxiety. c. access unconscious feelings and memories. d. prevent conflict among the id, ego, and superego.

ANS: B

Theorists widely accept the Freudian concept that ego defense mechanisms operate unconsciously to lower anxiety. The function of defense mechanisms is limited to anxiety control, so the other options are incorrect.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 67

TOP: Nursing process: Planning

2. A nurse plans an intervention to supports a patient’s ego. This intervention is therapeutic,

because the individual’s ego: a. provides rational, logical reality testing. b. is primarily concerned with right and wrong. c. uses primary process imagery to meet basic needs. d. is derived from the individual’s pattern of thinking.

ANS: A

The ego focuses on the reality principle and uses secondary-process thinking, a logical, rational operation to maintain the well-being of the individual. The superego is concerned with right and wrong. The id uses primary process. Ego formation is influenced by heredity, environment, and maturation.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 67 MSC: NCLEX: Psychosocial Integrity

3. A patient asks, “Why is it important to uncover memories and conflicts hidden in the

unconscious?” A Freudian therapist would explain that bringing unconscious information to consciousness will: a. resolve developmental issues, fears, and crises. b. allow an individual control over the id and superego. c. suppress painful feelings and increase rational thinking. d. provide insight into behavior and allow meaningful change to occur.

ANS: D

Freud believed that uncovering unconscious material generates an understanding of behavior that enables individuals to make choices about behavior and thus improve mental health. It will not, however, automatically resolve issues, give the patient control over id and superego strivings, or result in rational thinking.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 67 MSC: NCLEX: Psychosocial Integrity

4. A patient uses defense mechanisms excessively. The nurse should expect to find evidence

that: a. the patient has difficulty with problem solving. b. the patient has an increased risk for psychosis. c. emotions are experienced with great intensity. d. reality is denied.

ANS: A

Excessive use of defense mechanisms results in the distortion of reality. When reality is not perceived accurately, problem solving is impaired. The other options might or might not be experienced by the patient.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 67 MSC: NCLEX: Psychosocial Integrity

5. A patient experiences severe panic attacks and uses denial, repression, and displacement.

Nursing interventions should be directed toward: a. teaching more effective coping strategies. b. setting limits on use of the defense mechanisms. c. assisting the patient to change values and beliefs. d. helping the patient uncover unconscious conflicts.

ANS: A

A desired outcome would be that the patient will use more effective coping strategies. Nursing intervention would focus on helping the patient identify and use more adaptive coping strategies. Setting limits on the use of defense mechanisms is impossible. Values clarification might be unnecessary. UncovNeU rinRgScI onNflG icT tsBis.nC oO t aMfocus of nursing intervention.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 67-68 MSC: NCLEX: Psychosocial Integrity

6. A young adult lives with his parents, has few interpersonal relationships, and says, “Most

people can’t be trusted.” This person makes decisions only after consulting with his parents.

Using Erikson’s developmental theory, the nurse can draw which conclusion? a. The patient has evidence of inferiority and lacks a sense of direction. b. Developmental deficits in early life have impaired the patient’s adult functioning. c. The patient’s developmental problems will probably lead to a serious mental illness. d. It is impossible for the patient to proceed to the next developmental stage until mastering earlier stages.

ANS: B

The patient achieved only partial mastery of the trust-versus-mistrust stage. Deficits in development carried from one stage to the next interfere with functioning at the adult level.

Individuals do progress from stage to stage when mastery is not attained; however, adjustment is usually impaired. Developmental problems might lead to a serious mental disorder but might also produce less serious results.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 69-71 MSC: NCLEX: Health Promotion and Maintenance

7. When the nurse conducts a developmental assessment with a new patient, the assessment can

be expected to yield information regarding what? a. The use of defense mechanisms b. The degree of mastery of critical tasks c. Strategies to help the patient make rational decisions d. The mobilization of defenses against the patient's stressors ANS: B

According to Erikson’s developmental theory, a developmental assessment is conducted for the purpose of determining the extent to which an individual has successfully mastered the critical task of each stage of development up to his or her chronologic age. Lack of mastery or partial mastery will yield clues about issues to be addressed in working with the patient.

Because of its focus, the developmental assessment might yield only minimal information about defense mechanism use and defenses used to cope with stress. Rational decision making is not expected to be fostered as a result of developmental assessment.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 70-71 MSC: NCLEX: Health Promotion and Maintenance

8. A patient diagnosed with lung cancer continues to smoke and says, “I think my cancer is more

the result of a bad gene than of smoking.” The patient shows the use of which defense mechanism? a. Denial b. Compensation c. Intellectualization d. Reaction formation ANS: A

Denial is the unconscious refusal to admit an unacceptable idea or behavior, as shown in this example. Compensation refers to covering a weakness by overemphasizing a desirable trait.

Intellectualization involves using a logical explanation without expressing emotion or affect.

Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: 67 MSC: NCLEX: Psychosocial Integrity

9. A patient tells the nurse, “The reason I use drugs is because everybody nags me to do things

that don’t interest me.” The patient shows use of which defense mechanism? a. Sublimation b. Introjection c. Identification d. Rationalization ANS: D

Rationalization is an attempt to prove that one’s behaviors or feelings are justifiable and involves making justifications of feelings or behaviors. Sublimation channels instinctual drives into acceptable channels. The patient is not modeling after another person or incorporating another’s values.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 67 MSC: NCLEX: Psychosocial Integrity

10. A patient is mute, curled in a fetal position, and incontinent of urine. The patient eats small

amounts only if spoon-fed. The nurse assesses this behavior as most indicative of: a. displacement. b. compensation. c. conversion. d. regression.

ANS: D

Regression is defined as the return to an earlier, more comfortable developmental state—in this case, infancy. Displacement involves discharging feelings to an object that is less threatening. Compensation refers to covering a weakness by overemphasizing a desirable trait.

Conversion refers to the unconscious expression of conflict symbolically through physical symptoms.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 68 MSC: NCLEX: Psychosocial Integrity

11. A young adult has a realistic sense of self, a commitment to reasonable career goals, a

satisfying intimate-partner relationship, and a circle of loyal friends. This person says, “I volunteer for important projects in my community.” The nurse can draw which conclusion? a. There is lack of mastery of critical tasks associated with the stage of industry versus inferiority. b. Mastery of critical tasks associated with the stage of identity versus role diffusion is evident. c. Fear of criticism and affection affect mastery of critical tasks associated with intimacy. d. The person vacillates between dependence and independence.

N R I G B.C M ANS: B

U S N T

O

Adult behavior reflecting mastery of the critical tasks associated with the stage of identity versus role diffusion includes confident sense of self, emotional stability, commitment to career planning, sense of having a place in society, establishing a relationship with the opposite sex, fidelity to friends, and development of personal values. The behaviors given in the scenario are not indicators of any of the other options.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 69-71 MSC: NCLEX: Health Promotion and Maintenance

12. A young adult reports overwhelming guilt about minor social errors, feels self-pity, and says,

“I stay on the sidelines of life so I can avoid the embarrassment of being noticed.” The nurse can assess deficits in mastery of critical tasks associated with which developmental stage? a. Trust versus mistrust b. Industry versus inferiority c. Autonomy versus shame and doubt d. Generativity versus self-absorption ANS: B

Adult behaviors reflecting developmental problems associated with the stage of industry versus inferiority include excessive guilt and embarrassment, passivity, apathy, rumination and self-pity, assumption of the victim role, and underachievement of potential. The behaviors given in the scenario reflect the critical tasks of industry versus inferiority. Tasks of the other stages are entirely different.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 69-71 MSC: NCLEX: Health Promotion and Maintenance

13. An older retired executive reports, “I am unable to say ‘no’ when asked to help with

community causes. These projects overtax my strength, but if I don’t do them, who will?” The nurse can assess that this person is having difficulty with critical tasks related to which developmental stage? a. Trust versus mistrust b. Integrity versus despair c. Identity versus role diffusion d. Autonomy versus shame and doubt ANS: B

Adult behaviors reflecting problems associated with the developmental stage of integrity versus despair include inability to reduce activities, overtaxing strength, and feeling indispensable, or the opposite: feeling helpless, useless, or lonely; focusing on past mistakes; and inability to occupy oneself with satisfying activities. Tasks of the other stages are not described in the scenario.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 69-71 MSC: NCLEX: Health Promotion and Maintenance

14. The nurse who uses the interpersonal model as a basis for practice will focus assessment on

identifying: a. intrapsychic conflicts. b. relationship problems. c. how the environment affects behavior. d. the patient’s achievement of development tasks.

ANS: B

Interpersonal therapists assess for current difficulties in the patient’s relationships with others.

Learning new, more effective interpersonal skills becomes a goal of therapy. Psychoanalytic therapists focus on intrapsychic conflicts. The other options are not the focus of the model.

DIF: Cognitive level: Understanding REF: pp. 71-72 MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing process: Planning

15. Which goal is most likely to be chosen by the nurse for a patient who uses the interpersonal

model as a basis for practice? a. The patient will develop mature, satisfying relationships that are relatively free of anxiety. b. The patient will rid himself of irrational beliefs, including “shoulds,” “oughts,” and “musts.” c. The patient will learn to meet basic needs responsibly. d. The patient will manage stress adaptively.

ANS: A

The goal of interpersonal therapists is to assist the patient in developing healthy interpersonal relationships that are relatively anxiety-free. The other distracters state a goal appropriate for cognitive therapy, reality therapy, and stress management therapy, respectively.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 71-72 TOP: Nursing process: Planning

16. A 26-month-old child displays negative behaviors. The parent says, “My child refuses toilet

training and shouts ‘No!’ when given direction. What do you think is wrong?” Select the nurse’s best reply. a. “This is normal for your child’s age. The child is striving for independence.” b. “The child needs firmer control. Punish the child for defiance and saying ‘no.’” c. “There may be developmental problems. Most children are toilet trained by age 2.” d. “Some undesirable attitudes are developing. A child psychologist can help you develop a remedial plan.”

ANS: A

The distracters indicate that the child’s behavior is abnormal when, in fact, this behavior is typical of a child around the age of 2 years whose developmental task is to develop autonomy.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 69 MSC: NCLEX: Health Promotion and Maintenance

17. A nurse clinician uses rational-emotive therapy with a patient who is chronically depressed.

The initial step in this process is to help the patient: a. identify developmental taN sksR andIproGgreB ss. .C M U S N T b. manage environmental stressors more effectivO ely. c. explore childhood influences on the patient’s emotional state. d. recognize how irrational beliefs are related to painful feelings.

ANS: D

Cognitive therapists believe that irrational beliefs or automatic thoughts cause self-defeating behaviors to be maintained. Individuals can challenge their self-defeating behaviors once they identify irrational beliefs and see their connection to painful feelings. The other options reflect interventions that might occur later.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 72-75 MSC: NCLEX: Psychosocial Integrity

18. A patient says, “It’s my fault because I always make bad decisions. I should never have taken

that job.” Using a rational-emotive approach, how would the nurse respond? a. “What can you do to solve your problems at work?” b. “You’re experiencing a great deal of stress right now. How can you manage it more effectively?” c. “Can you describe a time in your childhood when your parents blamed you for things you didn’t do?” d. “Consider the words you are using to talk about yourself. Let’s try to change those words to more positive ones.”

ANS: D

The therapist using rational-emotive therapy helps the patient identify irrational thoughts and replace them with new, more positive self-statements to enable the patient to think, feel, and behave differently. The other options do not make use of the combination of cognitive, emotive, and behavioral components.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 73 MSC: NCLEX: Psychosocial Integrity

19. During an interdisciplinary team meeting, a nurse says, “The patient’s psychological distress

seems to result from automatic thoughts that cause self-defeating behaviors.” The nurse is conceptualizing the patient’s problem from the viewpoint of which model? a. Interpersonal b. Psychoanalytic c. Stress-adaptation d. Cognitive-behavioral ANS: D

The cognitive-behavioral model recognizes the role of automatic thoughts (irrational beliefs) in promulgating self-defeating behaviors. The information given in the scenario does not reflect conceptualization using any of the other models.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 72-73

TOP: Nursing process: Analysis

20. Which statement by an adult would lead a nurse to suspect deficits in mastery of the

developmental task of infancy? a. “I have many warm and close friendships.” b. “I am afraid to let anyoneNrU eaR llS yI geN tG toTkB no.wCm OeM.” c. “I am always right. Keep your opinion to yourself.” d. “I am ashamed I did that wrong. Please forgive me.”

ANS: B

According to Erikson, the developmental task of infancy is the development of trust. The the only statement clearly showing the lack of ability to trust others mentions being "afraid to let anyone really get to know me".. The distracters suggest that the developmental task of infancy was successfully completed: rigidity rather than mistrust, and failure to resolve the crisis of initiative versus guilt.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 69-71 MSC: NCLEX: Health Promotion and Maintenance

21. A student nurse says, “I don’t need to interact with my patients. I learn by observing them.”

The instructor can best interpret the nursing implications of Sullivan’s theory to this student by responding: a. “Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills.” b. “Observing patient interactions can help you formulate priority nursing diagnoses and appropriate interventions.” c. “I wonder how accurate your assessment of the patient’s needs can be if you do not interact with the patient.” d. “It is important to note patient behavioral changes because these signify changes in

personality.”

ANS: A

Sullivan believed that the nurse’s role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan’s theory. These cornerstones cannot be demonstrated by the nurse who does not interact with the patient.

Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The other distracters relate to Maslow’s theory and behavioral theory.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 71-72 MSC: NCLEX: Psychosocial Integrity

22. An individual diagnosed with alcohol dependence will begin motivational enhancement

therapy. The nurse will explain this therapy to significant others as a way of: a. altering the patient’s irrational thoughts. b. enhancing the patient’s willingness to change behavior. c. managing anxiety through satisfying interpersonal interactions. d. mastering critical developmental tasks not attained earlier in life.

ANS: B

This variation of cognitive-behavioral therapy uses motivational interviewing to bolster the patient’s readiness and willingness to change habits related to the addiction. Motivational enhancement therapy is a nonconfrontational approach that uses empathy and promotes self-efficacy. The other options are consistent with interpersonal therapy, cognitive therapy, and the use of Erikson’s model.

NURSINGTB.COM REF: p. 73

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

MSC: NCLEX: Psychosocial Integrity

23. After an episode of self-mutilation, a patient diagnosed with borderline personality disorder

will begin individual therapy and group skills training. The goals are to decrease use of dissociation, increase distress tolerance, and regulate affect. Which type of therapy is evident? a. Rational-emotive behavioral b. Motivational enhancement c. Dialectical behavioral d. Interpersonal ANS: C

Each of the components described in the scenario is a component of dialectical behavioral therapy. The scenario information is not consistent with the components of any of the other types of therapy given as options.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation MULTIPLE RESPONSE

REF: p. 73 MSC: NCLEX: Psychosocial Integrity

1. A student goes to a party the night before a test and then fails the exam. After seeing the

score, the student slams a book on the table and says, “I have to work so much and have no time to study. It wouldn’t matter anyway because the teacher is unreasonable.” The nurse identifies use of which defense mechanisms? Select all that apply. a. Denial b. Compensation c. Rationalization d. Projection e. Displacement f. Reaction formation ANS: C, D, E

The student slams down the book, displacing anger, rationalizes (makes excuses), and projects blame onto the teacher. Compensation involves making up for a perceived weakness by emphasizing a desirable trait. Projection refers to blaming others or attributing unacceptable thoughts or behaviors to others. Reaction formation involves doing the opposite of an unacceptable desire.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 67-68 MSC: NCLEX: Psychosocial Integrity

2. After being informed of a diagnosis of lung cancer, a patient says in a cheerful voice, “I feel

fine. I will do some reading online about it. Right now, I want to take a nap.” The nurse assesses the use of which defense mechanisms? Select all that apply. a. Repression b. Undoing c. Introjection d. Reaction formation e. Intellectualization f. Suppression ANS: D, E, F

The cheerful voice is probably the result of reaction formation. The wish to read more about the diagnosis reflects intellectualization. Taking a nap is suppression and allows the patient to avoid having to think about the problem. Repression results in unconscious forgetting.

Undoing involves doing something to make up for an unacceptable act. Introjection is incorporating values and attitudes of others as if they were one’s own.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 67-68 MSC: NCLEX: Psychosocial Integrity

Chapter 08: Learning to Communicate Professionally MULTIPLE CHOICE 1. Which skill is most important for a nurse preparing to work in the psychiatric setting? a. Helpful transference b. Sympathetic listening c. Supportive confrontation d. Therapeutic communication ANS: D

Therapeutic communication provides the basis for effective use of each stage of the nursing process, as explained by the authors. The other options are skills basic to effective use of the nursing process.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 79 MSC: NCLEX: Psychosocial Integrity

2. When observing and interpreting a patient’s nonverbal communication, which nursing

consideration is important? a. Patients are usually aware of their nonverbal cues. b. Verbal responses are more important than nonverbal cues. c. Nonverbal cues have obvious meaning and are easily interpreted. d. Nonverbal cues provide significant information but must be validated.

ANS: D

Body language has meaning,NbutRmeI aninGg caBn. noCt beMglobally ascribed. Validation with the U S N T individual is necessary to accurate interpretation. The other options are incorrect.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 78 MSC: NCLEX: Psychosocial Integrity

3. A patient diagnosed with schizophrenia, paranoid type, frequently gets up and walks away

during interactions with a nurse. The nurse can best increase the patient’s comfort level by: a. arranging the chairs side by side, about 2 feet apart. b. sitting at eye level across the table from the patient. c. standing a few feet away from where the patient sits. d. talking in the patient’s room with the door closed.

ANS: B

Suspicious patients require increased personal space. Sitting across the table provides that space. Being at the same eye level fosters communication. Side-by-side placement of chairs might not give the suspicious patient the ability to watch the nurse closely enough for comfort. Being in a closed room might be threatening to the patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 78 MSC: NCLEX: Psychosocial Integrity

4. During a one-on-one interaction with the nurse, a patient frequently looks nervously at the

door. Select the best comment by the nurse to this nonverbal cue. a. “I notice you keep looking toward the door.”

b. “This is our time together. No one is going to interrupt us.” c. “It looks as if you are eager to end our discussion for today.” d. “If you are uncomfortable in this room, we can move someplace else.”

ANS: A

Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 79 MSC: NCLEX: Psychosocial Integrity

5. Effective use of the nursing process is dependent on communication that: a. is structured and goal-directed. b. meets the needs of both patient and nurse. c. is spontaneous and affords mutual self-disclosure. d. fosters emotional distance between patient and nurse.

ANS: A

Therapeutic communication occurs with the purpose of helping patients. It is patient-centered, structured, and goal-directed. It is not expected to meet the needs of the nurse or to include mutual self-disclosure. These are characteristics of social communication. The nurse maintains objectivity, rather than emotional distance.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 79 MSC: NCLEX: Psychosocial Integrity

6. A patient is withdrawn, suspiN ciouRs, aI nd G maiB nt. aiC ns pM hysical distance from staff and other

U S N Tappropriate O use of touch with this patient? patients. Which intervention demonstrates a. Refraining from touch b. Patting the patient’s arm when fear is expressed c. Reaching out to shake the patient’s hand as an initial greeting d. Placing an arm around the patient’s shoulders while walking down the hall ANS: A

Withdrawn, suspicious patients often consider touch a violation of personal space or might misinterpret touch as being sexual or aggressive. Refraining from touching a suspicious patient is wise until there is evidence that the patient can tolerate touch. The more intimate or extensive the touching, the more threatening it might be to the patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 79-80 MSC: NCLEX: Psychosocial Integrity

7. When assessing a patient’s social skills, which remark would serve the nurse best? a. “It sounds as if you need to develop some assertiveness skills.” b. “Describe an example of a time when you felt uncomfortable in a social situation.” c. “It is not easy to be assertive. We can role-play some situations to give you

practice.” d. “What do you plan to do the next time you find yourself in an uncomfortable social situation?”

ANS: B

The nurse is seeking clarification, a therapeutic technique that is a useful assessment tool.

Mention of assertiveness skill development indicates that the assessment has been made.

Asking for the patient’s plan would occur during problem solving rather than assessment.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 80 MSC: NCLEX: Psychosocial Integrity

8. A patient’s plan of care includes this nursing diagnosis: Impaired verbal communication

related to lack of assertiveness skills. To include the patient in prioritizing this problem, the nurse should say: a. “Who are the people with whom you are most passive?” b. “How important is it for you to become more assertive?” c. “Let’s look at how we can address this problem together.” d. “Are you interested in attending the assertiveness class?”

ANS: B

The technique of encouraging evaluation is useful to the nurse who is attempting to interpret meaning and importance. It seeks the patient’s view of the situation and provides a basis for setting priorities. The other options are not concerned with priority.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 80-81 MSC: NCLEX: Psychosocial Integrity

9. A patient has difficulty expressing anger appropriately. The nurse encourages the patient to

set realistic goals by stating: a. “You seem to have problems expressing anger in a nonaggressive way.” b. “I thought you sounded angry when I told you it was time for group.” c. “What do you think needN s tU oR chSaI ngNeGaT boB u. t hCoO wM you express anger?” d. “What bothers you about your actions when you get angry?”

ANS: C

Goal-setting is most directly related to the technique of asking patients to decide on the type of change needed. The distracters demonstrate making observations and exploring.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 81 MSC: NCLEX: Psychosocial Integrity

10. A nurse wants to provide opportunities for a patient to try out new, more assertive behaviors.

Which technique should the nurse use? a. Clarifying b. Role-playing c. Giving feedback d. Encouraging evaluation ANS: B

Role-playing permits the patient to practice new behaviors in a safe setting and to develop comfort with the use of the new behaviors. The nurse plays a particular role and provides coaching and feedback. The other techniques given as options do not encourage the patient to practice new behaviors.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 81 MSC: NCLEX: Psychosocial Integrity

11. The nurse tells a patient, “I noticed that you frowned when we discussed your relationship

with your family.” Which communication technique is the nurse using? a. Clarifying b. Interpreting c. Giving information d. Making observations ANS: D

Making observations is defined as commenting on what is seen or heard to encourage discussion. The nurse’s statement cannot be interpreted as using any of the other techniques listed.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 80 MSC: NCLEX: Psychosocial Integrity

12. A nurse realizes that the comment just made to a patient was inconsiderate. Select the nurse’s

most therapeutic statement in this situation. a. “How do you feel about what I just said?” b. “See, even nurses say stupid things sometimes.” c. “Sorry about that. Let’s continue where we left off.” d. “That was an insensitive remark. I’m sorry if it hurt you.”

ANS: D

Acknowledging insensitivity and apologizing for it will usually repair damage. Patients usually evaluate the nurse on overall caring rather than on one single comment. None of the other options includes both acknowledgment and apology.

N R I G B.C M

T p. 82O DIF: Cognitive level: ApplyingU S N REF: TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 13. A common mistake nurses make when developing therapeutic communication techniques is: a. using too many different techniques during an interaction. b. allowing patients to become too anxious before responding. c. giving advice rather than encouraging patients to solve problems. d. focusing on what patients say rather than on communication techniques.

ANS: C

Giving advice is a common pitfall for nurses who are unsure of how to encourage patients to become involved in analyzing and problem solving. The other options are incorrect, because most novice nurses tend to rely heavily on direct questions, avoid anxiety-producing topics, and focus on communication techniques.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 82 MSC: NCLEX: Psychosocial Integrity

14. A patient says to the nurse, “My family was mean to me when they visited today. They have

no right to treat me like that.” Select the nurse’s best initial response. a. “Why do you think they were mean?” b. “Perhaps you overreacted to what they said.” c. “How do you feel about your family treating you that way?” d. “Describe what happened when your family visited you today.”

ANS: D

Before proceeding, the nurse needs to have a better understanding of what happened in the interaction between the patient and family. The correct option seeks that clarification, whereas none of the other options takes that approach.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 80 MSC: NCLEX: Psychosocial Integrity

15. A patient scheduled to attend various group sessions complains, “I’m really mad about having

to attend all those groups. No one else spends all day in a circle in a little room.” Select the nurse’s best response. a. “Why are you upset?” b. “I can hear that you are upset. Let’s talk about it.” c. “Just go along with the plan, even if you do not agree.” d. “The groups are carefully planned by staff to benefit patients.”

ANS: B

This remark exemplifies therapeutic listening. It acknowledges the patient’s negative feelings and the nurse’s willingness to listen as the patient offers his concerns. It implies a willingness to assist with problem solving. “Why” questions are not therapeutic, because they often elicit rationalization. Justification is defensive and closes off communication.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 79-80 MSC: NCLEX: Psychosocial Integrity

16. A patient states, “I’m tired of all these therapy sessions. It’s just too much for me.” Using

supportive confrontation, the nurse should reply: N RSINGTB.C OM a. “It will get better if you jusU t keep trying.” b. “You are doing fine. Don’t be so hard on yourself.” c. “Tell me more about how the therapy sessions are too much.” d. “I know you find this difficult, but I believe you can get through it.”

ANS: D

Supportive confrontation is a technique in which the nurse acknowledges the difficulty in changing, but pushes for action. The other options clarify or give reassurance.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 81 MSC: NCLEX: Psychosocial Integrity

17. A patient at the crisis intervention clinic states, “When I got up this morning, I realized I could

not go on any longer.” Select the nurse’s best response to facilitate analyzing the problem and making a nursing diagnosis. a. “How long have you been feeling this way?” b. “What is different about your feelings today?” c. “We are here to help you. I’m glad you decided to come to the center.” d. “You said you felt like you could not go on. Tell me more about that.”

ANS: B

Encouraging comparison is a useful technique when the nurse wishes to analyze the problem and draw conclusions to facilitate establishing a nursing diagnosis. None of the other options would be as effective in encouraging the patient to analyze feelings.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 80 MSC: NCLEX: Psychosocial Integrity

18. A newly admitted patient asks the nurse, “Can you hear those people laughing at me? They

are making fun of me.” Select the nurse’s best response. a. “You are mistaken. No one is laughing at you.” b. “I know the sound of laughter is real to you, but I don’t hear it.” c. “Your mind is playing tricks on you, making you think you hear laughter.” d. “When people are mentally ill, they often experience things that others cannot relate to.”

ANS: B

This reply acknowledges the patient’s perceptions and gently casts doubt on the reality of the patient’s conclusions through the use of an “I” statement. It is not argumentative or accusative.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 80 MSC: NCLEX: Psychosocial Integrity

19. Select the best description of therapeutic use of self to provide to a new psychiatric nurse. a. “Most nurses have caring personalities that equip them to be helpful to patients.” b. “It’s mostly about using good verbal and nonverbal communication, objectivity,

genuineness, and empathy.” c. “It means that you keep yourself at a distance so you are not affected by patients’ problems and emotions.” d. “The most important aspect of practice is when and how much to touch, as well as when to listen and give aN dvU icR e.S ” INGTB.COM ANS: B

The correct answer lists several of the components of therapeutic use of self. The other options provide less information for the new nurse to use to continue to develop skills.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 79 MSC: NCLEX: Psychosocial Integrity

20. During an interview with a depressed patient, the nurse sits with folded arms and fidgets when

long silences occur. When the patient expresses hopelessness about getting better, the nurse replies, “You will feel better when your medication takes effect.” This interaction: a. shows therapeutic use of limit-setting. b. is minimally therapeutic but effective. c. evidences therapeutic use of self. d. is nontherapeutic and ineffective.

ANS: D

The nurse is demonstrating a closed posture, suggesting lack of interest in the interaction.

Fidgeting suggests boredom or lack of comfort during the interaction. The quoted response minimizes the patient’s problem and sounds short. Cumulatively, these indicate that the nurse’s behaviors are nontherapeutic and ineffective.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 82

TOP: Nursing process: Evaluation

21. What is the best analysis of this described nurse-patient interaction?

a. b. c. d.

Patient: I get discouraged when I realize I’ve been struggling with my problems for over a year.

Nurse: Yes you have, but many people take even longer to resolve their issues. You shouldn’t be so hard on yourself.

The nurse has responded ineffectively to the patient’s concerns.

The patient is expressing lack of willingness to collaborate with the nurse.

The patient is offering the opportunity for the nurse to revise the plan of care.

The nurse is using techniques that are consistent with the evaluation step of the nursing process.

ANS: A

In this response, the nurse has minimized the patient’s feelings and problems, used clichés, and given advice—all considered ineffective responses. None of the other options provides an accurate assessment of the interaction.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 82

TOP: Nursing process: Evaluation

22. A patient says to the nurse, “I dreamed I could not breathe and was being attacked. When I

woke up, I felt emotionally drained, as though I hadn’t rested well.” Which comment would be appropriate if the nurse seeks to interpret? a. “It sounds as though you were uncomfortable with the content of your dream.” b. “So you are saying that you were not able to breathe and felt in danger?” c. “I understand. Thank you for telling me about your bad dream.” d. “So, you feel as though you had a poor night’s sleep?”

ANS: A

N R I G B.C M U S N T O

The technique of interpreting is therapeutic and helps the nurse examine meaning and importance of the experience. The distracters use other techniques.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 81 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. Which techniques are therapeutic when interacting with a patient? Select all that apply. a. Avoiding direct questions b. Validating and clarifying c. Using empathy sparingly d. Assuming an attending posture e. Maintaining constant eye contact ANS: B, D

Using validation and clarification ensures that the nurse understands what the patient is saying. Using an attending posture conveys the message that the nurse is interested in what is being communicated. Giving feedback appropriately conveys interest and understanding. The other options are ineffective behaviors.

DIF: Cognitive level: Understanding

REF: pp. 79-80

TOP: Nursing process: Implementation

MSC: NCLEX: Safe, Effective Care Environment

2. A patient cries as the nurse explores the patient’s feelings about the death of a close friend.

The patient sobs, “I shouldn’t be crying like this. It happened a long time ago.” Which responses by the nurse facilitate communication? Select all that apply. a. “Why do you think you are so upset?” b. “I can see that you feel sad about this situation.” c. “The loss of your friend is very painful for you.” d. “Crying is a way of expressing the hurt you’re experiencing.” e. “Let’s talk about something else, since this subject is upsetting you.”

ANS: B, C, D

Reflecting and giving information are therapeutic techniques. “Why” questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 80-82 MSC: NCLEX: Psychosocial Integrity

Chapter 09: Working with an Individual Patient MULTIPLE CHOICE 1. A patient is hospitalized for severe depression. Knowing that the patient will be discharged

after a short stay, what is the nurse’s first priority? a. Maximize the benefits of milieu management. b. Immediately begin to explore acute patient issues. c. Develop a goal-directed, problem-centered relationship. d. Choose a specific theoretical model as the basis for care.

ANS: C

Therapeutic relationships are planned, patient-centered, and goal-directed. This is of particular importance if progress is to be made when the duration of the relationship will be brief. The other options are not the priority. Exploration of patient issues requires trust development before it can proceed.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 84 MSC: NCLEX: Safe, Effective Care Environment

2. A nurse tells a patient, “I know how you feel. My spouse can be very insensitive too. I am

also considering divorce.” Analysis suggests that the nurse is: a. self-disclosing inappropriately. b. experiencing countertransference. c. using empathy to establish trust with the patient. d. encouraging the patient to express negative feelings.

ANS: A

NURSI NG TB.C OM

Brief self-disclosure is used to help the patient clarify specific issues, to feel less vulnerable, or to feel more “normal.” When used appropriately, self-disclosure benefits the patient. When used inappropriately, it benefits the nurse. In this case, the self-disclosure burdens the patient with the nurse’s problems. Empathy focuses on the patient. Countertransference would result in different behaviors. Encouraging expression of negative feelings would be more direct.

DIF: Cognitive level: Understanding REF: p. 85 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

3. A patient diagnosed with schizophrenia says to the nurse, “I feel really close to you. You’re

the only true friend I have.” Select the nurse’s most therapeutic response. a. “We are not friends. Our relationship is a professional one.” b. “I feel sure there are other friends in your life. Can you name some?” c. “I am glad you trust me. Trust is important for the work we are doing together.” d. “Our relationship is professional, but let’s explore ways to strengthen friendships.”

ANS: D

The patient’s remarks call for the nurse to remind the patient of the parameters of their relationship and take the opportunity to discuss the issue of friends. Only this option incorporates both desired elements.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 85 MSC: NCLEX: Psychosocial Integrity

4. As a patient and nurse move into the working stage of a therapeutic relationship, the nurse’s

most beneficial statement is: a. “I want to be helpful to you as we explore your problems and the way you express feelings.” b. “A good long-term goal for someone your age would be to develop better job-related skills.” c. “Of the problems we have discussed so far, which ones would you most like to work on at this time?” d. “When someone gives you a compliment, I notice that you become very quiet and appear uncomfortable.”

ANS: C

With this remark, the nurse seeks patient collaboration and offers the opportunity to set priorities for the work toward change that will be undertaken. The distracters relate to the orientation stage.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 87-88 MSC: NCLEX: Psychosocial Integrity

5. Complete this goal statement for a newly admitted patient in the orientation stage. “By the end

of the orientation stage of the therapeutic relationship, the patient will demonstrate: a. greater independence.” b. increased self-responsibility.” c. trust and rapport with two staff members.” d. ability to problem-solve one issue.”

ANS: C

Establishing trust is the primary task of the orientation stage of the nurse–patient relationship.

The other options are too ambitious for this early stage.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 86

TOP: Nursing process: Planning

6. A patient is withdrawn and avoids talking to the nurse. The best initial intervention for the

nurse would be to: a. offer to listen and help. b. directly ask why the patient does not wish to talk. c. involve the patient in a group activity to decrease isolation. d. respect the patient’s desire not to talk and leave the patient alone.

ANS: A

Patients might be afraid or unable to approach nurses. Nurses must take the initiative to approach the patient, thus acknowledging the patient’s worthiness and conveying acceptance.

“Why” questions usually elicit rationalization. Leaving the patient alone does not foster trust.

Decreasing isolation will not build trust in the nurse.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 86 MSC: NCLEX: Psychosocial Integrity

7. A patient has identified the need for better anger management and tells the nurse, “I’m afraid

that someday I might explode.” The best strategy for reducing this patient’s fear of losing control is to: a. talk about these feelings openly and directly. b. discuss feelings in general without reference to the patient. c. avoid talking about the feelings until the patient feels comfortable. d. reassure the patient that expressing feelings is the first step to resolving them.

ANS: A

Talking openly about feelings conveys the message that feelings are natural and can be handled. Once feelings can be discussed, the focus can shift to learning to cope more effectively with them. The other options are either avoidant or nontherapeutic.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 86 MSC: NCLEX: Psychosocial Integrity

8. The nurse believes that a patient is having emotional pain. Which remark is most therapeutic? a. “I hear how painful this is for you. I would like to help you deal with it.” b. “I’m so sorry this has happened to you. You don’t deserve it.” c. “What would you like me to do to help you through this?” d. “I don’t think this is as serious as you believe it is.”

ANS: A

This remark uses empathy to acknowledge the patient’s feelings and then offers help. Using empathy tells the patient that his or her feelings are understood. Offering help implies hope for a positive resolution. Empathy, rather than sympathy, is a useful tool. Asking what to do for the patient implies helplessness on the part of the nurse. Minimizing the problem is demeaning to the patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 85 MSC: NCLEX: Psychosocial Integrity

9. A nurse and patient agree on problems to be addressed during a brief hospital stay. Which

inference is correct? a. The relationship is moving into the working stage. b. The nurse should reinforce messages about termination. c. The nurse needs to direct the patient to begin journaling. d. Management of emotions must be ensured before work can continue.

ANS: A

Problems are defined and priorities for work are set as the nurse and patient collaborate during the orientation stage. This sets the stage for transition into the working stage. Management of emotions can occur during the working stage.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 87 MSC: NCLEX: Psychosocial Integrity

10. A patient with a history of self-mutilation says to the nurse, “I want to stop hurting myself.”

What is the initial step of the problem-solving process to be taken toward resolution of a patient’s identified problem? a. Deciding on a plan of action b. Determining necessary changes

c. Considering alternative behaviors d. Describing the problem or situation ANS: D

The nurse learns how well the patient understands the problem by asking for a detailed, in-depth description of situations, thoughts, feelings, and behaviors relevant to the identified problem. This step must be completed before moving through the problem-solving process.

The other actions are premature.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 86 MSC: NCLEX: Psychosocial Integrity

11. A patient says, “I went out drinking only one time last week. At least I’m trying to change.”

The nurse responds, “I appreciate your effort, but you agreed to abstain from alcohol completely.” The nurse is: a. using cognitive restructuring. b. preventing manipulation. c. showing empathy. d. using flooding.

ANS: B

The correct comment prevents the nurse from being manipulated by the patient. The nurse should address what happened, along with the expectations. The remaining options do not attempt to address the patient's manipulation of the situation.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 89 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

U Sa therapeutic N T O 12.1 A nurse and patient who developed relationship enter into the final phase of their 2 relationship as the patient prepares for discharge. An important nursing intervention for this . stage is for the nurse to: a. provide structure and intensive support. b. inform the patient of the progress made. c. encourage the patient to describe goals for change. d. discuss feelings about termination with the patient.

ANS: D

Healthy closure is facilitated when the patient discusses his or her reactions to termination and the feelings that she or he might be experiencing. The nurse serves as a role model during termination. Providing structure is related more to the orientation and working stages.

Informing the patient of progress is paternalistic. The process of termination is facilitated by collaborative work. Describing goals takes place with passage from the orientation to the working stage.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 88 MSC: NCLEX: Psychosocial Integrity

13. Which statement by a patient would the nurse interpret as willingness to collaborate in the

nurse–patient relationship? a. “I know you are here to help me, and will do whatever you tell me to do.” b. “I didn’t want to deal with this at first, but I’m glad you made me face it.” c. “I realize that I have some issues that I need help resolving.”

d. “I will do anything to get out of this hospital.”

ANS: C

Collaboration takes place when patients recognize problems and the need for assistance. The other responses suggest coercion or simple compliance. They fail to demonstrate the element of self-reflection on the part of the patient.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 84-85 MSC: NCLEX: Psychosocial Integrity

14. A novice nurse says, “I have more important things to do than play games with patients.

These activities are not a worthwhile use of my time.” Select the nurse manager’s best response. a. “Games are part of the therapeutic milieu.” b. “Patients need a break from intensive individual therapy.” c. “Informal activities help patients develop social skills and take risks.” d. “Please review material on the psychotherapeutic management model.”

ANS: C

Nurses who engage in therapeutic activities with patients recognize that each encounter with patients is part of an overall therapeutic picture. Patients discuss real problems and solutions and practice skills needed in real-life situations. These encounters offer opportunities for assessment, for patients to process feelings, and for validation and feedback, as well as for tension relief. The correct answer is the most global response. The distracters do not educate the new nurse about the purpose of informal activities.

DIF: Cognitive level: Analyzing TOP: Nursing process: ImplemNentR ationI

REF: p. 85

: C NCLMEX: Psychosocial Integrity U S NGMTSBC. O

15. An inpatient says, “Last time I was here, a primary nurse talked with me every day. This time,

different nurses work with me. How can I make progress?” Select the nurse’s best response. a. “Your comments are interesting. With your permission I will share them with the treatment team.” b. “We are using a new system because of managed-care requirements. We are hopeful it will be effective.” c. “Shift reports, care plans, and progress notes help different nurses work with all patients toward their individual goals.” d. “It sounds like you are feeling dissatisfied with your care. After you are discharged, you will receive a form to provide feedback.”

ANS: C

This reply explains how many nurses are able to share responsibility and accountability for the care of patients. Good communication enables the nurses to be “on the same page” when it comes to working toward the achievement of patient-centered goals that are appropriate for each stage of the nurse-patient relationship. The other options fail to provide the information the patient needs to understand the current practices.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 93 MSC: NCLEX: Psychosocial Integrity

16. Which nursing intervention will initially be most helpful for trust building with a suspicious

patient?

a. b. c. d.

Enforcing rules Keeping appointments and promises Agreeing not to document the patient’s disclosures Openly challenging unclear statements by the patient

ANS: B

Consistency and honesty regarding intentions are behaviors that promote patient trust.

Enforcing rules is important but not necessarily related to trust building. The other options are nontherapeutic.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 86 MSC: NCLEX: Psychosocial Integrity

17. A patient shouts at a nurse who just entered the room, “You’re an incompetent fool. Leave me

alone.” The nurse’s response should be based on which rationale? a. The anger was created by a situation or significant person, not the nurse. b. The reaction probably results from transference and countertransference. c. The patient is probably reacting to fear of loss of emotional control. d. The patient has a right to openly express negative feelings.

ANS: A

Anger toward the nurse is often displaced anger that has arisen from some situation or significant person in the patient’s life. Nurses feel the brunt of the anger because they are “handy” and might be considered by the patient to be a safe object for the displacement.

Knowing that the nurse is not the true object of the anger allows the nurse to plan a therapeutic strategy for helping the individual manage the emotion. None of the other options provides an accurate basis for planning intervention.

NURSINGTB.COM REF: p. 86

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

MSC: NCLEX: Psychosocial Integrity

18. Which patient behavior would require the most immediate limit-setting? a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. A patient shouts at a roommate, “You are perverted! You watched me undress.” d. During dinner, a patient manipulates an older adult patient to obtain a second

dessert.

ANS: C

Behaviors that require the most immediate limit-setting are verbal and physical aggression, self-destructive behavior, fire setting, alcohol or drug use, manipulation, inappropriate sexual behaviors, and attempts to leave the hospital without consent. In this case the verbal aggression toward the roommate requires immediate intervention to prevent further escalation.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 87 MSC: NCLEX: Psychosocial Integrity

19. A patient playing pool with another patient throws down the pool cue and begins swearing.

The nurse should initially intervene by: a. asking other patients to leave the room. b. calling for assistance to restrain the patient. c. suggesting a time-out in the patient’s room.

d. restating rules of the milieu related to swearing.

ANS: C

Suggesting a time-out in the patient’s room is often an effective initial strategy, because it permits the patient to go to an area with fewer stimuli. It also removes the patient from other patients who are at risk for injury if the patient’s behavior escalates. Restating the rules of the milieu does not help the patient diffuse the anger. Removing other patients is unnecessary unless the patient’s behavior escalates.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 89 MSC: NCLEX: Safe, Effective Care Environment

20. A newly admitted patient tells the nurse, “The voices are bothering me.” The nurse should

first: a. ignore the patient’s reference to voices. b. distract the patient from the hallucinations. c. tell the patient that the voices do not exist. d. seek a description of the voices and identify themes.

ANS: D

Early assessment of hallucinations is based on the content of the messages. Content often reveals the dynamics of the patient’s symptoms and typically revolves around a theme such as powerlessness, hate, guilt, or loneliness. Ignoring the reference is nontherapeutic and thwarts assessment. Distraction is a possible strategy after the nurse understands the content of the hallucinations. Saying that the voices do not exist negates the patient’s experience. Saying you do not hear them is preferable.

DIF: Cognitive level: ApplyinN g R I GREB F:.C p. 89M U S N T TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 21. A nurse says, “What step would you like to take next to resolve this issue?” The patient stands

up and shouts, “You are so controlling! You want me to do everything your way.” What is the likely basis of the patient’s behavior? a. Projection b. Dissociation c. Transference d. Emotional catharsis ANS: C

Transference involves a patient’s emotional reaction to the nurse that is actually based on an earlier relationship or experience. In this case, the transference is negative and might be related to an earlier experience with an authority figure. Although projection is a possibility, it is less obvious. Dissociation and emotional catharsis do not apply.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 90 MSC: NCLEX: Psychosocial Integrity

22. A nurse considers interventions for a diabetic patient who needs to change eating habits and

lose weight. The nurse will base strategies on which principle? a. The nurse’s primary responsibility is to encourage the change. b. Patient-initiated change is more successful than imposed change. c. For successful change, both the benefit and the risk to the patient must be high.

d. Patients value advice from nurses because of the trusting dimensions of the

relationship.

ANS: B

The answer indicates that the patient is invested in the change process. Nurses have multiple responsibilities in the change process, including education and reinforcement. Nurses should avoid giving advice.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF:

pp. 87-88

TOP: Nursing process: Planning

23. A psychotic patient tells the nurse, “Get away from me or I’ll hit you. You’re sucking the

thoughts out of my head.” To best de-escalate the situation, the nurse should: a. direct the patient to a chair. b. deny taking the patient’s thoughts. c. increase the distance between nurse and patient. d. tell the patient, “You will be restrained if you hit me.”

ANS: C

The nurse should do as the patient requests when the request is reasonable. Patients perceiving alterations in reality often need increased personal space to feel less anxious. Denials, touching, and threatening are likely to promote escalation of violent behavior.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 89 MSC: NCLEX: Safe, Effective Care Environment

24. The nurse caring for a hyperactive patient should be particularly concerned about assessing: a. physical safety. b. emotional trauma. c. manipulative behaviors. d. feelings about the relationship.

ANS: A

Hyperactive patients are at high risk for injury and physical exhaustion, both of which compromise physical safety. Safety needs take priority over emotional needs.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 90 MSC: NCLEX: Safe, Effective Care Environment

25. Assessment findings by the multidisciplinary team after a patient-intake interview are used

primarily to: a. confirm ongoing discharge planning. b. expand and confirm the initial assessment. c. verify the appropriateness of nursing diagnoses. d. analyze the patient’s feelings about hospitalization.

ANS: B

As members of the multidisciplinary team interact with the patient, their impressions might support or differ slightly from the initial assessment. The findings are synthesized and used in planning ongoing treatment. The other options have less relevance or are not applicable.

DIF: Cognitive level: Understanding

REF: p. 91

TOP: Nursing process: Assessment

MSC: NCLEX: Psychosocial Integrity

26. Objective data obtained in an initial assessment of a patient are of particular value when: a. the patient is too ill to participate. b. the patient’s admission is involuntary. c. family members have admitted the patient. d. the patient has been transferred from a subacute setting.

ANS: A

Some patients are too ill to participate in or complete the assessment interview. When this is the case, the interviewer uses objective data obtained from patient observation and the reports of family or others present at the time of admission. The other options do not reflect situations in which objective data have maximal value.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 91 MSC: NCLEX: Psychosocial Integrity

27. As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors

will provide the focus for: a. evaluation. b. nursing diagnosis. c. nursing interventions. d. outcome identification.

ANS: C

The nurse recognizes that dysfunctional behaviors are behaviors that would benefit the patient to change. These dysfunctional behaviors are written as defining characteristics in the nursing diagnosis. Nursing interventiN onsR areI form t address changing dysfunctional behaviors Gula Bte.dCthaM U S N T to more adaptive behaviors. The focus of evaluation is patient progress; the focus of nursing diagnosis is patient problems; the focus of outcome identification is adaptive behaviors.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 93

TOP: Nursing process: Planning

28. A patient tells the nurse, “I was raped a month ago. Since then I’ve felt anxious and have been

unable to talk normally to my husband. I’ve had frequent thoughts about cutting my wrists.”

What is the priority nursing concern regarding this patient? a. The risk for self-directed violence b. The development of rape traumatic syndrome c. The damage that could result in poor self-esteem d. The demonstration of signs and symptoms of acute anxiety ANS: A

The risk for self-injury is of highest priority, because patient safety is involved.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 93 MSC: NCLEX: Physiologic Integrity

29. When the nurse formulates nursing diagnoses, it is necessary to be specific in describing

dysfunctional behaviors so as to: a. select appropriate desirable behaviors for outcome criteria. b. analyze how the patient was feeling at the time of assessment.

c. explore the context that precipitated the exacerbation of the illness. d. determine how the illness relates to the patient’s total life experience.

ANS: A

A goal or outcome specifies an adaptive behavior to replace one that is dysfunctional. The more specific the description of the dysfunctional behavior in the nursing diagnosis, the easier it is to specify an appropriate adaptive behavior. The other options are not relevant reasons for describing dysfunctional behaviors in nursing diagnoses.

DIF: Cognitive level: Understanding REF: pp. 92-93 TOP: Nursing process: Outcome Identification MSC: NCLEX: Psychosocial Integrity 30. A realistic outcome for a patient with situational low self-esteem who will have a short

inpatient stay would be for the patient to: a. write a list of strengths, abilities, and talents. b. role-play with others to improve social skills. c. replace a negative self-image with a positive one. d. respond with positive self-esteem in all encounters.

ANS: A

A short-term goal is one that can be attained in 4 to 6 days. Identification of strengths, abilities, and talents is attainable within this time frame. The other options are long-term goals.

DIF: Cognitive level: Analyzing REF: p. 93 TOP: Nursing process: Outcome Identification/Planning MSC: NCLEX: Psychosocial IN ntegR rity I G B.C M

U S N T

O

31. Realistic short-term goals for a patient who is newly admitted to the hospital should be

achievable in: a. 1 to 2 days. b. 4 to 6 days. c. 1 to 2 weeks. d. 2 to 4 weeks.

ANS: B

Short-term goals are those achievable in 4 to 6 days for hospitalized patients and somewhat longer for patients in other settings. A period of 1 to 2 days allows too little time. The other options suggest longer times than necessary.

DIF: Cognitive level: Understanding REF: p. 93 TOP: Nursing process: Outcome Identification/Planning MSC: NCLEX: Safe, Effective Care Environment 32. A patient with suicidal ideation is hospitalized. What is the priority intervention? a. Negotiating a no-harm contract b. Facilitating attendance at groups c. Administering a psychotropic drug d. Determining the precipitating situation ANS: A

Preservation of patient safety is of higher priority than any of the other interventions.

DIF: Cognitive level: Analyzing REF: p. 93 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

33. A patient hospitalized for 6 days has made little progress toward outcomes written at the time

of admission. The nurse decides that the lack of progress toward goals indicates that: a. needs for reassessment exist. b. discharge should be delayed. c. nursing diagnoses were incorrect. d. nursing interventions were inadequate.

ANS: A

When the evaluation is made that goals are not being attained, reassessment should take place.

Nursing diagnoses might need to be reformulated, more realistic outcomes identified, or nursing interventions changed, but none of these measures can be determined to be appropriate until the reassessment has been completed.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 92-93

TOP: Nursing process: Evaluation

34. The nurse writing a discharge summary for a patient should include achievements as well as: a. care plan updates. b. a list of patient strengths. c. effective nursing interventions. d. outcomes that still need to be addressed.

ANS: D

Information included in discharge summaries includes outcomes attained, outcomes still to be attained, discharge instructions, medication instructions, and follow-up appointments. The other items are not part of a discharge summary.

DIF: Cognitive level: Understanding REF: p. 94 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

35. A student grumbles to an instructor, “I do not see the value of process recordings.” The best

justification of a process recording is that it is a: a. tool for analyzing communication. b. verbatim record of a patient interview. c. legal document that becomes part of the medical record. d. note written at the time of a patient interview to provide information to team members.

ANS: A

A process recording is a tool for the nurse to learn about the effectiveness of communication and interventions during an interpersonal interaction. It is more than a verbatim record. It is for use by the nurse, rather than the interdisciplinary team. It is not placed into the medical record.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 93 MSC: NCLEX: Psychosocial Integrity

36. Select the best outcome for a nurse to include in the care plan for a withdrawn patient who

says, “I would like to have more friends.” Within 3 days, the patient will: a. be more outgoing. b. develop greater independence. c. participate in one group activity. d. increase socialization with others.

ANS: C

This outcome is behavioral, measurable, and related directly to the problem of social isolation.

The other outcomes are neither measurable nor relevant to socialization.

DIF: Cognitive level: Analyzing REF: p. 93 TOP: Nursing process: Outcome Identification MSC: NCLEX: Psychosocial Integrity 37. Following the admission interview, a spouse of a patient asks the nurse, “Why did you ask my

partner all those questions? Some of them had nothing to do with current problems.” The nurse’s best response is, “Those questions help us understand: a. the patient’s current status.” b. the complete family history.” c. the patient’s past experiences.” d. what the patient’s prognosis will be.”

ANS: A

The mental status examination (MSE) is designed to provide information about the patient’s current level of functioning. Other specific information might be obtained that contributes to the overall picture. The MSE does not provide information relating to the other options.

N R I G B.C M

T p. 91O DIF: Cognitive level: ApplyingU S N REF: TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 38. The nurse performing a mental status examination wants to assess for hallucinations. The

nurse should ask: a. “Can you tell me where you are now?” b. “Do you hear or see things when others don’t?” c. “Do your moods shift more than those of other people?” d. “What would you do if you found a stamped, addressed letter on the floor?”

ANS: B

Hallucinations are false sensory perceptions. The correct answer directly inquires about possible hallucinations. The other options seek information about other aspects of the MSE. DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 89 MSC: NCLEX: Psychosocial Integrity

39. During an MSE a patient says, “I am a special messenger sent to provide the world a cure for

cancer.” The patient’s statement indicates the presence of: a. a phobia. b. a delusion. c. hypervigilance. d. loose associations.

ANS: B

Delusions are false beliefs. Grandiose delusions are beliefs that one possesses greatness or special powers. A phobia is an excessive fear. Hypervigilance refers to being hyperalert and suspicious. Loose associations refer to a thought disorder in which ideas are only loosely connected.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 89 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. A psychiatric aide asks, “Can you give me some examples of how we provide structure for

patients?” The nurse should offer which suggestions? Select all that apply. a. Set limits on destructive behavior. b. Direct a patient to go to a quiet place. c. Sit with a withdrawn, isolated patient. d. Distract a patient who is hallucinating. e. Help a patient contemplate needed change.

ANS: A, B, C, D

Providing structure means that staff members meet patient needs for organizing elements in the environment to produce specific outcomes. Contemplating change is the only option that would not be considered an example of structuring.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 87 MSC: NCLEX: Safe, Effective Care Environment

N R I G B.C M

Ut toShavNe sT 2. A patient tells the nurse, “I wan ex withO you.” Which nursing responses are appropriate? Select all that apply. a. “I will forget you said that.” b. “Your suggestion frightens me.” c. “You must keep your distance.” d. “Sex is not part of our relationship.” e. “We are here to work on your problems.”

ANS: D, E

The correct responses provide information to the patient about the purpose of the relationship and recognize the underlying need. The other options are ineffective.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 85 MSC: NCLEX: Psychosocial Integrity

3. A nurse plans to teach a group of patients the basics of the change process. How should the

elements be sequenced for the presentation? a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Determine that change is necessary.

ANS: A, B, C, D, E

This sequence proceeds logically from assessment of the problem to analysis of the problem to determining that change is necessary to testing new behaviors and evaluating their efficacy.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 87-88 MSC: NCLEX: Psychosocial Integrity

Chapter 10: Working with Groups of Patients MULTIPLE CHOICE 1. A psychiatric nurse clinician on an inpatient unit plans to lead a special-problems group for

withdrawn patients. Which information will be of most assistance as the nurse prepares for this assignment? a. Inpatient groups rarely have a lasting beneficial effect. b. Inpatient groups have short-term, goal-oriented sessions. c. Inpatient groups are helpful for patients with verbal skills. d. Inpatient groups facilitate insight into deeply rooted life issues.

ANS: B

Because inpatient stays are so short and accountability is a major treatment issue, inpatient groups typically have short-term, goal-oriented sessions designed to teach patients more adaptive strategies for coping with life’s problems. Beneficial effects are often lasting.

Patients with or without verbal skills may be helped by selected types of groups.

Insight-oriented therapy is conducted on an outpatient basis and usually occurs over the long term.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 100-101

TOP: Nursing process: Planning

2. A patient in a support group says, “I’m tired of being sick. Everyone always helps me, but I’ll

be glad when I can help someone else.” This statement reflects: a. altruism.

N R I G B.C M b. universality.

U S N T O c. cohesiveness. d. corrective recapitulation.

ANS: A

Altruism refers to the experience of being helpful or useful to others, a condition that the patient anticipates will happen. The other options are also therapeutic factors identified by Yalom.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 100 MSC: NCLEX: Psychosocial Integrity

3. A positive outcome from attending a special-problems group is evidenced by which statement

by a patient? a. “You’re a great group leader and kept things moving smoothly.” b. “This experience wasn’t as bad as I thought it would be.” c. “I rely on the group to help me make decisions.” d. “I learned how my anger affects other people.”

ANS: D

Learning more about one’s behavior and its effects on others is an appropriate outcome for group therapy. The other options do not reflect patient growth.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 101

TOP: Nursing process: Evaluation

4. After attending a group, which statement by a patient shows evidence of benefits associated

with universality? a. “I’ve learned to identify my anxious feelings.” b. “The group really gave me the support to change.” c. “I’ve learned that I can be helpful to others.” d. “My problems are not unique. I’m not alone.”

ANS: D

Universality refers to patients’ realization that they are not alone and unique, and that others experience similar problems, feelings, and concerns. The remaining options do not reflect that sense of belonging.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 100

TOP: Nursing process: Evaluation

5. Which intervention would be most appropriate for the nurse to use when conducting a

maintenance group? a. Helping patients identify better coping strategies b. Accepting, empathizing, and showing concern c. Asking patients to identify topics for the group d. Confronting ingrained behaviors and defenses ANS: B

Support means accepting, empathizing, and showing concern while listening and talking with patients. The nurse’s focus is on responding to patients’ needs. Maintenance and support groups have the purpose of reinforcing or maintaining existing strengths, rather than confronting or changing behaNvU ioR rsS ,w keC s idM entification of better coping strategies and IhNicGhTmBa. confronting ingrained behaviors and defenses less acceptable answers. Sessions are usually structured and goal-oriented, so patients might not be offered the opportunity to talk about any topic of their choice.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 101 MSC: NCLEX: Psychosocial Integrity

6. An anxious, withdrawn patient is experiencing auditory hallucinations. This patient could

benefit most at this time from participation in: a. a recreation group. b. an insight-oriented group. c. a reality orientation group. d. a stress management group.

ANS: C

A reality orientation group is a type of support group for patients who have confusion and short attention spans and who might be frightened, anxious, and isolated. The focus is on the “here and now,” which is an aid to reality testing. The other types of groups would not be as beneficial.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 101

TOP: Nursing process: Planning

7. What is the primary purpose of referring a patient to an activity group?

a. b. c. d.

Assess the patient’s social skills.

Provide cognitive and sensory stimulation.

Encourage socialization and communication.

Educate the patient about use of leisure time.

ANS: C

Activity groups are vehicles to facilitate patient interaction and communication with others and provide enjoyment. Although the other options are true, they are secondary in nature.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 102

TOP: Nursing process: Planning

8. A patient admitted to an inpatient unit after a suicide attempt says, “I feel so overwhelmed.

There are so many issues I have to deal with.” The nurse should schedule the patient to attend which type of group? a. Social skills b. Psychodrama c. Problem-solving d. Medication information ANS: C

Problem-solving groups teach the skills necessary to solve problems. A patient with multiple problems will benefit from learning the process for problem solving, because the multiple problems to which he or she refers probably will not be resolved during a short inpatient stay.

The scenario does not pose problems with social skills or medication. Psychodrama is rarely offered in an inpatient setting.

DIF: Cognitive level: AnalyziN ng R I GREB p. 10M1 U S N TF:.C MSC: NCLEX: Psychosocial Integrity

TOP: Nursing process: Planning

9. A patient says, “I wish I could express my depressed feelings rather than keeping them

inside.” The nurse should schedule the patient to attend which type of group? a. Social skills b. Special problems c. Reality orientation d. Relapse prevention ANS: B

Scheduling the patient for group sessions with others with depression would allow the patient to address this need in a supportive, understanding environment. The patient does not need reality orientation or social skills and has not expressed a need for relapse prevention information.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 102

TOP: Nursing process: Planning

10. A nurse leads a psychoeducational group for patients diagnosed with residual schizophrenia.

A realistic outcome for group members is that they will: a. discuss ways to manage their illness. b. develop a high level of trust and cohesiveness. c. understand unconscious motivation for behavior. d. demonstrate insight about development of their illness.

ANS: A

Patients with residual schizophrenia almost universally have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.

DIF: Cognitive level: Understanding REF: pp. 100-101 TOP: Nursing process: Outcome Identification MSC: NCLEX: Psychosocial Integrity 11. A talkative member of a support group for patients diagnosed with bipolar disorder has

monopolized the group discussion for 15 minutes. The nurse leading the group would best intervene by: a. maintaining silence. It is important for group members to give feedback to each other. b. encouraging the patient to continue. Patients learn from each other in group sessions. c. saying, “You must allow some of the other members of the group to talk. You cannot monopolize the conversation.” d. addressing the patient by name and saying, “I’m glad you shared your thoughts with us. Let’s hear what others think.”

ANS: D

This intervention provides suN ppUoR rt S foIr N thGe T doBm nantMpatient but opens the floor for .iC contributions from others. Doing nothing or encouraging the patient to continue would be ineffective strategies, because they fail to recognize the needs of others in the group.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 103 MSC: NCLEX: Psychosocial Integrity

12. During a support group meeting focusing on strategies to manage symptoms, a patient asks

the nurse leader how to deal with angry outbursts from a supervisor. Select the nurse’s best action. a. Answer the question, and then move on to another topic. b. Offer to answer the question privately after the group session. c. Inform the patient that only illness-related problems can be discussed in the group. d. Matter-of-factly explain that the topic being discussed is the importance of medication.

ANS: D

Some patients ask distracting questions, seeking answers directly from the leader. The nurse leader preserves the group process by returning the focus to the group and the topic being discussed. Only the correct option accomplishes this.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 105 MSC: NCLEX: Psychosocial Integrity

13. The nurse asks members of a group for recovering alcoholics how they handle the urge to

drink. Which communication technique is the nurse using? a. Summarizing b. Presenting reality c. Encouraging comparison d. Seeking consensual validation ANS: C

Distinguishing among the techniques listed shows that the nurse is encouraging comparisons.

Asking members to compare and contrast their experiences promotes group sharing.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 104 MSC: NCLEX: Psychosocial Integrity

14. After a patient’s first group session, the nurse asks, “How was the experience of participating

in group for you?” Which communication technique is the nurse using? a. Summarizing b. Seeking clarification c. Making observations d. Encouraging evaluation ANS: D

Distinguishing among the techniques listed shows that the nurse is encouraging evaluation when asking a patient to make a judgment about the experience. This opens the door to further exploration of thoughts and feelings.

DIF: Cognitive level: Understanding TOP: Nursing process: ImplemNentR ationI

REF: p. 104

: C NCLMEX: Psychosocial Integrity U S NGMTSBC. O

15. A patient in a detoxification unit asks, “What good will it do to go to Alcoholics Anonymous

and talk to other people with the same problem?” The nurse’s best response would be to explain that self-help groups such as AA provide opportunities for: a. newly discharged alcoholics to learn about the disease of alcoholism. b. people with common problems to share their experiences with alcoholism and recovery. c. patients with alcoholism to receive insight-oriented treatment about the etiology of their disease. d. professional counselors to provide guidance to individuals recovering from alcoholism.

ANS: B

The patient needs basic information about the purpose of a self-help group. The basis of self-help groups is sharing by individuals with similar problems. Self-help is based on the belief that an individual with a problem can be truly understood and helped only by others who have the same problem. The other options fail to address this or provide incorrect information.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 102 MSC: NCLEX: Psychosocial Integrity

16. Which patient would benefit most from a group that focuses on reality orientation? a. Adolescent with mixed drug and alcohol abuse

b. Adult with undifferentiated schizophrenia c. Older adult with depression d. Young adult in crisis ANS: B

Reality orientation groups are helpful for patients who are confused and unable to perceive and interpret reality accurately. The patient with undifferentiated schizophrenia is the choice of patients for the reality group, because misperception of reality and poor reality testing are usually part of the patient’s clinical picture.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 101

TOP: Nursing process: Planning

17. Which type of group is a staff nurse with 2 months’ psychiatric experience best qualified to

conduct? a. Social skills group b. Family therapy group c. Medication education group d. Insight-oriented psychotherapy group ANS: C

All nurses receive information about patient teaching strategies and basic information about psychotropic medications, making a medication education group a logical group for a beginner to conduct.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 100-101 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

U S Nin aTsupportOgroup. Which comment best contributes to 18.1 These comments are made by patients 8 group cohesiveness and effectiveness? . a. “Talking about my problems helps me think of ways to solve them. Let me explain them to everyone.” b. “We aren’t making progress because our group leader has as many problems as we

do.” c. “No one in this group wants to hear anything else about your financial problems.” d. “We started out talking about guilt, but we wandered off from that subject.”

ANS: D

Group leaders must recognize and manage a group process and content. Cohesiveness helps the group achieve its goals. The speaker has made an observation of the group process.

Distracting, dominant, or hostile comments distract from the curative factor of universality.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 100 MSC: NCLEX: Psychosocial Integrity

19. A leader begins the discussion at the first meeting of a new group. Which comment would be

most appropriate? a. “Let’s start by establishing some rules for our group.” b. “Let’s begin with each person here defining his or her problem.” c. “I want each person to explain why he or she is attending this group.” d. “Talking to family about our group will help us achieve our goals.”

ANS: A

The leader must set ground rules for the group before members can effectively participate.

Bringing family members would jeopardize confidentiality. Members share feelings after the group develops an identity and cohesiveness.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 103 MSC: NCLEX: Psychosocial Integrity

20. A leader begins the discussion at the first meeting of a new group. Which comment should be

included? a. “It is important for everyone to arrive on time for our group.” b. “Talking to family members about our group will help us achieve our goals.” c. “Everyone is expected to share a personal experience at each group meeting.” d. “Groups provide more cost-effective treatment in this time of budget constraints.”

ANS: A

The leader must set ground rules for the group before members can effectively participate.

Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. Although groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 103 MSC: NCLEX: Psychosocial Integrity

21. While a member of a group shares painful feelings of guilt, another member begins humming

and tapping the side of the chair. Select the leader’s best initial action with the disruptive patient. a. Recognize that the behavior is an expression of anxiety, and do not interrupt it. b. Say, “Please stop humming and tapping. It is disruptive to our group.” c. Say, “Please leave the group now. Your behavior is inappropriate.” d. Say, “You seem uncomfortable with our discussion.”

ANS: D

The leader must help group members show respect for each other. Identifying the possible feelings of the disruptive or hostile person addresses the process in the group. It will invite self-expression in a more constructive way or extinguish the behavior. If the disruption continues, the leader may need to confront the behavior or excuse the disruptive person.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 105 MSC: NCLEX: Psychosocial Integrity

22. As members disperse at the conclusion of a productive group meeting, one member says,

“Let’s have a big group hug.” Select the leader’s most appropriate response. a. “Hugging is not permitted.” b. “I am glad you found the meeting so helpful.” c. “Thanks for that suggestion, but not everyone may be comfortable with hugs.” d. “The group is over now. Members may not have continued contact with each other.”

ANS: C

The leader must facilitate maintenance of the group norms. Some persons may feel comfortable with hugs; others may not. The leader should not prohibit the behavior but rather should gently set limits that recognize the needs of all.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 103 MSC: NCLEX: Psychosocial Integrity

23. A nurse prepares to lead an anger management group, which is what type of group? a. Psychoeducational b. Self-help c. Activity d. Support ANS: A

Psychoeducational groups include anger management, relapse prevention, medication education, and living skills.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 100-101 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. When a patient voices a delusion during a group session, the nurse can effectively handle the

situation by (select all that apply): a. using empathy. b. presenting reality. c. exploring the delusional cNontR ent.I G B.C M d. focusing on the underlyingU neeS d exNpreT ssed. O e. asking the group what they think about the delusion.

ANS: A, B, D

Responding to the voicing of a delusion during a group session is best handled by using empathy, focusing on the underlying need, and presenting reality. Delusional thinking does not respond to logic or criticism.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 104-105 MSC: NCLEX: Psychosocial Integrity

2. A leader begins the discussion at the first meeting of a new group. Which comments should be

included? Select all that apply. a. “We use groups to provide treatment, because it’s a more cost-effective use of staff in this time of budget constraints.” b. “When someone shares a personal experience, it’s important to keep the information confidential.” c. “Talking to family members about our group discussions will help us achieve our goals.” d. “Everyone is expected to share a personal experience at each group meeting.” e. “It is important for everyone to arrive on time for our group.”

ANS: B, E

The leader must set ground rules for the group before members can effectively participate.

Confidentiality of personal experiences should be maintained. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. While groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 103 MSC: NCLEX: Psychosocial Integrity

Chapter 11: Working with the Family MULTIPLE CHOICE 1. When a nurse assesses a family, which family task has the highest priority to healthy family

functioning? a. Allocation of family resources b. Physical maintenance and safety c. Maintenance of order and authority d. Reproduction of new family members ANS: B

Physical and safety needs are given greater importance in Maslow’s hierarchy of needs than other needs.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 107 MSC: NCLEX: Health Promotion and Maintenance

2. Which documentation of family assessment indicates a healthy and functional family? a. Members provide mutual support. b. Power is distributed equally among all members. c. Members believe that there are specific causes for events. d. Under stress, members turn inward and become enmeshed.

ANS: A

Healthy families nurture and support their members, buffer against stress, and provide stability and cohesion. The dN istU raR ctS erI sN arG eT unBre.laCteOdMor incorrect.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 107 MSC: NCLEX: Health Promotion and Maintenance

3. A 15-year-old patient is hospitalized after a suicide attempt. The adolescent lives with his

mother, stepfather, and several siblings. When performing a family assessment, the nurse must first determine: a. how the family expresses and manages emotion. b. the names and relationships of the patient’s family members. c. the communication patterns between the patient and parents. d. the meaning the patient’s suicide attempt has for family members.

ANS: B

The names and relationships of the patient’s family members constitute the most fundamental information and should be obtained first. Without this, the nurse cannot fully process the other responses.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 108 MSC: NCLEX: Health Promotion and Maintenance

4. Which information is the nurse most likely to find when assessing the family of a patient with

a serious and persistent mental illness? a. The family exhibits many characteristics of dysfunctional families. b. Several family members have serious problems with their physical health.

c. Power in the family is maintained in the parental dyad and rarely delegated. d. The stress of living with a mentally ill individual has negatively affected family

function.

ANS: D

The information almost universally obtained is that the family is under stress associated with having a mentally ill member. This stress lowers the family’s level of functioning in at least one significant way. Stress does not necessarily mean the family has become dysfunctional.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 108 MSC: NCLEX: Psychosocial Integrity

5. The patient’s parent asks the nurse, “Why do you want to do a family assessment? My child is

the patient, not the rest of us.” Select the nurse’s best response. a. “Family dysfunction might have caused the mental illness.” b. “Family members provide more accurate information than the patient.” c. “Family assessment is part of the protocol for care of all patients with mental illness.” d. “Every family member’s perception of events is different and adds to the total picture.”

ANS: D

This response helps the family understand that the opinions of each will be valued. It allows the nurse to assess individual coping and prepares the family for the experience of working together to set goals and solve problems. The other responses are either incorrect or evasive.

DIF: Cognitive level: Applying TOP: Nursing process: ImplemNentR ationI

REF: p. 108 M : N G SBC. CCLMEX: Psychosocial Integrity

U S N T

O

6. An adult diagnosed with paranoid schizophrenia lives with older adult parents. The patient

was recently hospitalized with acute psychosis. One parent is very anxious, and the other is ill from all the stress. Select the most applicable nursing diagnosis. a. Ineffective family coping related to parental role conflict b. Caregiver role strain, related to the stress of chronic illness c. Impaired parenting, related to patient’s repeated hospitalizations d. Interrupted family processes, related to relapse of acute psychosis ANS: B

Caregiver role strain refers to a caregiver’s felt or exhibited difficulty in performing a family caregiver role. In this case one parent exhibits stress-related illness, and the other exhibits increased anxiety. The other nursing diagnoses are not substantiated by the information given and are incorrectly formatted (one nursing diagnosis should not be the etiology for another).

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 108-109 MSC: NCLEX: Psychosocial Integrity

7. An adult recently diagnosed with AIDS is hospitalized with pneumonia. The patient and

family are very anxious. Select the best outcome to add to the plan of care for this family. a. Identify and describe effective coping methods. b. Describe the stages of the anticipatory grieving process. c. Recognize the ways dysfunctional communication is expressed in the family. d. Examine previously unexpressed feelings related to the patient’s sexuality.

ANS: A

Desired outcomes might be set for the family as a whole or for individuals within the family.

The outcome most closely associated with the anxiety that each is experiencing is to focus on identifying and describing ways of coping with the anxiety. The other options are not appropriate at this time.

DIF: Cognitive level: Applying REF: pp. 108-109 TOP: Nursing process: Outcome Identification/Planning MSC: NCLEX: Psychosocial Integrity 8. A parent is admitted to a chemical dependency treatment unit. The patient’s spouse and

adolescent children participate in a family session. What is the most important aspect of family assessment? a. Spouse’s co-dependent behaviors b. Interactions among family members c. Patient’s reaction to the family’s anger d. Children’s responses to the family sessions ANS: B

Interactions among all family members are the raw material for family problem solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are too narrow in scope when compared with the correct option.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 108-109 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

9. A parent is admitted to a chemU icalS depN endT ency treOatment unit. The patient’s spouse and

adolescent children attend a family session. What is the priority assessment question to ask family members? a. “What changes are most important to you?” b. “How are feelings expressed in your family?” c. “What types of family education would benefit your family?” d. “Can you identify a long-term goal for improved functioning?”

ANS: B

It is important to understand family characteristics in both the family of origin and the present family. The other questions are related more to outcome identification and planning intervention, neither of which should be attempted until assessment is complete.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 109 MSC: NCLEX: Psychosocial Integrity

10. A nurse interviews a homeless parent with two teenage children. To best assess the family’s

use of resources, the nurse should ask: a. “Can you describe a problem your family has successfully resolved?” b. “What community agencies have you found helpful in the past?” c. “Do you feel you have adequate resources to survive?” d. “What is one thing you dislike about this family?”

ANS: B

The correct option asks about resource use in an open, direct fashion. It will give information about choices that the family has made to use other family members or resources in the community. The other questions do not address prior use of resources.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 108 MSC: NCLEX: Psychosocial Integrity

11. Two divorced people plan to marry. The man has a teenager, and the woman has a toddler.

This family will benefit most from: a. guidance about parenting at two developmental levels. b. role-playing opportunities for conflict resolution. c. formal teaching about problem-solving skills. d. referral to a family therapist.

ANS: A

The newly formed family will be coping with tasks associated with the stages of rearing preschool children and dealing with teenagers. These stages require different knowledge and skills. There is no evidence of a problem, so the distracters are not indicated.

DIF: Cognitive level: Applying REF: pp. 107-108 MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing process: Planning

12. Parents of a teenager recently diagnosed with serious mental illness express dismay. One

parent says, “Our hopes for our child’s future are ruined. We probably won’t ever have grandchildren.” The nurse should use interventions to assist with the parent’s: a. denial. b. grieving. c. acting out. d. manipulation.

ANS: B

Grief is a common reaction to having a family member diagnosed with mental illness. The grief stems from actual or potential losses such as ability to function, altered family functioning, income, and altered future prospects. Data do not support choosing any of the other options.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 107-108 MSC: NCLEX: Psychosocial Integrity

13. Parents of a teenager recently diagnosed with serious mental illness express dismay. One

parent says, “Our child sometimes acts so strangely that we don’t invite friends to the house.

Sometimes we don’t get any sleep. We quit taking vacations.” Which nursing diagnosis applies? a. Impaired parenting b. Dysfunctional grieving c. Impaired social interaction d. Interrupted family processes ANS: D

Interrupted family processes are evident in the face of disruptions in family functioning as a result of having a mentally ill member. Data support the possibility of this diagnosis. Data are insufficient to consider the other diagnoses.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 108-109 MSC: NCLEX: Health Promotion and Maintenance

14. A family expresses helplessness related to dealing with a mentally ill member’s odd

behaviors, mood swings, and argumentativeness. An appropriate nursing intervention for the family would be to: a. express sympathy. b. involve local social services. c. explain symptoms of relapse. d. role-play problem situations.

ANS: D

Helping a family learn to set limits and deal with difficult behaviors can often be accomplished by using role-playing situations, which give family members the opportunity to try new, more effective approaches. The other options would not provide learning opportunities.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 109 MSC: NCLEX: Health Promotion and Maintenance

15. Parents of a mentally ill teenager say, “We’ve never known anyone who was mentally ill. We

have no one to talk to because none of our friends understand the problems.” The nurse’s most helpful intervention would be to: a. refer the parents to a support group. b. build their self-esteem as coping parents. c. teach techniques of therapeutic communication.

RS d. facilitate achievement of N noUrm alI deNvG elT opBm.eC ntO alMtasks.

ANS: A The need for support can be clearly identified. Referrals are made when working with families whose needs are unmet. A support group such as the National Alliance for the Mentally Ill (NAMI) will provide these parents with the support of others who have had similar experiences and with whom they can share feelings and experiences. The distracters are less relevant.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 109 MSC: NCLEX: Health Promotion and Maintenance

16. Select the best question to assess a family’s ability to cope. a. “What strengths does your family have?” b. “Do you think your family copes effectively?” c. “Describe how you successfully handled one family problem.” d. “How do you think the current family problem should be resolved?”

ANS: C

The correct option is the only statement addressing coping strategies used by the family. The other options seek opinions or are closed-ended.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 108-109 MSC: NCLEX: Health Promotion and Maintenance

17. Which scenario best illustrates scapegoating within a family? a. Messages of aggression are sent by the identified patient to selected family

members. b. Family members project problems of the family onto one particular family

member. c. The identified patient threatens separation to induce feelings of isolation and

despair. d. Family members give the identified patient nonverbal messages that conflict with

verbal messages.

ANS: B

Scapegoating projects blame for family problems onto a member who is less powerful. The purpose of this projection is to distract from issues or dysfunctional behaviors in the family members.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 106-107 MSC: NCLEX: Health Promotion and Maintenance

18. A parent has become verbally abusive toward the spouse and oldest child since losing a job 6

months ago. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family? a. Impaired parenting, related to verbal abuse of oldest child b. Impaired social interaction, related to disruption of family bonds c. Ineffective individual coping, related to fears about economic stability d. Disabled family coping, related to insecurity secondary to loss of family income ANS: D

Disabled family coping referN s tU oR thS eI beNhG avT ioBr . ofCaOsM ignificant family member that disables his or her own capacity as well as another’s capacity to perform tasks essential to adaptation. The distracters are inaccurate because more than one individual is affected by the stressors.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 107 MSC: NCLEX: Health Promotion and Maintenance

19. A parent says, “My son and I argue constantly since he started using drugs. When I talk to

him about not using drugs, he tells me to stay out of his business.” What is the nurse’s most appropriate action? a. Educate the parent about the stages of family development. b. Report the son to law enforcement authorities. c. Refer the son for substance abuse treatment. d. Make a referral for family therapy.

ANS: D

Family therapy is indicated, and the nurse should provide a referral. Reporting the child to law enforcement would undermine trust and violate confidentiality. The other distracters may occur later.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 108-109 MSC: NCLEX: Health Promotion and Maintenance

20. Which option describes a healthy family? a. One parent takes care of the children. The other parent earns income and maintains

the home. b. A family has strict boundaries that require members to address problems inside the

family. c. A couple requires their adolescent children to attend church services three times a

week. d. A couple renews their marital relationship after their children become adults.

ANS: D

Revamping the marital relationship after children move out of the family of origin indicates that the family is moving through its stages of development. Strict family boundaries or roles interfere with flexibility and the use of outside resources. Adolescents should have some input into deciding their activities.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 107 MSC: NCLEX: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. A parent was recently hospitalized with severe depression. Family members say, “We’re

falling apart. Nobody knows what to expect, who should make decisions, or what to do to keep the family together.” Which interventions should the nurse use when working with this family? Select all that apply. a. Help the family set realistic expectations. b. Provide empathy, acceptance, and support. c. Empower the family by teaching problem solving. d. Negotiate role flexibility among family members. e. Focus on the family ratheN rU thR anSoInNthGeT pB at. ienCtO inMplanning.

ANS: A, B, C, D

The correct answers address expressed needs of the family. The other option is inappropriate.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 109 MSC: NCLEX: Psychosocial Integrity

2. Which situations are most likely to place severe, disabling stress on a family? Select all that

apply. a. A parent needs long-term care after sustaining a severe brain injury. b. The youngest child in a family leaves for college in another state. c. A spouse is diagnosed with liver failure and needs a transplant. d. Parents of three children, age 9, 7, and 2 years, get a divorce. e. A parent retires after working at the same job for 28 years.

ANS: A, C, D

Major illnesses place severe, potentially disabling stress on families. The distracters identify normal milestones in a family’s development.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 109-110 MSC: NCLEX: Health Promotion and Maintenance

Chapter 12: Introduction to Psychotropic Drugs MULTIPLE CHOICE 1. A nurse administers a highly protein-bound medication. Which patient would have the most

immediate and powerful effect from this drug? a. A healthy adolescent b. A 76-year-old patient with malnutrition c. A woman in the second trimester of pregnancy d. An adult with a fractured femur from a sporting accident ANS: B

The older malnourished patient would have fewer serum proteins to bind the drug; therefore, higher amounts of free drug would be available to act immediately. The patients described in the distracters would have normal protein levels, so the drug would be bound.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 119 MSC: NCLEX: Physiologic Integrity

2. A novice nurse asks, “What is the role of psychopharmacology in the psychotherapeutic

management model?” A mentor should respond that psychopharmacology makes it possible to: a. use the least restrictive treatment alternatives. b. prevent violence against nurses. c. identify desirable outcomes. d. determine psychopathology.

I G B.C M ANS: A

NUR S N T

O

By effectively treating psychotic symptoms, the incidence of violent behaviors has been reduced. This makes possible the use of the least restrictive treatment alternative, an important facet of psychotherapeutic management. Psychopharmacology does not make the other options possible.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 128 MSC: NCLEX: Safe, Effective Care Environment

3. The parent of a teen diagnosed with schizophrenia asks, “Why does schizophrenia usually

appear in adolescence?” The nurse’s reply would be based on which premise? a. Stimulation of neurotransmitters is unstable. b. Neuronal system complexity stabilizes. c. Dendrite branching becomes complete in adolescence. d. Amino acid production increases.

ANS: C

Arborization, or branching of dendrites, is a process that continues into adolescence. Some authorities have suggested that this might account for the appearance of schizophrenia at this period in life. The other options are of no relevance.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 124 MSC: NCLEX: Physiologic Integrity

4. The primary mechanisms of action of certain antidepressants result from neurotransmitter

inactivation by enzyme-based metabolism and: a. electrochemical stimulation. b. stimulation of natural precursors. c. extraction of precursors from the bloodstream. d. reuptake into the presynaptic storage vesicles.

ANS: D

Neurotransmitters are inactivated in two ways: (1) they are metabolized by enzymes, and (2) they are taken back into the presynaptic storage vesicles—a process called reuptake. The other options have no physiologic basis in fact.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 125 MSC: NCLEX: Physiologic Integrity

5. When discussing treatment of an aggressive patient with psychosis, a health care provider

says, “I plan to prescribe the original antipsychotic drug.” Which medication is relevant to the statement? a. Paroxetine (Paxil) b. Clozapine (Clozaril) c. Imipramine (Tofranil) d. Chlorpromazine (Thorazine) ANS: D

Only chlorpromazine and clozapine are antipsychotics. Chlorpromazine is a traditional drug, introduced in the early 1950s, whereas clozapine is a newer drug, introduced in the 1990s.

Paroxetine and imipramine are antidepressants.

NURSINGTB.COM REF: p. 118

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

TOP: Nursing process: Planning

6. A nurse assesses a newly hospitalized patient with a long history of serious and persistent

mental illness. The priority assessment information to obtain regarding medication safety is: a. adverse reactions to drugs taken previously. b. history of drug compliance and noncompliance. c. level of support available from significant others. d. length of time on various psychotropic medications.

ANS: A

Information related to safety is the nurse’s priority. Adverse reactions to psychotropic medications can be dangerous, even life-threatening. If a patient has had an adverse reaction to a particular drug, it would be unwise to administer it again. The other options do not address a safety issue.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 128 MSC: NCLEX: Psychosocial Integrity

7. Studies about psychiatric patients’ understanding of psychopharmacology suggest that the

nursing diagnosis most applicable is: a. deficient knowledge related to drug therapy. b. impaired memory related to drug side effects. c. impaired decision making related to drug dependency.

d. disturbed thought processes related to anticipation of side effects.

ANS: A

Research has shown that most patients do not know important facts about the medications prescribed for them. As a result, they are often noncompliant. As knowledge deficits are removed, better compliance can be expected. Data are not present to suggest applicability of the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 126-127 MSC: NCLEX: Psychosocial Integrity

8. A realistic outcome of patient teaching about psychotropic medication is that the patient will: a. understand physiologic responses to drug therapy. b. assess effectiveness of prescribed drugs in controlling symptoms. c. describe onset, peak, and duration of action of each drug prescribed. d. state the purpose, dose, and significant side effects of each drug prescribed.

ANS: D

The correct response identifies basic information that each patient should have. Because the information is basic, the outcome, as stated, is realistic. The other options are less basic and less attainable.

DIF: Cognitive level: Applying REF: pp. 127-128 TOP: Nursing process: Outcome Identification MSC: NCLEX: Psychosocial Integrity 9. A week after beginning fluoxetine (Prozac), a patient complains, “I still feel so depressed all

the time.” Based on pharmacodynamics, the nurse’s best action is to: N Rn I GTstoma B.CO M Npty a. administer the medication oUn aS em ch. b. advise the health care provider that the drug is ineffective. c. reassess the expected outcomes of antidepressant therapy. d. educate the patient that the drug needs more time to be effective.

ANS: D

One week is probably an insufficient time for antidepressants to become effective in reducing patient symptoms. The phenomenon of receptor down-regulation develops in 2 to 4 weeks.

The other options are not supported by research studies.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 122 MSC: NCLEX: Psychosocial Integrity

10. Bearing in mind the function of the blood–brain barrier, dangers associated with administering

large doses of water-soluble drugs relate primarily to the: a. rapid development of tolerance. b. high risk of adverse systemic effects. c. liver’s inability to metabolize water-soluble drugs. d. rapid passage into the brain increasing the risk of overdose.

ANS: B

Water-soluble drugs penetrate the blood–brain barrier slowly and in insignificant amounts. A dose high enough to affect the brain would invariably cause adverse systemic side effects. The other effects are not related.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 123

TOP: Nursing process: Evaluation

11. A nurse administering a selective serotonin reuptake inhibitor (SSRI) antidepressant should

carefully observe the patient for symptoms related to: a. dopamine excess. b. decreased GABA level. c. increased serotonin level. d. decreased acetylcholine level.

ANS: C

Depression is thought to be related to decreased amounts of the neurotransmitters norepinephrine and serotonin. SSRIs increase the reuptake of serotonin, increasing the availability of this neurotransmitter at the synapse. If the SSRI is effective, the increased serotonin will result in a decrease in symptoms of depression. The other options would not be related to SSRI administration.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 125 MSC: NCLEX: Physiologic Integrity

12. Bioavailability of orally administered drugs is initially associated with which physiologic

phenomenon? a. Rate of renal excretion b. First-pass metabolism c. Synaptic transmission d. Blood–brain barrier ANS: B

First-pass metabolism in the liver reduces the bioavailability of orally administered drugs. The other options do not occur first.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 119 MSC: NCLEX: Physiologic Integrity

13. A patient taking clozapine (Clozaril) says, “I get plenty of vitamin C by drinking 8 ounces of

grapefruit juice each morning.” Select the nurse’s best response. a. “High doses of Vitamin C support the immune system and general good health.” b. “Name another juice you would drink, because grapefruit juice can cause a bad reaction while taking clozapine.” c. “Grapefruit juice lessens the effectiveness of your medication. You might need higher doses.” d. “New research shows papaya juice is a better source of vitamin C than grapefruit juice.”

ANS: B

Only the correct option provides vital information based on the cytochrome P-450 enzyme system’s involvement in drug metabolism. Clozapine metabolism is inhibited by the ingestion of grapefruit juice, making the likelihood of a toxic reaction to the drug more likely, because the drug accumulates in the body.

DIF: Cognitive level: Applying

REF: p. 120

TOP: Nursing process: Implementation

MSC: NCLEX: Physiologic Integrity

14. A patient taking a psychotropic medication reports, “This medicine isn’t working right for me.

It’s causing side effects.” Select the nurse’s best comment to further assess the scenario. a. “Has the drug caused diaphoresis?” b. “Have you experienced urinary retention?” c. “Are you experiencing episodes of tachycardia?” d. “Tell me more about how the medication is affecting you.”

ANS: D

Open-ended communication techniques are important strategies for exploring the patient’s concerns. It is also important for the nurse to use culturally familiar terms. Patients are unlikely to know the meaning of terms such as tachycardia, diaphoresis, and urinary retention.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 126-127 MSC: NCLEX: Physiologic Integrity

15. A patient takes a psychotropic medication that affects acetylcholine receptors. The patient

complains of dry mouth and constipation. What effect is the drug having on the acetylcholine receptors? a. Activation b. Antagonism c. Stimulation d. Paradoxical ANS: B

The patient’s complaints indiN cateRsupIpreG ssioBn.oC f theMparasympathetic nervous system, which U S N T is associated with antagonism of the action of acetylcholine.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 126

TOP: Nursing process: Evaluation

16. A patient takes a psychotropic medication that affects serotonin receptors. The patient

complains of anxiety, insomnia, and loss of appetite. What effect is the drug having on the serotonin receptors? a. Activation b. Antagonism c. Paradoxical d. Inhibition ANS: A

The patient’s complaints indicate activation of serotonin receptors. None of the other options correctly identifies this effect.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 125

TOP: Nursing process: Evaluation

17. A patient takes a psychotropic medication that affects norepinephrine receptors. The patient

reports, “It feels like my heart is pounding in my chest.” What effect is the drug having on the norepinephrine receptors? a. Inhibition

b. Activation c. Paradoxical d. Antagonism ANS: B

The patient’s complaints indicate activation of norepinephrine receptors. The medication has stimulated the action of 1-receptors. None of the other options correctly identifies this outcome.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 126

TOP: Nursing process: Evaluation

MULTIPLE RESPONSE 1. What information should the nurse include in patient teaching about psychotropic medication?

Select all that apply. a. Drug pharmacokinetics b. Common drug interactions c. Management of common side effects d. Descriptive list of all possible adverse effects e. Written copies of information about the drug and its effects ANS: B, C, E

Teaching about how to manage common annoying side effects, such as dry mouth and orthostatic hypotension, can promote medication compliance by the patient. Knowing what side effects to report promotes patient safety. In addition, knowing about common drug–drug interactions, such as the potentiating effects of alcohol on sedating drugs, promotes patient NUials RSisIhNelpGT safety. Providing written mater fulB.C to paOtients who can then refer to these resources rather than having to rely on memory. Pharmacokinetics and an extensive list of side effects are major aspects of the nurse’s role but are not expected from patients.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 126-127 MSC: NCLEX: Psychosocial Integrity

2. An outpatient diagnosed with schizophrenia has been omitting doses of medication. Which

questions should the clinic nurse ask to determine the reasons for the problem? Select all that apply. a. “Are you experiencing any troublesome side effects?” b. “Is the medicine affecting your sexual performance?” c. “Does the medicine make you think slower?” d. “Do you believe your dose is too high?” e. “Do you believe you have an illness?”

ANS: A, B, C, D, E

Each question listed refers to a common reason for patients not taking medication as prescribed.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 126-127 MSC: NCLEX: Psychosocial Integrity

3. Sequence the following historical events beginning with the evolution of psychotropic

medications: a. SSRI antidepressants were developed. b. Drugs became available to treat patients diagnosed with Alzheimer’s disease. c. Clozapine (Clozaril), the first atypical antipsychotic drug, was marketed. d. Chlorpromazine (Thorazine) was discovered.

ANS: A, B, C, D

Evolutionary events in the development of psychotropic drugs changed the care environment for patients with mental illness and had significant effects on the nurse’s role.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 118 MSC: NCLEX: Safe, Effective Care Environment

Chapter 13: Antiparkinsonian Drugs MULTIPLE CHOICE 1. A psychiatric nurse should base care of patients diagnosed with Parkinson’s disease and

patients demonstrating extrapyramidal side effects (EPSEs) caused by antipsychotic drug therapy on the premise that symptoms: a. are the same for both problems. b. result from deficits in dopamine synthesis. c. result from acetylcholine and dopamine imbalance. d. are produced by neurodegeneration of the substantia nigra.

ANS: C

In both problems, acetylcholine and dopamine are not in balance. In Parkinson’s disease, this results from neurodegeneration of the substantia nigra, and in the case of EPSEs, the cause is blockade of dopamine receptors in the basal ganglia. The other options are not valid premises.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: pp. 130-131

TOP: Nursing process: Planning

2. A patient who is receiving an antipsychotic drug is restless, paces, and cannot sit still when

watching television. The nurse should use which term to document these findings? a. Dystonia b. Akathisia c. Dyskinesia d. Bradykinesia ANS: B

A patient with akathisia describes feeling restless, jittery, and unable to sit, and has restless legs that feel better only if the patient is moving. Dystonia refers to sustained, twisted muscle contractions. Dyskinesia refers to jerky motions. Bradykinesia refers to slow movement.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 131 MSC: NCLEX: Physiologic Integrity

3. A patient who is receiving an antipsychotic drug is restless, paces, and cannot sit still when

watching television. The patient says, “I couldn’t sleep last night because I needed to pace.”

The nurse’s communication to the health care provider would be to suggest: a. prescribing an anticholinergic drug. b. discontinuing the antipsychotic drug. c. prescribing dopaminergic medication. d. using an antihistamine at bedtime to promote sleep.

ANS: A

The patient’s motor symptoms can be assessed as akathisia. Anticholinergic medication provides relief for some patients. The nurse should report the patient’s symptoms to the health care provider and anticipate the order to begin anticholinergic therapy. The other options do not provide acceptable alternatives.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 133 MSC: NCLEX: Physiologic Integrity

4. A patient who has taken three doses of haloperidol (Haldol) suddenly cries out for help. The

nurse observes that the patient’s eyes are rolled upward in a fixed gaze. The nurse should assess this finding as: a. akathisia. b. nystagmus. c. tardive dyskinesia. d. an oculogyric crisis.

ANS: D

Oculogyric crisis is a specific dystonia in which the eyes roll upward and remain in a fixed position. It results from involuntary muscle spasms and occurs early in the course of treatment. Akathisia refers to motor restlessness. Nystagmus refers to a different type of abnormal eye movements. Tardive dyskinesia refers to abnormal movements primarily of the face and mouth muscles.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 132 MSC: NCLEX: Physiologic Integrity

5. A patient who has taken three doses of haloperidol (Haldol) suddenly cries out for help. The

nurse observes that the patient’s eyes are rolled upward in a fixed gaze. The nurse should administer which drug from the patient’s PRN list? a. Vitamin E b. Carbidopa (Sinemet) c. Benztropine (Cogentin) d. Amantadine (Symmetrel) ANS: C

Benztropine is an anticholinergic that can be given orally or parenterally in case of an emergency, such as oculogyric crisis or dystonic reaction. The other options would not relieve the dystonia.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 133-134 MSC: NCLEX: Physiologic Integrity

6. A patient has taken perphenazine (Prolixin) for a year. The nurse observes lip smacking and

grinding teeth. Which tool should the nurse use to complete the assessment? a. AIMS b. EPSE c. SAD PERSONS d. CAGE questionnaire ANS: A

AIMS is the Abnormal Involuntary Movement Scale. It was developed to screen for tardive dyskinesia. EPSE refers to extrapyramidal side effects. The other tools are for assessing alcohol abuse and suicidality.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: pp. 132-133

TOP: Nursing process: Planning

7. Which symptom of Parkinson’s disease has the highest priority for nursing intervention? a. Tremor

b. Akathisia c. Dysphagia d. Tardive dyskinesia ANS: C

Dysphagia is difficulty swallowing. Because dysphagia can lead to a compromised airway, it is the priority symptom among those listed.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 132 MSC: NCLEX: Physiologic Integrity

8. A patient diagnosed with Parkinson’s disease begins levodopa therapy. The nurse understands

that administration of levodopa will: a. improve symptoms of Parkinson’s disease by increasing dopamine in the CNS. b. improve symptoms of Parkinson’s disease by decreasing levels of GABA. c. cause the patient to develop symptoms of depression and an unsteady gait. d. lead to an increased risk of dysphagia.

ANS: A

Levodopa is converted to dopamine in the central nervous system (CNS), so its administration will cause a reduction in the symptoms of Parkinson’s disease related to dopamine deficiency.

The other options are incorrect. Levodopa increases dopamine levels. Levodopa is not associated with changes in -aminobutyric acid (GABA). Levodopa will improve the patient’s swallowing ability and gait, and will reduce symptoms of depression.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 131

TOP: Nursing process: Evaluation

N R I G B.C M

U S Na dopaminergic T O drug should assess the individual for 9. The nurse caring for a patient receiving early symptoms of: a. psychosis. b. fluid imbalance. c. tardive dyskinesia. d. labile hypertension.

ANS: A

Dopamine excess is associated with schizophrenia. When dopaminergic drugs are given, symptoms of psychosis might appear or be exacerbated. Tardive dyskinesia is associated with dopamine deficiency. The other options are unrelated.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 133-134 MSC: NCLEX: Physiologic Integrity

10. Which statement by the nurse should be included in the teaching plan for patients receiving

anticholinergic agents? a. “Avoid eating foods high in tyramine.” b. “Do not abruptly stop taking the drug.” c. “Take oral medications on an empty stomach.” d. “Take a multivitamin and mineral supplement daily.”

ANS: B

Tapering off the drug over a 1-week period is advisable instead of abruptly stopping the drug.

This prevents uncomfortable withdrawal symptoms. Avoiding foods high in tyramine is important teaching for patients taking monoamine oxidase inhibitors (MAOIs). The other statements are not applicable.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 135-136 MSC: NCLEX: Physiologic Integrity

11. A patient began trihexyphenidyl (Artane) for treatment of drug-induced parkinsonism. Which

finding demonstrates a positive response to the medication? a. Blood pressure returns to patient’s normal range. b. Gait is steady with decreased rigidity. c. Patient reports fewer feelings of depression. d. Patient has tremors with voluntary movement.

ANS: B

Gait disturbance, tremor, bradykinesia, and rigidity are symptoms of drug-induced parkinsonism. Reduction in these symptoms constitutes a positive outcome. The other options are not expected outcomes.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 134

TOP: Nursing process: Evaluation

12. When developing a teaching plan for a patient receiving benztropine (Cogentin), a priority

consideration for the nurse is: a. anticholinergic drugs often cause blurred vision. b. urinary frequency may impair the patient’s concentration.

GaTkBe . c. akathisia produced by theNdU ruRgSwIilN lm coC nO ceM ntration difficult. d. increased peristalsis might cause gastrointestinal distress and impair concentration.

ANS: A

CNS effects include confusion, drowsiness, and decreased memory and learning. This might affect the patient’s ability to learn. Anticholinergics do not cause urinary frequency, akathisia, or increased peristalsis.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 134

TOP: Nursing process: Planning

13. A patient who takes haloperidol (Haldol) for a diagnosis of schizophrenia has a dystonic

reaction. Benztropine (Cogentin) 2 mg is given intramuscularly and then continued orally twice daily. Three days later, the patient has fever, disorientation, and tachycardia. Select the best analysis of this scenario. a. Tardive dyskinesia has emerged. b. Benztropine toxicity has developed. c. Extrapyramidal symptoms have returned. d. Dopaminergic benztropine effects have exacerbated the psychosis.

ANS: B

CNS hyperstimulation from anticholinergics causes fever, disorientation, excitement, agitation, delirium, and hallucinations as well as cardiovascular, urinary, and gastrointestinal symptoms. Collectively, these findings indicate anticholinergic toxicity. The symptoms described in the scenario do not accurately reflect any of the other options.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 135

TOP: Nursing process: Evaluation

14. An older adult patient who takes trihexyphenidyl (Artane) for drug-induced parkinsonism

begins taking diphenhydramine (Benadryl) for cold symptoms. The nurse should carefully monitor this patient for: a. polyuria. b. tachycardia. c. constipation. d. hypothermia.

ANS: B

An anticholinergic effect on the vagus nerve causes tachycardia by removing the braking effect on the sinoatrial node. The additive effects of trihexyphenidyl and diphenhydramine would be likely to produce tachycardia, which could lead to cardiac decompensation in an older adult. In terms of priority of problems, hyperthermia may occur later, after toxic levels of anticholinergics had been ingested; constipation would be less life-threatening than cardiac decompensation. Anticholinergics cause urinary retention, not polyuria.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 135-136 MSC: NCLEX: Physiologic Integrity

15. Patient teaching for a patient beginning an anticholinergic drug should include: a. limiting fluid intake to 1000 ml/day. b. limiting strenuous activity on hot days. c. eating small, frequent meals to decrease nausea. d. wearing adequate clothinN gU toRpS reI veNnG t hTyB po.thCeO rmMia. ANS: B

An anticholinergic side effect is decreased sweating. Sweating produces body cooling through evaporation. Heat stroke is a greater possibility when the body cannot cool itself. The other options have no particular relevance to anticholinergic therapy.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 135 MSC: NCLEX: Physiologic Integrity

16. Which patient receiving fluphenazine (Prolixin) should be monitored most closely for EPSEs? a. 35-year-old man b. 45-year-old woman c. 74-year-old woman d. Patient with a 5-year history of schizophrenia ANS: C

Women, older adults, patients with affective symptoms, and patients with first episodes of schizophrenia have a higher risk for EPSEs. DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 133 MSC: NCLEX: Physiologic Integrity

17. An elderly nursing home resident has been diagnosed with type 2 diabetes, hypertension, and

dementia. The patient begins taking an antipsychotic drug for agitation. Tremor and bradykinesia develop, so an anticholinergic is added to the drug regimen. Within 3 days the patient displays a marked cognitive deficit. Which medication is the most likely cause of the cognitive change? a. Antihypertensive b. Anticholinergic c. Antipsychotic d. Antidiabetic ANS: B

Anticholinergic medications often produce cognitive changes in older adults. Although the other medications listed might produce untoward effects, because the symptoms appeared after the introduction of the anticholinergic, one would suspect this drug first.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 134

TOP: Nursing process: Evaluation

18. Of the patients the nurse will see at the mental health center, which one should be assessed

most carefully for EPSEs? a. 59-year-old man with severe mental illness for 20 years; takes olanzapine (Zyprexa) b. 18-year-old woman with a first episode of schizophrenia; takes haloperidol (Haldol) c. 26-year-old man with generalized anxiety disorder; takes lorazepam (Ativan) d. 30-year-old woman with depression; takes amitriptyline (Elavil) ANS: B

Risk factors for EPSEs include female gender, first episode of schizophrenia, and use of a traditional antipsychotic medication. The other patients are at lower or no risk because of taking an atypical antipsychotic, a tricyclic antidepressant, and an antianxiety drug. Men are at lower risk.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 133 MSC: NCLEX: Physiologic Integrity

19. Which medication from a patient’s pharmacologic profile is most likely to precipitate

neuroleptic malignant syndrome (NMS)? a. Diphenhydramine (Benadryl) b. Risperidone (Risperdal) c. Haloperidol (Haldol) d. Clozapine (Clozaril) ANS: C

Haloperidol is a first-generation high-potency antipsychotic drug. It has a greater risk for producing NMS than atypical antipsychotic drugs. Diphenhydramine is not an antipsychotic drug.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 133 MSC: NCLEX: Physiologic Integrity

20. Which neurotransmitter is most affected by an anticholinergic drug?

a. b. c. d.

Acetylcholine Dopamine Serotonin GABA

ANS: A

Anticholinergic drugs inhibit acetylcholine, thereby preventing stimulation of the cholinergic excitatory pathways. The other neurotransmitters are associated with the etiology of schizophrenia, anxiety, and depression.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 133 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. When patients are treated with antipsychotic medications, a variety of side effects and adverse

reactions may occur. Sequence the following list in order of intervention priority, beginning with the most urgent: a. Akathisia b. Dystonic reaction c. NMS d. Tardive dyskinesia ANS: A, B, C, D

NMS is considered a medical emergency requiring immediate intervention to save the patient’s life. A dystonic reaction is extremely uncomfortable and requires swift intervention to restore patient comfort. Akathisia is uncomfortable but is not considered an emergency.

NU RS IN B.CO Tardive dyskinesia is a serious , po ssib lyGuT nremitt ing problem that might require discontinuing the medication. It develops over weeks, months, or years.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: pp. 131-133

TOP: Nursing process: Planning

Chapter 14: Antipsychotic Drugs MULTIPLE CHOICE 1. A patient receiving a traditional high-potency antipsychotic medication should be closely

monitored for: a. adrenergic effects. b. extrapyramidal side effects. c. anticholinergic side effects. d. changes in pain perception.

ANS: B

High-potency antipsychotics are more likely to cause extrapyramidal side effects (EPSEs) than low-potency antipsychotics. The other effects are not related to potency classification.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 143 MSC: NCLEX: Physiologic Integrity

2. A patient receives a traditional low-potency antipsychotic medication. The nurse should

assess closely for: a. urinary frequency. b. urinary retention. c. hypertension. d. diarrhea.

ANS: B

Low-potency antipsychotics N tendRto I causGe anBt. ichColiM nergic side effects. Urinary retention and U S N T other anticholinergic effects are important findings for which the nurse should be alert. The other effects would not be expected.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 138, 143 MSC: NCLEX: Physiologic Integrity

3. A patient diagnosed with schizophrenia has taken thiothixene (Navane) 5 mg/day for 4 years

with good symptom control. Today, the patient is admitted with paranoia and auditory hallucinations. The nurse should determine if the patient’s symptoms are related to: a. not taking the drug as prescribed. b. activation of serotonin receptors. c. development of tolerance to the drug. d. an expected illness-exacerbation cycle.

ANS: A

When a patient does not respond to a drug, or when symptoms reappear after a good response to the drug, the nurse should assess for compliance. Is the patient taking the drug? Is the patient taking less of the drug than ordered? The other options are less relevant or of no value.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 147 MSC: NCLEX: Physiologic Integrity

4. When assessing for a positive outcome to drug therapy with fluphenazine (Prolixin), the nurse

would look primarily for improvement in:

a. b. c. d.

hallucinations. range of affect. personal hygiene. social interactions.

ANS: A

Fluphenazine, a typical antipsychotic, will produce improvement in the positive symptoms associated with schizophrenia, such as hallucinations. Less improvement is expected in negative symptoms such as affect, activity, and grooming.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 140-141

TOP: Nursing process: Evaluation

5. A patient diagnosed with schizophrenia tells the clinic nurse, “I stopped taking my

antipsychotic medication two days ago.” Previously, the patient was compliant and had good symptom control. What assessment finding would the nurse expect at this visit? a. Mood instability b. Paranoid delusions c. No evidence of symptoms d. Mental clouding and confusion ANS: C

Antipsychotic drugs accumulate in fatty tissue and are released slowly. This explains why symptoms might still be controlled for several days after discontinuing the drug.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 140, 142 MSC: NCLEX: Physiologic Integrity

N R I G B.C M

U S Nmalignant T Osyndrome. Which medication from the 6. A patient is diagnosed with neuroleptic patient’s pharmacologic profile most likely led to this problem? a. Divalproex sodium (Depakote) b. Amitriptyline (Elavil) c. Haloperidol (Haldol) d. Paroxetine (Paxil) ANS: C

Neuroleptic malignant syndrome is more likely to occur in patients taking traditional high-potency antipsychotic drugs. The distracters are not antipsychotic drugs.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 144 MSC: NCLEX: Physiologic Integrity

7. During a psychiatric emergency, a patient is given a traditional antipsychotic drug

intramuscularly and placed in seclusion. Over the next 2 hours, concerns for safety and physiologic stability require that the patient be carefully monitored for: a. tardive dyskinesia. b. gastrointestinal hyperactivity. c. drug-induced parkinsonian movements. d. orthostatic hypotension and cardiac arrhythmias.

ANS: D

Hypotension is the major antiadrenergic effect of antipsychotic drugs. It is related to the blocking of 1-receptors on peripheral blood vessels, preventing the vessels from constricting automatically to positional changes. Hypotension is frequently noted following intramuscular administration and is of concern because it relates to patient safety and injury from falls.

Cardiac arrhythmias may also occur, jeopardizing the patient’s physiologic stability.

Drug-induced parkinsonism and tardive dyskinesia develop over time.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 143 MSC: NCLEX: Physiologic Integrity

8. During a psychiatric emergency, a patient is given a traditional antipsychotic drug

intramuscularly and placed in seclusion. Over the next 2 hours, which aspect of physical assessment is most important? a. All vital signs b. Urinary output c. AIMS scale d. Temperature ANS: A

A traditional antipsychotic medication administered intramuscularly might produce the marked antiadrenergic side effect of hypotension, thus making blood pressure an important assessment. It may also precipitate cardiac arrhythmias, so monitoring pulse and respirations is important. Decreased urinary output is related to anticholinergic side effects and would not be a priority assessment during the first 2 hours. The AIMS scale assesses for tardive dyskinesia, a late complication of antipsychotic therapy. Temperature assessment is relevant if assessing for neuroleptic malignant syndrome, a complication that develops after several doses of antipsychotic medicN atioR n. I G B.C M

U S N T

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

O

REF: p. 143 MSC: NCLEX: Physiologic Integrity

9. After an unsuccessful trial with fluphenazine (Prolixin), a patient’s medication was changed to

trifluoperazine (Stelazine). Three months later the patient is still hallucinating and delusional.

What is the most likely explanation for the persistent symptoms? a. Trifluoperazine (Stelazine) is a low-potency antipsychotic, and the patient might need higher doses. b. The patient has not taken trifluoperazine (Stelazine) long enough to decrease symptoms significantly. c. Delusions and hallucinations are negative symptoms of schizophrenia that do not respond to traditional antipsychotic medications. d. Both fluphenazine (Prolixin) and trifluoperazine (Stelazine) are traditional antipsychotics, and the patient does not respond well to this class of drug.

ANS: D

When a trial of a drug produces little change in symptoms and a new drug is to be prescribed, the best plan is to use a drug of another class, because the response to a drug of the first class will usually be poor. The other options are misleading.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 138

TOP: Nursing process: Evaluation

10. Thioridazine (Mellaril) is prescribed for a 72-year-old patient with a psychiatric disorder. It is

most critical for the nurse to obtain information about preexisting: a. cataracts. b. heart disease. c. diabetes mellitus. d. chronic bronchitis.

ANS: B

The anticholinergic and antiadrenergic effects of this drug might produce reflex tachycardia and/ or arrhythmias. Individuals with known heart disease must be carefully evaluated before and during therapy. The remaining options are not influenced as directly by this medication.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 140-141, 143 MSC: NCLEX: Physiologic Integrity

11. When a patient is taking a traditional antipsychotic medication, the nurse should assess

carefully for EPSEs, particularly: a. akathisia. b. mydriasis. c. hypotension. d. constipation.

ANS: A

It is estimated that more than 25% of all patients receiving antipsychotic medication experience akathisia, a subjective feeling of restlessness and jitteriness and a desire to stand or walk. Akathisia typically manifests itself early in treatment. The other options are not considered EPSEs.

NURSINGTB.COM REF: p. 143

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

MSC: NCLEX: Physiologic Integrity

12. A patient who takes haloperidol (Haldol) 10 mg/day orally developed restlessness, agitation,

and an inability to sit still. The nurse then administered a PRN dose of haloperidol 5 mg intramuscularly. One hour later the patient’s symptoms were worse. What is the most likely explanation? a. The PRN medication has not yet taken effect. b. The patient needs an additional PRN dose of haloperidol to control the rising agitation. c. The patient was experiencing akathisia, which worsened after receiving the PRN medication. d. The nurse should consider an adjunctive dose of an antianxiety drug such as lorazepam (Ativan).

ANS: C

Akathisia is characterized by subjective feelings of restlessness accompanied by the inability to sit still and the need to pace. It is an EPSE of antipsychotic medication, made more intense by higher doses of medication and use of PRN doses. It is unnecessary to change to a more sedating drug. The addition of an antianxiety drug is unnecessary.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 143

TOP: Nursing process: Evaluation

13. The patient receiving antipsychotic medication who should be most carefully monitored for

development of neuroleptic malignant syndrome is the individual who: a. has a history of hypothermia. b. has an elevated serum prolactin level. c. is beginning treatment with a high-potency drug. d. has taken antipsychotics for more than 6 months.

ANS: C

Neuroleptic malignant syndrome (NMS) is more common among patients receiving high-potency drugs. NMS is associated with hyperthermia and occurs within the first 3 to 9 days of administration. Prolactin levels and NMS are not causally related.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 144 MSC: NCLEX: Physiologic Integrity

14. An adult diagnosed with schizophrenia was started on clozapine (Clozaril) 4 days ago. At

2100 today, the patient’s vital signs are temperature 101° F; pulse 143 beats/min; respirations 20 breaths/min; blood pressure 100/60 mm Hg. What is the nurse’s best action regarding the 2100 dose of clozapine? a. Recognize the alterations in vital signs as typical for early therapy, and administer the medication. b. Hold the medication, and notify the health care provider. c. Give the drug and continue to monitor vital signs every 4 hours. d. Postpone the dose until vital signs are normal.

ANS: B

Clozapine might cause agranulocytosis, a potentially fatal illness. Any symptoms or signs of infection raise suspicion and N caUllRfoSrIinNvG esT tigBa. tioCnOoM f white cell differential counts. Clozapine should be withheld until the white blood cell (WBC) count and absolute neutrophil count (ANC) are known. Administering the drug has the potential for further lowering the WBC count and ANC. DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 149-150 MSC: NCLEX: Physiologic Integrity

15. Which third-generation antipsychotic medication acts by stabilizing the dopamine system? a. Aripiprazole (Abilify) b. Ziprasicone (Geodon) c. Quetiapine (Seroquel) d. Risperidone (Risperdal) ANS: A

Aripiprazole is novel in action. It acts by stabilizing the dopamine system through partial agonism of dopamine D2 and 5-HT2. The other drugs are atypical antipsychotics, which have other modes of action that produce therapeutic effects.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 151

TOP: Nursing process: Planning

16. A patient is being switched to clozapine (Clozaril) from therapy using a traditional

antipsychotic. The patient asks, “What’s the advantage of the new drug?” Select the nurse’s best response.

a. b. c. d.

“It is much less expensive.”

“It has a lower risk for seizure activity.”

“It is sometimes effective when other drugs fail.”

“It has a lower risk for causing blood abnormalities.”

ANS: C

Clozapine is often effective against refractory schizophrenia. The distracters are incorrect statements.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 149 MSC: NCLEX: Physiologic Integrity

17. Which drug would a nurse expect to produce a favorable response for both positive and

negative symptoms? a. Haloperidol (Haldol) b. Risperidone (Risperdal) c. Fluphenazine (Prolixin) d. Trifluoperazine (Stelazine) ANS: B

Risperidone is an atypical antipsychotic. It has proven to be effective in managing both positive and negative symptoms of schizophrenia in many patients. The other drugs are traditional antipsychotics, all of which are more effective against positive symptoms.

DIF: Cognitive level: Applying REF: p. 150 TOP: Nursing process: Outcome Evaluation MSC: NCLEX: Physiologic Integrity

N R I G B.C M

18. A patient has taken a traditionaU l anS tipsN ychT otic meO dication for several years. The nurse

observes involuntary tongue movements and lip smacking. The nurse should: a. notify the health care provider. b. administer PRN doses of an anticholinergic drug. c. offer a reward when the patient stops these motions. d. counsel the patient that the movements are annoying to others.

ANS: A

These symptoms suggest the presence of tardive dyskinesia and should be reported to the health care provider, who will probably discontinue the drug or change to an atypical drug.

The movements are involuntary. Tardive dyskinesia does not respond to anticholinergics.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 146-147 MSC: NCLEX: Physiologic Integrity

19. A patient who takes a traditional antipsychotic medication says, “I feel shaky and very warm.”

The patient is diaphoretic. The nurse should further assess for what complication? a. Acute dystonia b. Tardive dyskinesia c. Drug-induced parkinsonism d. NMS ANS: D

NMS is a relatively rare but serious reaction to antipsychotic therapy. It is characterized by muscle rigidity, fever, sweating, autonomic instability, altered levels of consciousness, and possible death. The data given in the scenario are not consistent with other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 144 MSC: NCLEX: Physiologic Integrity

20. A patient who takes a traditional antipsychotic medication says, “I feel shaky and very warm.”

The patient is diaphoretic. What is the nurse’s best first action? a. Take the patient’s vital signs. b. Position the patient in the semi-Fowler’s position. c. Begin oxygen by nasal cannula at 2 L/min. d. Place the patient on one-to-one supervision.

ANS: A

The signs and symptoms suggest that the patient might be experiencing NMS. The first action would be to check vital signs. NMS produces elevated temperature, blood pressure fluctuations, and irregular heart rate in addition to muscle rigidity and altered levels of consciousness.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 144 MSC: NCLEX: Physiologic Integrity

21. A patient who takes a traditional antipsychotic medication says, “I feel shaky and very warm.”

The patient is diaphoretic. The nurse anticipates that the health care provider will prescribe: a. olanzapine (Zyprexa). b. dantrolene (Dantrium). c. benztropine (Cogentin). d. chlorpromazine (Thorazine).

ANS: B

Dantrolene is a drug of choice for treating NMS. It is a direct-acting skeletal muscle relaxant that will be administered for 8 to 12 days after improvement.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 144 MSC: NCLEX: Physiologic Integrity

22. A nurse reviews laboratory reports for a patient who has taken clozapine (Clozaril) for 1 year.

Which value would prompt the nurse to notify the health care provider of the need to suspend treatment? The total WBC count and granulocyte count are: a. 2900 cells/mm3 and 1450 cells/mm3. b. 3500 cells/mm3 and 1850 cells/mm3. c. 4000 cells/mm3 and 2000 cells/mm3. d. 4500 cells/mm3 and 2500 cells/mm3.

ANS: A

These values indicate that leukopenia is present. Agranulocytosis is a sometimes fatal side effect of clozapine. The other values are above baseline.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 144 MSC: NCLEX: Physiologic Integrity

23. A nurse cares for four patients diagnosed with schizophrenia who are receiving antipsychotic

medication. Which patient will receive the nurse’s priority attention? The patient: a. with diaphoresis and a temperature of 104° F b. who reports feelings of neck and shoulder stiffness c. who reports auditory hallucinations of church bells clanging loudly d. who chants, “I am the messiah, delivered to earth from the heavens above” ANS: A

These findings indicate NMS, a serious adverse reaction to antipsychotic medication. The other findings may be significant, but are a lesser priority.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 144 MSC: NCLEX: Physiologic Integrity

24. A patient is to be discharged on a maintenance dose of a high-potency antipsychotic

medication. Which remark indicates that discharge teaching about the medication was effective? a. “I will be able to have a few glasses of wine.” b. “I have to use sun block when I go to the beach.” c. “It is important for me to dress warmly in all seasons.” d. “If I miss a dose, I will take an extra one the next day.”

ANS: B

The patient understands that antipsychotics cause photosensitivity and sunburn with minimal exposure to the sun. The other remarks suggest that the patient does not understand the additive effects of the antipsychotics and other central nervous system depressants, and does not understand what to do in the event of a missed dose.

NURSINGTB.COM REF: p. 147

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

TOP: Nursing process: Evaluation

25. A 60-year-old female patient who has taken traditional antipsychotic medication for 20 years

should be screened for: a. osteoporosis. b. metabolic syndrome. c. polycystic ovary disease. d. NMS. ANS: A

Traditional antipsychotic medications increase prolactin levels, placing patients at risk for development of osteoporosis. Atypical antipsychotics increase the risk for metabolic syndrome. Screening for NMS and polycystic ovary disease are not indicated.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 144 MSC: NCLEX: Physiologic Integrity

26. Which information should the nurse include in the teaching plan for a patient receiving

clozapine (Clozaril)? a. “Abstain from using tobacco products.” b. “Increase your daily carbohydrate intake.” c. “Notify your health care provider if you start drooling.” d. “You will need monthly electrocardiographic tracings done.”

ANS: A

Use of tobacco products speeds metabolism of clozapine in the liver, reducing the clozapine level and diminishing its effectiveness in reducing symptoms. Increasing carbohydrate intake is contraindicated because of the possibility of developing metabolic syndrome. Drooling is a common side effect. Monthly electrocardiographic tracings are unnecessary, but annual or semiannual tracings might be suggested, because arrhythmia development is possible.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 149 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. Patient teaching for individuals taking risperidone (Risperdal) should include (select all that

apply): a. measures to prevent episodes of orthostatic hypotension. b. strategies to maintain fluid and electrolyte balance. c. importance of determining monthly WBC count. d. dietary management to avoid weight gain. e. self-monitoring for facial tics.

ANS: A, D

Risperidone causes orthostatic hypotension, sedation, and appetite stimulation. When taken in moderate doses, its favorable side effect profile suggests that teaching regarding EPSEs and tardive dyskinesia can be minimal. Fluid and electrolyte imbalance and agranulocytosis are not usual side effects.

DIF: Cognitive level: ApplyinN gURSINGRT EB F:.C p. O 15M0 TOP: Nursing process: Implementation MSC: NCLEX: Physiologic Integrity 2. When comparing major differences between traditional and atypical antipsychotic drugs,

which statements are correct? Select all that apply. a. Traditional antipsychotic drugs produce more EPSEs. b. Traditional antipsychotic drugs are more likely to produce weight gain. c. Traditional antipsychotic drugs alter dopamine and serotonin transmission. d. Atypical medications have a greater therapeutic effect on both positive and negative symptoms. e. Atypical medications are more likely to cause tardive dyskinesia.

ANS: A, D

Traditional antipsychotics have a higher incidence of EPSEs and tardive dyskinesia. Atypical antipsychotics are more likely to produce weight gain and alter dopamine and serotonin transmission.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 138

TOP: Nursing process: Evaluation

Chapter 15: Antidepressant Drugs MULTIPLE CHOICE 1. A secondary amine tricyclic antidepressant is prescribed for a patient. The medication will

significantly increase the availability of which neurotransmitter? a. GABA b. Glutamate c. Serotonin d. Norepinephrine ANS: D

Secondary amines increase the availability and enhance the action of norepinephrine.

DIF: Cognitive level: Understanding TOP: Nursing process: Planning

REF: pp. 156, 163-164 MSC: NCLEX: Physiologic Integrity

2. Nortriptyline (Aventyl) was prescribed for a 68-year-old patient diagnosed with depression

and insomnia. Benefits specific to use of nortriptyline would include: a. regular bowel movements. b. improved sleep pattern. c. weight loss. d. anhedonia.

ANS: B

Nortriptyline is a secondary amine with a good side effect profile. It has a minimal tendency to cause orthostatic hypotensN ion,RmeI aninGg thBe.riC sk oMf falls is low. It is somewhat sedating, U S N T O which is helpful to patients with insomnia. The other options are either undesirable or nonspecific outcomes.

DIF: Cognitive level: Analyzing REF: p. 164 TOP: Nursing process: Outcome Planning MSC: NCLEX: Physiologic Integrity 3. Priority assessments for a patient beginning amitriptyline (Elavil) include: a. nausea, diarrhea, and irritability. b. seizures, agranulocytosis, and insomnia. c. headache, sexual dysfunction, and weight loss. d. history of falls, arrhythmias, and blurred vision.

ANS: D

Tricyclic antidepressants (TCAs) produce anticholinergic (blurred vision) and antiadrenergic (orthostatic hypotension leading to falls and arrhythmias) side effects. Gastrointestinal symptoms, sexual dysfunction, and weight variations are related to selective serotonin reuptake inhibitor (SSRI) therapy. Seizures are seen with bupropion therapy. Agranulocytosis is not considered a major problem with any of the groups of antidepressants.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 164 MSC: NCLEX: Physiologic Integrity

4. A 75-year-old patient with a long history of depression begins amitriptyline (Elavil) 100

mg/day. The patient also takes a diuretic daily for hypertension. The highest priority nursing diagnosis is risk for: a. falls related to dizziness and orthostatic hypotension. b. ineffective thermoregulation related to anhidrosis. c. infection related to suppressed white blood cell count. d. constipation related to slowed peristalsis.

ANS: A

Amitriptyline is a TCA that has a high risk of producing orthostatic hypotension. The patient is placed at even greater risk because of older age and diuretic therapy, which reduces fluid volume. The other options are either unassociated or are remote possibilities.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 166

TOP: Nursing process: Planning

5. A depressed patient prepares for discharge. The patient is prescribed desipramine (Norpramin)

and will have outpatient visits. The patient reports, “They gave me only a 1-week supply of my medicine.” Select the nurse’s best reply. a. “Federal law limits the amount you may be given at any one time.” b. “It will save you money if the drug doesn’t work well for your symptoms.” c. “This is a way of ensuring that you will come in for your follow-up appointment.” d. “Prescribing a small amount of drug addresses our concerns for your continuing safety.”

ANS: D

Desipramine is an activating antidepressant, and it might provide a patient who has suicidal .eCcaOuM ideation with the energy to mN akUeRaS nI atN teG mT ptB .B se the therapeutic dose and lethal dose are not widely separated, TCA overdose is an often-used suicide plan. Because desipramine appears to be the most toxic TCA, prescribing only a 7-day supply limits the possibility of using the drug in a suicide attempt. The other options are either less relevant or incorrect.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 164, 167 MSC: NCLEX: Psychosocial Integrity

6. Evaluation of a patient’s response after 1 week of tricyclic antidepressant therapy would be

expected to show: a. no change in objective or subjective symptoms. b. increased appetite and weight gain. c. decreased suicidal ideation. d. improved mood and affect.

ANS: B

Improved appetite might be caused by the antihistaminic effect of the drug. Improvement in mood might not occur for 2 to 4 weeks. Suicidal ideation might not improve for 2 to 4 weeks.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: pp. 163-164

TOP: Nursing process: Evaluation

7. A patient diagnosed with depression who has reported vague suicidal ideation will stay at

home, have close family supervision, and make weekly visits to the health care provider.

Bupropion (Wellbutrin) is prescribed. What is the benefit of bupropion in this scenario?

a. b. c. d.

It has antianxiety properties as well as antidepressant effects.

It lowers the seizure threshold to a lesser extent than TCAs. There is reduced potential for lethal overdose.

It stimulates appetite and weight gain.

ANS: C

Bupropion has no lethal-overdose potential, making it well suited for use in outpatient treatment of depression. Bupropion has a narrow therapeutic index but is far less lethal than TCAs or monoamine oxidase inhibitors (MAOIs). However, it might cause agitation, anxiety, seizures, anorexia, and weight loss.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 163

TOP: Nursing process: Planning

8. A patient with depression has taken an SSRI for 1 month. The nurse should use direct

questions to evaluate which potential side effect? a. Aggressive impulses b. Sexual dysfunction c. Paranoid delusions d. Weight gain ANS: B

SSRIs often produce sexual dysfunction, such as decreased libido. Patients readily tell nurses about anticholinergic, gastrointestinal, and other side effects, but are not as forthcoming in reporting sexual problems. The nurse might need to ask directly to elicit this information.

Patients are more willing to discuss the other options.

DIF: Cognitive level: ApplyinN g R I GREB p. 15M8-160 U S N TF:.C MSC: NCLEX: Psychosocial Integrity

TOP: Nursing process: Planning

9. A patient prescribed fluoxetine (Prozac) is being changed to tranylcypromine (Parnate). The

nurse schedules a time lapse between the last dose of fluoxetine and the first dose of tranylcypromine of at least: a. 7 days. b. 14 days. c. 3 weeks. d. 6 weeks.

ANS: D

Drugs that have a high probability for serious interactions (e.g., MAOIs) will need to be withheld for up to 6 weeks or more as fluoxetine is washing out of the system. The remaining options are too short an interval.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 162 MSC: NCLEX: Physiologic Integrity

10. A patient tells the nurse that he stopped taking sertraline (Zoloft) because the drug made him

impotent. The nurse can be most helpful by saying: a. “Your doctor wants you to continue taking your medication.” b. “Have you talked with your therapist regarding your feelings about sex?” c. “Let’s talk with your doctor. Changing your medication might be a possibility.” d. “Our priority is to treat your depression. Impotence can be addressed in a few

weeks.”

ANS: C

SSRIs commonly cause sexual dysfunction. Sertraline is a widely marketed SSRI and was the second drug of this class to be used in the United States. Sertraline can also be given once daily (morning or evening) with or without food. Sertraline causes sexual dysfunction in men and women. Sexual function typically returns to normal 2 to 3 days after drug cessation.

Changing to another type of antidepressant or adding bupropion in small doses can be helpful.

The other options are not compassionate or therapeutic.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 162-163 MSC: NCLEX: Psychosocial Integrity

11. A TCA is prescribed for a patient newly diagnosed with depression. What information should

be included in patient teaching? a. “Take this medication on an empty stomach.” b. “Do not eat aged cheese while using this medication.” c. “You might experience sweating, tremors, and excessive urination.” d. “It might be 2 weeks or more before you notice the effects of this medicine.”

ANS: D

Antidepressant effects might take several weeks to be noticeable. Avoidance of tyramine (as is present in aged cheeses) is necessary for MAOI therapy but not for TCAs. It is not necessary to take TCAs on an empty stomach. Sweating, tremors, and urination problems are not commonly experienced with TCA therapy.

DIF: Cognitive level: Applying TOP: Nursing process: ImplemNentR ationI

REF: p. 163-164 M : N G SBC. CCLMEX: Physiologic Integrity

U S N T

O

12. Patients taking TCAs exhibit more side effects than patients taking SSRIs, because TCAs: a. inhibit reuptake of norepinephrine and serotonin. b. selectively inhibit dopamine reuptake. c. selectively block serotonin uptake. d. block enzymatic breakdown.

ANS: A

TCAs inhibit the reuptake of both norepinephrine and serotonin and because of their nonselectivity produce many side effects. The other options are incorrect statements about the action of TCAs. DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 163-164 MSC: NCLEX: Physiologic Integrity

13. The nurse cares for four patients receiving SSRIs. Which assessment finding warrants the

nurse’s priority attention? a. Dry mouth and stuffy nose b. Malaise and frontal headache c. Confusion, agitation, and hyperthermia d. Constipation, photophobia, and anhidrosis ANS: C

The correct response suggests serotonin syndrome, an acute medical problem requiring immediate medical and nursing attention. The distracters are examples of anticholinergic effects and are not considered emergencies.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 161, Box 15-7 MSC: NCLEX: Physiologic Integrity

14. When teaching about the MAOI tranylcypromine (Parnate), the nurse should consider it a

priority to: a. provide a list of tyramine-rich foods. b. instruct the patient to avoid direct sunlight. c. advise the patient to manage fever with acetaminophen. d. direct the patient to report dry mouth and blurred vision.

ANS: A

MAOIs and ingested tyramine interact to produce hypertensive crisis, a life-threatening medical emergency, so it is necessary to teach the patient foods to avoid. The other options are unrelated to tranylcypromine therapy.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 169 MSC: NCLEX: Physiologic Integrity

15. A patient for whom phenelzine (Nardil) is prescribed complains of a sudden headache and

palpitations. The nurse observes dilated pupils and diaphoresis. The nurse’s first action should be: a. assess for cogwheel rigidity. b. notify the health care provider. c. assess the patient’s bloodNpU reR ssS urIe.NGTB.COM d. withhold the morning dose of phenelzine.

ANS: C

The patient’s symptoms are suggestive of hypertensive crisis. It is vital to know whether or not the blood pressure is elevated, so obtaining the blood pressure is the necessary first action.

The most probable reason for the reaction would be drug–food interaction. The nurse may notify the health care provider and withhold the morning dose as subsequent actions.

Cogwheel rigidity is associated with antipsychotic medications.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 168 MSC: NCLEX: Physiologic Integrity

16. What is the nurse’s highest priority when caring for a patient after a TCA overdose? a. Frequently monitor blood pressure and heart rate/rhythm. b. Monitor for skin rashes, particularly on the torso. c. Measure and record intake and output every 12 hours. d. Institute cooling blankets for hyperthermia.

ANS: A

It is necessary to assess cardiovascular function, because cardiovascular reactions can occur suddenly, even several days after the TCA overdose, and can result in acute heart failure. The other options are not as closely aligned with cardiovascular problems.

DIF: Cognitive level: Analyzing

REF: p. 168

TOP: Nursing process: Implementation

MSC: NCLEX: Physiologic Integrity

17. The nurse’s priority assessment for a patient taking an antidepressant medication is for the

presence of: a. suicidal ideation. b. antiadrenergic side effects. c. anticholinergic side effects. d. symptoms of sexual dysfunction.

ANS: A

Antidepressant medication tends to energize depressed patients, possibly giving them the impetus to act on suicidal ideation that has been present related to the depression. This complication is particularly applicable to adolescents. Some suggest that suicidal ideation might be the actual result of antidepressant therapy. In either case the implication for nursing is clear: patients should be carefully assessed for the presence of suicidal ideation, suicidal plans, and means for carrying out the plans. This option is related to patient safety and takes priority over the other options.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 164-165 MSC: NCLEX: Psychosocial Integrity

18. A pregnant patient took SSRI antidepressants during the third trimester of pregnancy. The

newborn will be carefully assessed for neonatal: a. temperature dysregulation. b. serotonin syndrome. c. seizure disorder. d. diabetes.

ANS: B

The neonate whose mother has received SSRIs might experience respiratory depression, hypoglycemia, tremor, and low birth weight as part of neonatal serotonin syndrome. The disorder normally is resolved within 2 weeks of birth. The other options are not usually seen as a result of in utero exposure to SSRIs. DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 165-166 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. A nurse teaches a patient taking an MAOI antidepressant about important dietary guidelines.

Which nutritional choices by the patient indicate that the teaching was effective? Select all that apply. a. Sausage b. Avocados c. Pork chops d. Strawberries e. Chocolate chip cookies ANS: C, D

The patient must avoid foods high in tyramine so as to prevent a hypertensive crisis. Sausage, avocados, and chocolate contain significant amounts of tyramine.

DIF: Cognitive level: Applying TOP: Nursing process: Evaluation

REF: p. 169, Box 15-8 MSC: NCLEX: Physiologic Integrity

Chapter 16: Antimanic Drugs MULTIPLE CHOICE 1. Maintenance of a therapeutic serum level of lithium is dependent on adequate serum levels of: a. sodium. b. chloride. c. potassium. d. magnesium.

ANS: A

It is believed that lithium substitutes for the sodium (Na) ion in neurons. Reductions or increases in Na intake affect the serum lithium level. The other options have not been identified as critical to lithium level.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 174 MSC: NCLEX: Physiologic Integrity

2. Select the accurate information about the pharmacokinetics of lithium. a. Wide therapeutic index b. Excreted by the kidneys c. Poorly absorbed in the gastrointestinal (GI) tract d. Provides immediate relief of symptoms ANS: B

Lithium is excreted via the kidneys. The other options are incorrect. The nursing implication is that individuals with renal N damRageIshoGuldBn. otCbe M given lithium or should be monitored U S N T closely if lithium must be administered.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 174-175 MSC: NCLEX: Physiologic Integrity

3. For 2 weeks a patient has taken lithium (Lithane) and risperidone (Risperdal) daily for mania.

The patient now reports diarrhea, vomiting, and blurred vision. The nurse observes a coarse hand tremor. Select the nurse’s priority action. a. Administer a PRN dose of benztropine (Cogentin) to relieve extrapyramidal symptoms (EPSEs). b. Hold the next dose of risperidone to prevent further drug–drug interaction. c. Reassure the patient that these side effects will decrease with time. d. Notify the prescribing physician immediately.

ANS: D

The symptoms the patient is experiencing are consistent with a serum lithium level above the therapeutic level. The nurse should withhold the next dose, arrange for a stat serum lithium level determination, and notify the health care provider. Risperidone can be continued because this is not a drug–drug interaction problem. Administration of benztropine is inappropriate because these are not EPSE symptoms. Reassurance would be appropriate, but the patient should not be told that these symptoms will decrease with time and continued dosing.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 178 MSC: NCLEX: Physiologic Integrity

4. A patient has taken lithium (Lithobid) 300 mg three times daily for 1 week. The patient

reports the presence of fine hand tremors and thirst. Select the nurse’s best action. a. Increase sodium in the patient’s diet. b. Immediately obtain a serum lithium level determination. c. Comfort the patient that these effects will probably decrease over time. d. Withhold the lithium until the patient no longer exhibits these side effects.

ANS: C

These side effects are common and often decrease or disappear over time with continued lithium therapy. Dietary sodium should remain unchanged to keep the lithium level stable.

These side effects do not suggest the need for determination of a lithium level. Lithium should not be withheld, because these are not toxic symptoms.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 175-176 MSC: NCLEX: Physiologic Integrity

5. A patient who has taken lithium for 6 months reports, “I go to the bathroom many times a day

and pass large amounts of very pale urine.” The nurse’s action should be based on the understanding that these symptoms may indicate which problem? a. Atactic toxicity b. Uremic syndrome c. Diabetes insipidus d. Interstitial nephritis ANS: C

Symptoms of diabetes insipidus include voiding large amounts of dilute urine many times a day. Nephrogenic diabetes inN sipiR Udus SIisNcGause TBd.bCy thMe inhibition of the cyclic adenosine monophosphate (cAMP)–dependent action of the antidiuretic hormone on the distal-tubule collecting duct cells. This problem is sometimes associated with lithium therapy. The symptoms detailed are not consistent with any of the other options.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 175-176

TOP: Nursing process: Evaluation

6. Which patient should be assessed most carefully for evidence of lithium toxicity? A patient

taking lithium (Lithobid) and: a. indomethacin (Indocin). b. risperidone (Risperdal). c. ziprasidone (Geodon). d. olanzapine (Zyprexa).

ANS: A

The combination of lithium and indomethacin is more likely to produce lithium toxicity than lithium and any other drug listed. Nonsteroidal antiinflammatory drugs reduce renal elimination of lithium, thereby increasing serum lithium levels.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 177-178 MSC: NCLEX: Physiologic Integrity

7. A patient with rapid-cycling bipolar disorder is not responding to lithium therapy. At the next

multidisciplinary team meeting, the nurse should point out that many rapid-cycling patients have been effectively treated using: a. sertraline (Zoloft). b. phenytoin (Dilantin). c. benztropine (Cogentin). d. divalproex (Depakote).

ANS: D

Valproates (like divalproex) are considered first-line agents in the treatment of mania.

Valproates are especially effective in the treatment of rapid-cycling bipolar disorders. None of the other drugs mentioned are indicated for treatment of manic states.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 177-178 MSC: NCLEX: Physiologic Integrity

8. A patient diagnosed with mania begins lithium therapy on October 1. What is the earliest date

a nurse can expect to see clinical improvement in the patient’s condition? a. October 3 b. October 8 c. October 21 d. November 1 ANS: B

Lithium must be given for 7 to 10 days before clinical improvement is achieved.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic InN tegriR ty I

REF: p. 174

U S NGTB.COM

TOP: Nursing process: Evaluation

9. A patient diagnosed with bipolar disorder asks the nurse, “Why can’t I take my lithium just

once a day at bedtime? It’s hard to remember to take it three times.” The nurse’s reply should be based on what information? a. The half-life of lithium is short. b. Renal excretion is greater at night. c. GI absorption is diminished at night. d. The toxicity potential increases with once-a-day dosing.

ANS: A

Lithium has a short half-life, high toxicity, and rapid renal excretion, so multiple daily doses are required. The other statements are incorrect or are not factors considered in dosing.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 174 MSC: NCLEX: Physiologic Integrity

10. A patient has taken lithium (Lithane) 600 mg three times daily for 1 week. A laboratory result

in which range shows that the desired serum lithium level was achieved? a. 0.2 to 0.6 mEq/L b. 0.6 to 1.2 mEq/L c. 1.2 to 2 mEq/L d. 2 to 2.6 mEq/L ANS: B

Therapeutic serum lithium levels are 0.6 to 1.2 mEq/L. The other options are either too low or too high. Serum levels above 1.5 mEq/L can cause symptoms of toxicity.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: pp. 175, 177

TOP: Nursing process: Evaluation

11. The nurse scheduling the serum lithium level blood draw for a patient should arrange for it to

be obtained: a. before the first morning dose. b. 2 hours after the morning dose. c. at bedtime. d. any time during the day.

ANS: A

Lithium levels should be drawn 8 to 12 hours after the last dose, making premedication morning blood draws optimal.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 177 MSC: NCLEX: Physiologic Integrity

12. A patient’s serum lithium level is 1.8 mEq/L. Select the nurse’s priority action. a. Restrict fluid intake. b. Assess for signs of toxicity. c. Encourage intake of high-potassium foods. d. Ensure that the patient is swallowing the capsules.

ANS: B

A serum level of 1.8 mEq/L iN s hiR gheI r thaGn dB es. irC ableM. It suggests that the patient might be U S N T experiencing toxic effects. Clinical assessment should be conducted. A nurse should not rely entirely on laboratory tests but should make careful clinical assessments. None of the other options would be appropriate.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 177 MSC: NCLEX: Physiologic Integrity

13. A patient has mild lithium toxicity with a serum level of 1.6 mEq/L. Which assessment

findings are most likely? a. Coarse hand tremor, coordination problems, and dizziness b. Elevated white blood cell count, temperature, and blood pressure c. Orthostatic hypotension, fainting, and nystagmus d. Restlessness, shuffling gait, and tics ANS: A

The symptoms of mild toxicity are often related to central nervous system disturbance.

Difficulty concentrating might also be noted. Mild GI disturbances are also seen. The other options are not symptoms of early lithium toxicity.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: 173; Table 16-1 MSC: NCLEX: Physiologic Integrity

14. Before beginning lithium therapy, the nurse should educate a patient about laboratory tests to

assess for adequate function of which system?

a. b. c. d.

Peripheral vascular Reproductive Respiratory Renal

ANS: D

Because lithium is excreted via the kidneys, renal system function must be adequate if lithium toxicity is to be prevented. Functioning of the other systems has no direct relationship to lithium therapy.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 174 MSC: NCLEX: Physiologic Integrity

15. A patient who is to be discharged on a maintenance dose of lithium should be taught to report

which symptoms/signs immediately? a. Large amounts of dilute urine and blurred vision b. Nasal congestion and dry mouth c. Muscle stiffness and anorexia d. Drowsiness and sweating ANS: A

Patients must be taught the difference between symptoms of minor toxicity and those of major toxicity, such as giddiness, tinnitus, blurred vision, dilute urine, and ataxia.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: 173; Table 16-1 MSC: NCLEX: Physiologic Integrity

16. Teaching for a patient who isNto b ed.oC n aM maintenance dose of lithium should Re dIischGargB

emphasize the importance of: U S N T a. keeping appointments for serum lithium level testing. b. engaging in daily cardiotonic exercise. c. reporting anticholinergic side effects. d. maintaining a tyramine-free diet.

ANS: A

Regular evaluation of serum lithium levels will be part of the patient’s aftercare for as long as he or she takes lithium. The other items are not included in discharge teaching for a patient taking lithium.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 177-178 MSC: NCLEX: Physiologic Integrity

17. The spouse of a patient diagnosed with bipolar disorder tells the nurse, “Every time my

partner recovers from a manic episode, depression follows soon. It’s very discouraging.” The nurse’s reply should include what information? a. As the partner ages, rapid cycling will decrease. b. Combining lithium with haloperidol (Haldol) might prevent rapid cycling. c. Depression associated with bipolar disorder is usually time-limited, so treatment is not indicated. d. Recent addition of olanzapine (Zyprexa) to this patient’s drug regime can be helpful as a mood stabilizer.

ANS: D

Olanzapine, an atypical antipsychotic, has proven effective in controlling mania and acting as a mood stabilizer to reduce depression following treatment for acute mania. The other statements are incorrect or irrelevant.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 179-180 MSC: NCLEX: Physiologic Integrity

18. For patients with bipolar disorder, valproate anticonvulsants are likely to help control

rapid-cycling episodes by: a. inhibition of kindling activity in the brain. b. decreasing availability of norepinephrine. c. increasing dopamine levels at synapses. d. decreasing GABA metabolism.

ANS: A

The effectiveness of valproate anticonvulsants for management of bipolar disorder may be related to inhibition of kindling activity, which stabilizes neuronal activity and increases the threshold of stimulation necessary for cell firing. There is no current research to support any of the other options.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 178

TOP: Nursing process: Planning

19. A patient with a long history of multiple sclerosis developed psychosis with acute mania. The

nurse should anticipate that the health care provider will probably prescribe which medication to help stabilize the mania? a. Lithium (Lithobid) b. Amitriptyline (Elavil) c. Divalproex (Depakote) d. Diphenhydramine (Benadryl) ANS: C

The valproates are first-line drugs for treatment of manic episodes associated with bipolar disorder or resulting from general medical problems. They have a rapid onset and are well tolerated. Lithium takes 7 to 10 days to modify symptoms. Diphenhydramine and amitriptyline have sedative side effects but would not stabilize the mania.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: pp. 178-179

TOP: Nursing process: Planning

20. Which patient would require careful assessment for toxic effects of lithium? The individual

taking lithium and: a. hydrochlorothiazide (HCTZ). b. lorazepam (Ativan). c. clozapine (Clozaril). d. oxazepam (Serax).

ANS: A

Hydrochlorothiazide is a diuretic used to treat hypertension. The diuretic effect would increase serum concentrations of lithium, potentially producing toxicity. Benzodiazepine and antipsychotic drugs are commonly used concurrently with lithium to control mania.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 174 MSC: NCLEX: Physiologic Integrity

21. A nurse should schedule a weekly complete blood cell count (CBC) for a patient beginning

therapy with which antimanic drug? a. Lithium b. Valproate (Depakote) c. Quetiapine (Seroquel) d. Carbamazepine (Tegretol) ANS: D

Agranulocytosis is known to be an occasional but potentially dangerous adverse effect of carbamazepine therapy, hence the need for regular CBCs. The other drugs have a lower risk of causing this effect.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 179

TOP: Nursing process: Planning

MULTIPLE RESPONSE 1. Which assessment findings validate that a patient with bipolar disorder is experiencing mania?

Select all that apply. a. Pacing b. Agitation c. Drowsiness d. Delusional thoughts e. Psychomotor retardation ANS: A, B, D

Agitation, increased motor activity (pacing), and delusional thoughts may all accompany mania. The patient with mania would have an increased level of alertness rather than drowsiness. Psychomotor retardation would be expected with depression.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: 174; Box 16-1 MSC: NCLEX: Psychosocial Integrity

2. A nurse prepares to lead a psychoeducational group for patients who take anticonvulsants to

manage bipolar disorder. The nurse should invite patients who take which drugs? Select all that apply. a. Lithium b. Aripiprazole (Abilify) c. Lamotrigine (Lamictal) d. Gabapentin (Neurontin) e. Carbamazepine (Tegretol) ANS: C, D, E

Lamotrigine, carbamazepine, and gabapentin are anticonvulsants. Lithium is effective in treatment of bipolar disorder, but it is not an anticonvulsant. Aripiprazole is an antipsychotic medication.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 179

TOP: Nursing process: Planning

Chapter 17: Antianxiety Drugs MULTIPLE CHOICE 1. Lorazepam (Ativan) reduces anxiety by: a. increasing serotonin levels. b. blocking dopamine receptors. c. depressing norepinephrine levels. d. potentiating gamma-aminobutyric acid (GABA).

ANS: D

Benzodiazepines enhance the effects of the inhibitory neurotransmitter GABA, slowing neuronal firing. They do not affect dopamine, serotonin, or norepinephrine.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 184

TOP: Nursing process: Planning

2. A patient started diazepam (Valium) 5 mg twice daily 6 months ago. Now, the patient requires

10 mg to achieve the same effect. This phenomenon results from: a. addiction. b. tolerance. c. dependence. d. disinhibition.

ANS: B

Tolerance is the need for increasing amounts of a substance to achieve the same effects. The other terms, defined in the teN xtU , dRoSnI otNaG ccT ouBn. t fC oO r tM his phenomenon.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: pp. 187

TOP: Nursing process: Evaluation

3. A patient diagnosed with agoraphobia took alprazolam (Xanax) 0.5 mg three times daily for 3

months and then discontinued it. The next day the patient called the nurse reporting insomnia, shakiness, and sweating. The nurse’s assessment questions should focus on whether the patient: a. may have also been drinking alcohol or taking antihistamines. b. has built up tolerance to alprazolam and needs an increased dose. c. is having withdrawal symptoms from abrupt discontinuation of the drug. d. has progressed to panic attacks and needs a non-benzodiazepine medication.

ANS: C

The patient’s symptoms suggest benzodiazepine withdrawal. The nurse knows that patients often attempt to manage their own care by discontinuing medication when they begin to feel better. Benzodiazepines should be slowly withdrawn if withdrawal symptoms are to be avoided. Drinking alcohol would result in different symptoms. Development of tolerance and panic attack symptoms would be different from those mentioned.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 187 MSC: NCLEX: Physiologic Integrity

4. An emergency room patient was very anxious after a serious car accident. Lorazepam

(Ativan) 2 mg intramuscularly was administered. One hour later, which finding indicates to the nurse that the medication was effective? a. Impaired problem-solving skills b. Increased alertness and attention c. Increased verbalization and activity d. Reduced agitation and environmental scanning ANS: D

Benzodiazepines mute incoming stimuli and evoke less reaction. The hyperalertness and environmental scanning that accompany high anxiety are notably decreased when the drug is effective. Impaired problem solving is a negative outcome. Because of its sedating properties, the individual might not be more alert, talkative, or active.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 185-186

TOP: Nursing process: Evaluation

5. A patient has taken diazepam (Valium) for 1 week for back spasms. The patient complains of

“feeling sleepy all the time.” The nurse should tell the patient: a. “The dosage probably needs to be decreased.” b. “Drowsiness indicates a paradoxical reaction to the drug.” c. “Tolerance to the sedative effect of the drug will develop quickly.” d. “Sleepiness is an unavoidable side effect of non-benzodiazepine drugs.”

ANS: C

Tolerance to most side effects of benzodiazepines, including drowsiness, develops quickly.

There is no need to decrease the dosage. Drowsiness is an expected reaction, not a paradoxical one. Valium is a benzodiazepNinUeR . SINGTB.COM DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 187 MSC: NCLEX: Psychosocial Integrity

6. A patient has taken clonazepam (Klonopin) for years to manage panic attacks but impulsively

stopped the drug. Thirty hours later, the patient comes to the emergency room in distress.

What is the nurse’s priority action? a. Begin seizure precautions. b. Refer the patient for addiction counseling. c. Institute a behavior modification program. d. Prepare to administer flumazenil (Romazicon).

ANS: A

There is evidence to suggest that abrupt withdrawal of clonazepam might precipitate status epilepticus. With this in mind, withdrawal from long-term use warrants seizure precautions.

The patient does not have an overdose, so flumazenil (Romazicon) is not indicated. The other options are inappropriate.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 188-189 MSC: NCLEX: Physiologic Integrity

7. Which patient has the greatest risk for overdose with a benzodiazepine? A patient who: a. takes the drug with antacids. b. takes the drug before meals.

c. combines the drug with alcohol. d. experiences depression as well as anxiety.

ANS: C

Benzodiazepines taken with alcohol produce marked central nervous system (CNS) depression, even death. Antacids prevent absorption. Larger doses of benzodiazepines by themselves are rarely lethal. Depression in and of itself is not an indicator of overdose risk.

Suicidal ideation might be present, but benzodiazepines by themselves are rarely lethal.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 188

TOP: Nursing process: Evaluation

8. The nurse would expect to administer flumazenil (Romazicon) for a patient: a. in acute alcohol withdrawal. b. with a benzodiazepine overdose. c. with benzodiazepine-resistant anxiety. d. with anxiety associated with a psychotic disorder.

ANS: B

Flumazenil is a benzodiazepine receptor antagonist. Response occurs within 30 to 60 seconds; however, it might not reverse associated respiratory depression. Because it has a short duration of action and does not speed metabolism of benzodiazepines, administration of flumazenil might need to be repeated several times. Flumazenil is not indicated for treatment of any of the other conditions.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 188

TOP: Nursing process: Planning

N R I G B.C M

S N T(Romazicon).

O 9. A patient received one dose of U flumazenil What is the nurse’s next action? a. Carefully observe for pre-flumazenil symptoms. b. Teach the patient about dietary restrictions. c. Prevent injury during seizure activity. d. Force 500 ml oral fluids over 2 hours.

ANS: A

Flumazenil, which is given to patients who have overdosed with benzodiazepines, is a benzodiazepine receptor antagonist. Response occurs within 30 to 60 seconds; however, it might not reverse associated respiratory depression. Because it has a short duration of action and does not speed metabolism of benzodiazepines, the nurse must be vigilant for signs that the patient is reverting to the pre-flumazenil state. Administration of flumazenil might need to be repeated several times.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 188 MSC: NCLEX: Physiologic Integrity

10. The nurse would expect a patient with which co-morbid diagnosis to have a magnified

response to the usual dose of a benzodiazepine drug? a. Rheumatoid arthritis b. Migraine headache c. Hepatic cirrhosis d. Osteoporosis

ANS: C

Benzodiazepines are metabolized in the liver. The cirrhotic liver will slow the metabolism rate of the drugs, leading to an exaggerated response. The distracters are not associated with decreased hepatic function.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 188

TOP: Nursing process: Evaluation

11. A patient in the emergency room has status epilepticus. The nurse should anticipate

administration of: a. diazepam (Valium). b. buspirone (BuSpar). c. clorazepate (Tranxene). d. chlordiazepoxide (Librium).

ANS: A

Valium is the drug of choice in status epilepticus because of its rapid action. Each of the other benzodiazepines has a slower onset of action. Buspirone is not indicated to treat seizures.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 188-189 MSC: NCLEX: Physiologic Integrity

12. The teaching plan for a patient beginning buspirone (BuSpar) should include information

identifying this drug as a: a. norepinephrine inhibitor. b. serotonergic antagonist. c. serotonin agonist. d. GABA inhibitor.

ANS: C

It is believed that buspirone is a serotonin agonist. Because buspirone is not a benzodiazepine, it does not bind to benzodiazepine receptor sites, affect GABA, or affect norepinephrine. This accounts for its different effects and lack of CNS depression as side effects.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 189 MSC: NCLEX: Physiologic Integrity

13. A patient seeking treatment for anxiety says, “I can’t think. My job depends on my ability to

think. I need medicine, but the drugs I took a few years ago made me too sleepy. I could lose my job.” What information is most important for the nurse to consider when formulating a response? a. All antianxiety medication has sedating properties. b. Buspirone (BuSpar) alleviates anxiety without sedation or cognitive clouding. c. The patient’s description of anxiety does not warrant treatment with medication. d. The patient may be trying to manipulate the nurse to assist with getting the desired prescription.

ANS: B

Buspirone’s action is entirely different from that of the benzodiazepines. It reduces anxiety, with its accompanying concentration and cognitive problems, but without CNS depression.

The patient’s description of anxiety indicates that it is interfering with daily life, so medication may be helpful. There is no evidence that the patient is trying to manipulate the nurse.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 189 MSC: NCLEX: Physiologic Integrity

14. A patient diagnosed with social phobia begins propranolol (Inderal). The nurse should teach

the patient to expect: a. that sympathetic nervous system symptoms of anxiety will be reduced. b. to experience a sense of euphoria for 30 minutes after taking the drug. c. to have amnesia for the social situations that are most intimidating. d. to feel a little drowsy but have no orthostatic hypotension.

ANS: A

Propranolol is a beta blocker that interrupts the physiologic responses of anxiety associated with social phobias, such as sweaty palms. Bradycardia may be associated with lightheadedness. The other options are not likely.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 191 MSC: NCLEX: Physiologic Integrity

15. A patient states, “I have the same thoughts over and over. I feel compelled to count all my

footsteps.” The nurse can expect the health care provider to prescribe: a. alprazolam (Xanax). b. propranolol (Inderal). c. clonazepam (Klonopin). d. clomipramine (Anafranil).

ANS: D

Clomipramine is an antidepressant that has proven effective for obsessive-compulsive disorder (OCD). The other drugs have no proven effectiveness in treating OCD. DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 190

TOP: Nursing process: Planning

16. A patient took a benzodiazepine for 4 weeks but will now change to buspirone (BuSpar) for

long-term treatment of anxiety. The benzodiazepine is tapered off as the buspirone is begun.

Important information the patient should receive about buspirone is that it: a. produces profound sedation. b. will be effective in 7 to 10 days. c. has a high risk for development of dependence. d. is often associated with cross-tolerance with other CNS depressants.

ANS: B

Buspirone provides anxiety relief within 7 to 10 days from the time it is begun. For this reason, benzodiazepines are continued for their anxiolytic effect and gradually tapered as the buspirone becomes effective. The other options are incorrect.

DIF: Cognitive level: Applying

REF: p. 189

TOP: Nursing process: Implementation

MSC: NCLEX: Physiologic Integrity

17. A patient had five emergency room visits in the past month and reports, “I feel so nervous. I

think I’m having heart attacks.” The patient is diagnosed with panic attacks. Which comment by the nurse shows understanding of treatment for panic attacks? a. “SSRI antidepressants are often helpful for long-term treatment and prevention of panic attacks.” b. “Benzodiazepine tranquilizers are therapeutic for long-term treatment and prevention of panic attacks.” c. “No medications are particularly helpful for panic attacks. Let’s work on some strategies to help you manage your fears.” d. “Panic attacks result from an instability of the neurotransmitter acetylcholine.

Meditation will be more helpful than drugs.”

ANS: A

Selective serotonin reuptake inhibitors (SSRIs) are approved for panic disorder and might be the most effective and safest agents for prophylaxis and long-term treatment. Benzodiazepines are effective during a panic attack but should not be used for long-term treatment because of the abuse and dependence potentials. It’s important that the nurse show compassion for the patient’s distress. Meditation may help overall, but not during panic attacks.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 189-190 MSC: NCLEX: Psychosocial Integrity

18. The half-life of a benzodiazepine drug is 20 hours for a young adult, but for an older adult it is

likely to be: a. 10 hours. b. 30 hours. c. 40 hours. d. 80 hours.

ANS: D

Because of decreased liver size and function in older adults, the half-life of benzodiazepines is markedly lengthened. Benzodiazepines with long half-lives are unsuitable for older adults.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 186

TOP: Nursing process: Evaluation

19. A health care provider prescribes lorazepam (Ativan) for an anxious older adult. What is the

nurse’s best action? a. Assess for a history of drug abuse. b. Administer the drug as prescribed. c. Confer with the health care provider. d. Assess the patient’s pupillary reaction to light.

ANS: B

Lorazepam is a benzodiazepine that has a short half-life. It might be administered safely to older adult patients, although the dose should often be modified downward. It is inadvisable to give benzodiazepines with longer half-lives to older adult patients.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 186, 188 MSC: NCLEX: Physiologic Integrity

20. A patient who has been taking a benzodiazepine for panic attacks is to be started on buspirone

(BuSpar). Which instruction should the nurse provide? a. “Take decreasing doses of the benzodiazepine for several days until the buspirone becomes effective.” b. “Stop taking the benzodiazepines immediately. Wait 2 days, and then start the buspirone.” c. “You should take buspirone only once a day. More frequent dosing can cause dependency.” d. “Tolerance to buspirone may develop in about a month, requiring larger doses to be prescribed.”

ANS: A

Two factors suggest that the patient should take tapering doses of benzodiazepine while beginning buspirone therapy. Benzodiazepines should be tapered gradually for discontinuation to avoid withdrawal. Buspirone takes 7 to 10 days to begin to exert its therapeutic effect. The other statements about buspirone are incorrect.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 189 MSC: NCLEX: Physiologic Integrity

21. Singer Michael Jackson allegedly abused alprazolam (Xanax) and propofol (Diprivan), an

anesthetic. Which inference applies? a. The singer had a substance dependence problem, but these medications had no interaction. b. Potentially lethal sedation and CNS depression would be expected with this drug combination. c. Tolerance to propofol probably developed very quickly in the presence of alprazolam. d. This drug combination was safe, but the singer needed closer medical supervision.

ANS: B

Propofol, an anesthetic, would have a predictable additive effect with alprazolam in producing significant sedation and CNS depression. The singer probably needed closer medical supervision, but one cannot state that the combination of drugs was safe. Tolerance to alprazolam would occur regardless of use of propofol.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 188

TOP: Nursing process: Evaluation

22. Which individual would be most likely to experience a paradoxical reaction to a

benzodiazepine drug? a. A child with attention deficit–hyperactivity disorder (ADHD) b. An adult with obsessive-compulsive disorder c. A teenager with an eating disorder d. An adult with major depression ANS: A

Paradoxical reactions to benzodiazepines are most likely in children, older adults, and persons with poor impulse control (such as ADHD) or organic brain syndromes.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: 186 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. The teaching plan for a patient beginning oxazepam (Serax) should include instructions to

(select all that apply): a. take the drug on an empty stomach. b. avoid discontinuing the drug abruptly. c. stop taking the drug if side effects occur. d. drink only moderate amounts of alcohol. e. avoid herbal preparations.

ANS: B, E

Patients must be informed that abrupt discontinuation of benzodiazepines produces withdrawal symptoms. Use of herbal preparations such as kava-kava and valerian can produce harmful additive effects. The other options contain information that is inappropriate to teach patients.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 188 MSC: NCLEX: Physiologic Integrity

2. A patient takes antacids, cimetidine (Tagamet), and phenytoin (Dilantin). The health care

provider prescribes a benzodiazepine for anxiety. Which drug interactions would the nurse anticipate? Select all that apply. a. Increased plasma level of benzodiazepine related to cimetidine therapy b. Increased absorption of th odiaG zepB in. eC if taM ken with the antacid NeUbRenz I S N T c. Euphoria and disinhibition associated with phenytoin therapy d. Serotonin syndrome associated with cimetidine use e. Potential phenytoin toxicity ANS: A, E

Cimetidine increases the plasma level of benzodiazepines. The benzodiazepine interferes with phenytoin metabolism, thus increasing serum levels of the anticonvulsants. The distracters do not reflect actual interactions.

DIF: Cognitive level: Applying TOP: Nursing process: Planning

REF: 187; Table 17-3 MSC: NCLEX: Physiologic Integrity

3. A patient in the emergency room is suspected to have an overdose of benzodiazepines. Which

assessment findings validate this diagnosis? Select all that apply. a. Blood pressure 180/94 mm Hg b. Diminished reflexes c. Hypervigilance d. Somnolence e. Confusion ANS: B, D, E

Benzodiazepine toxicity may result from an overdose. Assessment findings include hypotension, somnolence, confusion, and diminished reflexes.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 187-188 MSC: NCLEX: Physiologic Integrity

Chapter 18: Antidementia Drugs MULTIPLE CHOICE 1. The spouse of a patient with Alzheimer’s disease (AD) asks, “Can you give me a simple

explanation of what happened in my partner’s brain?” Select the nurse’s best response. a. “Dementia developed.” b. “The brain became overstimulated with chemical messages.” c. “Brain cells and chemical messengers that form memories are dying.” d. “The substantia nigra, a tissue that makes dopamine, has degenerated.”

ANS: C

The pathology that should be simply explained is that AD is characterized by neuronal degeneration of the brain and deficiencies of neurotransmitters. Degeneration of the substantia nigra is associated with Parkinson’s disease.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 193-194 MSC: NCLEX: Psychosocial Integrity

2. The family of a patient diagnosed with AD asks the nurse, “How can drugs help our parent?”

The reply that provides the most realistic expectations would be: a. “Unfortunately, drugs are not helpful.” b. “Drugs are available to stop the disease process.” c. “Drugs can help preserve mental abilities for a time.” d. “We will teach you ways of helping your parent adjust.”

ANS: C

Medication can elevate acetylcholine (ACh) levels and maintain cognitive abilities for a time.

The progress of the disease is not slowed or halted, however. Stating that no help is available is neither therapeutic nor true. Stating that the family will be taught how to help the patient adjust might not be realistic.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 196 MSC: NCLEX: Psychosocial Integrity

3. Most drugs used to treat AD affect: a. monoamine oxidase reuptake systems. b. serotonin and norepinephrine production. c. cholinergic pathways, enzymes, and receptors. d. the Krebs cycle and GABA neuronal inhibition.

ANS: C

The drugs most prescribed to treat AD are agents that restore ACh. The cholinergic pathways, enzymes, and enzyme inhibition are most related to drug action. The other systems are not relevant to AD. DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 193-194 MSC: NCLEX: Physiologic Integrity

4. Select the most realistic short-term goal for the care of a patient with mild AD who takes

donepezil (Aricept). The patient will:

a. b. c. d.

maintain present cognitive ability. show improved cognitive ability. engage in abstract thinking. communicate clearly.

ANS: A

Donepezil can be expected to inhibit cholinesterase (ChE), increasing the amount of intrasynaptic ACh. This drug does not cure AD, nor will it stop its eventual progression. For the present it should, however, preserve the patient’s level of cognitive function.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 196

TOP: Nursing process: Planning

5. A patient takes donepezil (Aricept) for AD. Vital signs for this patient are: temperature

98.2°F; blood pressure 135/82 mm Hg; pulse 54 beats/min; respirations 18 breaths/min.

Which variance should the nurse consider most likely attributable to donepezil therapy? a. Temperature b. Blood pressure c. Pulse rate d. Respiratory rate ANS: C

Donepezil selectively inhibits ACh; however, some peripheral effects, including bradycardia, are sometimes seen. The other parameters are within normal limits.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 196

TOP: Nursing process: Evaluation

N R I G B.C M

S N T withOa ChE inhibitor drug. The patient develops 6. A patient diagnosed with AD isUbeing treated facial flushing, sweating, and leg cramps. The nurse should attribute these symptoms to: a. irreversible acetylcholinesterase stimulation. b. inhibition of butyrylcholinesterase(BChE). c. neurodegeneration in the hippocampus. d. cytochrome P-450 system activation.

ANS: B

Gastrointestinal (GI) and other peripheral side effects of ChE inhibitor drugs are attributable to inhibition of BChE. The other options are not viable explanations.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 195

TOP: Nursing process: Evaluation

7. Of the drugs given to treat AD, which one has a potential to slow neurodegeneration? a. Galantamine (Razadyne) b. Memantine (Namenda) c. Rivastigmine (Exelon) d. Donepezil (Aricept) ANS: B

Memantine acts as an N-methyl-D-aspartate (NMDA) antagonist, preventing glutamine from overstimulating neurons causing neuronal death. This interference would hypothetically slow the advance of AD. The other drugs act as ChE inhibitors. This process does not slow cellular death.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 196

TOP: Nursing process: Evaluation

8. Which statement by a family member of a patient diagnosed with AD demonstrates that

medication education was effective? “The medication my parent is receiving: a. affects glutamate receptors and will stabilize late-stage dementia.” b. inhibits the action of dopamine and will restore short-term memory.” c. offers no positive effects on performance of activities of daily living.” d. inhibits breakdown of an important neurotransmitter and may slow disease progression.”

ANS: D

ChE inhibitors act by increasing the brain’s supply of ACh, a neurotransmitter that is lacking in individuals with AD. They do not provide a cure but do often have a positive effect on cognitive function.

DIF: Cognitive level: Applying TOP: Nursing process: Evaluation

REF: pp. 193-194, 196 MSC: NCLEX: Physiologic Integrity

9. An adult says, “I take provastatin (Pravachol) for my high cholesterol. It will prevent stroke

and heart attack.” Select the nurse’s most informative response. a. “That’s correct. I’m glad to see you taking such good care of yourself.” b. “There is limited researchN-b f tO heMeffectiveness of statin UaRseSdIevNidGeTncBe.oC medications.” c. “Some research indicates that statin drugs may also interfere with development of AD.” d. “Perhaps you should discuss your family history with your doctor. Statin drugs may cause early development of AD.” ANS: C

Statin drugs may provide protection against AD, in addition to reducing the incidence of cardiovascular and cerebrovascular incidents. The distracters are incorrect statements.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 198 MSC: NCLEX: Physiologic Integrity

10. An adult says, “I take vitamins B and E to prevent AD, but these vitamins are so expensive.”

Select the nurse’s most informative response. a. “Yes, these vitamins are very expensive, but it is money well spent to prevent AD.” b. “There is conflicting research evidence about effectiveness of these vitamins for prevention of AD.” c. “Most researchers now believe that preventing anemia is more important than taking vitamins to prevent AD.” d. “Aspirin is much cheaper. You should take it instead if you want to prevent AD.” ANS: B

Research findings about the effectiveness of vitamins B and E for the prevention of AD are inconclusive. The adult in this scenario may benefit more from using health care dollars on proven causes. The distracters are incorrect statements.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 198-199 MSC: NCLEX: Physiologic Integrity

11. A 63-year-old woman says, “I want to take estrogen to prevent AD, but my doctor won’t

prescribe it.” Select the nurse’s most informative response. a. “Perhaps you should seek a second opinion. Estrogen clearly provides protection against AD.” b. “Most researchers now believe that estrogen is not actually deficient after menopause. It simply works in different ways.” c. “Most online resources indicate that estrogen provides important protection against development of AD.” d. “There is conflicting evidence about whether estrogen prevents Alzheimer’s disease, but research clearly shows cardiovascular problems with estrogen therapy.”

ANS: D

Research findings about the effectiveness of estrogen for prevention of AD are inconclusive; however, estrogen therapy is clearly associated with increased risk of cardiovascular events.

The distracters are incorrect statements.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 198-199 MSC: NCLEX: Physiologic Integrity

12. A nursing assistant reports toNth haTt B a. paC tiO enM t diagnosed with AD is experiencing UeRnSurIseNtG

severe diarrhea. Administration of which classification of medication is most associated with this problem? a. ChE inhibitor b. Secretase inhibitor c. NDMA antagonist d. Nonsteroidal antiinflammatory drug ANS: A

ChE inhibitors used in treatment of AD increase the availability of ACh, which stimulates action of the parasympathetic nervous system. This stimulation is likely to produce diarrhea.

The other classifications work by different actions.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 195

TOP: Nursing process: Evaluation

MULTIPLE RESPONSE 1. A nurse explains galantamine (Razadyne) therapy to family members of a patient who is to

begin treatment with the drug. What information should be included? Select all that apply. a. Facial flushing and leg cramps might worsen. b. It acts by making more dopamine available. c. Report slow heartbeat immediately. d. Restrict fluid intake to 1500 ml/day.

e. Side effects include GI symptoms.

ANS: A, C, E

Anticipated side effects include nausea and vomiting, diarrhea, facial flushing, sweating, rhinitis, bradycardia, and leg cramps. The incorrect options include fluid restriction and stimulation of dopamine. Adequate intake is necessary to address GI symptoms. Galantamine stimulates action of ACh, not dopamine.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 195 MSC: NCLEX: Physiologic Integrity

2. An adult tells the nurse, “I’m taking large doses of vitamin B. I read that it prevents AD, but I

don’t understand how it works.” Which statements would be applicable as the nurse responds to the individual? Select all that apply. a. “Research has not proven the effectiveness of B vitamins in Alzheimer’s prevention.” b. “B vitamins lower the amino acid homocysteine, which is associated with a lower incidence of AD.” c. “A favorable response occurs when these vitamins block NMDA.” d. “B vitamins may reduce risk of AD by lowering cholesterol levels.” e. “B vitamins reduce the body’s inflammatory response.”

ANS: A, B

The keyed statements provide correct information regarding the inconclusiveness of B vitamin therapy in prevention of AD and its effects on lowering Homocysteine levels. The distracters provide misleading or incorrect information.

DIF: Cognitive level: ApplyinN g R I GREB F:.C p. 19M8 U S N T TOP: Nursing process: Implementation MSC: NCLEX: Physiologic Integrity 3. Which receptors carry out primary functions of the parasympathetic nervous system? Select

all that apply. a. NMDA b. COX-1 c. COX-2 d. Nicotinic e. Muscarinic ANS: D, E

Nicotinic and muscarinic receptors are involved in the action of ACh, the primary neurotransmitter for the parasympathetic nervous system. The other options are not involved.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 194 MSC: NCLEX: Physiologic Integrity

Chapter 19: Over-the-Counter Drugs MULTIPLE CHOICE 1. Alternative therapy refers to: a. any natural therapy without a research basis. b. evidence-based pharmacologic use of plant products. c. therapies used in conjunction with Western medicine. d. therapies not generally accepted by Western medicine.

ANS: D

Alternative therapies are therapies that are not generally accepted by mainstream Western medicine—for example, herbaceuticals. Some alternative therapies have been researched.

Focusing on herbs is too narrow. Therapies used in conjunction with Western medicine are called complementary therapies.

DIF: Cognitive level: Understanding REF: p. 201 MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing process: Planning

2. Which intervention is an example of a complementary and alternative medicine therapy? a. Acupuncture b. Bright-light therapy c. Electroconvulsive therapy d. Repetitive transcranial magnetic stimulation ANS: A

Acupuncture is considered a N comRpleI menGtaryBa.nC d alM ternative therapy. The other therapies are U S N T accepted by Western medicine.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 200-201 MSC: NCLEX: Health Promotion and Maintenance

3. For which patient co-morbid diagnosis would it be most important for the nurse to urge the

patient to immediately discontinue using kava-kava? a. Cirrhosis b. Osteoarthritis c. Multiple sclerosis d. Chronic back pain ANS: A

Kava-kava should be used with caution in patients with liver disease because of its potentially hepatotoxic effects. The other health problems do not pose immediate dangers.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 203-204 MSC: NCLEX: Physiologic Integrity

4. Select the example of complementary therapy. a. St. John’s wort used with valerian b. Acupuncture used with disulfiram (Antabuse) c. Fluoxetine (Prozac) used with lorazepam (Ativan) d. Propranolol (Inderal) used with systematic desensitization

ANS: B

Complementary therapy is an alternative therapy used in conjunction with conventional Western medicine. Acupuncture is an alternative therapy, and disulfiram is a Western medical therapy for alcohol abuse. None of the other options demonstrate components of both alternative and Western medicine.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 200-201 MSC: NCLEX: Health Promotion and Maintenance

5. A patient reports taking melatonin daily. Which aspect of the patient’s health and function

would be most important for the nurse to assess? a. Urinary and bowel elimination b. Energy and activity tolerance c. Sleep hygiene and patterns d. Memory and cognition ANS: C

Melatonin is used to reduce sleep-onset latency and decrease the number of nocturnal awakenings. The nurse should assess the patient’s sleep patterns and hygiene. It does not directly relate to the aspects of function identified in the distracters.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 205 MSC: NCLEX: Physiologic Integrity

6. A nurse assesses four new patients. Which statement causes the nurse to suspect the patient

may be self-medicating with an alternative therapy? a. “I frequently have skin rashes that itch.”

NUyRpS INem G Tfor B.C b. “Constipation is an everyda robl me.O ”M c. “My computed tomography scan shows that I have uterine fibroid tumors.” d. “I’ve been very depressed and anxious since I lost my job.”

ANS: D

Herbals are among the most frequently used alternative therapies for depression. Four of the 12 most common herbs are used to treat or prevent psychiatric symptoms. None of the other options reflects such a common problem that is treated with an alternative therapy.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 202

TOP: Nursing process: Evaluation

7. Select the desired outcome for a patient who uses valerian. The patient will report: a. a lower stress level. b. undisturbed sleep throughout the night. c. an increased interest in recreational activities. d. awakening without an alarm clock in the morning.

ANS: B

Valerian decreases sleep latency and nocturnal awakening, and it leads to a subjective sense of good sleep. Sleeping through the night is the best indicator that the herb was effective. The herb is not associated with the conditions identified by the other options.

DIF: Cognitive level: Applying

REF: p. 204

TOP: Nursing process: Evaluation

MSC: NCLEX: Physiologic Integrity 8. An anxious patient diagnosed with diabetes says, “I’m considering taking angelica to help me

relax.” Select the best outcome for the plan of care. The patient will: a. report subjective feelings of improved sleep. b. identify other options to manage anxiety. c. monitor fingerstick blood glucose daily. d. rate anxiety as 5 or less on a scale of 10.

ANS: B

Angelica is contraindicated in diabetes. The patient should identify other strategies to manage anxiety. The other options imply that this herb is safe to use in this situation.

DIF: Cognitive level: Analyzing REF: 202; Table 19-2 TOP: Nursing process: Outcome Identification/Planning MSC: NCLEX: Physiologic Integrity 9. A patient who takes phenytoin (Dilantin) regularly has begun taking valerian. Patient teaching

should focus on which possible consequence of the patient’s action? a. Breakthrough seizures b. Spontaneous bleeding c. Impaired dentition d. Gum disease ANS: A

Valerian is thought to negate the effects of several drugs, including phenytoin, making an increase in seizures probable. The other outcomes are not associated with valerian use, though they are associated with phenNytoR in. I G B.C M

U S N T

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

O

REF: p. 204 MSC: NCLEX: Physiologic Integrity

10. A patient takes valerian. Which instruction should the nurse provide? a. Store the herb in a cool place. b. Store the herb in a dry, dark place. c. This herb loses potency after 30 days. d. Avoid crushing the herb before taking it.

ANS: B

Valerian must be protected from light and moisture. The other instructions are not true statements regarding this herb.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 204 MSC: NCLEX: Physiologic Integrity

11. A patient with which disorder would most likely benefit from taking St. John’s wort? a. Suicidal depression b. Hypomanic symptoms c. Mild depressive symptoms d. Panic disorder with agoraphobia ANS: C

Research has found St. John’s wort to be effective in treating mild to moderate depression. St. John’s wort has not been found to be effective in treatment of severe depression, bipolar disorder, or anxiety disorders.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 203

TOP: Nursing process: Planning

12. During an admission interview, a patient who reports high levels of anxiety says, “I’ve been

using kava-kava for about a week to relieve anxiety.” When the nurse assesses mental status, expected findings would be: a. reduced coordination and slurred speech. b. intact cognitive functioning. c. slow response times. d. paranoid thinking.

ANS: B

Kava-kava relieves anxiety without producing cognitive impairment, reducing mental acuity, or affecting coordination. Kava-kava is known to have an affinity for benzodiazepine receptors. It does not usually produce any of the effects cited in the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 203-204 MSC: NCLEX: Psychosocial Integrity

13. A patient tells the nurse, “I’ve been having problems with my memory. I read some

information on the Internet and started taking gingko.” Select the nurse’s best response. a. “The Internet does not have reliable health information.” b. “More recent studies indicate that gingko does not help memory problems.” c. “SAM-e has been shownN toUhR avSeIbN etG teT r eBff.ecCtsOfM or treating memory problems.” d. “Your memory problems are related to your mental illness. Herbs will not help.”

ANS: B

Recent studies indicate that gingko does not help with cognition or memory problems. SAM-e is useful for treating mild depression. The other distracters are misleading.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 204 MSC: NCLEX: Health Promotion and Maintenance

14. A patient diagnosed with a history of depression disorder tells the nurse, “My primary-care

provider told me to start taking fish oil capsules to prevent heart disease. Will it cause problems with my mental illness?” Select the nurse’s best response. a. “It will not cause problems. It may actually help with your depressed feelings.” b. “I cannot discuss recommendations you received from another health care provider.” c. “It would be better for you to take vitamins C and E. I will notify your primary-care provider.” d. “Please have your primary-care provider call me so we can discuss issues related to this preparation.”

ANS: A

Fish oil capsules supplement omega-3 and omega-6 fatty acids. These substances not only provide cardiovascular benefits; studies have demonstrated positive results in ameliorating depression after 2 or more weeks of omega-3. The other options fail to support the patient with appropriate information.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 205-206 MSC: NCLEX: Physiologic Integrity

15. A patient asks, “I want to consult an herbalist. What should I do to make sure I don’t get some

impostor?” The nurse should advise the patient to first ask the provider: a. “How much will treatments cost?” b. “Have you treated this condition before?” c. “Do the treatments pose any dangers to me?” d. “What group has certified you in this practice?”

ANS: D

The priority question is whether the individual is credentialed to practice via license or certification. Either credential suggests, but does not guarantee, some degree of knowledge and competence. The other questions are reasonable to ask but are not as fundamental.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 208 MSC: NCLEX: Safe, Effective Care Environment

16. A neighbor asks a nurse, “Are there any resources that would help me get reliable information

about alternative and complementary therapies?” Which resource should the nurse recommend? a. National Center for Complementary and Alternative Medicine b. American Psychiatric AsN soU ciR atS ioI n NGTB.COM c. American Medical Association d. Centers for Disease Control and Prevention ANS: A

The National Center for Complementary and Alternative Medicine, a part of the National Institutes of Health, has responsibility for providing information to the public regarding the safety and efficacy of alternative therapies and for funding research for these therapies. The other options would be inappropriate to recommend.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 208 MSC: NCLEX: Safe, Effective Care Environment

17. A patient diagnosed with depression tells the nurse, “I’ve been supplementing my paroxetine

(Paxil) with St. John’s wort, and it has helped a great deal.” What is the nurse’s priority action? a. Assess changes in the patient’s level of depression. b. Remind the patient to use a secondary form of birth control. c. Educate the patient about the risks of serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.

ANS: C

Research has suggested that St. John’s wort inhibits serotonin reuptake by elevating extracellular sodium; thus it may interact with medication, particularly selective serotonin reuptake inhibitors, to produce serotonin syndrome. Discussing the patient’s birth control method is a secondary priority.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 203 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. Which important points should the nurse teach a patient about using herbal preparations?

Select all that apply. a. Check active and inactive ingredients. b. Discontinue use if side effects or adverse effects occur. c. Buying from online sources is preferable and cheaper. d. Avoid herbals during pregnancy and breast-feeding. e. Inform your health care provider about the use of herbals.

ANS: A, B, D, E

All of the instructions are correct except the one regarding purchase of herbals. Internet purchasing of herbals might not be the best plan unless the reputation of the firm can be confirmed.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: 207; Box 19-2 MSC: NCLEX: Physiologic Integrity

2. A patient reports frequent sleN ep dRistuIrbaG nceB s. .

WChich preparations could be considered to help

U SSelect N Tall thatOapply. improve the patient’s sleep pattern? a. Yohimbine b. Vitamin C c. Melatonin d. Valerian e. SAM-e ANS: C, D

Melatonin and valerian have relaxant effects that help sleep. Yohimbine can actually cause insomnia. SAM-e may help with mild depression. Vitamin C has no effect on sleep.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 204-205 MSC: NCLEX: Physiologic Integrity

Chapter 20: Introduction to Milieu Management MULTIPLE CHOICE 1. During orientation the clinical nurse leader tells a novice nurse, “You will be involved in

purposeful creation of corrective learning experiences for all patients so as to provide a healing atmosphere.” The clinical nurse leader is explaining aspects of: a. balance. b. limit-setting. c. a therapeutic environment. d. establishing behavioral norms.

ANS: C

A therapeutic environment requires creation of corrective learning experiences to promote a therapeutic atmosphere. Limit-setting, balance, and norms are individual elements of the therapeutic environment and are answers that are too narrow.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 212-213 MSC: NCLEX: Safe, Effective Care Environment

2. Four nurses describe their unit environments. Which description can most clearly be identified

as therapeutic? a. “My unit uses behavior modification to enhance patients’ social skills.” b. “My unit allows patients to test new behaviors in a secure environment.” c. “My unit helps patients deal with childhood issues by providing a safe setting.” d. “My unit allows patients to deal with personal issues without interpersonal NURSI NG TB.C OM stressors.”

ANS: B

The unit described in the correct answer provides a broad therapeutic focus for providing corrective experiences that helps patients recover. The distracters are too narrow in their therapeutic scope.

DIF: Cognitive level: Applying REF: p. 214 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

3. Which nursing action best supports maintenance of a therapeutic environment? a. Creating therapeutic relationships with patients b. Providing purposeful structured activities c. Maintaining patient records and care plans d. Administering medication ANS: A

A therapeutic environment requires nurses to be active and willing to engage in therapeutic relationships with patients. These relationships support patients’ development of coping and problem-solving skills. Maintaining records, administering medications, and providing activities are important in the therapeutic environment, but to a lesser extent than meaningful nurse–patient interactions.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 214 MSC: NCLEX: Psychosocial Integrity

4. While nurses are engaged in shift change report, one patient becomes loud and aggressive.

This patient verbally harasses and frightens another patient. Which element of the therapeutic environment has been jeopardized? a. Norms b. Safety c. Balance d. Structure ANS: B

Psychologic safety is violated when one patient is allowed to harass another. Staff must set limits to protect the vulnerable patient. Norms, balance, and structure refer to other elements of the environment.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 215

TOP: Nursing process: Evaluation

5. Which nursing action best supports the maintenance of psychologic safety for a patient with

mental illness? a. Helping a depressed patient to inventory personal flaws b. Assisting a patient to change clothes after an episode of incontinence c. Allowing an anxious patient to pace in isolation and without interruptions d. Requiring a restrained patient to remain silent until restraints are removed ANS: B

Assisting a patient to change clothes after an episode of incontinence saves embarrassment for the patient, which contributes to a positive self-concept. Requiring a restrained patient to remain silent implies punishm t ratI her G thanBu.sC e ofMan external control until they are able to Nen R U S N T O regain control. The other options are not therapeutic and do not promote psychologic safety.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 214-216 MSC: NCLEX: Psychosocial Integrity

6. Which element of therapeutic environmental management has the highest priority? a. Clearly establishing norms and designating limits b. Scheduling purposeful activities throughout the day c. Creating an environment of psychologic and physical safety d. Promoting a balance between patient dependence and independence ANS: C

Safety is the most basic milieu element and therefore is of highest priority. Norms often contribute to safety. Activities and balance are other important milieu elements but are of lower priority.

DIF: Cognitive level: Applying REF: pp. 214-215 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

7. In which instance would it be most important for the nurse to set limits? a. An involuntarily hospitalized patient insists on being discharged. b. Two patients are found kissing in an obscure area of the unit. c. A patient with suicidal ideation asks to leave the unit. d. A depressed patient seeks daily telephone privileges.

ANS: B

Limits should be set on acting-out behavior, self-destructive acts, physical aggressiveness, sexual behavior, lack of compliance, use of illicit substances, and elopement. The correct answer is an example of sexual behavior. The distracters depict instances in which a therapeutic response is indicated from the nurse but not necessarily limit-setting.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 214-215 MSC: NCLEX: Safe, Effective Care Environment

8. A newly admitted patient is withdrawn and does not seek out interaction with staff or patients.

Nursing interventions should focus on which element of the treatment environment? a. Norms b. Safety c. Structure d. Limit-setting ANS: C

Structure refers to the physical environment, regulations, and daily schedule of classes and groups provided. The unit activities will provide an opportunity for the nurse to interface with the patient to develop a trusting relationship. The other treatment environment elements are important but are of lower priority for this patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 215-216 MSC: NCLEX: Psychosocial Integrity

9. Which statement about balance provides a basis for a nurse’s management of the therapeutic

environment? a. Independence is best gained in increments. b. Independence is a fundamental right of all patients. c. Independence jeopardizes safety in an inpatient setting. d. Dependence is a characteristic of most persons with mental illness.

ANS: A

Balance is the process of gradually allowing independent behaviors in a dependent situation.

Independence must be gained in increments to avoid overwhelming the patient. The distracters are false, since they do not describe the basis of balance.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 216-217

TOP: Nursing process: Planning

10. A patient demonstrating manic behaviors gathered other patients in the dayroom and gave a

sales talk, pressuring others to purchase shares of stock in a gold mine. Which element of a therapeutic environment is jeopardized? a. Connection b. Exploration c. Structure d. Balance ANS: D

The patient is violating the rights of others by being allowed to give unsolicited discourses and exert pressure on others. Balance is lacking when patients are not protected from the symptom expression of other patients.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 216-217

TOP: Nursing process: Evaluation

11. During a community meeting, a patient reports about having only two patient-accessible

phones on the unit. Many other patients join in, all talking at the same time. The nurse requests that only one person talk at a time. The nurse’s request seeks to maintain: a. norms. b. safety. c. balance. d. structure.

ANS: A

Norms establish expectations that promote safety and trust in a therapeutic environment through sanctioning of socially appropriate behaviors. The other elements cannot be assessed as related to the scenario.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 216 MSC: NCLEX: Safe, Effective Care Environment

12. The framework of schedules, rules, and activities around which a therapeutic environment

revolves is termed: a. structure. b. balance. c. norms. d. safety.

ANS: A

Structure refers to the physical environment, regulations, and daily schedule of classes and groups provided in a treatment setting. Structure provides the base on which the other elements are built.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 216 MSC: NCLEX: Psychosocial Integrity

13. Complete the sentence. In a therapeutic environment, norms are: a. opportunities for self-expression that relieve stress. b. expectations for socially acceptable behavior. c. the behaviors most people display daily. d. shared experiences among patients.

ANS: B

Norms are defined as specific expectations of behavior that pervade a setting. They are intended to promote community living through socially acceptable behaviors. The other explanations are not as comprehensive as the correct answer.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 216

TOP: Nursing process: Planning

14. A patient has been bumping and pushing other patients. The nurse carefully explains to the

patient that such behavior is unacceptable. The nurse has provided: a. balance. b. limit-setting. c. personal control. d. environmental modification.

ANS: B

Limit-setting provides a patient with a clear explanation of the acceptability or unacceptability of a behavior. Limit-setting reinforces norms and encourages the milieu concept of responsibility for self. The other options are not applicable.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 217 MSC: NCLEX: Safe, Effective Care Environment

15. A nurse plans ways to promote patient safety and security. A proactive approach would

include: a. restricting psychotic patients’ rights. b. enforcing consequences of limit-setting. c. setting limits when a patient acts out aggressively. d. clearly communicating expectations for patients’ behavior.

ANS: D

Proactive is the key word in this question. Communicating clear rules for expected behavior from the beginning reinforces norms and structure, and encourages self-responsibility. The other options are reactive.

DIF: Cognitive level: ApplyinN g R I GREB p. 21M7 U S N TF:.C MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

16. The nurse leading a social skills group is engaged in managing which environmental element? a. Balance b. Structure c. Accountability d. Risk management ANS: B

By definition, the element of structure includes the schedule of planned therapeutic activities and groups. Balance refers to dependence–independence behaviors. Accountability and risk management are not identified elements of the therapeutic environment.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 215 MSC: NCLEX: Safe, Effective Care Environment

17. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards

mandate that: a. orientation programs detail safety issues and precautions. b. patients’ room doors remain open during hours of sleep. c. safety precautions are simple and apply commonsense behaviors. d. patients’ personal belongings are kept in secure areas under staff control.

ANS: A

JCAHO standards require agencies to provide an orientation program that addresses safety issues. The other options are not part of the standards of this accrediting agency.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: 123; Box 20-1 MSC: NCLEX: Safe, Effective Care Environment

18. Which adjective best characterizes custodial care? a. Paternalistic b. Beneficent c. Essential d. Safe ANS: A

Custodial care focuses on activities of daily living, hygiene, nutrition, elimination, and safety needs rather than supporting patients to develop skills for self-care. Staff members decide what is best for patients.

DIF: Cognitive level: Understanding REF: p. 213 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

19. A psychiatric facility is “accredited by JCAHO.” Which asset would be expected? a. A 4:1 patient-to-staff ratio b. Private rooms for all patients c. Use of a therapeutic milieu treatment model d. Telephones for private patient conversations ANS: D

JCAHO environment-of-careNstaR ndaI rds G stipuBla.teCthaMt telephones must be available to allow U S N patients to conduct private conversations. T The other options are not specified in JCAHO standards.

DIF: Cognitive level: Understanding TOP: Nursing process: Evaluation

REF: 213; Box 20-1 MSC: NCLEX: Safe, Effective Care Environment

MULTIPLE RESPONSE 1. Which aspects of the environment of a psychiatric unit comply with JCAHO environment-of

-carestandards? Select all that apply. a. Visitor badges b. Identification badges for employees c. Telephones located in enclosed booths d. Requiring patients to wear hospital-issue clothing e. Guidelines for staff interaction with media representatives ANS: A, B, C, E

JCAHO standards mandate clothing suitable for the clinical environment, but they do not require patients to wear hospital-issue clothing. The other answers comply with standards.

DIF: Cognitive level: Applying TOP: Nursing process: Evaluation

REF: 213; Box 20-1 MSC: NCLEX: Safe, Effective Care Environment

2. Which research findings about the therapeutic environment of an inpatient psychiatric unit

have implications for nursing practice? Select all that apply. a. Patients valued interactions with other patients. b. Patients perceived other patients as dissimilar from self. c. Hospitalization interferes with planning for the future. d. Patients failed to experience bonding with other patients. e. Hospitalization creates feelings of safety from self-destructiveness.

ANS: A, E

Findings from the work of Thomas and associates suggest that patients see the hospital as a refuge from self-destructiveness and are fearful of discharge from this safe environment.

Furthermore, patients confirmed their identity with other patients (bonding), valued socialization with other patients, and perceived peer-administered therapy as the most valuable aspect of hospitalization.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 214

TOP: Nursing process: Planning

3. Which statements indicate that a patient understands the unit norms? Select all that apply. a. “I need quiet time after art therapy today.” b. “I will not yell during the community meeting.” c. “I realize that I need help with my problems.” d. “I will show up on time to take my medication.” e. “I will talk to staff if I get angry instead of punching somebody.”

ANS: B, D, E

Norms are specific expectations of socially acceptable behavior intended to promote community living, such as beNhU avR inS gI wN itG hT ciB vi. litC yO duMring a community meeting, behaving in nonviolent ways, maintaining personal control, and accepting personal responsibility. The correct options are desirable behaviors related to norms rather than individual treatment goals.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 216

TOP: Nursing process: Evaluation

Chapter 21: Variables Affecting the Therapeutic Environment: Violence and Suicide MULTIPLE CHOICE 1. A student tells the school nurse, “My friend threatened to take an overdose of pills.” The

nurse talks to the friend who verbalized the suicidal threat. Select the most critical question for the nurse to ask. 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 patient’s access to a means to carry out the plan and, if there is access, alert the parents to remove the medications from the home. The information in the other questions is important to ask, but it is not the most critical.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

2. A tearful patient at the mental health center says, “I should be dead.” What is the most

important first task for the nurse in assessing this patient? a. Ascertain the lethality of the suicide plan. b. Establish a rapport with the patient. c. Determine the risk factors for suicide. d. Encourage expression of feelings. G B.C M ANS: B

NURSI N T

O

Establishing rapport 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.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

3. A patient being treated at the mental health center says, “I am having thoughts about suicide.”

Select the nurse’s most therapeutic response. a. “Thank you for telling me, but there’s nothing to worry about. We will handle it together.” b. “Telling me about these feelings is a very positive action on your part.” c. “It’s important for you to be hospitalized as soon as possible.” d. “Let’s talk about the things you have to live for.”

ANS: B

This response gives the patient reinforcement and validation for making a positive response rather than acting out a 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 patient’s ambivalence and sets the stage for more realistic problem solving.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

4. Select the most appropriate comment by the nurse when a depressed patient says, “What’s the

use in going on?” a. “Are you thinking about suicide?” b. “I am not sure I understand what you are saying.” c. “Keep your hope alive. It’s always darkest just before light.” d. “Tell me more about your activities before you got depressed.”

ANS: A

The possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation. The subject must be addressed directly.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

5. A nurse counsels a patient who made a suicide attempt 3 days ago. Select the nurse’s most

therapeutic comment. a. “I’m glad you voluntarily admitted yourself to the hospital. We can help you here.” b. “When you have bad feelings, try to remember the good things about your life.” c. “You must take control of your problems and try to find solutions.” d. “Let’s discuss some ways to solve your most important problem.”

ANS: D

The nurse helps the patient to develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by generating and testing ways to solve them. The distracters present overwhelming approaches to problem solving.

DIF: Cognitive level: Applying TOP: Nursing process: ImplemNentR ationI

REF: pp. 225-226

: C NCLMEX: Psychosocial Integrity U S NGMTSBC. O

6. When assessing a patient’s plan for suicide, what aspect has priority? a. Patient’s cultural heritage. b. Patient’s insight into suicidal motivation. c. Availability of means and lethality of method. d. Quality and access to an intact social support system.

ANS: C

If a person has definite plans that include choosing a method of suicide readily available to the person, 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 considered high. These areas provide a better indication of risk than the areas mentioned in the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

7. Which emotion experienced by a patient should be assessed by the nurse as most predictive of

an increased suicide risk? a. Anger b. Elation c. Sadness d. Hopelessness ANS: D

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.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 225-226 MSC: NCLEX: Psychosocial Integrity

8. Four individuals have suicide plans. Which plan evidences the highest risk for completed

suicide? a. Drinking dishwashing detergent before a family meal. b. Jumping from a suspension bridge in a rural location late at night. c. Cutting the wrists in the bathroom while a patient’s spouse reads in the next room. d. Overdosing on acetaminophen (Tylenol) 1 hour before the patient’s spouse is expected home from work.

ANS: B

The correct response presents a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

9. A novice nurse on an inpatient psychiatric unit says to a colleague, “My newest patient has

been diagnosed with schizophrenia. At least I won’t have to monitor for a suicide risk.” Select the colleague’s most accurate response. a. “Our structured milieu provides a safe environment for all patients, regardless of their suicide risk.” b. “Delusions usually protecNt U aR paS tiI enN tG wT ithBs. chCizOoM phrenia from thinking about suicide.” c. “Suicide is a higher risk for adolescents than for patients with schizophrenia.” d. “Any mental illness substantially increases the risk of suicide.”

ANS: D

Up to 15% of patients with schizophrenia and other mental illnesses die from suicide, more than adolescents or older adults. Delusions offer no protection.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 226 MSC: NCLEX: Safe, Effective Care Environment

10. A depressed patient admitted following a suicide attempt by overdose of sedatives states, “I

don’t feel like signing your papers. My partner should have let me die.” What level of suicide precautions should the nurse apply? a. No precautions because the patient is in a secure setting b. Routine observation that is appropriate for all patients c. One-to-one continuous supervision by staff members d. Observation by staff members every 15 minutes ANS: C

One-to-one constant supervision is appropriate for suicidal patients who are considered at high risk: those who still have suicidal ideation, those who are angry that an attempt failed, or those who refuse to participate in their own care by agreeing to talk with staff before harming themselves. The other options are not appropriate for a patient whose suicide risk is high.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Safe, Effective Care Environment

11. A suicide crisis line caller states, “I called to say goodbye to someone.” Select the nurse’s best

response. a. “You seem ambivalent about committing suicide. Let’s talk about that.” b. “You must be feeling a lot of pain. What are you planning to do?” c. “I hope you realize how much you have to live for.” d. “I think I can help you, if you’ll let me.”

ANS: B

Expressing empathy and genuine concern while offering to work with the patient is a good beginning. Asking about the plan is appropriate and enables the nurse to assess risk. The other options fail to offer both empathy and help.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Psychosocial Integrity

12. Social-psychological models describe aggression as: a. intentional harm toward others. b. an unhealthy way of managing anxiety. c. a conflict with others expressed aggressively. d. a response to frustration in the social environment.

ANS: D

Social-psychological models of aggression focus on the interaction of individuals with their environment and locate the sN ourcRe oI f anG ger B in.inCterpMersonal requirements and frustrations. The U S N T other options are not consistent with this model.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 220-221 MSC: NCLEX: Psychosocial Integrity

13. A patient is shouting loudly and is verbally aggressive. What analysis should the nurse make

about this behavior? a. It is acceptable if directed toward staff but not toward another patient. b. It is not harmful and might prevent the patient from physically acting out. c. It is a significant warning sign that the patient may become physically aggressive. d. It allows the patient to vent frustration and alleviate stress without hurting anyone.

ANS: C

Research findings indicate that verbally aggressive attacks on others are among the major warning signs of assault and battery, making the other answers mutually exclusive. Verbal aggression is part of the assault cycle.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 222

TOP: Nursing process: Evaluation

14. The nurse cares for a patient who was verbally aggressive upon admission. Three days later

the patient says, “My family put me here. They wanted to get rid of me.” When should the nurse be most vigilant for signs of escalating aggression? a. During one-on-one sessions

b. During group activities c. During visiting hours d. In the early morning ANS: C

Patients are more likely to become aggressive at admission, at shift change, at mealtimes, during visiting hours, during the evening, when being transported, and during periods of change. In this case the patient will probably be increasingly upset if the family does not visit, because it will reinforce her thinking that they are against her. She is also likely to become increasingly upset if they do visit, because she accuses them of unfairly hospitalizing her. The other times are possible, but research has not supported them as being exceptionally high risk.

DIF: Cognitive level: Applying REF: p. 223 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

15. A patient is becoming increasingly tense, pacing the hall, alternately whispering and shouting.

Other patients receive hostile, suspicious glares as they walk by. Which phase of the assault cycle is the patient demonstrating? a. Crisis phase b. Triggering phase c. Escalation phase d. Depression phase ANS: B

The triggering phase is characterized by increased tension, readiness to retaliate, pacing, irritability, suspiciousness, glaring, breathing changes, and diaphoresis. The other stages are defined by behaviors specific to the stage and are not described in the scenario.

NURSINGTB.COM REF: pp. 222-223

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

MSC: NCLEX: Psychosocial Integrity

16. A patient is increasingly tense, pacing the hall and glaring angrily at others. Select the nurse’s

best comment to this patient. a. “It looks as though you are feeling upset. Please tell me what’s concerning you.” b. “I can see you are on the verge of losing control. What can I do to help you?” c. “You must maintain control of your feelings even if you are feeling angry.” d. “I’m going to give you an injection of your medication to prevent loss of control.”

ANS: A

In the triggering phase the patient’s behaviors are nonviolent and present no immediate danger to others. The nurse should convey empathic support and encourage ventilation using clear, calm, and simple statements.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 222-223 MSC: NCLEX: Psychosocial Integrity

17. A patient has entered the escalation phase of the assault cycle. Select the most appropriate

nursing intervention. a. Direct the patient to the quiet room. b. Process the incident with the patient. c. Encourage ventilation of feelings. d. Place the patient in seclusion.

ANS: A

During the escalation phase the patient is still capable of cooperation when the nurse takes charge and gives calm, firm directions. This intervention observes the principle of using the least restrictive alternative. Oral PRN medication might be used if the least restrictive alternative is not effective. Ventilation of feelings would have been used in the triggering phase. Processing the incident occurs in the recovery and depression phases. Seclusion is necessary in the crisis phase.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 223 MSC: NCLEX: Safe, Effective Care Environment

18. Which principle guides nursing intervention in the assault cycle? a. Contagiousness of violence b. Least restrictive alternative c. Containment d. Control ANS: B

It is a regulatory requirement to care for patients using the least restrictive alternatives. These efforts at treatment should be documented. Only when less restrictive alternatives prove ineffective can more restrictive alternatives be used.

DIF: Cognitive level: Applying REF: p. 223 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

19. A patient’s behavior has continued to escalate despite nursing interventions designed to

achieve de-escalation. The paNtienRt beIginG s toB k. ickCanM d strike at staff. This behavior evidences U S N T which phase of the assault cycle? a. Triggering b. Depression c. Escalation d. Crisis ANS: D

The crisis phase is characterized by a patient’s loss of self-control with fighting, hitting, kicking, scratching, biting, and throwing things. Each of the other phases has selected characteristics, none of which were described in the scenario.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 224 MSC: NCLEX: Safe, Effective Care Environment

20. A patient whose behavior has continued to escalate despite nursing interventions begins to

kick and strike out at the nurse. What is the priority nursing intervention? a. Offer an oral PRN medication. b. Have staff stand by at a distance. c. Physically control the patient’s behavior. d. Allow the behavior until the patient de-escalates.

ANS: C

When a patient loses control, staff must take physical control to prevent injury to the patient or others. A determination must then be made as what measures are necessary (intramuscular medication, involuntary seclusion, or restraint), keeping in mind the importance of using the least restrictive alternatives that will achieve the goal of safety.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 224 MSC: NCLEX: Safe, Effective Care Environment

21. The nurse in charge of a crisis team determines that a patient who has lost control requires

restraint. What is the most important factor in the safe and effective use of physical restraint? a. A calm, well-trained staff b. Taking the patient off guard c. Administering an antipsychotic drug d. Talking to the patient throughout the procedure ANS: A

Six to eight staff members are required. Each must know his or her role. With training, staff can carry out the various functions smoothly and calmly. Calmness helps ensure that physical contact is protective, rather than aggressive. Hospital protocols and legal requirements must be observed. The other options are either less important elements or inappropriate.

DIF: Cognitive level: Applying REF: p. 224 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

22. A patient has been placed in four-point leather restraints following a violent episode. The

nurse establishing the care plan must ensure that the restraints are removed: a. after a minimum of 12 hours of seclusion. b. every 2 hours, one restraiN ntUaR t aStI imNeG , fT orB1.0CmOinMutes. c. to allow the patient to eat, drink, or use the bathroom. d. after the patient is sedated with antipsychotropic medication.

ANS: B

Restraints must be removed at intervals specified by agency protocol (in no case less often than 2 hours) to inspect for injuries, check circulation, and provide limb range of motion. The other options do not follow regulatory policies.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 227

TOP: Nursing process: Planning

23. Staff members take an aggressive patient to seclusion. Before leaving the patient in the room,

the priority action should be: a. remove potentially harmful objects from the patient. b. require the patient to use the bathroom. c. have the patient lie on the bed. d. offer the patient fluids.

ANS: A

Use of seclusion promotes safety, so removal of harmful objects is necessary. Seclusion is also designed to decrease stimulation. The patient might be asked if he or she needs to go to the bathroom but will not be forced to do so. In some facilities there is no bed in the room, only a mattress on the floor.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 223-224 MSC: NCLEX: Safe, Effective Care Environment

24. A nurse who has worked on an acute psychiatric unit for 5 years has begun describing patients

in insensitive ways and is less creative when dealing with patient problems. What is the most likely explanation for the nurse’s behavior? a. Marginalization b. Depersonalization c. Secondary traumatization d. Poor conflict management skills ANS: C

Secondary traumatization occurs as a result of listening to and empathizing with other people’s traumas. Synonyms include compassion fatigue and helper stress. The individual becomes less able to help others. Clinical supervision is indicated.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 229

TOP: Nursing process: Evaluation

25. Which management practice should the clinical nurse leader of a psychiatric unit institute to

enhance the therapeutic environment? a. Encourage staff efficiency and time management. b. Emphasize timely and comprehensive documentation. c. Prepare a comprehensive policy and procedure manual. d. Implement positive reinforcement for upholding professional standards.

ANS: D

Institutional constraints and bNureR racyGaffB the M caring ethic of nurses. Positive UaucSI Nprofessional Tec.t C reinforcement for upholding nursing’s standards is a management practice that supports nursing and will contribute positively to the therapeutic environment. The other options are not supportive of nursing.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 229 MSC: NCLEX: Safe, Effective Care Environment

26. Which nursing intervention for an angry, hostile patient would best contribute to prevention

and management of aggression? a. Loudly calling the patient by name b. Conveying personal interest in the patient c. Positioning oneself directly in front of the patient d. Firmly directing the patient to discontinue the behavior ANS: B

Research has indicated that the nurse’s ability to be with the patient as a unique person in a unique situation is essential for dealing with potentially violent patients. De-escalation techniques include listening, empathizing, using a calm voice, offering alternatives rather than ultimatums, and conveying genuine interest in the patient and his or her well-being. The other options listed are not therapeutic.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 222-223 MSC: NCLEX: Psychosocial Integrity

27. Which characteristic of an inpatient unit organizational culture predisposes the highest risk for

patient violence and aggression? a. Staff member behavior authoritarian b. High degree of structural flexibility c. Feeling of safety among patients d. Bland colors used in decor ANS: A

An important variable affecting the risk of aggression is staff attitude. A higher risk for assault is present for staff with authoritarian attitudes. Such attitudes demean patients, who might act out in anger or defense against feeling depersonalized and powerless.

DIF: Cognitive level: Understanding REF: p. 222 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

28. For which situation would clinical supervision be most important? a. A patient asks to visit with the consumer advocate. b. A new clinical nurse leader is hired to reorganize the unit. c. A newly admitted patient makes a nearly lethal suicide attempt. d. The treatment model for the unit is changed by the psychiatrist in charge.

ANS: C

Clinical supervision for staff can be a tool to facilitate improved staff cohesion, morale, and ability to maintain therapeutic relationships with patients. During clinical supervision, nurses examine attitudes, reactions, and conflicts with patients on the unit and find ways of approaching problems. Nurses often require clinical supervision when working with suicidal patients. The distracters do not pose hazards to patients’ well-being.

NURSINGTB.COM

DIF: Cognitive level: Analyzing REF: p. 230 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

29. An experienced staff nurse describes feeling emotionally burdened and yet engages actively in

gossip and spreading rumors about other staff members. The clinical nurse leader can assess these behaviors as consistent with: a. antisocial personality disorder. b. mild-to-moderate depression. c. depersonalization. d. burnout.

ANS: D

Burnout often produces a clinical picture similar to the one described in this question.

Depression cannot be diagnosed based on this information, nor can one suggest that the behavior is antisocial. Depersonalization is a symptom of burnout.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 229 MSC: NCLEX: Safe, Effective Care Environment

30. A psychiatric nurse is suffering from burnout. What effect would be expected on patients

under this nurse’s care? Patients will probably feel: a. safe. b. empowered. c. impaired trust in the nurse.

d. universality with the nurse.

ANS: C

A nurse who is burned out will not spend adequate time with patients, which reduces trust.

Patients feel devalued, demoralized, and powerless, and they express low levels of satisfaction with care. The patient’s sense of safety and security is jeopardized. The patient looks to the nurse as a caregiver; universality is not desirable in this instance.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 229

TOP: Nursing process: Evaluation

31. A staff nurse tells a peer, “I find it difficult to deal with patients who have personality

disorders. They can control their behavior, whereas patients with depression truly need my services.” Select the peer’s most helpful response. a. “Even though it’s bothering you, the patients seem to like you.” b. “Our clinical nurse specialist is a good resource to help you explore those feelings.” c. “Fortunately, managed care has reduced inpatient services for people with personality disorders.” d. “Your comment tells me you have personal problems. Maybe psychiatric nursing is not the best practice arena for you.”

ANS: B

Clinical supervision can help nurses examine attitudes, reactions, and conflicts with patients on the unit and arrive at new ways of approaching patient problems. This option is the only one that recognizes that the nurse is voicing a legitimate problem for which help should be available.

NURSINGTB.COM REF: p. 230

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

TOP: Nursing process: Evaluation

32. Which scenario presents a high risk for violence? a. A nurse empathizes with a patient who dislikes attending exercise class. b. A nurse enforces the rule that patients must attend all scheduled activities. c. A patient spends free time with a group of other patients talking about issues in

their lives. d. A patient with high anxiety is allowed to remain in a quiet room instead of

attending a community meeting.

ANS: B

Being forced into a treatment activity reduces trust in staff. Struggles over rules are control battles. Patients who do not feel that they have control over their lives might react violently, because they believe that they have little to lose. The other options do not exemplify control battles.

DIF: Cognitive level: Applying REF: p. 221 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Evaluation

MULTIPLE RESPONSE 1. What common themes apply to persons who have suicidal ideation? Select all that apply.

a. b. c. d. e.

Belief that life is meaningless Absolute intention to die Existence of cognitive impairment Experiencing hopelessness Feeling out of control

ANS: A, D

Hopelessness, meaninglessness, and feeling out of control are the most common themes underlying suicidal ideation. The other options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are cognitively impaired.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 225-226 MSC: NCLEX: Psychosocial Integrity

2. A patient with suicidal impulses is placed on suicide precautions. Which measures will the

nurse incorporate into the plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects. c. Maintain continuous one-on-one nursing observation. d. Check the patient’s whereabouts every 15 minutes, and make frequent verbal contacts. e. Keep the patient within visual range while he or she is awake, and check every 15 to 30 minutes while asleep.

ANS: A, B, C

One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient’s possession are measN uU reR s iS ncIluNdG edTiB n. anCyOleMvel of suicide precautions. The distracters are insufficient to assure the patient’s safety.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 227 MSC: NCLEX: Safe, Effective Care Environment

3. Sequence these expressions of suicidality from least to most acute. a. Threat b. Gesture c. Ideation d. Attempt e. Completion ANS: A, B, C, D, E

Suicidality exists on a continuum, beginning with ideation and then progressing to threats, gestures, attempts, and finally completed suicide.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 226-227 MSC: NCLEX: Safe, Effective Care Environment

Chapter 22: Therapeutic Environment in Various Treatment Settings MULTIPLE CHOICE 1. A nurse working in an intensive inpatient psychiatric unit should place emphasis on which

area of care? a. Behavior modification principles b. Personality restructuring and insight c. Improving interpersonal relationships d. Symptom stabilization and daily living skills ANS: D

The nurse will emphasize symptom stabilization and daily living skills, because the length of stay will be short. Behavior modification principles are not used in all settings. Developing insight, restructuring personality, and improving interpersonal relationships are lengthy endeavors.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 234

TOP: Nursing process: Planning

2. What is the primary purpose of a community meeting? a. Making assignments for patients’ chores for the day b. Determining patients’ eligibility for increases in privileges c. Encouraging patients to share their feelings and individual problems d. Providing a forum for patients to have input into daily program operations ANS: D

An emphasis of community meetings is on democratic aspects of unit life. The meeting serves as a forum for patients to voice opinions about the environment and to initiate discussion of community concerns. Making assignments and sharing are only some of the issues addressed in a community meeting. Privilege eligibility would not be discussed in a community meeting.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 234 MSC: NCLEX: Safe, Effective Care Environment

3. A patient asks, “Who will be at the community meeting?” The nurse responds: a. “Patient representatives and staff” b. “Members of the mental health team” c. “All patients and the nurse manager” d. “All patients, nursing staff, and students” ANS: D

Typically, all patients, students assigned to the unit, and all nursing staff attend community meetings. Members of other disciplines might or might not attend.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 234 MSC: NCLEX: Safe, Effective Care Environment

4. During the community meeting a patient says, “I’m having problems in my sex life.” The

leader of the meeting will make which response? a. “Go on. We are here to listen.”

b. “That’s a topic to discuss with your therapist today.” c. “How does everyone else feel about discussing this topic?” d. “Perhaps you should leave the meeting until you are in better control.”

ANS: B

Individual problems are not dealt with in community meetings. It is suggested to patients that individual issues be discussed with one’s therapist. The focus of community meetings is on matters of general concern to the group at large. When the patient is informed of when and where to address the individual problem, it should be done in a nonpunitive manner.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 234 MSC: NCLEX: Psychosocial Integrity

5. The priority treatment goal for a patient with severe and persistent mental illness being treated

in a community-based facility will be to: a. form new relationships. b. self-administer medications. c. participate in community activities. d. independently attend to activities of daily living.

ANS: D

Priority outcomes for community treatment focus on the individual being able to function at his or her optimal level by attending to activities of daily living. The other options have a lower priority or can be managed by others.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 235

TOP: Nursing process: Planning

N R I G B.C M

N for T physical O activity when the patient moves from 6. What is the best way to supportUtheSneed acute care into community-based care? a. Use video-based exercise programs on television. b. Enroll in a swim class at the community center. c. Attend outpatient psychoeducational groups. d. Join a social club.

ANS: B

The key combination affords the patient physical exercise as well as opportunities for social interaction at a community center. Exercise on television is solitary. Psychoeducational and social interaction do not achieve the goal.

DIF: Cognitive level: Analyzing REF: pp. 233-234 MSC: NCLEX: Health Promotion and Maintenance

TOP: Nursing process: Planning

7. Which diagnosis meets criteria for admission to a co-occurring inpatient unit? a. Bipolar disorder, manic phase, patient has abused alcohol daily to self-medicate b. Undifferentiated schizophrenia and hallucinations of angels playing harps c. Major depression, suicidal intent, and a highly lethal suicide plan d. Anorexia nervosa and 30% underweight ANS: A

The patient experiencing a bipolar episode and abusing alcohol would meet criteria for such a diagnosis unit, since its focus is on the treatment of substance abuse and mental illness in a psychiatric hospital setting. The other three patients require acute psychiatric care but do not meet the admitting criteria.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 234 MSC: NCLEX: Psychosocial Integrity

8. Which therapeutic intervention should the nurse suggest for a patient with panic attacks and

problems with concentration? a. Occupational therapy b. Medication education c. Recreational therapy d. Group therapy ANS: A

Occupational therapists prescribe activities that can help the patient increase concentration and focus. The other activities are not designed to increase concentration and attention span.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 233

TOP: Nursing process: Planning

9. A patient diagnosed with depression has a need for divisional activities. Which team member

is best qualified to assess the patient’s leisure needs and plan the interventions? a. Occupational therapist b. Recreational therapist c. Exercise physiologist d. Chaplain ANS: B

Recreational therapists are qualified to assist patients to find leisure interests that will enable the patient to learn to balance work and play. The other professionals do not have this focus.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity 10.

REF: pp. 233-234

TOP: Nursing process: Planning

Which patient would benefit most from closed, process-oriented group therapy? a. Adult with disorganized schizophrenia admitted to an acute psychiatric unit b. Outpatient living independently with chronic low self-esteem and anxiety c. Patient receiving treatment in an assertive community treatment program d. Resident of a group home attending a partial hospitalization program ANS: B

Group therapy is seldom an option during short-term treatment. The individual with low self-esteem, anxiety, and living independently meets criteria for being able to develop plans for change and coping, and is able to attend group sessions long enough to benefit from group therapy’s curative features. A patient in an assertive community program is someone who receives care from a team that seeks him or her out in the community. Group home residents might or might not be suitable for inclusion in group therapy sessions.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 234

TOP: Nursing process: Planning

11. A patient says, “I’m like a wind-tossed leaf. My goal is to find meaning in life.” The nurse

should consider referring the patient to which group? a. Self-help b. Spirituality c. Reality orientation d. Psychoeducational ANS: B

Lack of meaning in one’s life is a spiritual concern. Referral to a spirituality group has potential for helping the client. The other options do not address the patient’s expressed concern.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 234

TOP: Nursing process: Planning

12. An adolescent has an autism spectrum disorder. Which psychoeducational group topic would

best meet the patient’s needs? a. Signs of relapse b. Interpersonal skills c. Anger management d. Medication management ANS: B

Individuals with autism spectrum disorders almost universally have impaired relationships and need help learning effective social skills to support relationships. Anger and medication management might or might not be needs of such individuals. Deficits are constant, so relapse is not an issue.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 234 MSC: NCLEX: Psychosocial Integrity

13. A nurse works in a geropsychiatric unit. Which intervention will be most helpful for patients

experiencing confusion and disorientation? a. Door locks b. Environmental cues c. Community meetings d. Psychoeducational groups ANS: B

Environmental cues can be helpful to patients with cognitive impairment, such as signs with names or graphic images, orientation boards, and color-coding locations. These elements are usually present on dementia units and geropsychiatric units. Community meetings and psychoeducational groups may be helpful but may also overstimulate patients with dementia.

Door locks help the staff rather than patients.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 235 MSC: NCLEX: Psychosocial Integrity

14. A large mental health facility has several specialized units. A patient admitted for alcohol

withdrawal asks, “Will I be with patients who have schizophrenia or dementia while I’m here?” Select the nurse’s best answer.

a. “No. Patients with alcoholism often become violent and must be isolated from our

general psychiatric population.” b. “No. Patients with needs for alcohol detoxification are treated on our acute

substance abuse unit.” c. “Yes. Our patients often help each other, so they are all on the same unit.” d. “Your question leads me to wonder if you’re feeling frightened.”

ANS: B

Specialty units serve specific populations of patients. The patient in need of alcohol detoxification will receive care on an acute substance abuse unit. It’s important to answer the patient’s question. Afterward, the nurse can explore the patient’s feelings. Violence is a risk during alcohol withdrawal, but the risk alone is not a reason to isolate the patient from others.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 234 MSC: NCLEX: Psychosocial Integrity

15. Which outcome of hospital-based psychiatric care should the nurse consider a priority for a

patient to achieve before discharge? a. Referral for vocational rehabilitation b. Safe level of functioning c. Medication stabilization d. Problem resolution ANS: B

Safe level of functioning is of paramount importance before a patient returns to the community. Work toward problem resolution and medication stabilization can continue in the community. Referral for aftercare might or might not be necessary, depending on a patient’s needs.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 234

TOP: Nursing process: Planning

16. Which treatment setting would necessitate the most restrictive environment? a. Partial hospitalization b. Geropsychiatric unit c. Forensic hospital d. Group home ANS: C

Patients in forensic hospitals have mental illness as well as conviction or charges for criminal activity. These settings must be therapeutic but also confine patients from society. Rules, regulations, and restrictions have similarities to those of prisons.

DIF: Cognitive level: Applying REF: p. 235 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

17. A nurse working on a geropsychiatric unit designs new clinical protocols. Which potential

problems have the highest priority? a. Risks for falls b. Cognitive errors c. Memory deficits d. Nutritional deficits

ANS: A

Patients in geropsychiatric units have an especially high risk for falls. Safety is the nurse’s priority concern.

DIF: Cognitive level: Analyzing REF: p. 235 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

Chapter 23: Introduction to Psychopathology MULTIPLE CHOICE 1. Which argument effectively supports the importance of funding services for persons with

mental illness in the United States? a. During any given year 25% of Americans are affected by mental disorders. b. Increasing toxins in the environment are increasing the incidence of mental illness. c. The high prevalence of mental illness is directly linked to increasing violence in the media. d. The incidence of mental illness is increasing because of deterioration of the American family.

ANS: A

Funding is justified based on the high incidence of mental illness. The origins of mental illness are multifaceted. It is overly simplistic to associate these problems with one or two variables.

DIF: Cognitive level: Understanding REF: p. 242-243 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

2. What is the purpose of the DSM-V? a. It provides a detailed list of clinical psychiatric disorders. b. It details data and statistics about mental disorders in the United States. c. It serves as the official American resource manual detailing diagnostic criteria of

psychiatric disorders. N R I G B.C M d. It acts as a compendium ofU theS inteN rnaT tional dO emographics of substance abuse and mental disorders.

ANS: C

The Diagnostic and Statistical Manual, Fifth Edition (DSM-V) is published by the American Psychiatric Association. It provides diagnostic criteria for mental and substance abuse disorders and is used throughout the United States. The other options are not descriptive of the DSM-V. DIF: Cognitive level: Understanding REF: p. 242-243 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

3. What is the most prevalent psychopathologic condition diagnosed in the United States? a. Schizophrenia b. Mood disorder c. Anxiety disorder d. Alcohol dependency ANS: C

Anxiety disorders are the most prevalent, followed by mood disorders and alcohol disorders.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 242-243 MSC: NCLEX: Safe, Effective Care Environment

4. Which assessment finding should be documented as subjective information?

a. b. c. d.

Flushed face White blood cell (WBC) count 12,000 cells/L Lithium level 1.2 mEq/L Reports of abdominal pain

ANS: D

Subjective data are what the patient relates to the nurse such as reports of pain. Objective data are measurable data obtained by the nurse.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 242-243 MSC: NCLEX: Physiologic Integrity

5. A nurse reads this information in a patient’s record: suffered anoxia at birth; foster home

placement at age 3; taunted by peers during childhood; low self-esteem since adolescence.

Which item would be classified as a biologic factor associated with the patient’s mental illness? a. Anoxia at birth b. Low self-esteem c. Taunted by peers d. Trauma caused by parental death ANS: A

Biologic causes arise from nature; that is, they are organic or genetic. Anoxia is an organic etiology. The other conditions are of psychologic etiology.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 244 MSC: NCLEX: Physiologic Integrity

N R I G B.C M

U S N Tguideline O nurses should apply when caring for all 6. A general psychotherapeutic management patients is to: a. strengthen patients’ self-esteem. b. keep reality testing to a minimum. c. ignore hostile behavior when possible. d. provide unrestricted opportunities for self-expression.

ANS: A

Strengthening patients’ self-esteem is an important aspect of psychotherapeutic management and a key part of the nurse’s role. The distracters are not always therapeutic.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 244 MSC: NCLEX: Psychosocial Integrity

7. Which principle is applicable to nursing care of patients with all types of psychopathology? a. Avoid competitive situations. b. Treat patients as individuals. c. Confront patients with consequences of behavior. d. Assume that patients will make self-enhancing decisions.

ANS: B

Treating all patients as individuals is a key aspect of showing respect. The distracters are not universally therapeutic measures.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 244 MSC: NCLEX: Psychosocial Integrity

8. A patient who has taken antipsychotic medication for a year presents with these signs and

symptoms: jaundice, headache, pruritus, and abdominal discomfort. Which finding should be documented as objective data? a. Pruritus b. Jaundice c. Headache d. Abdominal discomfort ANS: B

Objective data are obtained by the nurse through direct observation or measurement. Jaundice is seen by the nurse. The other choices are considered subjective data.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 244 MSC: NCLEX: Physiologic Integrity

9. A patient with low self-esteem and feelings of failure would benefit most from which

activity? a. Attending a dance b. Playing board games c. Leading the chorus for a party d. Helping make favors for a party ANS: D

Making favors is a productive task that holds little opportunity for failure and ample opportunity for receiving supN porR t anI d poG sitiB ve.fC eedbMack. The other options hold a greater risk U S N T for failure.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 244

TOP: Nursing process: Planning

10. How does a multiaxial diagnostic and classification tool contribute to successful treatment of

persons with mental illness? a. It provides for consistency and continuity in formulation of diagnoses. b. It assesses more dimensions of illness than simply the medical diagnosis. c. It establishes prevalence rates for psychiatric disorders across various cultural groups. d. It provides treatment algorithms for psychotherapeutic management of persons with mental illness.

ANS: B

A multiaxial tool looks more holistically at the individual. The DSM-V-TR axes consider medical conditions, presence of personality and developmental disorders, relevant psychosocial and environmental factors, and global assessment of functioning. The other options listed are not advantages that contribute to treatment success.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 242-243 MSC: NCLEX: Psychosocial Integrity

11. Prevalence rates for substance abuse disorders in the United States are:

a. b. c. d.

higher for men. higher for women. equal for both genders. higher than anxiety disorders.

ANS: A

Prevalence rates for substance abuse disorders are highest in men. The remaining options are not true regarding substance abuse prevalence.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 242 MSC: NCLEX: Psychosocial Integrity

12. Which assessment finding should be documented as objective information? a. Rated anxiety 8 on a scale of 10 b. Reported depressed mood c. Reports of headache d. Wore layered clothing ANS: D

Objective data are measurable data obtained or observed by the nurse. Layered clothing is an example of objective data. Subjective data are what the patient relates to the nurse.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 243-244 MSC: NCLEX: Physiologic Integrity

13. The nurse reads this information in a patient’s record: history of agranulocytosis from

antipsychotic medication; victim of childhood sexual abuse; weight loss of 27 lb in 3 months; parent diagnosed with bipolaN r disRordI er. W hiB ch.iC temMwould be classified as a psychodynamic U Smental NG Tillness? factor associated with the patient’s a. History of agranulocytosis from antipsychotic medication b. Parent diagnosed with bipolar disorder c. Weight loss of 27 lb in 3 months d. Victim of childhood sexual abuse ANS: D

Psychodynamic causes of mental illness arise from “nurture”—for example, childhood sexual abuse. The distracters are of biologic (“nature”) etiology.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 243-244 MSC: NCLEX: Psychosocial Integrity

14. Long- and short-term goals are documented in which part of the plan of care? a. Assessment b. Diagnosis c. Outcomes d. Interventions e. Evaluation ANS: C

Long- and short-term goals are the product of outcome identification, and documentation is appropriate only in the “outcomes” part of the plan of care.

DIF: Cognitive level: Understanding REF: p. 244 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

15. A patient’s areas of strength are documented in which part of the plan of care? a. Assessment b. Diagnosis c. Outcome identification d. Interventions e. Evaluation ANS: A

Areas of strength are part of the nurse’s assessment, and documentation is appropriate only in that part of the plan of care. This information is very important for the later steps of outcome identification and planning.

DIF: Cognitive level: Understanding REF: p. 244 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

16. Which adjective best describes a therapeutic psychiatric nurse? a. Holistic b. Organized c. Diplomatic d. Compassionate ANS: A

Holism is crucial to knowledgeable, safe, and effective practice as a psychiatric nurse. The distracters are incomplete. Compassion is an aspect of holism.

N R I G B.C M N REF: T p.O243-244

U S DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

TOP: Nursing process: Planning

MULTIPLE RESPONSE 1. Which guidelines should be included by the nurse who will provide staff development training

to unlicensed assistive personnel about psychotherapeutic management? Select all that apply. a. Support should be minimal to prevent development of dependence. b. Norms and limits are more important than individual needs. c. Hostility should run its course without staff interference. d. Plan opportunities to strengthen patients’ self-esteem. e. Provide encouragement for patients in distress.

ANS: D, E

Important guidelines include provision of encouragement, especially when patients are in distress, and strengthening patients’ self-esteem. The other options are actually the opposite of accepted guidelines.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 243-244 MSC: NCLEX: Psychosocial Integrity

Chapter 24: Schizophrenia Spectrum and Other Psychotic Disorders MULTIPLE CHOICE 1. A patient laughs while saying, “My dog died yesterday.” The nurse documents this behavior

using what terminology? a. Autistic b. Ambivalence c. Inappropriate affect d. Associative looseness ANS: C

Speaking of a sad topic while laughing exemplifies inappropriate affect. Autism is characterized by having little concern for external reality. Ambivalence is the simultaneous presence of opposite emotions. Associative looseness is characterized by stringing unrelated topics together.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 252 MSC: NCLEX: Psychosocial Integrity

2. How long must the symptoms of schizophrenia be present before a diagnosis can be made? a. At least 6 months b. At least 1 month c. More than 1 week d. On at least three occasions in the past year ANS: A

To meet diagnostic criteria, signs of schizophrenia must be continuously present for a minimum of 6 months and not caused by substance abuse or a medical disorder.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 249 MSC: NCLEX: Psychosocial Integrity

3. A patient displays disorganized speech and behavior as well as a flat affect. The patient

prefers to sit alone and often appears to be listening and responding to unseen stimuli. To begin a therapeutic relationship, the nurse should: a. take the patient to a medication education class. b. offer a simple activity, and sit with the patient. c. ask the patient what the voices are saying. d. quietly watch television with the patient.

ANS: B

For withdrawn patients, nurses should begin with undemanding one-to-one interactions.

Providing a simple activity might help the patient focus on the here and now and provide a basis for reality-oriented communication. Watching television together does nothing to build trust. Medication education might be of little benefit if the patient is hallucinating and unable to pay attention to what is being taught. Asking what the voices are saying time after time is not beneficial to the patient, who needs to be distracted from them and focus on the real world.

DIF: Cognitive level: Applying

REF: p. 256

TOP: Nursing process: Implementation

MSC: NCLEX: Psychosocial Integrity

4. Parents of a 17-year-old patient diagnosed with schizophrenia ask the nurse what the future

will be like for their child. The nurse’s answer should be based on knowledge that the usual course of illness is: a. a steady lessening of symptoms until stability is achieved. b. characterized by alternating acute and stable phases. c. totally different for each individual patient. d. progressive deterioration.

ANS: B

Most patients with schizophrenia experience alternating acute and stable phases throughout life. Complete and permanent remission is rare. The course of the illness might be somewhat different from individual to individual, but the alternating phases are seen more often than any other course.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 248 MSC: NCLEX: Psychosocial Integrity

5. The nurse should focus assessment for a patient with type I schizophrenia primarily on

gathering data about: a. cognition and perception. b. attention and motivation. c. grooming and hygiene. d. abstract thinking skills.

ANS: A

Altered perception includes hNalluRcinI atioG ns, iB ll. usC ionsM, and paranoid thinking. These positive U S N T symptoms, along with abnormal thoughts, are hallmarks of type I schizophrenia. The other options are more often seen in patients with type II schizophrenia.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 249 MSC: NCLEX: Psychosocial Integrity

6. When a patient experiencing a first episode of type I schizophrenia is hospitalized, the nurse

can expect to administer: a. a typical antipsychotic drug. b. an atypical antipsychotic drug. c. a mood-stabilizing anticonvulsant. d. a selective serotonin reuptake inhibitor.

ANS: A

Delusions, hallucinations, and other symptoms of type I schizophrenia usually respond to the typical antipsychotic medications. Positive symptoms are considered to be the result of a subcortical dopaminergic process. The typical antipsychotics are dopamine blockers.

DIF: Cognitive level: Analyzing TOP: Nursing process: Planning

REF: pp. 249, 251, 255 MSC: NCLEX: Physiologic Integrity

7. The family of a patient with type I schizophrenia asks, “Did this illness occur because of all

the chaos in our family?” Select the nurse’s best response. a. “It is likely that the chaos in your family caused the disorder. It is very important

for every family member to keep calm.” b. “Stress in your family may make the disorder more difficult to manage, but it is

not the cause.” c. “Too little is known about the cause of this illness for anyone to speculate.” d. “That question would be best answered by the psychiatrist.”

ANS: B

The concept of disordered family interaction as the cause of schizophrenia is largely outdated.

There is more reliance on the dopamine hypothesis or the stress-vulnerability model at present. Two options are dismissive, and the other suggests that the nurse is not qualified to give information.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 255 MSC: NCLEX: Psychosocial Integrity

8. A newly admitted patient is mute, immobile, and holds a fixed body position for long periods.

The nurse caring for this patient should: a. assign unlicensed assistance personnel to feed the patient. b. provide a stimulating, active environment. c. encourage independent social behaviors. d. forewarn the patient before touching.

ANS: D

Nurses should explain the need for and purpose of touch to patients before actually touching.

This is particularly true for patients who are at highest risk for misinterpreting touch: those who are inattentive to reality or those who are suspicious. The environment should be calm and predictable. A patient who is mute and motionless is incapable of independent social behaviors. The patient’s oralN inU taR keSsIhN ouGldTbBe. mCoO niM tored, but the correct response also applies to feeding, if it is necessary.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 255 MSC: NCLEX: Psychosocial Integrity

9. A patient tells the nurse, “Air Force jets flying overhead are looking for me. They want to

capture me.” The patient has not previously verbalized this information. The nurse’s initial interventions should: a. set firm limits on disruptive behaviors. b. forcefully refute all perceptual distortions. c. encourage complete description of delusions. d. voice doubt about delusions without arguing.

ANS: D

A nurse cannot agree with a delusion, but arguing is counterproductive, because it might cause the patient to cling to the idea. Voicing doubt and stating one’s own perception of reality is therapeutic. Encouraging discussion of the delusion reinforces it. Because the behavior described is not disruptive, this principle is not relevant.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 255 MSC: NCLEX: Psychosocial Integrity

10. Which type of perceptual alteration is most commonly displayed by patients with

schizophrenia?

a. b. c. d.

Auditory hallucinations Inappropriate affect Loose associations Illusions

ANS: A

Auditory hallucinations are the most commonly experienced perceptual alteration noted in schizophrenia. Illusions are less common. The other symptoms are not altered perceptions.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 251 MSC: NCLEX: Psychosocial Integrity

11. Research on neurostructural theories of schizophrenia indicates that pathoanatomic findings

often include: a. ventricular enlargement, brain atrophy, and diminished cerebral blood flow. b. ventricular blocking, brain swelling, and enhanced cerebral blood flow. c. decreased cortical thickness and hippocampal hyperplasia. d. increased cortical thickness and temporal lobe scarring.

ANS: A

Theorists have suggested that type II schizophrenia is the result of pathoanatomy, specifically increased ventricular brain ratios, brain atrophy, and decreased cerebral blood flow. The other alterations are not supported by research findings.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 253 MSC: NCLEX: Physiologic Integrity

12. Genetic evidence regarding tN winR s anI d thG e risBk.foCr scMhizophrenia supports which fact?

U S N a. Identical and fraternal twins are equal T in concordancy for schizophrenia. b. Monozygotic twins have a lower concordancy rate for schizophrenia than the

general population. c. Fraternal twins have a higher concordancy rate for schizophrenia than

monozygotic twins. d. Monozygotic twins are significantly more likely than the general population to be

concordant for schizophrenia.

ANS: D

Concordancy rates are 50% for monozygotic twins. This rate is 50 times higher than for the general population. The other options are not accurate representations of research data.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 253-254 MSC: NCLEX: Physiologic Integrity

13. A therapist believes that persons diagnosed with schizophrenia have ego disintegration. This

concept is based on which model? a. Biologic b. Interpersonal c. Developmental d. Stress-vulnerability ANS: C

The concept of ego disintegration is distinctly freudian. Freud is considered a developmental theorist. This theory is not considered biologic, interpersonal, or stress-vulnerability based.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 253-254 MSC: NCLEX: Psychosocial Integrity

14. A patient diagnosed with schizophrenia expresses fear of being pursued by hostile forces. The

patient carries a tablet and writes notes in a code. The patient says, “I’m the only one who understands this code.” How should the nurse document these findings? a. Grandiose and paranoid delusions b. Affective blunting and anhedonia c. Autism and loose associations d. Delusions of reference ANS: A

Delusions are fixed false beliefs. Paranoid delusions reflect the idea that the person is being persecuted. Grandiose delusions are characterized by the idea that one is of great importance.

The scenario does not describe any of the behaviors that would be consistent with the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 251-252 MSC: NCLEX: Psychosocial Integrity

15. A patient diagnosed with schizophrenia expresses fear of being pursued by hostile forces. The

patient carries a tablet and writes notes in a code. The patient says, “I’m the only one who understands this code.” What is the priority nursing diagnosis? a. Impaired environmental interpretation syndrome related to inability to reason b. Disturbed thought procesN seU sR reS laI teN dG toTthBin.kC inO gM not based on reality c. Risk for other-directed violence related to persecutory delusions d. Powerlessness related to feelings of persecution ANS: B

Disturbed thought processes based on thinking not based on reality is a priority diagnosis for a delusional patient. Impaired environmental interpretation is more useful for an individual who has been disoriented for more than 3 months. Risk for violence might be considered if the patient had given any indication of wishing to attack his persecutors or of willingness to fight back if personally attacked. Further investigation is necessary. No information was presented to suggest that the patient feels powerless. This would require further investigation.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 257

TOP: Nursing process: Evaluation

16. A patient diagnosed with schizophrenia expresses fear of being pursued by hostile forces. The

patient carries a tablet and writes notes in a code. The patient says, “I’m the only one who understands this code.” Select a realistic and desirable outcome for this patient. The patient will: a. express a willingness to be supervised by staff by day 2. b. report feeling safe from harm by others by day 3. c. allow the nurse to read coded writings by day 2. d. recognize the need for medication by day 1.

ANS: B

Reporting that he is no longer afraid of harm emanating from hostile forces would suggest a reduction in delusions. Allowing the nurse to read the coded writings or wishing to have a staff member nearby do not necessarily suggest improvement in reality-based thinking.

Stating that he needs medication to clear his thinking by day 1 is not realistic, because delusions are fixed beliefs.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 257

TOP: Nursing process: Planning

17. An initial short-term outcome for a withdrawn, socially isolated patient diagnosed with

schizophrenia is that the patient will: a. participate in scheduled activities. b. identify barriers to social communication. c. consistently interact with an assigned nurse. d. share feelings of isolation with group members.

ANS: C

Consistently interacting with one person reduces isolation. One-to-one interaction is the basis for developing trust and a therapeutic nurse–patient relationship. Later, the patient’s willingness to participate in activities or discuss feelings indicates progress.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 257

TOP: Nursing process: Planning

18. A highly suspicious patient tells the nurse, “When I sit in the dayroom I can see other people

whispering about me and laughing. It makes me want to punch them.” The direction that the nurse should give staff is: a. “Gently and frequently toN uU chRtS heIpN atG ieT ntBw.hC ileOcMonversing.” b. “Stop laughing immediately when the patient enters the room.” c. “Be direct. Do not whisper, laugh, or look sideways at the patient.” d. “Engage the patient in conversation by leaning close to speak softly.”

ANS: C

Suspicious patients misinterpret the actions of others as being potentially harmful to self. Be direct and open, and avoid behaviors that can be misinterpreted, such as whispering or laughing. In addition, the suspicious patient needs additional personal space. Leaning close is ill-advised. Touching should be avoided because of the high potential for misinterpretation of staff members’ motives by the suspicious patient. To stop laughing abruptly when the patient appears would make the individual even more suspicious.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 255-256 MSC: NCLEX: Psychosocial Integrity

19. Which therapeutic activity would be most important in helping a patient diagnosed with

schizophrenia remain in the work force? a. Social skills training b. Physical therapy to develop muscle strength c. Occupational therapy to improve coordination d. Group therapy to improve motivation for working ANS: A

Patients with schizophrenia often cannot obtain and hold jobs, not from lack of work skills but from inability to cope socially on the job. Social skills training would therefore be of greatest assistance if work skills are present. This premise is especially true for an individual with residual schizophrenia, since active psychosis is no longer present.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 250 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons with

schizophrenia. Which topics would take priority? a. The importance of taking your medication correctly b. How to complete an application for employment c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking ANS: A, E

Stabilization is maximized by adherence to the antipsychotic medication regime. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients’ physiologic well-being. The other topics are also important, but are not priority topics.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 253

TOP: Nursing process: Planning

Chapter 25: Depressive Disorders MULTIPLE CHOICE 1. Which account of history and symptoms is most consistent with dysthymia? a. Depressed mood for 2 weeks; anhedonia; feelings of worthlessness b. Delusions of guilt and poverty; weight loss; agitation beginning 3 weeks ago c. Depressed mood for 3 months; suicidal ruminations; hypersomnia; sullen affect d. Depressed for 3 years; poor concentration; anhedonia; low self-esteem; indecision ANS: D

Dysthymia is a depressive disorder marked by chronicity. The depression must have been present more than 50% of the time for at least 2 years. The other options describe major depression and psychotic depression.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 272 MSC: NCLEX: Psychosocial Integrity

2. A 74-year-old patient is admitted diagnosed with anhedonia, weight loss of 20 lb in 6 weeks,

and pervasive guilt over issues that occurred in early adulthood. The patient is diagnosed with melancholic depression. Which intervention has the highest priority for inclusion in the care plan? a. Assess history of seasonal variations of mood. b. Observe for increased sensitivity to rejection. c. Monitor and document sleep patterns. d. Assess for echolalia and posturing.

B.C M ANS: C

NURSI NG T

O

Individuals with the depressive variant of melancholia often display anhedonia, depression worse in the morning, early-morning awakening, anorexia and/or weight loss, and inappropriate guilt. It is appropriate to monitor sleep patterns to ascertain if sleep disturbance is present. Homeostasis is contingent on adequate sleep. The distracters are seen in depression with catatonic features, atypical depression, and seasonal affective disorder.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 273

TOP: Nursing process: Planning

3. A patient diagnosed with seasonal affective disorder asks, “Will I ever feel better?” Based on

an understanding of this psychopathology, the nurse’s best response is: a. “Your depressed mood will probably spontaneously improve in 6 months to a year.” b. “People with seasonal affective disorder usually feel better in spring and summer, when there are longer periods of light.” c. “It’s important to engage in community activities to improve your depressed mood. Activity stimulates important brain chemicals.” d. “Most people with seasonal affective disorder feel better during the fall and winter seasons as they experience the pleasure of the holidays.”

ANS: B

Seasonal affective disorder is a depression occurring in conjunction with a seasonal change, most often beginning in fall and winter and remitting in spring in the Northern Hemisphere.

The correct answer is the only option that reflects the information regarding the seasonal nature of the disorder.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 273 MSC: NCLEX: Psychosocial Integrity

4. Which adolescent would the nurse consider to have the highest priority for health promotion

interventions aimed at reducing risk for depression, based on the person’s history? a. Parents killed in an auto accident b. Lived with adoptive parents since birth c. Allergies to dust, pollen, and mold d. Frequent conflicts with siblings ANS: A

The events that predispose children and adolescents to develop depression involve loss such as death or separation from parents, death of a close relative, death of a pet, a move to another neighborhood, academic problems, or illness or injury that requires hospitalization. This is the only answer that reflects the relationship of loss to the disorder.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 274 MSC: NCLEX: Psychosocial Integrity

5. A clinic nurse assesses a new Latino patient who repeatedly reports feeling nervous and

having headaches. No organic pathology is present. The symptoms began about 3 years ago when the patient’s parent died. Select the nurse’s best first action. a. Explore the patient’s grieN f.URSINGTB.COM b. Encourage the patient to take frequent rest periods. c. Reassure the patient that these feelings are normal. d. Screen for additional signs and symptoms of depression.

ANS: D

Latino patients often do not express depression as being related to their mood; rather, they present vague somatic symptoms. Nurses often have good understanding of cultural differences. The nurse should first screen for other signs and symptoms of depression. The patient’s feelings are not normal when considered from a cultural viewpoint. Reassuring the patient that the feelings are normal would be nontherapeutic. Exploring grief may come later.

Frequent rest periods would isolate the patient who actually needs support.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 274-275 MSC: NCLEX: Psychosocial Integrity

6. A patient diagnosed with depression paces and pulls at clothing constantly. The patient cannot

sit for longer than 5 minutes, even at meals. How should the nurse document this behavior? a. Perseveration b. Hypomanic activity c. Catatonic excitement d. Psychomotor agitation ANS: D

Psychomotor agitation is marked by increased, purposeless, repetitive motor activity, often performed with a sense of urgency. The description of the patient’s behavior is consistent with this definition, rather than any of the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 275 MSC: NCLEX: Psychosocial Integrity

7. A patient with depression paces, pulls at clothing constantly, and cannot sit for longer than 5

minutes. The patient ruminates about being a “bad” person. Select the most effective nursing intervention. a. Reassure the patient. b. Direct the patient to lie down every 2 hours. c. Ask the patient to assist in a simple, repetitive activity. d. Seek a prescription for a PRN antipsychotic medication.

ANS: C

The psychomotor energy of agitation might be channeled into simple, repetitive activities.

Providing an activity that is of value to others can help relieve guilt. As for the other options, the patient will be unable to lie down, global reassurance is ineffective, and an antipsychotic medication is not indicated.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 282-283 MSC: NCLEX: Psychosocial Integrity

8. After breakfast a depressed patient pleads with the nurse, “Please let me go to my room to lie

down for a while.” The nurse should: a. explain that the patient must attend scheduled activities. b. bargain with the patient tN oU atR tenSdIthNeGnT exBt . acCtiO viM ty, then rest. c. rearrange the patient’s schedule to accommodate the request. d. explain that the team will be displeased if the schedule is not followed.

ANS: A

Depressed patients often want to lie down, whether or not they wish to sleep. Solitude permits self-defeating ruminations and should not be encouraged. Kind firmness in helping the patient adhere to the treatment program is necessary. Because the patient has only been up long enough to eat breakfast, rest should not be necessary. Bargaining is not therapeutic.

Threatening the team’s displeasure is not therapeutic as a motivator.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 282-283 MSC: NCLEX: Psychosocial Integrity

9. The nurse sees a depressed patient who has psychomotor retardation leaving the dining room.

The patient’s shirt is soiled from spilled food. The nurse should: a. foster independence by suggesting changing shirts. b. ignore the spill to avoid embarrassing the patient. c. assist the patient to change into a clean shirt. d. notify the patient of the soiled shirt.

ANS: C

A patient with psychomotor retardation might need assistance with hygiene and grooming. It is important for the nurse to help the patient appear well groomed so as to avoid embarrassment. Ignoring the situation is nontherapeutic. The patient should be assisted by staff. The patient might not have the physical energy to respond to a suggestion.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 281-283 MSC: NCLEX: Psychosocial Integrity

10. Which nursing diagnosis is almost universally applicable to persons with depression? a. Ineffective denial b. Disturbed body image c. Chronic low self-esteem d. Risk for other-directed violence ANS: C

The overall affective sense of the depressed person is one of low self-esteem. Guilt often accompanies the low self-esteem. Data about depressed individuals do not suggest the applicability of body image disturbance. Denial and risk for violence may or may not be present.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 281

TOP: Nursing process: Planning

11. The medical record notes that a newly admitted depressed patient has delusional thoughts.

Which statement by this patient is most likely? a. “I am a presidential advisor.” b. “Cancer is rotting my body.” c. “There are aliens chasingNmUeR .”SINGTB.COM d. “I discovered a cure for cancer.”

ANS: B

Delusions associated with depression are congruent with the depressed mood. They often relate to somatic function or being a bad person, or they focus on faults. The other delusions are more likely to be present in an individual with schizophrenia.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 276

TOP: Nursing process: Evaluation

12. A patient who started taking a selective serotonin reuptake inhibitor (SSRI) 3 days ago says,

“This medicine isn’t working.” The nurse’s best intervention would be to: a. explain the time lag before antidepressants relieve symptoms. b. reassure the patient that the medication will be effective soon. c. critically assess the patient for lessening symptoms. d. explore the patient’s self-concept.

ANS: A

Antidepressant medications typically have a lag time of 2 to 4 weeks before being maximally therapeutic. A patient should be made aware of this instead of expecting symptom relief within 24 to 48 hours. Global reassurance is meaningless. Symptom abatement would not have occurred. Exploring the patient’s self-concept does not address the patient’s question.

DIF: Cognitive level: Applying

REF: p. 289

TOP: Nursing process: Implementation

MSC: NCLEX: Physiologic Integrity

13. A patient is to have a dexamethasone suppression test in the morning. Which statement should

be included in patient teaching? a. “This test will determine whether or not you are clinically depressed.” b. “This test is like a computed tomography scan. It will take about 20 minutes and will be painless.” c. “You will be given an injection; then, blood and urine samples will be collected.” d. “You will not be allowed to eat or drink after midnight, and a fasting blood sample will be collected in the morning.”

ANS: C

After the dexamethasone is given, periodic blood and urine samples are collected and sent to the laboratory to determine whether or not cortisol suppression has occurred.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 280 MSC: NCLEX: Psychosocial Integrity

14. During an interview with a depressed person, it is important for the nurse to assess social

interactions to determine: a. disruptions in relationships with others. b. needs for diversional-activities therapy. c. needs for implementation of a no-harm contract. d. the patient’s ability to make decisions about care.

ANS: A

Assessing for altered social interactions will give the nurse information about whether relationships with significantNothR ers I are G intaB ct. oC r disM rupted. Often, the depressed person has U S N T withdrawn to the extent that formerly supportive relationships have been disrupted, leaving the patient without situational support. Diversional activities are an integral part of management of the therapeutic milieu. The patient’s ability to make decisions would be assessed in other ways. A no-harm contract relates to suicidal ideation.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 279 MSC: NCLEX: Psychosocial Integrity

15. The plan for a depressed patient includes use of cognitive therapy. The nurse supports this

therapy by: a. uncovering unconscious conflicts by encouraging description of childhood traumas. b. challenging pessimistic beliefs and recognizing the patient’s accomplishments. c. determining areas of mutual understanding between the nurse and patient. d. using role-playing to rehearse new behaviors.

ANS: B

Depressed patients evaluate situations as being negative. Cognitive therapy aims at symptom removal by identifying and correcting distorted negative thinking. The other options are not directed at correcting negative thinking.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 278-279 MSC: NCLEX: Psychosocial Integrity

16. Which entry in the medical record best indicates that the treatment plan for a depressed patient

was successful? a. Gained 2 lb; sleeping 8 hours nightly; states, “I’m feeling better about my life situation” b. Weight stable; sleeping 6 hours nightly; complains of frequent abdominal pain and headache c. Gained 6 lb; sleeping 10 hours nightly; sensitive to interpersonal conflicts d. Lost 2 lb; sleeping 5 hours nightly; shows minimal interest in activities ANS: A

The correct entry suggests that weight, sleep pattern, and mood are returning to normal. The other entries suggest that symptoms of depression continue to be present.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 275-276

TOP: Nursing process: Evaluation

17. A depressed patient has just responded to the nurse in an overtly angry manner. Select the

nurse’s best response. a. “I seem to have hit a raw nerve. I’m sorry.” b. “You are angry. Let’s talk about the issue.” c. “Please watch your tone of voice when you speak to me.” d. “I don’t think I deserved to be shouted at. What’s really the matter?”

ANS: B

To be of maximal benefit to the patient, anger should be accepted and explored. Apologies by the nurse are unnecessary. The other options are defensive and rigid reactions.

DIF: Cognitive level: ApplyinN g R I GREB F:.C p. 28M1 U S N T TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 18. A patient says, “The doctor said I have dysthymic disorder.” What priority assessment data

should the nurse obtain to confirm the diagnosis? a. Changes in appetite and weight b. Presence of suicidal ideation c. How long symptoms have persisted d. Presence of delusions or hallucinations ANS: C

The major distinguishing factor between major depressive disorder (MDD) and dysthymic disorder is that dysthymic disorder has persisted for 2 years or more, with low mood occurring more than 50% of the time. It is a disease of chronicity, whereas MDD is a disease of severity.

Suicidal ideation can be present in any type of depression. Delusions and hallucinations are noted primarily in psychotic depression.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 272 MSC: NCLEX: Psychosocial Integrity

19. The sibling of a depressed patient says, “When we were children my sister always gave up

easily. Now as an adult, everyone in the family takes advantage of her.” What is the most appropriate nursing intervention? a. Begin cognitive therapy to reduce negative thinking. b. Plan measures to reduce inappropriate feelings of guilt.

c. Discuss the value of assertiveness training with the patient. d. Invite the sibling to join the patient’s group therapy sessions.

ANS: C

Depressed patients often allow people to violate their rights and then feel resentful or angry.

Assertiveness training will help the patient change her interpersonal style from acquiescent to assertive and reduce resentfulness. Cognitive therapy and working on guilt feelings will not address the passive behavior. It would not be appropriate to include the sibling in the patient’s group therapy.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 281 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. Which topics should be included by the nurse preparing psychoeducational groups for patients

with MDD and their families? Select all that apply. a. Flight of ideas b. Changes in weight and sleep c. Feelings of importance or elation d. Psychomotor retardation or agitation e. Inability to concentrate or make decisions ANS: B, D, E

Patients with MDD characteristically display weight change; anorexia produces weight loss, and excessive eating produces weight gain. Sleep disturbance is characteristically present in MDD, with many or early awakenings and hypersomnia seen. Changes in activity include RSsive I NG B.C psychomotor retardation andN exUces moTtor agitO ation. Indecision and poor concentration are characteristic cognitive symptoms. Flight of ideas and increased energy, importance, and elated mood are seen in bipolar disorder, manic type.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 274-275

TOP: Nursing process: Planning

Chapter 26: Bipolar Disorders MULTIPLE CHOICE 1. Which indicator of disordered communication is the nurse most likely to assess in a patient

having a manic episode? a. Loose associations b. Flight of ideas c. Echolalia d. Mutism ANS: B

Flight of ideas is a continuous flow of speech marked by jumping from topic to topic. The other options are most likely to be assessed in patients with schizophrenia.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 295; Box 26-1 MSC: NCLEX: Psychosocial Integrity

2. A patient at the clinic describes periods of sadness and depression as well as episodes of

elation over the past 3 years. The patient adds, “Fortunately, I have been able to keep my job despite these mood changes.” These findings are most consistent with which disorder? a. Bipolar I b. Bipolar II c. Cyclothymic d. Seasonal affective ANS: C

Cyclothymic disorder is characterized by mood swings between hypomania and depressive symptoms, with behavior at the poles being less severe than mania or depression. The patient’s ability to remain employed indicates that the periods of elation were hypomania rather than mania. The patient’s description does not meet criteria for any of the other options listed.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 299 MSC: NCLEX: Psychosocial Integrity

3. Which principle is most useful and effective when interacting with a patient experiencing a

manic episode? a. Encourage the patient to freely express feelings. b. Use a calm, matter-of-fact approach. c. Do not interrupt the patient. d. Frequently use silence.

ANS: B

A calm, matter-of-fact approach minimizes the need for the patient to respond defensively and avoids power struggles. Using this approach, the nurse conveys both control of the situation and empathy. The other options are not principles related to therapeutic interactions with a patient experiencing a manic episode. The distracters allow for manipulation of the nurse and for the patient to control the interaction.

DIF: Cognitive level: Applying

REF: pp. 302-303

TOP: Nursing process: Implementation

MSC: NCLEX: Psychosocial Integrity

4. A nurse assesses a new patient experiencing a manic episode. Which behavior is most likely

to have occurred before hospitalization? a. Watching others closely but avoiding interaction b. Taking frequent rest periods during the day c. Going rapidly from one activity to another d. Remaining in the home for long periods ANS: C

There is increased physical and mental activity exhibited during a manic episode. Moving rapidly from one activity to another is characteristic behavior during a manic episode. The other behaviors mentioned are not consistent with what occurs during a manic episode.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 297; Criteria for Bipolar Disorders MSC: NCLEX: Psychosocial Integrity

5. A patient diagnosed with bipolar I disorder says, “I will lead the next group about

medications. I have studied all the effects and problems with drugs on the Internet, so I can answer patients’ questions.” How should the nurse document this finding? a. Flight of ideas b. Distractibility c. Limit-testing d. Grandiosity ANS: D

Grandiosity is reflected when the individual makes statements that show an inflated sense of self-worth. Flight of ideas refNers R to rI apidG ly sB hi. ftC ing M topics of conversation. Limit-testing refers U S N T to attempting to override the structure of the milieu. Distractibility refers to inability to maintain concentration when environmental stimuli shift.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 295; Box 26-1 MSC: NCLEX: Psychosocial Integrity

6. The nurse prepares to take vital signs for a patient experiencing mania. What is the nurse's

best intervention when the patient's talking interferes with the assessment? a. Use a voice volume louder than the patient’s to say, “Stop talking now.” b. Interrupt by saying, “It’s time to take your vital signs now.” c. Delay taking the vital signs until the patient is quieter. d. Wait tolerantly for the patient to finish talking.

ANS: B

There are times when the nurse must simply, calmly, and firmly interrupt a manic patient.

Waiting is counterproductive. Yelling at the patient and delaying necessary assessments are inappropriate.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 303-304 MSC: NCLEX: Psychosocial Integrity

7. During community lunch, a manic patient tells another patient, “Push yourself away from the

table. You’re too fat for your own good!” How should the nurse intervene? a. Say to the patient, “You may remain at lunch only if you apologize.”

b. Tell the patient, “You must leave lunch and go to your room now.” c. Calmly tell the patient that insulting others is not permitted. d. Extinguish the behavior by ignoring it.

ANS: C

The nurse must protect vulnerable patients and keep them from being drawn into the manic patient’s angry behavior. By stating that the behavior is not permitted, the nurse sets limits and does not enter into an argument. The distracters will further anger the patient, may cause escalation, or may allow for loss of control.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 303-304 MSC: NCLEX: Psychosocial Integrity

8. Within a 15-minute period, a patient having a manic episode voices these complaints. “Dinner

was cold. The bath towels are rough. The solarium is too hot. I have a sore throat. Another patient needs a shower. The medication nurse is too slow.” The nurse should: a. listen but ignore the patient’s complaints. b. tell the patient to use the suggestion box. c. assess the patient’s throat, and take vital signs. d. invite the patient to share the concerns at the community meeting.

ANS: C

The hypercritical manic patient offers so many complaints that it is easy to discount his or her concerns. Legitimate complaints should always be investigated, however. By listening and ignoring complaints, the nurse might fail to intervene to provide care. Telling the patient to use the suggestion box or asking him to share his complaints at the community meeting are placating and may anger the patient.

NURSINGTB.COM REF: p. 303; Key Nursing Interventions Box

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

MSC: NCLEX: Safe, Effective Care Environment

9. A patient diagnosed with bipolar disorder is laughing and giddy one minute and seconds later

is angry and sarcastic. How should the nurse document the patient’s mood? a. Incongruent b. Inappropriate c. Blunted d. Labile ANS: D

Lability refers to rapid mood shifts, often seemingly without provocation. This is the only term that fits the description given in the scenario.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 300 MSC: NCLEX: Psychosocial Integrity

10. When a hyperactive, aggressive patient with bipolar disorder threatens to beat up another

patient, the initial nursing intervention should be to: a. provide firm verbal limits. b. place the patient in seclusion. c. ask the patient, “Why are you so angry?” d. distract the patient with diversional activities.

ANS: A

Unless a physical attack has taken place, verbal limit-setting should precede the use of more restrictive measures.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 303-304 MSC: NCLEX: Safe, Effective Care Environment

11. A medication teaching plan for a patient receiving lithium should include: a. directions to eat one or two bananas daily. b. dietary teaching to limit daily sodium intake. c. the need to restrict daily fluid intake to 1000 ml. d. the importance of laboratory testing to monitor the lithium level.

ANS: D

Maintaining serum lithium levels within 0.6 and 1.2 mEq/L is vital to symptom control. The patient must be made aware that frequent monitoring will foster symptom control and prevent toxicity. The other options are inappropriate in a teaching plan.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: pp. 303-304 MSC: NCLEX: Physiologic Integrity

12. The spouse of a patient diagnosed with bipolar I disorder says, “We want to have children, but

I worry they could inherit this problem. There is also bipolar disorder on my side of the family.” What is the nurse’s most appropriate action? a. Direct the couple to seek genetic counseling. b. Encourage the couple to consider adopting children. c. Encourage the spouse to discuss options with a spiritual advisor. d. Educate the spouse aboutNeU nvRirS onIm NeGntTalBd.etCerOmMinants of bipolar disorder.

ANS: A

The nurse’s advice should be based on knowledge that there appears to be a genetic role in the cause of bipolar disorder. Genetic counseling will provide the couple with the best possible basis for decision making. The other options will not provide the information that the couple needs to make an informed decision.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 301-302 MSC: NCLEX: Psychosocial Integrity

13. A newly admitted patient is experiencing a manic episode. The patient is verbally and

physically aggressive. The plan for care should include: a. setting clear limits, providing a quiet environment, and limiting activities. b. avoiding use of antipsychotic drugs for 24 hours and providing nourishment ad lib. c. orienting to unit activities, encouraging gross motor activity, and watching television. d. avoiding confrontations by not enforcing limits and encouraging physical exercise at bedtime.

ANS: A

Stimuli should be reduced to provide a simple, quiet, and nonstimulating environment. Clear limits should be explained in as few words as possible, and then maintained. Gross motor activity should be limited to prevent exhaustion, and exercise should not be encouraged at bedtime. Quiet activity is more conducive to initiating sleep. Intake should be monitored and food and fluids encouraged to compensate for the higher energy expenditure of the patient.

Antipsychotic drugs will probably be needed to reduce activity and aggressiveness.

DIF: Cognitive level: Applying REF: pp. 302-303 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

14. A nurse presents a psychoeducational program to patients with bipolar disorder and their

families. Information about signs of impending relapse of mania should include: a. diarrhea, thirst, and gross tremor. b. sleep disturbances and racing thoughts. c. decreased libido, anhedonia, and hypersomnia. d. delusional thinking, excessive guilt, and passivity.

ANS: B

Relapse symptoms are congruent with early symptoms of a manic episode. They include sleeping less, experiencing racing thoughts, and having boundless energy. Diarrhea, thirst, and tremor relate to lithium side effects. Libido increases. Delusional thinking may occur in an exacerbation of the illness but not usually before relapse.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 304; Patient and Family Education 26-1 MSC: NCLEX: Psychosocial Integrity

15. A nurse presents a psychoeducational program to patients with bipolar disorder and their

families. Information about sN igU nsRoSf I imNpG enTdB in. gC reO laM pse of depressive episode should include: a. diarrhea, thirst, and gross tremor. b. sleep disturbances and racing thoughts. c. decreased libido, anhedonia, and inertia. d. anorexia, excessive guilt, and aggression.

ANS: C

Relapse symptoms are congruent with early symptoms of a depressive episode. They include decreased libido, loss of pleasure, and lack of energy. Sleeping less, experiencing racing thoughts, experiencing aggression, and having boundless energy suggest impending mania.

Diarrhea, thirst, and tremor relate to lithium side effects.

DIF: Cognitive level: Understanding TOP: Nursing process: Implementation

REF: p. 295; Box 26-1 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. A nurse teaching about bipolar disorder should inform patients and their families of possible

depressive symptoms. Which symptoms should the nurse include? Select all that apply. a. Passivity b. Aggression c. Hyperactivity d. Psychomotor retardation e. Preoccupation with death

ANS: A, D, E

The symptoms of a bipolar depressive episode are often atypical, such as those consistent with the atypical depressive symptoms of major depressive disorder. They include preoccupation with death, psychomotor retardation, and passivity.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 295; Box 26-1 MSC: NCLEX: Psychosocial Integrity

2. What are the best menu selections for lunch for a hyperactive patient during a manic episode?

Select all that apply. a. Cherry pie b. Macaroni and cheese c. Chocolate chip cookies d. Tossed salad with ranch dressing e. Roast beef sandwich on whole-grain bread ANS: C, E

A hyperactive patient experiencing a manic episode is often too overactive to sit and eat, so the nurse must provide food that can be eaten out of hand while the patient walks around. A sandwich and cookies provide protein, carbohydrates, fat, and fiber.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 303; Key Nursing Interventions 26-1 MSC: NCLEX: Physiologic Integrity

3. A patient is hospitalized with new onset of manic behavior. It would be important for the

nurse to inspect and report results of which laboratory tests? Select all that apply. a. Calcium b. Creatinine c. Potassium d. Drug screens e. Thyroid function ANS: A, D, E

Medical conditions may cause mania, including hypercalcemia, hyperthyroidism, and selected drugs of abuse, particularly stimulants. Steroids may also produce mania.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 297; Box 26-3, Box 26-4 MSC: NCLEX: Physiologic Integrity

Chapter 27: Anxiety-Related, Obsessive-Compulsive, Trauma- and Stressor-Related, Somatic, and Dissociative Disorders MULTIPLE CHOICE 1. Which intervention should the nurse use first when caring for a patient experiencing anxiety? a. Assist the patient to problem solve. b. Provide support and understanding. c. Reorient the patient. d. Provide privacy.

ANS: B

Patients with anxiety disorders experience discomfort from the anxiety. The patient must feel safe, acknowledged, and cared for before problem solving can begin. The nurse’s first priority is to provide support and understanding. Allowing the patient to remain alone fosters social withdrawal and may allow anxiety to increase. Patients with anxiety seldom lose contact with reality.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 313

TOP: Nursing process: Planning

2. A patient diagnosed with obsessive-compulsive disorder (OCD) experiences improvement

after beginning treatment with a selective serotonin reuptake inhibitor (SSRI). This phenomenon supports the theory that OCD is associated with: a. norepinephrine deficiency. b. serotonin dysregulation.

NURSINGTB.C M O c. dopamine excess. d. GABA deficiency.

ANS: B

Serotonin dysregulation is hypothesized to play a part in OCD. Relief associated with SSRIs supports this hypothesis. The other theories are nonrelated.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 318

TOP: Nursing process: Evaluation

3. A patient says, “I have the same continuous and intrusive thoughts that my house is

contaminated with lethal bacteria. I spend hours cleaning the walls, floors, and furniture.”

These symptoms are most consistent with which diagnosis? a. Social phobia b. Panic disorder c. Somatoform disorder d. OCD ANS: D

The patient’s persistent intrusive thoughts are obsessions, and the need to continually clean is a compulsion. Hence, the patient’s disorder can be identified as OCD. The symptoms are not consistent with any of the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 317 MSC: NCLEX: Psychosocial Integrity

4. A patient’s family member died in the 9/11 World Trade Center explosion. The patient says,

“I can’t go into tall buildings because I get sweaty, my heart races, and I can’t breathe. I get terrifying feelings the building will explode.” These symptoms suggest which diagnosis? a. OCD b. Generalized anxiety disorder c. Acute stress disorder d. Specific phobia ANS: D

The patient has a severe and persistent fear of entering tall buildings. The extreme physical and emotional reactions are consistent with panic-level anxiety. The scenario does not suggest any of the other options as diagnoses.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 316-317 MSC: NCLEX: Psychosocial Integrity

5. When working with a patient diagnosed with dissociative amnesia, the nurse should begin by: a. setting mutual goals for behavioral changes. b. instituting measures to prevent identity diffusion. c. identifying and supporting the patient’s strengths. d. helping the patient develop a realistic self-concept.

ANS: C

Strengths serve as the foundation for later therapeutic work to promote more adaptive coping, so identifying and supporting strengths is a fundamental initial intervention. The other options are useful but are not fundamental.

N R I G B.C M

T p.O326 DIF: Cognitive level: ApplyingU S N REF: TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 6. A patient diagnosed with OCD paces up and down the corridor counting every tile. Select the

nurse’s best action. a. Offer to play cards with the patient in the dayroom. b. Ask the patient, “Why are you pacing and counting?” c. Take the patient’s arm and escort the patient to a quiet area. d. Permit the patient to pace and count until feeling more comfortable.

ANS: D

The performance of the pacing-counting ritual is decreasing the patient’s anxiety. Stopping her will increase anxiety. Rituals should be restricted only when they physically endanger the patient. The other options will not promote anxiety reduction.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 317 MSC: NCLEX: Psychosocial Integrity

7. A driver was trapped in a car for several hours after an earthquake caused a bridge to collapse.

A year later this person still has nightmares and reexperiences feelings of fear associated with being trapped in the car. The assessment findings are consistent with symptoms of: a. agoraphobia. b. panic attacks. c. generalized anxiety disorder.

d. posttraumatic stress disorder (PTSD).

ANS: D

PTSD follows exposure to a traumatic event. Symptoms include those described in the scenario, as well as persistent symptoms of arousal and avoidance of stimuli associated with the traumatic event. The symptoms presented are inconsistent with the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 319 MSC: NCLEX: Psychosocial Integrity

8. A patient is hospitalized with blindness of sudden onset. According to the spouse, the patient

entered a room and found the spouse in a romantic embrace with a neighbor. The patient is unconcerned about the blindness and says, “I’m sure things will turn out all right.” Which term best describes this reaction? a. La belle indifference b. Agoraphobia c. Dissociation d. Fugue ANS: A

La belle indifference refers to an attitude of unconcern or indifference about a symptom when the symptom is unconsciously used to lower anxiety. The other options do not characterize the symptoms described.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 324 MSC: NCLEX: Psychosocial Integrity

9. Which principle best applies N to cR are I of aGpatB ie. ntCdiaM gnosed with conversion disorder?

U S N T a. Structure care to provide time for rituals. b. Facilitate progressive review of the trauma. c. Give attention to the patient, not the symptom. d. Permit dependence while the symptoms are acute.

ANS: C

Often, patients with conversion disorder think that their symptom makes them interesting and that they are not interesting as persons. The nurse should matter-of-factly accept the symptom without focusing on it and direct attention to the person as an individual. Two distracters refer to care of a patient with OCD and care of a patient with PTSD. DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: Key Interventions 27-6; p. 325 MSC: NCLEX: Psychosocial Integrity

10. A patient with panic attacks awakens from sleep complaining of chest pain. The patient is

diaphoretic and breathlessly says, “I feel like I’m going to die.” Select the nurse’s priority action. a. Have the patient lie flat and relax. b. Bring the crash cart to the patient’s room. c. Shake the patient and shout, “Are you okay?” d. Instruct the patient to breathe into a paper bag.

ANS: D

Hyperventilation should be addressed immediately by having the patient breathe using a paper bag. Bringing breathing under control will help diminish the other symptoms. The calm presence of the nurse is vital to symptom reduction. The other interventions would not be effective in relieving the hyperventilation.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: Key Interventions 27-3; p. 316 MSC: NCLEX: Psychosocial Integrity

11. What is the nurse’s initial action when working with a patient with PTSD? a. Develop trust. b. Promote problem solving. c. Encourage verbalization of anger. d. Have the patient evaluate past behaviors.

ANS: A

Patients with PTSD are often withdrawn and feel suspicious, detached, or estranged from others. Developing a trusting relationship might be difficult for them; however, the development of trust is fundamental to the therapeutic nurse–patient relationship. The other interventions will not be possible until a trusting relationship exists.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 321. Key Interventions 27-5; p. 322 MSC: NCLEX: Psychosocial Integrity

12. Which statement by an individual with PTSD best indicates that treatment was effective? a. “I’m drinking less now that I’ve faced my problems.” b. “I feel like the accident happened to someone else.” c. “I sleep for 3 to 4 hours a night without nightmares.” d. “My artwork distracts meNaU ndReSaI seN sG mT yB an.xC ieO tyM .”

ANS: D

Treatment has been successful when an individual can use coping mechanisms to move forward and find meaning in the traumatic event. Continued use of drugs and alcohol is maladaptive. Continued sleep disturbances and insomnia as well as dissociation or depersonalization do not indicate that treatment was effective.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 320-321

TOP: Nursing process: Evaluation

13. After a mass transit disaster many injured patients are expected at the emergency room. The

nurse expects victims to have which assessment findings? a. Dissociative symptoms, numbing, detachment, and derealization b. Auditory hallucinations and other perceptual distortions c. Physical symptoms that mimic neurologic disorders d. Exaggerated mood (either depression or elation) ANS: A

Acute stress reactions are marked by dissociative symptoms such as numbing of emotional responsiveness, feelings of detachment, and decreased awareness of surroundings. The other options list behaviors that are atypical of acute stress reactions.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 319-320 MSC: NCLEX: Psychosocial Integrity

14. Which statement by a patient diagnosed with somatic symptom disorder indicates that goals

for treatment are being achieved? a. “I need to be very careful about what I eat.” b. “I can focus on things other than my symptoms.” c. “I understand that my doctor is not an expert in everything.” d. “I try to figure out my diagnosis by reading articles on the Internet.”

ANS: B

This statement suggests that the patient’s preoccupation with physical symptoms has decreased. The other options suggest ongoing concern with his or her physical state.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 323

TOP: Nursing process: Evaluation

15. The nurse would expect which comment from a patient diagnosed with depersonalization

disorder? a. “I feel like I’m outside my body, watching what’s happening.” b. “I feel as though someone is reading thoughts in my mind.” c. “I know I have cancer, but the doctors can’t find it.” d. “When I woke up, my legs were paralyzed.”

ANS: A

In depersonalization, individuals feel detached from parts of their body or their mental processes. The distracters reflect somatization disorder, conversion disorder, and schizophrenia.

DIF: Cognitive level: ApplyinN g R I GREB pp. 3M25-326 U S N MSC: TF:.C TOP: Nursing process: Assessment NCLEX: Psychosocial Integrity 16. Which symptom would the nurse expect in a patient diagnosed with dissociative fugue? a. Worry about having a serious disease b. A feeling of detachment from one’s body c. Belief that part of the body is ugly or disproportionate d. Travel away from home and assumption of a new identity ANS: D

Dissociative fugue involves unplanned travel away from one’s usual home and either confusion about identity or assumption of a new identity. The person does not seem to be wandering but behaves purposefully. The other options relate to body dysmorphic disorder, depersonalization disorder, and hypochondriasis.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 326-327 MSC: NCLEX: Psychosocial Integrity

17. A priority focus of milieu management for a patient diagnosed with dissociative identity

disorder (DID) should be: a. ensuring safety. b. stimulating memory return. c. insight-oriented group therapy. d. gathering data about family relationships.

ANS: A

Patients with DID have a host personality and one or more alternates. It is not unusual for one of the alternate personalities to be depressed and wish to commit suicide or for a personality to wish to harm the others. Safety is the priority concern in care.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 327-328

TOP: Nursing process: Planning

18. Select the most important assessment question to ask a patient suspected of having a

dissociative disorder. a. “Do any members of your family have problems with drugs or alcohol?” b. “Do you ever find yourself in places with no idea how you got there?” c. “How would you describe your current level of anxiety?” d. “How do you think we can be of help to you?”

ANS: B

The correct response would provide information relevant to dissociative amnesia, dissociative fugue, or dissociative identity disorder, making it a good assessment question. The other questions are of no particular relevance.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 326-327 MSC: NCLEX: Psychosocial Integrity

19. Which term describes the final stage in the normal process of anxiety? a. Panic b. Crisis c. Disorganization d. Coping ANS: D

The individual moves from experiencing the symptoms of anxiety to the use of coping behaviors to alleviate these symptoms. Panic is a level of anxiety. Crisis involves disorganization, which is not always the end product of anxiety. Disorganization is not always experienced as the product of anxiety.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 309-310 MSC: NCLEX: Psychosocial Integrity

20. The effects of stress can be seen by measurement of clinical changes of the body. This

statement is a tenet of which theorist? a. Freud b. Selye c. Peplau d. Sullivan ANS: B

Selye found that the effects of stress can be seen by objective measurement of structural and clinical changes in the body. Roy’s nursing theory uses this foundation. None of the other options deal with stress.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 308 MSC: NCLEX: Physiologic Integrity

21. If a patient’s threshold set point for anxiety is lowered, the nurse can expect subsequent

stressors to: a. have a lesser effect. b. easily reactivate the anxiety response. c. produce marked personality disorganization. d. be easily managed using familiar coping strategies.

ANS: B

Lowering the threshold set point for anxiety will result in the patient becoming anxious more easily. Thus, lesser effect and ease of handling are incorrect options. Marked personality disorganization would not necessarily occur.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 311 MSC: NCLEX: Psychosocial Integrity

22. An anxious patient has distorted perceptions and ineffective reasoning. On an anxiety rating

scale, the nurse would expect to record the patient’s level of anxiety as: a. mild, +1. b. moderate, +2. c. severe, +3. d. panic, +4.

ANS: C

Cognitive symptoms of severe anxiety include distorted perceptions, difficulty focusing, and ineffective reasoning. Other symptom constellations relate to the other levels.

DIF: Cognitive level: ApplyinN g R I GREB TablM e 27-1; 309 U S N MSC: TF:.C TOP: Nursing process: Assessment NCLEX: Psychosocial Integrity 23. A patient is demonstrating severe (+3) anxiety. Nursing interventions will center around: a. encouraging ventilation and refocusing attention. b. discussing possible sources of anxiety. c. taking control to guide the patient. d. decreasing stimuli and pressure.

ANS: D

Severe anxiety requires intervention to relieve the heightened tension and discomfort that the patient is experiencing. Perceptions are often distorted, focusing is difficult, and problem solving is impossible, even with help. Environmental simplification and kind, firm directions are approaches to decreasing stimuli and pressure. The other options will not be as effective.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: Key Interventions 27-1; p. 313 MSC: NCLEX: Psychosocial Integrity

24. A nurse is assigned to care for a patient diagnosed with moderate (+2) anxiety. Which

assessment findings are most likely? a. Distorted perceptions, disorientation, and defensiveness. b. Poor concentration, narrow perceptions, and irritability. c. Irrational reasoning and loss of contact with reality. d. Alertness, attentiveness, and accurate perceptions.

ANS: B

In moderate anxiety states, the body is preparing for protective action. Cognitive symptoms include difficulty concentrating, distractibility, narrowed perceptions, short attention span, tangentiality or circumstantiality, and decreased problem-solving ability. Alertness is associated with mild anxiety. Distorted perceptions are associated with severe anxiety.

Irrational reasoning is associated with panic.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 309-310 MSC: NCLEX: Psychosocial Integrity

25. The nurse is assigned to care for a patient with moderate anxiety (+2). The most effective

nursing intervention will be: a. use of time-out. b. initiation of problem solving. c. providing firm guidance and control. d. administering a parenteral antianxiety drug.

ANS: B

Using problem solving is an appropriate goal for a patient experiencing moderate anxiety, because these patients are capable of problem solving with assistance. Use of time-out, providing firm guidance and control, and giving parenteral medication are interventions more often used for severe and panic-level anxiety.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: Key Interventions 27-1; p. 313 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. A patient diagnosed with PTSD has frequent flashbacks and persistent hyperarousal

symptoms. Which nursing interventions should be planned? Select all that apply. a. Offer empathy and support. b. Encourage relaxation activities. c. Encourage verbalization of anger. d. Set limits when the patient begins to tell of the story of the traumatic incident. e. Help the patient associate current feelings and behaviors with trauma experience.

ANS: A, B, C, E

These measures are designed to help reduce PTSD symptoms. Anger should be expressed and accepted. Patients with PTSD should learn that their feelings are commonly experienced by others with the same disorder. Recounting the traumatic event helps patients integrate the feelings of distress, so limiting such behavior is not therapeutic.

DIF: Cognitive level: Applying TOP: Nursing process: Planning

REF: pp. 319-322, Key Interventions 27-5; p. 322 MSC: NCLEX: Psychosocial Integrity

Chapter 28: Cognitive Disorders MULTIPLE CHOICE 1. The foundation of the cognitive process is: a. reasoning and logic. b. memory and learning. c. orientation and speech. d. perception and behavior.

ANS: B

Cognitive abilities revolve around memory and learning, with memory as foundational for learning. The other functions are dependent on memory and learning.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 331-332 MSC: NCLEX: Physiologic Integrity

2. A nurse assesses a newly admitted patient with possible delirium. Which aspect of the history

contributes to confirmation of the diagnosis? a. Acute onset of cognitive symptoms b. Unchanging level of consciousness c. Loss of ability to think abstractly d. Paranoid delusions ANS: A

Delirium develops rapidly, as opposed to dementia, which has an insidious onset. Other symptoms of delirium includN e fluRctuI atinG g leB ve.l C of cM onsciousness, logical thoughts alternating U S N T O with illogical thoughts, presence of visual hallucinations, and day–night sleep reversal. Loss of ability to abstract is also seen in dementia. Delusions are common to dementia.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 333 MSC: NCLEX: Psychosocial Integrity

3. Donepezil (Aricept) reduces symptoms for patients diagnosed with mild to moderate

Alzheimer’s disease (AD) by: a. enhancing acetylcholine (Ach) function. b. inhibiting serotonin reuptake. c. anti-oxidizing free radicals. d. reducing GABA action.

ANS: A

In AD, the level of ACh in the brain is reduced. ACh is the primary neurochemical that affects memory and the ability to acquire new information. Donepezil is an anticholinesterase inhibitor and improves symptoms by making more ACh available. The drug does not have any of the actions mentioned in the other options.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: pp. 346-347

TOP: Nursing process: Planning

4. The focus of nursing care for a patient diagnosed with dementia is: a. individualizing care.

b. improving cognition. c. maintaining optimum function. d. promoting self-confidence and self-esteem.

ANS: C

Because memory is impaired, an individual with dementia cannot learn easily, so maintaining functioning as long as possible is important. The patient’s abilities are expected to decline over time. Use of the word “optimum” suggests the changing nature of the level of functioning. Individualizing care and promoting esteem and confidence are of lesser importance than maintaining optimal function.

DIF: Cognitive level: Applying REF: p. 345 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

5. An older adult with dementia describes a pencil as “that thing that writes” and a water faucet

as “the thing you turn.” The nurse documents which problem? a. Echolalia b. Apraxia c. Agnosia d. Amnesia ANS: C

Agnosia is defined as failure to recognize or identify objects despite intact sensory function.

Apraxia refers to inability to carry out motor activities. Echolalia is repeating what others say.

Amnesia refers to learning and recalling information.

DIF: Cognitive level: Applying TOP: Nursing process: AssessN menR t

REF: Box 28-1; pg 340 M : N G SBC. CCLMEX: Psychosocial Integrity

U SIN T

O

6. An older adult patient has fluctuating levels of awareness, anxiety, and appears to be picking

things out of the air. The patient says, “I saw my granddaughter standing at the foot of the bed last night.” The nurse should suspect: a. delirium. b. dementia. c. schizophrenia. d. bipolar disorder.

ANS: A

The symptoms presented are consistent with the symptoms of delirium. Fluctuating levels of consciousness are not characteristic of dementia, schizophrenia, or bipolar disorder.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 333 MSC: NCLEX: Physiologic Integrity

7. An older adult patient is admitted with a diagnosis of delirium secondary to a urinary tract

infection. The family asks whether or not the patient will recover. Select the nurse’s best response. a. “The healthcare provider is the best person to answer your question.” b. “The confusion will probably get better as we treat the infection.” c. “Unfortunately, delirium is a progressively disabling disorder.” d. “I will be glad to contact the chaplain to talk with you.”

ANS: B

Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear.

The distracters mislead the family.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 334 MSC: NCLEX: Physiologic Integrity

8. An older adult presents with symptoms of delirium. The family says, “Everything was fine

until yesterday.” The most important assessment information to gather is: a. a list of medications the patient currently takes. b. whether or not the patient has experienced any recent losses. c. whether or not the patient has ingested aged or fermented foods. d. the patient’s recent personality characteristics and changes.

ANS: A

Delirium is often the result of medication interactions or toxicity. The distracters relate to monoamine oxidase inhibitor therapy and pseudodementia.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 334 MSC: NCLEX: Physiologic Integrity

9. An older adult patient developed delirium secondary to diphenhydramine (Benadryl) use. The

patient usually took this drug for allergies but recently added a cough syrup that also contained the drug. What information is most important to teach the family? a. Older adults are more prone to delirium. b. The patient is now susceptible to progressive cognitive decline. c. Toxic medication levels often occur because of slower metabolism in older adults. d. The older adult brain hasN feUwRerSnIeuNrG otT raB ns. mCitO teM rs than the brain of a younger person.

ANS: C

Older adult patients metabolize drugs more slowly as a result of declining liver function.

Excretion might also be slowed. Drugs might accumulate until toxic levels are reached and cognitive symptoms appear. Anticholinergic drugs, antihistamines, and antiarrhythmia drugs are of particular concern. For this reason, families need to be aware of the drugs that older adults are using and the possible interactions among the drugs, and be alert for early symptoms of cognitive disturbance. Although older adults are more prone to delirium, it’s important to provide more specific information to the family. None of the other options are correct.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 334 MSC: NCLEX: Physiologic Integrity

10. An older adult patient diagnosed with delirium is anxious, agitated, and experiencing visual

hallucinations. The nurse entering the room to assess vital signs should: a. announce his or her name and title, and what is happening. b. silently take the vital signs to minimize stimulation. c. ask the patient to identify place, person, and time. d. turn on all lights in the room.

ANS: A

A patient who is anxious, confused, and experiencing sensory perceptual alterations needs help coping with the environment. Nurses should identify themselves whenever entering the room, giving both their name and title, and provide simple explanations and directives. The other options are inadvisable.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 345-346 MSC: NCLEX: Physiologic Integrity

11. Which assessment finding would be expected in a patient in the later stages of Huntington’s

disease? a. Jerking movements b. Cogwheel rigidity c. Withdrawal d. Irritability ANS: A

Myoclonic jerking, as well as cognitive dysfunction, characterize the later stages of Huntington’s disease (HD). The distracters are seen in Parkinson’s disease, are not part of the clinical picture of HD, or are characteristic of earlier stages.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 344 MSC: NCLEX: Physiologic Integrity

12. A patient diagnosed with delirium stares at the corner of the room, wrings hands, and says,

“I’m scared those snakes will bite me.” The nurse should document: a. agnosia. b. disorientation. c. confabulation. d. visual hallucinations.

ANS: D

Seeing objects that are not visible to another person can be documented as having visual hallucinations, rather than any of the other choices.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 333 MSC: NCLEX: Psychosocial Integrity

13. The nurse teaches a family who provides in-home care for a patient diagnosed with dementia.

Which measure to facilitate environmental safety should the nurse include? a. Install gates at the tops and bottoms of stairs. b. Store medications in a clearly visible place. c. Vary the daily schedule to provide variety and stimulation. d. Include daily activities that call for use of higher cognitive functions.

ANS: A

Patients with dementia often have difficulty negotiating stairs and fall. Providing gates prevents the patient from entering the stairs and falling. The other options do not apply, because they do not promote safety or might produce demands that exceed the patient’s ability to function.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 334 MSC: NCLEX: Safe, Effective Care Environment

14. The family of a patient diagnosed with AD is concerned about the patient’s occasional urinary

incontinence. The nurse should give which suggestion? a. Use adult diapers. b. Put a sign on the bathroom door. c. Limit fluid intake to 1,000 ml daily. d. Take the patient to the bathroom every 2 hours.

ANS: D

Seeing to it that the patient goes to the bathroom every 2 hours will minimize episodes of incontinence. Severe dementia might require adult diapers. Limiting fluids is never advised.

Placing a sign on the bathroom door is effective only when the patient recognizes the need to void but is unable to find the bathroom.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 345 MSC: NCLEX: Physiologic Integrity

15. A nurse gives anticipatory guidance to the family of a patient diagnosed with mild AD. Which

problem common to that stage should be addressed? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self ANS: C

Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the diseNaU seR . SINGTB.COM DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 345 MSC: NCLEX: Psychosocial Integrity

16. What is the nursing care priority for a patient diagnosed with Stage 7 Alzheimer’s disease? a. Nutrition and hydration b. Promoting self-care activities c. Supporting attempts to communicate d. Preserving problem-solving abilities ANS: A

When dementia is severe, the individual is incapable of independently meeting nutrition and hydration needs and must receive assistance. The other options refer to inappropriate emphases for care.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 336

TOP: Nursing process: Planning

17. Which assessment finding would be expected in a patient in the early stage of HD? a. Cogwheel rigidity b. Irritability c. Apraxia d. Aphasia

ANS: B

Personality changes are often evident in increased irritability in early HD. The distracters are seen in Parkinson’s disease or dementia.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 344 MSC: NCLEX: Physiologic Integrity

18. An older adult suddenly develops urinary incontinence. A family member says the patient

“started walking oddly, like stepping on a sticky floor.” Which problem would the nurse suspect? a. Pick’s disease b. Parkinson’s disease c. HD d. Normal-pressure hydrocephalus (NPH) ANS: D

The classic triad of symptoms associated with NPH is urinary incontinence, ataxic gait, and dementia. Early dementia might be manifested by impairment in activities of daily living, dulling of personality, and lack of motivation. NPH is treatable with ventro-peritoneal shunting.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 334 MSC: NCLEX: Physiologic Integrity

19. Last year a patient had a subtotal gastrectomy after being diagnosed with stomach cancer.

Now the patient says, “I’d rather take vitamin pills than shots.” Which information should the nurse provide to this patient? a. Most patients have difficN ulU tyRreSmIeN mG beT riB ng.tC oO taM ke the vitamins. Deficits can precipitate a recurrence of the cancer. b. Injections are needed, because the loss of stomach tissue reduces absorption of vitamin B12. c. Injections will eventually be replaced with pills, but it is too soon after the gastrectomy. d. Injections prevent development of NPH and delirium.

ANS: B

Vitamin B12 is absorbed in the stomach, aided by intrinsic factor. Deficiency leads to dementia. Regular supplementation of vitamin B12 prevents the deficiency and development of cognitive symptoms. The injections will be needed for life.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 334-335 MSC: NCLEX: Physiologic Integrity

20. A patient diagnosed with vascular dementia gets more confused, agitated, and anxious in the

evening. This behavior represents: a. sundowning. b. moonlighting. c. differentiating. d. misinterpreting.

ANS: A

The sundown syndrome is the name given to behavior that occurs late in the afternoon or early evening when a patient with dementia becomes more confused. It is sometimes called “sundowning.” Moonlighting refers to working a second job. Differentiating refers to making distinctions between or among things. Misinterpreting refers to incorrectly perceiving the environment.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 341 MSC: NCLEX: Psychosocial Integrity

21. A patient has coronary artery disease, type 2 diabetes, and hypertension. The patient has risk

factors for: a. vascular dementia. b. Parkinson’s dementia. c. diffuse Lewy body disease. d. frontotemporal lobe dementia.

ANS: A

Risk factors for strokes causing dementia include hypertension, coronary artery disease, cardiac arrhythmias, and diabetes. These health problems are not associated with the other dementias mentioned.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 341 MSC: NCLEX: Health Promotion and Maintenance

22. A patient with vascular dementia does not remember family members’ names. The family

insistently reorients the patient, and the patient becomes more agitated. What is the most likely reason for the patient’s reaction? The patient is: B.thCe OcoMgnitive deficits. a. using agitation to distractNth UeRfaSmIilNyGfrTom b. overstimulated by the reorientation and reacting negatively. c. reliving family chaos that was previously unresolved. d. experiencing guilt about the memory deficits.

ANS: B

Reorientation in this case presents a demand that exceeds the patient’s capacity to function and creates stress. In this situation, it would be more humane to visit the patient and communicate love and acceptance without being concerned about whether or not the patient can remember names.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 339-340

TOP: Nursing process: Evaluation

23. A patient diagnosed with dementia is watching a crime story on television. Suddenly, the

patient begins to yell, “Stop! He’s got a gun.” What is the nurse’s best intervention? a. Administer a PRN dose of an atypical antipsychotic medication. b. Turn off the television and tell the patient, “You are safe.” c. Reassure the patient that there are no guns nearby. d. Provide a snack, and put the patient in bed.

ANS: B

Patients with cognitive deficits might be overwhelmed by stimuli and might misperceive something on television as occurring in reality. If this occurs, stimuli should be reduced to simplify the environment. The other measures would be somewhat less effective, because they do not include removing the offending stimulus (the television).

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 345-346 MSC: NCLEX: Psychosocial Integrity

24. A newly admitted patient diagnosed with AD has demonstrated apraxia. The nurse should

assist the patient with: a. grooming and hygiene. b. visual acuity. c. word finding. d. orientation.

ANS: A

Apraxia is the inability to carry out motor activities despite intact motor function. The patient activity that would be altered by lack of motor function is grooming and hygiene.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 340 MSC: NCLEX: Psychosocial Integrity

25. Which vector is associated with transmission of variant Creutzfeldt-Jakob disease? a. Dog ticks b. Mosquito bites c. Airborne particles d. Contaminated meat ANS: D

Contaminated meat is the vector for variant Creutzfeldt-Jakob disease. Dog ticks are the vector for Rocky Mountain spotted fever and Lyme disease. Mosquitoes are the vector for encephalitis. Airborne particles spread tuberculosis.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 342 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. Which aspects of assessment are most important for a patient with diffuse Lewy body disease

who is agitated? Select all that apply. a. Medications recently administered b. Objective signs of pain c. Sleep disturbances d. Urinary output e. Heart sounds ANS: A, B, C, D

Patients with dementia who exhibit disruptive behavior might be delirious, confused, or in pain. Because they cannot make their needs known, the nurse should investigate all possible causes. Agitation may result from urinary retention. Heart sounds are not likely to be affected.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 342-343 MSC: NCLEX: Physiologic Integrity

Chapter 29: Personality Disorders MULTIPLE CHOICE 1. Which statement accurately applies to personality disorders? a. One aspect of personality is usually involved. b. Personality traits are dysfunctional and inflexible. c. Patients have subjective distress, but not impaired functioning. d. Symptoms have a short duration and are responsive to treatment.

ANS: B

Patients with personality disorders suffer lifelong inflexible and dysfunctional patterns of relating and behaving. The patient experiences subjective distress, usually based on others’ reactions to him or her, and functioning is impaired. More than one aspect of personality is involved: personality disorders are described as pervasive. Behaviors are complex and difficult to manage.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 356

TOP: Nursing process: Planning

2. A patient demonstrating borderline personality disorder says, “When I met him, he was

perfect and gave me everything. Now I know how bad he really is. He left me alone tonight to go out with others, so I had to cut myself.” Which feature is evident? a. Splitting b. Paranoia c. Grandiosity d. Submissiveness ANS: A

Splitting involves the inability to integrate the good and bad aspects of an object, so her boyfriend is seen as perfect or entirely bad, not as a person with some traits that she likes and some that she dislikes. Paranoid tendencies involve feelings of persecution. There is no indication that the patient is submissive or grandiose.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 359-360

TOP: Nursing process: Evaluation

3. A patient has had long-term conflicts with two siblings over their parents’ wills. The patient

reacts quickly with anger, suspicious that the siblings are plotting to take all the inheritance.

These characteristics are most consistent with which personality disorder? a. Schizoid b. Paranoid c. Borderline d. Narcissistic ANS: B

The characteristics mentioned in the scenario fit the description of paranoid personality disorder. Schizoid personality is characterized by shyness, withdrawal, and poor social relationships. Borderline personality is characterized by problems with identity, self-image, mood, and impulsivity. Narcissistic personality is characterized by self-importance, grandiosity, and a sense of entitlement.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 357

TOP: Nursing process: Evaluation

4. The nurse working with a patient diagnosed with borderline personality disorder expects: a. grief and social isolation. b. withdrawal and social avoidance. c. mood shifts, impulsivity, and manipulation. d. seductiveness, grandiosity, and overreaction.

ANS: C

Characteristic behaviors of individuals with borderline personality disorder include rapid mood shifts, impulsive acting out, and manipulation of others, as well as problems with identity, dependency, self-mutilation, and unstable, intense interpersonal relationships.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 357

TOP: Nursing process: Planning

5. A nurse caring for a person diagnosed with schizoid personality disorder expects which

assessment findings? a. Impulsive, restless, socially aggressive behavior b. Few interactions with others; little verbalization c. Magical thinking; suspiciN ouUsR , oSdI dN beG hT avB io. r COM d. Distrustful, cold, often angry behaviors ANS: B

Individuals with schizoid personality disorder do not want to be involved in relationships.

They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The distracters characteristically apply to antisocial personality disorder, schizotypal personality disorder, and paranoid personality disorder.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 357 MSC: NCLEX: Psychosocial Integrity

6. Which characteristic of individuals diagnosed with personality disorders in the

dramatic-erratic cluster makes it advisable for staff to have frequent patient-centered meetings? a. Manipulating others to avoid limits b. Behaving responsibly in the peer group c. Withdrawing from interactions with others d. Depending excessively on others for support ANS: A

The group of dramatic-erratic personality disorders includes antisocial and borderline personality disorders. These patients are particularly skillful at manipulating others to get their needs met. The distracters list characteristics that would not require frequent meetings.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 361

TOP: Nursing process: Planning

7. A clinic nurse encounters a new patient diagnosed with schizoid personality disorder. What is

the best initial nursing intervention? a. Set firm limits. b. Engage in trust building. c. Involve the patient in group activities. d. Encourage identification of feelings.

ANS: B

Trust building is essential to developing a nurse–patient relationship. Firm limit-setting is rarely necessary when working with a patient with schizoid personality disorder. Involvement in activities might be difficult at first, because the patient will be highly uncomfortable around people. The patient must trust the nurse before responding to encouragement to express feelings.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 357 MSC: NCLEX: Psychosocial Integrity

8. When contrasting schizophrenia and schizotypal personality disorder, which statement

applies? a. In schizotypal personality disorder, the patient remains psychotic much longer. b. The patient with schizophrenia has better social skills and is not usually overtly psychotic. c. The person with schizotypal personality disorder may have cognitive distortions but not psychosis.

N R I G B.C M d. Schizotypal personality disU ordeSr isNassT ociatedO with more frequent and prolonged hospitalizations.

ANS: C

The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, overt psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, have poorer social skills, and have more frequent and prolonged hospitalizations.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 358

TOP: Nursing process: Planning

9. A distinctive characteristic in a patient with antisocial personality disorder is: a. feelings of guilt and remorse. b. disregarding the rights of others. c. responsiveness to antipsychotics. d. responsiveness to kind suggestions.

ANS: B

Individuals with antisocial personality disorders have no concern for what is right or wrong or for the rights of others. They frequently violate others’ rights and frequently break laws in their “me first” thinking. These individuals exhibit no guilt or remorse, show no improvement from antipsychotics, and walk all over anyone who is not able to set firm limits.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 358-359 MSC: NCLEX: Psychosocial Integrity

10. An adult has a history of intoxication and promiscuity. After stealing money from a

grandparent, this person says, “I deserved that money. My family had no right to press charges against me.” The scenario depicts features of which personality disorder? a. Histrionic b. Narcissistic c. Antisocial d. Borderline ANS: C

Individuals with antisocial personality disorder have no concern for what is right or wrong or for the rights of others. They frequently violate others’ rights and frequently break laws in their “me first” thinking. These individuals exhibit no guilt or remorse. Narcissistic personality disorder is characterized by grandiosity and a sense of entitlement. Borderline personality disorder is characterized by identity disturbances, impulsivity, self-mutilation, and affective instability.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 358-359 MSC: NCLEX: Psychosocial Integrity

11. Since admission, a patient diagnosed with antisocial personality disorder has been highly

manipulative and constantly tests staff. Now, the patient insists on watching a late movie instead of complying with the bedtime. Select the nurse’s best response. a. “It’s a unit rule that bedtime is at 10 PM.” b. “I will not allow you to manipulate me again.”

GeTwBi. c. “If you ask again, tomorrN ow beI dtN im ll C beO9MPM.” U’Rs S d. “I understand your sleep problems and can allow it just this once.”

ANS: A

Attempts at manipulation can be successfully handled by firm, matter-of-fact reiteration of unit policies and consistently adhering to them. The other responses are defensive, retaliative, or permissive.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 359-360 MSC: NCLEX: Psychosocial Integrity

12. A patient diagnosed with borderline personality disorder has demonstrated self-mutilation and

inappropriate expressions of anger. Which statement by the patient would the nurse evaluate as an improvement? a. “I think you are the nicest nurse on the unit.” b. “I got drunk last night, but I won’t ever do it again.” c. “I felt like cutting myself, so I came to talk to you.” d. “I hate my friends. They never help me when I need it.”

ANS: C

Ordinarily, the patient would impulsively engage in self-mutilation. When he or she is able to delay the action and seek the more adaptive coping strategy of talking with the nurse, the nurse can correctly evaluate the patient as showing improvement. The other responses suggest use of idealization, manipulation, impulsive behavior, and devaluation, all symptomatic of the disorder.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: pp. 360 -362 TOP: Nursing process: Evaluation

13. The history of an individual diagnosed with borderline personality disorder often includes: a. the loss of a parent at an early age. b. a family history of bipolar disorder. c. a dysfunctional, abusive childhood. d. an overindulged childhood with few limits.

ANS: C

There is no clear-cut cause for borderline personality disorder. It is probably multifactorial.

Environmental factors include childhood neglect and abuse. Biologic theories suggest neurotransmitter dysregulation. Object losses, family history of bipolar disorder, and overindulgence as a child have not been identified as causative factors.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 359-360 MSC: NCLEX: Psychosocial Integrity

14. Which nursing intervention is most likely to result in heightened self-awareness for a patient

diagnosed with a personality disorder in the dramatic-erratic cluster? a. Setting firm limits on behavior b. Providing clear expectatiN onU sR foS rI acN ceGpT taB bl. eC beO hM avior c. Using confrontational approaches to reduce self-mutilation d. Encouraging the patient to keep a daily journal to be shared with the nurse ANS: D

Patients can be helped to understand themselves and their feelings by keeping a journal.

Sharing the journal with the nurse fosters greater understanding and a sense of autonomy and responsibility. The other options do not heighten self-awareness.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 361

TOP: Nursing process: Planning

15. Characteristic behaviors a nurse would expect when working with a patient diagnosed with

narcissistic personality disorder are: a. preoccupied with details; perfectionism. b. socially isolated; odd, eccentric behavior. c. dramatic expression; easily influenced by others. d. grandiosity; sense of entitlement; lack of empathy.

ANS: D

The individual with narcissistic personality disorder displays grandiosity about self-importance and achievements, does not empathize or understand the feelings of others, exhibits a sense of entitlement, and expects special treatment. The other options reflect characteristics of histrionic personality disorder, obsessive-compulsive personality disorder, and schizotypal personality disorder.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 363-364

TOP: Nursing process: Planning

16. A person loves being the center of attention. Recently this person sustained a paper cut on a

finger and called an ambulance. The patient says, “I can’t believe my supervisor denied my sick leave request.” This individual most clearly displays traits of: a. dependent personality disorder. b. histrionic personality disorder. c. antisocial personality disorder. d. borderline personality disorder.

ANS: B

Individuals with histrionic personality disorder dramatize all events and draw attention to themselves. Patients might use somatic complaints to avoid responsibility and support dependency.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 364 MSC: NCLEX: Psychosocial Integrity

17. Patients diagnosed with dependent personality disorders behave submissively and cling to

others. What is the best explanation of this behavior? a. The patients are afraid of being alone or functioning without direction. b. The patients adhere to strict standards and fear failure. c. The patients have little regard for the rights of others. d. The patients are suspicious of the motives of others.

ANS: A

The individual with a dependent personality disorder has a pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviors. The other options are characteristic of individuals with obsessive-compulsive personality disorder, antisocial personality disorder, and paranoid personality disorder.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 364

TOP: Nursing process: Evaluation

18. When caring for a patient diagnosed with dependent personality disorder, the nurse should

positively reinforce which behavior? a. Choosing which clothing to wear b. Asking another patient for advice c. Sitting next to the nurse at a community meeting d. Concealing anger with a family member ANS: A

Dependent patients find it difficult to make even simple decisions. They often ask advice; thus, independently choosing their own attire is a behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 364-365 MSC: NCLEX: Psychosocial Integrity

19. Personality traits most likely to describe a patient diagnosed with obsessive-compulsive

personality disorder are: a. friendly; generous. b. dramatic; impulsive. c. perfectionist; inflexible. d. suspicious; submissive.

ANS: C

The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with this personality disorder.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 365 MSC: NCLEX: Psychosocial Integrity

20. Which behaviors are expected in patients diagnosed with avoidant personality disorders? a. Social aptitude; risk taking b. Promiscuity; impulsiveness c. Shyness; poor self-confidence d. Attention seeking; helplessness ANS: C

Individuals with avoidant personalities desire relationships but keep their anxiety at a low level by avoiding situations in which they might experience rejection. They are timid, uncertain, and often withdrawn. The other options describe behaviors that would not be seen in patients with avoidant personality disorder.

DIF: Cognitive level: UnderstN andiR ng I GREB F:.C pp. 3M64-365 U S N T TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity 21. Select the best outcome for a patient with schizotypal personality disorder. The patient will: a. adhere willingly to program norms. b. introduce himself or herself to a stranger in a social situation. c. report decreased incidence of impulses to self-mutilate. d. demonstrate fewer attempts at splitting or manipulating staff.

ANS: B

Schizotypal individuals have poor social skills. Social situations are uncomfortable for them.

It is desirable for the individual to develop the ability to meet and socialize with others.

Individuals with schizotypal personality disorder usually have no issues with adherence to unit norms, nor are they self-mutilating or manipulative.

DIF: Cognitive level: Applying REF: pp. 364-365 TOP: Nursing process: Outcome Identification/Planning MSC: NCLEX: Psychosocial Integrity 22. A psychiatric technician says, “I get annoyed with patients who self-mutilate over things other

people would ignore. I think they just do it to get attention.” Select the nurse’s best response. a. “Many people feel the way you do. If you are unable to come to terms with the issue, we can transfer you.” b. “Self-mutilation is a serious problem. Patients with this personality disorder may complete suicide.”

c. “We have to consider each case individually. Some are manipulative, and others

are serious.” d. “You seem to be having difficulty empathizing and remaining nonjudgmental.”

ANS: B

Every patient is entitled to respectful care. The nurse must respond by teaching the psychiatric technician that what he considers a minor problem is actually a major mental health problem.

The nurse should identify the risk for completed suicide. The other options do not capitalize on this teaching opportunity.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 360-362 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. Which behaviors create interpersonal relationship problems for an individual diagnosed with

narcissistic personality disorder? Select all that apply. a. Grandiose self-importance b. Sense of entitlement c. Lack of empathy d. Risk taking e. Shyness ANS: A, B, C

The individual with narcissistic personality disorder has difficult interpersonal relationships because of characteristic behaviors and tendencies toward grandiose self-importance, a sense of entitlement, and lack of empathy. Evidence does not suggest the other characteristics as NU IN GTpersona B.COlity disorder. behaviors or traits of individua l sR wS ith this DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 363-364 MSC: NCLEX: Psychosocial Integrity

2. A patient diagnosed with borderline personality disorder impulsively self-mutilates and has

severe mood lability with explosive outbursts, poor interpersonal relations, and inability to sustain employment. Which referrals should the nurse consider for the patient? Select all that apply. a. Dialectic behavior therapy b. Alcoholics Anonymous c. Vocational rehabilitation d. Desensitization therapy e. Anger management ANS: A, C, E

Referral to dialectic behavior therapy will address self-mutilation and interpersonal relations and might address mood lability. Vocational counseling can help with employment problems.

Assertiveness training and anger management will address the explosive outbursts.

Desensitization therapy is used for patients with phobias. There is no evidence of alcohol abuse.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 362-363

TOP: Nursing process: Planning

Chapter 30: Sexual Disorders MULTIPLE CHOICE 1. Paraphilia is defined as: a. any homosexual act. b. inhibition of the sexual response cycle. c. discomfort with one’s biologic gender. d. an intense sexual urge with an abnormal focus.

ANS: D

Paraphilias are conditions in which the sexual instinct is expressed in ways that are socially prohibited or unacceptable or are biologically undesirable. The distracters characterize other sexual behaviors.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 369 MSC: NCLEX: Psychosocial Integrity

2. Which characteristic fits the profile of an individual who is a pedophile? a. Homosexual b. High self-esteem c. Seeks access to children d. Self-confident and expressive ANS: C

It is known that pedophiles usually place themselves in jobs, activities, or relationships that provide easy access to childrN en. T y ofG ten B be. coCmeMtrusted by both parents and children. The Rhe I U S N T O to pedophilia. other characteristics have no particular relationship DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 369-370 MSC: NCLEX: Psychosocial Integrity

3. A patient’s 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 nonconsenting 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.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 370-371 MSC: NCLEX: Psychosocial Integrity

4. While volunteering at a homeless shelter, a nurse observes a known pedophile leaving the

restroom with a small child. Select the nurse’s priority action. a. Report the observation to authorities by the child abuse hotline. b. Protect the child without involving herself/himself with the perpetrator. c. Notify staff of the homeless shelter to address the situation. d. Continue to observe the interaction and document findings.

ANS: A

In every state, nurses are mandated reporters of child abuse. The nurse is obligated legally and morally to report the incident so that proper authorities can follow up. The distracters do not fulfill the nurse’s ethical or legal responsibilities.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 372 MSC: NCLEX: Safe, Effective Care Environment

5. Prior to working with patients regarding sexual concerns, a prerequisite for providing

nonjudgmental care is: a. sympathy. b. assertiveness training. c. sexual self-awareness. d. effective communication.

ANS: C

Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distracters are not prerequisites.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 372

TOP: Nursing process: Planning

6. 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, “Let’s go to my office.” b. responding, “I want to help. Go ahead. I’m listening.”

RSule INano GTther B.C c. telling the patient, “Let’sN scUhed appOointment.” 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. Offering to schedule an appointment blocks communication.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 372 MSC: NCLEX: Psychosocial Integrity

7. A man experiencing premature ejaculation tells the nurse, “I feel like such a failure. It’s so

awful for both me and my wife. Can you help me?” Select the nurse’s best response. a. “Sex therapy is not my specialty, but I will try to help.” 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 nurse’s role.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 372 MSC: NCLEX: Psychosocial Integrity

8. A pedophile tells the nurse, “I feel so guilty and shameful over molesting a child. My family

will be so disgusted with me. I could save them from embarrassment if I were gone.” What is the nurse’s priority action? a. Set limits on the patient’s disclosures. b. Further assess the patient’s suicidality. c. Administer a PRN medication for anxiety. d. Explore the patient’s feelings of guilt and shame.

ANS: B

Patients who describe guilt, shame, and the idea that others would be better off without them are suicide risks. The nurse should further assess the patient’s comments, document, report the data, and consider the need for suicide precautions. The other options do not fully consider the primary issue of patient safety.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 369 MSC: NCLEX: Psychosocial Integrity

9. Contemporary cultural rejection of certain sexual behaviors is determined primarily based on

sexual acts: a. involving coercion rather than consent. b. associated with homosexual contacts. c. using artificial devices. d. resulting in orgasm.

ANS: A

Sexual acts that are forced on another are considered both morally and legally unacceptable.

The other options are used leN ssUoR ften evT alB ua.tiC onOcMriteria.

SIaNs G DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 368-369 MSC: NCLEX: Psychosocial Integrity

10. A 10-year-old boy is diagnosed with gender identity disorder. Which assessment finding

would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with other boys who are athletic d. Intense urges to watch his parents having sex ANS: A

An individual with gender identity disorder feels trapped in the body of the “wrong” gender and 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 identity disorder.

DIF: Cognitive level: Applying REF: p. 371-372 DSM-5 for Gender Dysphoria in Children TOP: Nursing process: Assessment MSC: NCLEX: Psychosocial Integrity 11. A man tells the nurse, “I have trouble maintaining an erection.” This comment indicates: a. a sexual erectile disorder. b. a sexual desire disorder.

c. a sexual pain disorder. d. an orgasm disorder.

ANS: A

In sexual erectile disorders, the individual cannot maintain the physiologic requirements for sexual intercourse. The patient’s statement does not provide data to suggest one of the other options.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 368 MSC: NCLEX: Physiologic Integrity

12. An adult has felt much tension since losing a home by foreclosure. This person goes to a park,

feeds the birds, and then impulsively exposes himself/herself to a group of parents and children. Which term applies to this behavior? a. Voyeurism b. Dyspareunia c. Exhibitionism d. Sexual masochism ANS: C

Exhibitionism is obtaining sexual pleasure from exposing one’s genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. Dyspareunia refers to painful intercourse. Sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 370 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

S losing N Ta homeO by foreclosure. This person goes to a park, 13.1 An adult has felt much tensionU since 3 feeds the birds, and then impulsively exposes himself/herself to a group of parents and . children. Which intervention would have the greatest benefit for this person? a. Stress management b. Problem solving c. Sex education d. Social skills ANS: A

Because the individual demonstrated the exhibitionistic behavior during a period of increased stress, providing stress management would be beneficial. The other interventions may be acceptable but would not have the relevance that stress management would have.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 373

TOP: Nursing process: Planning

14. A nurse cares for a man diagnosed with pedophilia. Leuprolide (Lupron Depot) was

prescribed. One month later, which statement by the patient indicates that the medication is having a therapeutic effect? a. “I feel a lot less depressed since taking this drug.” b. “My sexual desire has practically disappeared.” c. “I can sustain an erection longer than before.” d. “There’s no pain during intercourse now.”

ANS: B

Leuprolide is an antiandrogen. When testosterone is reduced, sexual desire is decreased. The statement that sexual desire has “practically disappeared” suggests that the medication is having the desired effect. The distracters are unrelated to the desired effect of this drug.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 372

TOP: Nursing process: Evaluation

15. A nurse cares for a patient demonstrating paraphilia. The nurse expects the health care

provider may prescribe which type of medication to reduce paraphilic behaviors? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic d. Mood stabilizer ANS: A

SSRIs are reported to have a positive effect on paraphilia. The other medications are not indicated for this disorder.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 372

TOP: Nursing process: Planning

16. The clinic nurse sees a patient with a long-standing diagnosis of pedophilia who was recently

arrested and released on bail. Which perspective about pedophilia would the nurse expect from this patient? a. Extreme remorse for traumatizing a child to meet his/her own needs. b. Desire to be placed in jail to prevent acting on the sexual impulses.

NaUs RgiSveInNvG c. The belief that the child w alT uaB b. leC knOoM wledge and pleasure. d. A feeling of victimization related to genetic and environmental factors.

ANS: C

Individuals with pedophilia frequently do not believe that their behavior is harmful to the child. Instead, they point to having provided teaching and pleasure for the child. The other options are not characteristic of the thinking of the pedophile.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 369 MSC: NCLEX: Psychosocial Integrity

17. The clinic nurse sees a new patient with vague sexual complaints. Select the best question for

the nurse to help the patient express these concerns more clearly. a. “What are your concerns and feelings about your sexuality?” b. “Patients are frequently embarrassed to talk about sexuality.” c. “Don’t be embarrassed. Our conversation is completely private.” d. “As a clinician, I am accustomed to talking to patients about personal matters.”

ANS: A

Individuals with sexual concerns may need help and support to express the problem.

Approaching the subject directly is most appropriate. The patient is not concerned with the problems of other patients or the nurse’s level of comfort.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 368-369 MSC: NCLEX: Psychosocial Integrity

18. Studies indicate that which child has the highest risk for being sexually victimized? a. Boy, age 19 b. Boy, age 13 c. Girl, age 17 d. Girl, age 5 ANS: B

According to a study by John Jay College, the majority of victims of sexual misconduct were boys age 11 to 17.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 370 MSC: NCLEX: Psychosocial Integrity

19. A senator develops a sexual relationship with a 20-year-old receptionist. Which adjective

most likely applies to this relationship? a. Harmonious b. Consensual c. Coercive d. Illegal ANS: C

Relationships between powerful and less powerful persons usually have a coercive element.

They are not illegal unless the less powerful person is a minor. The relationship may be harmonious and consensual in the minds of the involved parties.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial IN ntegR rity I

REF: p. 367

TOP: Nursing process: Evaluation

U S NGTB.COM

MULTIPLE RESPONSE 1. A school nurse uses a participative approach to teach about safety to a group of third graders.

Which questions should the nurse pose to the students? Select all that apply. a. “What would you do if a stranger told you to get in his or her car because your parents were hurt?” b. “If you were playing on the Internet, and someone invited you into a private chat room, what would you do?” c. “If your parents told you that your pet was hurt, would you go with them to the veterinarian?” d. “Has anyone ever touched you in a way that embarrassed or frightened you?” e. “Which members of your family can you trust?”

ANS: A, B

Teaching about the risk of sexual misconduct is important for school-age children. Trickery, bribes, and the Internet are sources of potential danger. It would not be appropriate to ask students in a group setting if they had been inappropriately touched or which family members were trustworthy.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 369-370 MSC: NCLEX: Psychosocial Integrity

2. A nurse assesses a patient recently diagnosed with pedophilia. Which findings are most

likely? Select all that apply. a. History of childhood sexual abuse b. Antisocial personality traits c. Limbic system abnormalities d. An endocrine disorder e. Grandiosity ANS: A, C, D

Pedophiles commonly have a history of sexual abuse, limbic system abnormalities, and traits of some personality disorders. Endocrine problems are not associated with pedophilia.

Self-confidence is lacking; grandiosity would not be expected.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 369-370 MSC: NCLEX: Psychosocial Integrity

Chapter 31: Substance Abuse Disorders MULTIPLE CHOICE 1. A patient says, “I felt good from drinking a six-pack a few months ago. Now I need a few

extra cans to get the same high.” The nurse assesses this phenomenon as related to: a. tolerance. b. withdrawal. c. co-dependency. d. abstinence syndrome.

ANS: A

Tolerance refers to the need for increasing amounts of a substance to achieve the same effects.

The other terms are not related to needing more of a substance to achieve the same effect.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 387-388 MSC: NCLEX: Psychosocial Integrity

2. A blackout is described as: a. a comatose period related to alcohol withdrawal. b. a comatose episode associated with alcohol intoxication and poisoning. c. a time period in which a person who has used alcohol is unresponsive to the

environment. d. an episode in which a person under the influence of alcohol functions normally but

later is unable to remember.

ANS: D

A blackout is defined as a period of time in which a drinker functions socially but for which there is no memory. The distracters omit aspects of a blackout.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 388 MSC: NCLEX: Psychosocial Integrity

3. A patient with Wernicke-Korsakoff syndrome has the nursing diagnosis impaired memory,

related to neurotoxicity of alcohol. Which defining characteristic applies to this diagnosis? a. Confabulation b. Hallucinosis c. Flashbacks d. Blackouts ANS: A

Confabulation is a symptom typically displayed by an individual with Wernicke-Korsakoff syndrome. The individual attempts to make up for memory loss by filling in the blanks with false memories. The other options are not symptoms of memory impairment associated with Wernicke-Korsakoff syndrome.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 389

TOP: Nursing process: Evaluation

4. Which assessment findings would prompt the nurse to suspect a disulfiram (Antabuse)

reaction?

a. b. c. d.

Skin rash, itching, and urticaria Pallor, hypotension, and muscle cramping Dry skin, bradycardia, fatigue, and headache Headache, dyspnea, nausea, vomiting, and flushing

ANS: D

A disulfiram reaction consists of any combination of the following symptoms: flushing, sweating, rapid pulse, hypotension, throbbing headache, nausea, vomiting, palpitations, dyspnea, tremor, and weakness. The patient is acutely uncomfortable. The other options do not characterize the disulfiram–alcohol reaction.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 400 MSC: NCLEX: Physiologic Integrity

5. During the rehabilitation phase of alcoholism treatment, the medication is prescribed to reduce

the pleasurable effects of drinking alcohol. The nurse can expect to teach the patient about: a. chlordiazepoxide (Librium). b. disulfiram (Antabuse). c. lorazepam (Ativan). d. naltrexone (Revia).

ANS: D

Naltrexone is an opioid receptor antagonist. It compromises the pleasurable effects of alcohol and reduces craving. The distracters are anxiolytic drugs and a drug that makes drinking uncomfortable.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic InN tegriR ty I

REF: p. 400

U S NGTB.COM

TOP: Nursing process: Planning

6. A patient with insomnia reports taking diazepam (Valium) and wine in increasing amounts to

be able to sleep. The nurse should teach the patient about: a. dangers of central nervous system (CNS) depression. b. risks of acetaldehyde toxicity. c. risks of fetal alcohol syndrome. d. diazepam and dietary precautions.

ANS: A

Alcohol ingested with another CNS depressant can produce lethal depressant effects. The other options are not relevant based on the information given in the scenario.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 388 MSC: NCLEX: Physiologic Integrity

7. A patient has a history of alcohol abuse. The prescription drug that would cause the nurse to

be most concerned about cross-dependence is: a. hydrochlorothiazide (Diuril). b. benztropine (Cogentin). c. clonazepam (Klonopin). d. olanzapine (Zyprexa).

ANS: C

Cross-addiction occurs with CNS depressant drugs. Clonazepam is a benzodiazepine, so cross-dependence is expected. The other drugs will not produce cross-dependence.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 390 MSC: NCLEX: Physiologic Integrity

8. The most serious assessment findings associated with barbiturate withdrawal are: a. delirium and seizures. b. muscle twitching and anxiety. c. nausea, vomiting, and tremors. d. orthostatic hypotension and weakness.

ANS: A

Delirium and seizures are considered serious withdrawal symptoms requiring immediate medical attention because of the risk of death. Minor withdrawal symptoms include all the symptoms listed in the incorrect options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 391 MSC: NCLEX: Physiologic Integrity

9. Which assessment findings support a nurse’s suspicion that a patient has been using inhalants? a. Perforated nasal septum and hypertension b. Drowsiness, euphoria, and constipation c. Pinpoint pupils and respiratory rate 12 breaths/min d. Confusion, mouth ulcers, and ataxia ANS: D

Inhalants are usually CNS deN presRsanI ts, gGivinBg.riC se tM o confusion and ataxia. Mouth ulcers come U S N T O from the irritation of buccal mucosa by the inhalant. The other options relate to cocaine snorting and opioid use.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 392 MSC: NCLEX: Physiologic Integrity

10. A nurse cares for a patient who experienced an opioid overdose. Which focused assessment

has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic ANS: B

Opioid overdose causes respiratory depression, which is the primary cause of death among opioid abusers. The assessment of the other body systems is not the priority.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 392 MSC: NCLEX: Physiologic Integrity

11. An individual experiencing a heroin overdose has been given one dose of naloxone (Narcan)

intravenously. The priority nursing intervention is: a. close observation to determine the need for an additional dose of naloxone. b. seizure precautions for 2 hours immediately after administration of naloxone.

c. acidification of urine by encouraging the patient to drink cranberry juice. d. a nonstimulating environment and administration of oral fluids.

ANS: A

Naloxone, a narcotic antagonist, permits the individual to respond and respirations to improve.

However, because most opioids have a longer-lasting effect than naloxone, the effects of naloxone will wear off before the effects of the opioid. The administration of naloxone might have to be repeated. If it is not, the individual is in danger of death due to respiratory depression.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 393 MSC: NCLEX: Physiologic Integrity

12. A cocaine abuser complains, “There are bugs crawling under my skin.” Which term should

the nurse use to document this finding? a. Confabulation b. Formication c. Synesthesia d. Euphoria ANS: B

Formication is the term used when an individual describes feeling bugs crawling under the skin. It is seen in cocaine use. The other options refer to altered sensory perceptions of sight and sound or to inventing stories to make up for memory deficit.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 394 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

U abuses S N large T quantities O 13.1 The nurse assesses a patient who of amphetamines. Assessment 3 findings are likely to be similar to which psychiatric disorder? . a. Wernicke-Korsakoff syndrome b. Bipolar disorder, manic phase c. Generalized anxiety disorder d. Paranoid schizophrenia ANS: D

Amphetamines enhance dopamine activity. The psychosis that is induced by amphetamines closely mimics the symptoms of paranoid schizophrenia. The other disorders have less to do with dopamine dysregulation.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 397

TOP: Nursing process: Evaluation

14. When caring for patients withdrawing from cocaine and amphetamines, the nurse should plan

measures recognizing that: a. physical withdrawal is severe and often fatal. b. psychologic withdrawal is more severe than physical. c. physical and psychologic withdrawal are equally severe. d. physical withdrawal is a problem only if the individual used injection.

ANS: B

These drugs are highly addictive. Psychologic craving during withdrawal is intense. The physical symptoms of withdrawal, however, are relatively mild.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 397

TOP: Nursing process: Planning

15. A patient in the emergency department says, “I took a drug that makes me feel like I’m

outside my body looking at the world. Colors move like music.” The nurse should assess that the patient: a. probably has schizophreniform disorder. b. has probably ingested a hallucinogen. c. is experiencing formication. d. is using confabulation.

ANS: B

Symptoms of hallucinogen use include depersonalization, loss of reality, hallucinations, synesthesia, panic, paranoid thinking, and loss of contact with reality. Data given in the scenario do not support a schizophreniform disorder, formication (abnormal crawling sensations under the skin), or confabulation.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 398 MSC: NCLEX: Psychosocial Integrity

16. The milieu for a patient with a hallucinogen overdose should have which features? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challN enUgR inS gINGTB.COM ANS: A

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

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: p. 397

TOP: Nursing process: Planning

17. A patient who has ingested LSD describes experiencing chimes as the color blue and seeing

the blare of a horn. This occurrence can be assessed as: a. confabulation. b. synesthesia. c. formication. d. piloerection.

ANS: B

Synesthesia is the blending of senses, such as smelling a color or tasting a sound. Formication is the sensation of bugs crawling under the skin. Confabulation is making up stories to cover memory deficit. Piloerection is commonly called goose bumps.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 398 MSC: NCLEX: Psychosocial Integrity

18. A patient asks, “How does Alcoholics Anonymous (AA) work?” Select the nurse’s best

response. a. “The goal of AA is for members to learn controlled drinking with the support of a higher power.” b. “An individual is supported by peers while striving for abstinence one day at a time.” c. “You must make a commitment to permanently abstain from alcohol and other drugs.” d. “You will be given a sponsor who will plan your treatment program.”

ANS: B

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

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 401-402 MSC: NCLEX: Psychosocial Integrity

19. Family members of an individual undergoing a 30-day alcohol rehabilitation program ask,

“How can we help?” Select the nurse’s best response. a. “Alcoholism is a lifelong disease. Relapses are expected.” b. “Use search-and-destroy tactics to keep the home alcohol free.” c. “Prevent embarrassment by covering for your loved one’s lapses.” d. “Make your loved one responsible for the consequences of his or her behavior.”

ANS: D

Often the addicted individual has been enabled when others picked up the pieces for him or her. The individual never facN edUtR heScI onNsG eqT uB en. ceCs oM f his or her own behaviors. Learning to face those consequences is part of the recovery process. The other options are co-dependent behaviors or are of no help.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 399-340 MSC: NCLEX: Psychosocial Integrity

20. An unconscious patient is brought to the emergency department with a suspected heroin

overdose. Which vital signs support the suspected diagnosis? a. Blood pressure (BP) 200/100 mm Hg; pulse (P) 92 beats/min; respirations (R) 22 breaths/min b. BP 150/85 mm Hg; P 76 beats/min; R 28 breaths/min c. BP 110/70 mm Hg; P 84 beats/min; R 20 breaths/min d. BP 70/40 mm Hg; P 100 beats/min; R 10 breaths/min ANS: D

Heroin is a CNS depressant. It causes respiratory depression and lowered BP, with a compensatory rise in the pulse rate. Only the correct option follows this pattern.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 392-394 MSC: NCLEX: Physiologic Integrity

21. Loneliness, related to unacceptable interpersonal behaviors is the nursing diagnosis for a

patient in an alcohol rehabilitation program. Which AA step is most directly related to this problem?

a. b. c. d.

Admitted powerlessness over alcohol Turned our lives over to a higher power Made amends to persons we had harmed Tried to carry the AA principles to alcoholics

ANS: C

Steps 8 and 9, making amends, could restore relationships and reduce social isolation from family and former friends. The other steps are less clearly related to this goal.

DIF: Cognitive level: Applying TOP: Nursing process: Planning

REF: p. 382; Box 31-1 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. Naltrexone (ReVia) is prescribed for a patient with alcohol dependency. What information

should the nurse provide to the patient? Select all that apply. a. “This medication is part of a total program to help you remain abstinent from alcohol.” b. “Do not use alcohol-containing products, such as aftershave lotion and mouthwash.” c. “Avoid foods that contain tyramine, such as aged cheeses and meats.” d. “This medication will help reduce the likelihood of a relapse.” e. “This medication will eliminate your desire for alcohol.”

ANS: A, D

Naltrexone, like any drug for treatment of chemical dependence, is only part of a total treatment program. It will help decrease the pleasure associated with alcohol, but it will not NUcrav RSing IN, GwT B.C eliminate the desire. It reduces hich in O turn will help reduce the likelihood of relapses. The distracters relate to disulfiram and monoamine oxidase inhibitors.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 400 MSC: NCLEX: Psychosocial Integrity

2. Which statements accurately portray differences in the effects of alcohol between men and

women? Select all that apply. a. Women’s gastrointestinal systems have less alcohol dehydrogenase, so less ethanol is oxidized on first pass before it enters the bloodstream. b. Hot coffee increases the metabolic rate and speeds oxidation of ethanol more in men than in women. c. Women have higher proportions of body fat, which absorbs alcohol and releases it slowly. d. The microsomal ethanol-oxidizing system in women is less efficient than in men. e. Women become intoxicated more easily than men.

ANS: A, E

The correct options reflect accurate research findings.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 387 MSC: NCLEX: Physiologic Integrity

3. Substance dependence is defined by (select all that apply):

a. b. c. d. e.

a compulsion to use a substance. loss of control over use of a substance. a physiologic need to use a substance. continued use of a substance despite adverse consequences. a substance-specific syndrome due to recent ingestion of a substance.

ANS: A, B, C, D

Dependence is marked by multiple criteria defined in the DSM-V. A substance-specific syndrome due to recent ingestion of the substance refers to substance intoxication.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 385 MSC: NCLEX: Psychosocial Integrity

Chapter 32: Eating Disorders MULTIPLE CHOICE 1. Which assessment finding would the nurse document as subjective evidence of anorexia

nervosa? a. Lanugo b. Bradycardia c. 25-lb weight loss d. Patient states fear of gaining weight.

ANS: D

Fear of weight gain is a subjective symptom, because it is voiced by the patient. The distracters are objective signs.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 407 MSC: NCLEX: Psychosocial Integrity

2. A patient diagnosed with anorexia nervosa has the nursing diagnosis imbalanced nutrition,

less than body requirements, related to inadequate food intake. The long-term goal of the treatment plan is that the patient will: a. gain 1 to 3 lb weekly. b. exhibit fewer signs of malnutrition. c. restore healthy eating patterns and normalize weight. d. identify cognitive distortions about weight and shape.

ANS: C

The goal directly related to the nursing diagnosis is to restore healthy eating patterns and normalize weight. The distracters are short-term or vague or are not directly related to the nursing diagnosis.

DIF: Cognitive level: Applying REF: p. 411 TOP: Nursing process: Outcome Planning MSC: NCLEX: Physiologic Integrity 3. The nurse interviews a patient who restricts food and is 25% underweight. The patient says, “I

still need to lose weight. I’m not thin enough.” The patient is using which defense mechanism? a. Rationalization b. Projection c. Splitting d. Denial ANS: D

When the individual with anorexia nervosa insists that being 25% underweight is not a problem (and thinking that she is too fat, when in fact she is emaciated), the defense mechanism responsible is denial. Rationalization involves making excuses, projection involves blaming others, and splitting involves the inability to integrate good and bad in one concept.

DIF: Cognitive level: Analyzing

REF: pp. 405-406

TOP: Nursing process: Assessment

MSC: NCLEX: Psychosocial Integrity

4. A patient is 5 feet 4 inches tall and weighs 85 lb, a 20% loss of body weight over the past

year. The patient reports amenorrhea for 9 months. Vital signs are temperature (T) 96.6°F; pulse (P) 38 beats/min; blood pressure (BP) 70/42 mm Hg; respirations (R) 20 breaths/min.

Skin turgor is poor. Lanugo is present. She says, “I need to lose 10 more pounds.” These assessment findings indicate which medical diagnosis? a. Bulimia nervosa b. Anorexia nervosa c. Binge-eating disorder d. Dissociative identity disorder ANS: B

Data are consistent with the medical diagnosis of anorexia nervosa, a disorder in which intense fear of being fat leads to a body weight 15% or more below normal. Bulimic patients are usually near normal weight. Individuals who have binge-eating disorder tend to be overweight. Dissociative identity disorder refers to individuals who have multiple personalities.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 406-407 MSC: NCLEX: Psychosocial Integrity

5. An initial step in the nurse–patient relationship for a patient diagnosed with anorexia nervosa

should be: a. formulate the nurse–patient contract. b. exclude the family from treatment. c. recommend a therapeutic group.

G B.C M N R I d. use intense confrontation. U S N T O ANS: A

Trust is the foundation to the nurse’s effectiveness. A contract is formulated early in therapy to give the patient the opportunity to participate in treatment. This increases the patient’s sense of control. By establishing contractual behavioral limits, manipulation and power struggles can be minimized. Recommending a therapeutic group and using confrontation to attack denial are later interventions. Family members are encouraged to take part actively in the treatment of the patient.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 414 MSC: NCLEX: Psychosocial Integrity

6. A patient diagnosed with anorexia nervosa spills milk over a plate of partially eaten food.

Select the nurse’s best response. a. “That won’t work. You are manipulating.” b. “You are deliberately making mealtime difficult.” c. “I will get you a fresh plate of food so you can finish.” d. “You are required to eat your meal. I’ll wait until you finish.”

ANS: C

Patients with anorexia nervosa often use strategies to hide food, spill food, or discard it to avoid eating. The nurse can best handle these behaviors with nonjudgmental confrontation and adherence to established limits. Only the correct answer is a nonjudgmental response. The other options are judgmental or punitive.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 415-416; Key Nursing Interventions Box MSC: NCLEX: Psychosocial Integrity

7. A nurse planning care for a patient diagnosed with bulimia nervosa should recommend the use

of: a. b. c. d.

psychodynamic group therapy. cognitive-behavioral therapy. pharmacotherapy. psychodrama.

ANS: B

Research findings indicate that cognitive-behavioral therapy is effective in the treatment of both anorexia nervosa and bulimia nervosa. There is no evidence to suggest that the other options are as useful.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 408

TOP: Nursing process: Planning

8. Which personality characteristic would the nurse expect in a patient diagnosed with an eating

disorder? a. Grandiosity b. Impulsivity c. Perfectionism d. Suspiciousness ANS: C

Often, the individual with an eating disorder is seen as compliant, perfectionist, introverted, and having self-esteem and relationship problems. The other characteristics are rarely seen among patients with eating disorders.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 410 MSC: NCLEX: Psychosocial Integrity

9. Which information about a patient diagnosed with bulimia nervosa should the nurse document

as subjective data? a. Scarred fingers b. Sores around mouth c. Loss of tooth enamel d. Feeling out of control ANS: D

The distracters represent objective data, whereas the correct answer reflects feelings the patient has revealed.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 410 MSC: NCLEX: Psychosocial Integrity

10. A nurse teaches a class about bulimia nervosa to high school biology students. The nurse

should explain that a possible cause is: a. hypersensitivity of norepinephrine. b. excessive dopamine activity. c. overproduction of GABA. d. serotonin deficits.

ANS: D

Based on a few research studies, current thinking suggests that deficits in serotonin might play a role in bulimia nervosa. There is no research to support the correctness of any of the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 411 MSC: NCLEX: Physiologic Integrity

11. Which finding indicates that a patient diagnosed with anorexia nervosa has met a major

objective of psychotherapeutic management? a. The patient’s residual volume is less than 30 ml before tube feedings. b. The patient says, “I am no longer fearful of gaining weight.” c. The patient reads cookbooks and plans nutritious meals. d. The patient weighs 90% of average body weight.

ANS: D

The three objectives are increasing self-esteem, increasing weight to 90% of average body weight, and reestablishing appropriate eating behavior. Reading cookbooks or planning nutritious meals may be evidence of manipulation. A low residual volume simply indicates that the patient is utilizing the feedings and there is no intestinal obstruction. Lack of fear does IpNroGvTedBs.elCf-OesMteem. not translate to proper eatingN oU r aRnSim DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 411

TOP: Nursing process: Evaluation

12. A patient diagnosed with an eating disorder asks to be excused from a meal to use the

restroom. Select the nurse’s best response. a. “No one is permitted to leave the table during meals.” b. “You may go after you’ve finished your meal.” c. “I will go with you to the restroom.” d. “No. I know you want to vomit.”

ANS: C

Close observation is necessary to prevent patients with eating disorders from purging during and after meals. Patients should be accompanied to the bathroom and observed while in the bathroom to prevent purging. Bargaining, lying, and judgmental confrontation are not appropriate responses.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 416 MSC: NCLEX: Psychosocial Integrity

13. A nurse is engaged in psychoeducational activities with a hospitalized patient diagnosed with

bulimia nervosa. The nurse says, “When you feel the need to vomit, a. do vigorous aerobic exercise until the urge goes away.” b. seek out a staff member to talk about your feelings.”

c. call your parents on the phone to show you care.” d. allow yourself to vomit, but avoid purging.”

ANS: B

Resistance to the urge to vomit or purge can be strengthened by reporting it to a nurse and talking about the feelings that the individual experienced before the urge and the feelings being experienced presently. Once feelings are identified, the patient can begin to work on alternate coping strategies. The other options are not helpful.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 416 MSC: NCLEX: Psychosocial Integrity

14. To meet DSM-V criteria for bulimia nervosa, the patient’s history must reveal episodes of

binge eating and compensatory behaviors occurring at least: a. once a week for 6 months. b. once weekly for 3 months. c. three times weekly for a year. d. four times weekly for 6 months.

ANS: B

This information is taken from the DSM-V criteria.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 409; DSM-5 Criteria–32-2 MSC: NCLEX: Psychosocial Integrity

15. School nurses should be particularly vigilant for signs of eating disorders: a. in fourth-graders. b. in rebellious, aggressive g NirlsR. I G B.C M c. during summer breaks and U arouSnd N holiT days. O d. at transitions between elementary, middle, and high school.

ANS: D

Junior high and high school students are at particular risk for eating disorders, based on our culture’s emphasis on thinness and the adolescent’s need for peer approval. Stress makes the adolescent more vulnerable. Times of particular stress are moving from one school to another—thus, the need for vigilance on the part of the school nurse. Risk is lower in the other options.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 406 MSC: NCLEX: Psychosocial Integrity

16. How do assessment findings in individuals with bulimia and anorexia differ? a. Persons with bulimia tend to have lower body weights than those with anorexia. b. Fluid and electrolyte imbalance is more common in anorexia than in bulimia. c. Hormonal imbalance is more common in bulimia than in anorexia. d. Anorexia tends to begin at an earlier age than bulimia.

ANS: D

Anorexia tends to begin at an earlier age than bulimia. The other options are incorrect.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 406, 409 MSC: NCLEX: Psychosocial Integrity

17. A patient diagnosed with bulimia nervosa has not responded to psychotherapeutic

management. The health care provider is likely to prescribe a drug from which classification? a. Mood stabilizer b. Selective serotonin reuptake inhibitor (SSRI) antidepressant c. Typical antipsychotic d. Monoamine oxidase inhibitor antidepressant ANS: B

There is some evidence that SSRIs might be effective as adjunctive treatment of bulimia. The other drugs would not be considered appropriate.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 410

TOP: Nursing process: Planning

18. A patient diagnosed with an eating disorder refuses to be weighed and says, “I just drank a big

glass of water.” Select the nurse’s best response. a. “Call me after you have emptied your bladder.” b. “This is weight day. Please step on the scale.” c. “I will weigh you tomorrow.” d. “You know the rules.”

ANS: B

This response is matter-of-fact and reinforces the established limits. The distracters allow the patient to manipulate the nurse, are overly controlling, or use bargaining.

DIF: Cognitive level: Applying TOP: Nursing process: ImplemNentR ationI

REF: p. 416 : C NCLMEX: Psychosocial Integrity GMSBC.

U S N T

O

19. A nurse assesses a 25-year-old man with a suspected eating disorder. Which comment is most

likely from this patient when the nurse asks about the patient’s sexuality? a. “Sometimes I feel attracted to other men.” b. “I’m here because my girlfriend is worried about how much I exercise.” c. “I am sexually active, but I sometimes have trouble maintaining an erection.” d. “I’ve been involved in a satisfying relationship with my girlfriend for 3 years.”

ANS: A

Some research indicates that men with eating disorders have a higher incidence of concerns about sexual or gender identity. Homosexuality may also play a role. None of the remaining options reflect this concern.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 418 MSC: NCLEX: Psychosocial Integrity

20. One bed is available on the inpatient eating disorders unit. Assessment findings for four

patients are listed as follows. Which patient should receive the bed? a. Weight decreased from 150 to 102 lb in 4 months. Vital signs are T 96.9°F; P 46 beats/min; BP 68/48 mm Hg. Amenorrhea for 8 months. b. Weight decreased from 110 to 86 lb in 4 months. Vital signs are T 97.5°F; P 60 beats/min; BP 80/66 mm Hg. Amenorrhea for 2 months. c. Weight decreased from 120 to 90 lb in 3 months. Vital signs are T 98°F; P 50 beats/min; BP 70/50 mm Hg. Menstruation scant for 3 months.

d. Weight decreased from 90 to 78 lb in 5 months. Vital signs are T 97.7°F; P 62

beats/min; BP 74/52 mm Hg. Menstruation irregular for 6 months.

ANS: A

Physical findings indicative of an acute status include amenorrhea for 3 consecutive menstrual cycles, weight loss more than 30% of body weight within 6 months, hypothermia, pulse less than 40 beats/min, and systolic blood pressure less than 70 mm Hg. DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 405-406 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. What priority nursing assessments should be made early in the refeeding process for a patient

with anorexia nervosa? Select all that apply. a. Vital signs b. Skin integrity c. Peripheral edema d. Lung and heart sounds e. Level of consciousness ANS: A, C, D, E

If refeeding results in too rapid weight gain the cardiovascular system might be compromised, giving rise to symptoms such as pulse irregularities, peripheral edema, abnormal heart sounds, and moist lung sounds. Alterations in oxygenation and cardiac perfusion would produce changes in the level of consciousness. Changes in skin integrity would not be a priority.

DIF: Cognitive level: ApplyinN gURSINGRT EB F:.C p. O 40M7 TOP: Nursing process: Assessment MSC: NCLEX: Physiologic Integrity

Chapter 33: Survivors of Violence and Trauma MULTIPLE CHOICE 1. For a victim of spousal abuse, a deterrent to leaving the abusive situation are the events that

occur in which stage? a. Tension building b. Honeymoon c. Processing d. Battering ANS: B

In the honeymoon stage the perpetrator is apologetic and kind, attempting to undo the harm of the battering incident. The perpetrator promises never to repeat the battering. The events occurring in the other options would not be deterrents to leaving. The processing stage is not an actual stage in the cycle.

DIF: Cognitive level: Understanding TOP: Nursing process: Planning

REF: pp. 436- 437 Box 33-5 MSC: NCLEX: Psychosocial Integrity

2. A woman who has been repeatedly abused by her partner comes to the emergency department

with severe contusions. She tells the nurse, “He almost killed me this time. I guess I should do something.” What is the nurse’s priority intervention? a. Document the woman’s injuries. b. Help the patient devise a safety or escape plan. c. Encourage the patient to take independent action. d. Provide referrals contingeNnU t oRnSthIeNpG atT ieB nt.leCaO ving the abuser.

ANS: B

Individuals who are victims of partner abuse should have an escape plan. This is of high priority when the victim’s life is endangered. Encouraging the victim to take independent action is of less help than offering concrete assistance such as providing referrals and giving emergency phone numbers. Referrals should never be contingent on leaving, which might be possible only after the victim has made use of the referral and has assistance in place.

Documentation is important, but not the nurse’s first action.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 438-439; Box 33-7 MSC: NCLEX: Psychosocial Integrity

3. Which intervention would be most therapeutic as a nurse cares for a victim of partner abuse? a. Validate the truthfulness of the victim’s comments. b. Avoid pressuring the victim or disparaging the abuser. c. Acknowledge the victim’s inability to change the situation. d. Encourage the partner to stay with the victim during an interview.

ANS: B

Nurses should never pressure a victim to leave the abuser. The patient must make the decision without coercion. Leaving is dangerous, because it escalates the violence and might result in death. Neither should the nurse disparage the perpetrator. The victim still cares about the batterer. The nurse should ask directly about abuse. The nurse should not suggest that the individual is unable to take constructive action. The patient should have a safe environment, without the abuser, to discuss the events. The nurse should not question the truthfulness of the victim’s complaints.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 438- 439 MSC: NCLEX: Psychosocial Integrity

4. A survivor of childhood abuse is hospitalized following an episode of wrist cutting. The

patient has a history of binge–purge eating disorder as well as difficulty trusting and relating to others. What is the nurse’s priority intervention? a. Set limits on self-harmful behavior. b. Foster belief in and valuing of family unity. c. Confront abnormal eating patterns and self-mutilation. d. Encourage discussion of personal responsibilities associated with abuse.

ANS: A

Setting limits on self-mutilating behavior or purging is necessary to provide for the safety needs of the patient. Individuation should be fostered. The victim should not be encouraged to accept any personal responsibility for the abuse. The patient is aware of the eating patterns and self-mutilation; confrontation will not build trust.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 433-434, Key Interventions 33-1 MSC: NCLEX: Psychosocial Integrity

5. A woman comes to the clinic with neck pain. There’s a bald spot on her scalp. She explains

that she caught her hair in a door, which pulled it out and caused her neck injury. The partner wants to stay with the injured woman. What is the nurse’s best action? a. Encourage the partner to remain with the woman to provide emotional support. b. Require the partner to stay in the waiting room when the woman is examined. c. Call hospital security to have them stand by to prevent violence. d. Report the situation to local law enforcement authorities.

ANS: B

The victim’s explanation of being injured does not sound plausible. The nurse should suspect partner abuse. Regarding the other options, the victim and perpetrator must be separated to permit the victim the privacy to discuss what has really happened to her. It is unlikely that the perpetrator will act out when he can be observed by others. It is too early to involve the local police.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 438-439 MSC: NCLEX: Psychosocial Integrity

6. Choose the initial desired outcome for a person who was a victim of mind control and torture.

The person will: a. make independent decisions for herself. b. repress emotions experienced during event. c. reestablish relationships with support persons.

d. use desensitization strategies to restore equilibrium.

ANS: C

Relationships with family and former friends are invariably disrupted based on the victim’s inability to trust. Reestablishing relationships would be the first step toward reorganization.

Later, the victim will be able to make independent decisions for herself. Repression and desensitization are not the initial desirable outcomes.

DIF: Cognitive level: Applying TOP: Nursing process: Planning

REF: pp. 422-423, 425-426 MSC: NCLEX: Psychosocial Integrity

7. A male victim of gang rape comes to the emergency department. The victim is severely

anxious, but the nurse will not be able to care for the patient for at least 20 minutes based on the current patient load. Select the nurse’s best action. a. Assign a female nursing assistant to remain with the patient in a private cubicle. b. Assign a male nursing assistant to help the patient undress in a private cubicle. c. Direct hospital security personnel to monitor the patient in the waiting room. d. Notify law enforcement authorities immediately.

ANS: A

The patient should be moved from the waiting room to a cubicle as quickly as possible. He needs the reassuring presence of a woman who can reduce the fear of further sexual abuse.

Assigning a man would probably increase his anxiety to panic level. The initial priority would be to care for the patient rather than notifying law enforcement.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 428 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

S N assault T and O battery. What is the most therapeutic 8. The nurse cares for a victim ofU a violent intervention? a. Discourage expression of feelings until the victim enters the recoil stage. b. Use accepting, nurturing, and empathetic communication techniques. c. Educate the victim about strategies to avoid attacks in the future. d. Maintain a matter-of-fact manner, and remain objective.

ANS: B

Victims of violence require the nurse to provide unconditional acceptance of them as individuals, because the victim often feels guilty and engages in self-blame. The nurse must be nurturing if the victim’s needs are to be met and must be empathetic to convey understanding and promote establishment of trust.

DIF: Cognitive level: Applying REF: pp. 423, 439; Box 33-7, p. 433; Key Nursing Interventions 33-1 TOP: Nursing process: Implementation MSC: NCLEX: Psychosocial Integrity 9. A nurse caring for victims of violence plans care based on an understanding that after the

initial impact, most victims begin to react emotionally to effects of the trauma. This second stage of recovery is known as: a. disorganization. b. reorganization. c. retribution. d. recoil.

ANS: D

In the recoil stage, emotional stress is high as the individual strives to come to terms with what has happened. The victim talks about the incident and his or her feelings about the trauma. Reorganization is the third stage of recovery, in which grief over the incident is resolved. Retribution is not a stage in the recovery process. In the impact stage, common responses are shock, denial, and disbelief. Disorganization may be a reaction in the impact stage.

DIF: Cognitive level: Understanding MSC: NCLEX: Psychosocial Integrity

REF: pp. 422-423

TOP: Nursing process: Planning

10. Which comment by the nurse would best support relationship building with a victim of

partner abuse? a. “You are feeling violated, because you thought you could trust your partner.” b. “I’m here for you. I want you to tell me about the bad things that happened to you.” c. “I was very worried about you. I knew you were living in a potentially violent situation.” d. “Abusers often target people who are passive. I will refer you to an assertiveness class.”

ANS: A

The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.

DIF: Cognitive level: ApplyinN g R I GREB pp. 4M21, 439; Box 33-7 U S N MSC: TF:.C TOP: Nursing process: Implementation NCLEX: Psychosocial Integrity 11. In preparing a care plan for an abuse victim, it is most important to include a long-term

outcome that addresses the need to: a. move the individual from victim to survivor status. b. provide support groups for long-term assistance. c. use empathy to establish rapport and build trust. d. shift blame for the incident from patient to perpetrator.

ANS: A

Moving from victim to survivor status is a process that can go on for months to years. It involves integrating the memories of the trauma and moving on in life with restored functioning, a reasonable sense of safety and security, healthy relationships, and improved self-esteem. The other needs can usually be met in the short term.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 438

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

TOP: Nursing process: Planning

ANS: D

Rape is not a crime of sex, but rather a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 426 MSC: NCLEX: Psychosocial Integrity

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

ANS: C

The focus of care is first helping the victim feel safe. Assessment questions and the physical procedures often seem as intrusive violations of privacy, and even physically threatening to an already vulnerable individual. The patient might refuse to have evidence collected or to involve law enforcement.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 428

TOP: Nursing process: Planning

14. Select the best staff member for an emergency department triage nurse to assign to care for a

female rape victim. a. Ex-policeman with good communication skills b. Male nursing assistant who is tall and caring c. Nurse who is efficient anN dU atR teS ntI ivN eG toTdB et. ailCOM d. Soft-spoken and empathetic nurse ANS: D

The female rape victim might be frightened of or reluctant to interact with men, so a female nurse is preferable. The patient should not be made to feel hurried or pressured, but needs to feel nurtured and understood.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 428 MSC: NCLEX: Safe, Effective Care Environment

15. What is the difference between incest and sexual abuse? a. The two terms are interchangeable. b. Incest is committed by relatives. Sexual abuse can apply to anyone. c. Incest includes rape. Sexual abuse applies to voyeurism and molestation. d. Incest occurs between a parent and child. Sexual abuse involves any other person.

ANS: B

Sexual abuse can involve anyone, but incest refers to a family member. The terms are not interchangeable. The distinction between rape and sexual abuse is incorrect. The explanation of incest is too narrow.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 429 MSC: NCLEX: Psychosocial Integrity

16. Battered woman syndrome is an aspect of which medical diagnosis? a. Sexual abuse b. Major depression c. Impaired adjustment d. Post-traumatic stress disorder (PTSD) ANS: D

Many of the symptoms of battered woman syndrome correspond to the symptoms of PTSD; however, battered woman syndrome has additional symptoms not delineated as part of PTSD (e.g., depression, low self-esteem, self-blame, fatalism). It is not related to the other options.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 436 MSC: NCLEX: Psychosocial Integrity

17. A patient says, “I was raped 2 hours ago.” The patient coherently, quietly, and calmly states

the facts in a monotone voice. The nurse should assess this behavior as: a. a delayed reaction to the trauma. b. indicative of ego integrity. c. evidence of denial. d. sublimation.

ANS: A

In the impact stage of trauma response, the individual might appear quite normal because the reality of the attack has not yet “registered.” The emotional response might be delayed for hours or even days. The other options are not plausible.

DIF: Cognitive level: Applying TOP: Nursing process: AssessN menR t

REF: pp. 422, 426-427 M : N G SBC. CCLMEX: Psychosocial Integrity

U SIN T

O

18. A mother and two children are in the emergency department. She has just escaped from a

severe beating by her husband. What is the nurse’s priority intervention? a. Appeal to her maternal instincts regarding child care. b. Focus on physical safety and emotional security. c. Provide a support group referral. d. Disclose victims’ legal rights.

ANS: B

During the impact stage, the victim is acutely aware of the danger she has just escaped.

Believing that the next beating could be fatal might provide incentive to take constructive action. The nurse can assist the victim to begin to consider a plan for escape when the next beating seems imminent and can provide information about resources.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 438 MSC: NCLEX: Psychosocial Integrity

19. Which assessment findings would prompt a nurse to suspect that a 15-year-old patient may be

a victim of serial ritual abuse? a. Lying in a fetal position; echolalia; body rocking b. Multiple scars and burns; missing teeth; fear of being examined c. Scarred index finger; tooth enamel erosion; sores around mouth d. Acting-out behaviors; verbal aggression; arrested for grand larceny

ANS: B

Scarring, burns, and missing teeth fit the picture of ritual abuse. The fear of examination relates to having to remove clothes in preparation for torture. The distracters are more consistent with schizophrenia, bulimia nervosa, and antisocial personality disorder.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 424-425 MSC: NCLEX: Psychosocial Integrity

20. A patient comes to the clinic for the fifth time in a month with vague complaints of not feeling

well. The nurse notices fresh bruises on the patient’s upper body. Which assessment question should take priority? a. “How much do you drink each day?” b. “Are you annoying to anyone?” c. “Did anyone hurt you?” d. “Have you fallen?”

ANS: C

When the nurse suspects abuse, it is appropriate to speak directly to the issue. Two distracters are presumptuous and blaming. The other distracter offers a ready-made excuse for the bruises.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 439, Box 33-7 MSC: NCLEX: Psychosocial Integrity

21. An adult in the emergency department has wrist slashes, suggesting self-mutilation. The

patient’s history reveals alcohol and drug abuse, binge eating, and unstable interpersonal relationships. Which history should the nurse suspect? a. Rape trauma b. Partner abuse c. Serial ritual abuse d. Childhood sexual abuse ANS: D

Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in patients who were sexually abused as children and have repressed the trauma. These behaviors are not as closely aligned with any of the distracters.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 430 MSC: NCLEX: Psychosocial Integrity

22. A 15-year-old patient is seen for evaluation by court order. The parents seek to have this teen

declared incorrigible because of excessive drinking, habitually running away, and prostitution.

The nurse interviewing the patient should recognize that these behaviors often occur in adolescents who: a. are victims of childhood sexual abuse. b. have antisocial personality disorder. c. are experiencing schizophrenia. d. have been ritually abused.

ANS: A

Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in teens who are sexually abused. These behaviors are not as closely aligned with any of the other options.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 430 MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE 1. During the impact stage of response to a violent crime, which nursing interventions would be

appropriate for a victim? Select all that apply. a. Provide physical safety. b. Use empathetic responses. c. Distract the patient with humor. d. Provide clear, simple directions. e. Support expression of feelings.

ANS: A, B, D, E

Because the individual experiences disorganization during the impact stage, the nurse must provide for safety and security via use of empathy, encourage expression of feelings, and provide simple clear directions. Humor might be helpful in the reorganization stage, not the impact stage.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 422 MSC: NCLEX: Psychosocial Integrity

2. Which interventions should aNnuR rse incl udeB in.thCe plan of care for a woman who has been I G

N T SelectO all that apply. physically abused by a partnerU for S 10 years? a. Be objective and nonthreatening. b. Help the victim to assess strengths. c. Make referrals contingent on leaving the abuser. d. Inform the woman that marital counseling is rarely effective. e. Help the victim recognize that the perpetrator’s behavior is abusive.

ANS: A, B, E

An objective, nonthreatening approach builds trust. Identifying the perpetrator’s behavior as abusive is honest and supports the seriousness of the behavior. Helping the victim assess strengths will be necessary if the patient is to see herself as having sufficient resources to leave the abusive relationship. The distracters are nontherapeutic. Referrals should never be offered contingently. Marital counseling should be supported, if that is what the victim chooses. It might help reduce guilt feelings when the victim leaves the relationship.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 439, 80; Box 33-7 MSC: NCLEX: Psychosocial Integrity

Chapter 34: Children and Adolescents MULTIPLE CHOICE 1. Which factor presents the most imminent risk for a child to develop a psychiatric disorder? a. Having an uncle with schizophrenia b. Living in a middle-income family c. Being the oldest child in a family d. Living with an alcoholic parent ANS: D

Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Being in a middle-income family and being the oldest child are not considered psychosocial adversity.

Having a family history of schizophrenia presents a risk, but an alcoholic parent in the family is more imminent.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 449-450 MSC: NCLEX: Psychosocial Integrity

2. Which behavior indicates that the treatment plan for a child diagnosed with autistic disorder

has been effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent’s hand while walking. d. spins around and claps hands while walking.

ANS: C

NUR SI NG TB.C OM

Holding the hand of another person suggests relatedness. Usually, a child with autism would resist holding someone’s hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The other options reflect behaviors that are consistent with autistic disorder.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 452

TOP: Nursing process: Evaluation

3. A kindergartener is disruptive to the class. This child is unable to sit for expected lengths of

time, inattentive to the teacher, and aggressive toward others, bursting out talking while the teacher is talking. Other children shun this child. The nurse plans interventions designed to: a. provide inpatient treatment for the child. b. reduce loneliness and increase self-esteem. c. improve language and communication skills. d. promote individuation and integration of self-concept.

ANS: B

Because of their disruptive behaviors, children with attention deficit–hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These same behaviors lead peers to avoid the child with ADHD, who seems reckless and impulsive, and can rarely finish games, leaving the child with ADHD vulnerable to loneliness. The other options might or might not be relevant but are not the priority. The child does not need inpatient treatment at this time.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 452

TOP: Nursing process: Planning

4. A nurse will prepare teaching materials regarding which drug for the parents of a child

diagnosed with ADHD? a. Paroxetine (Paxil) b. Imipramine (Tofranil) c. Methylphenidate (Ritalin) d. Carbamazepine (Tegretol) ANS: C

Central nervous system (CNS) stimulants are the drugs of choice for treating children with ADHD. Methylphenidate and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD. DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 456

TOP: Nursing process: Planning

5. A desired outcome for a 12-year-old diagnosed with autism is to improve relationships with

other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Social skills group c. Response prevention d. Insight-oriented group therapy ANS: B

Social skills training teaches the child to recognize the impact of his or her behavior on others.

It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser to no impact on peer relationships.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 452

TOP: Nursing process: Planning

6. Which finding necessitates immediate nursing action for a child being treated for depression

with a selective serotonin reuptake inhibitor (SSRI)? a. Oversedation b. Behavioral activation c. Anticholinergic effects d. Extrapyramidal symptoms ANS: B

Behavioral activation, a common side effect of SSRI therapy, is demonstrated by motor restlessness, insomnia, hypomania, and disinhibition. Suicidal thoughts and planning are thought to be associated with behavioral activation, so individuals should be monitored closely as depression lifts. The other drug side effects are associated with typical antipsychotics and tricyclic antidepressants.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 455 MSC: NCLEX: Psychosocial Integrity

7. A child being treated for which of the following has a high risk for suicide and should be

monitored closely? a. Depression with fluoxetine (Prozac) b. ADHD with methylphenidate (Ritalin) c. Bipolar disorder with aripiprazole (Abilify) d. Asperger’s disorder with social skills training ANS: A

The child being treated for depression with fluoxetine is at risk for behavioral activation, a drug side effect. Increased suicide risk is part of the behavioral activation complex. The drugs mentioned in the other options do not place the individual in the same risk category as fluoxetine.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 455 MSC: NCLEX: Psychosocial Integrity

8. The parent of an 8-year-old says, “My child is in constant motion and talks all the time. My

child isn’t interested in toys, but is out of bed every morning before I am and into trouble.”

The child’s problem is most N coU nsRisS teI ntNwGiT thB : .COM a. anxiety disorder. b. Asperger’s disorder. c. pervasive developmental disorder. d. ADHD. ANS: D

The excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest the other possible choices. Developmental delays would be seen if pervasive developmental disorder or Asperger’s disorder were present.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 452 MSC: NCLEX: Psychosocial Integrity

9. A child with ADHD had this nursing diagnosis: impaired social interaction, related to

excessive neuronal activity, as evidenced by aggressiveness and dysfunctional play with others. Which finding indicates the plan of care was effective? a. Improved ability to identify anxiety and use self-control strategies b. Increased expressiveness in communication with others c. Engages in cooperative play with other children d. Increased responsiveness to authority figures ANS: C

The goal should be directly related to the defining characteristics of the nursing diagnosis; in this case improvement in the child’s aggressiveness and play. The distracters are more relevant for a child with pervasive developmental disorder or anxiety disorder.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 452

TOP: Nursing process: Evaluation

10. In the waiting room a 5-year-old child diagnosed with ADHD bounces out of a chair, runs

over to another child, and slaps the other child. What is the nurse’s best action? a. Direct the aggressive child to stop immediately. b. Call for emergency assistance from other staff. c. Instruct the parents to take the child home. d. Take the child to another waiting area.

ANS: D

The nurse should manage the milieu with structure and limit-setting. Removing the aggressive child to another waiting area is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency situation. Intervention is needed rather than sending the child away.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 456 MSC: NCLEX: Safe, Effective Care Environment

11. A child diagnosed with ADHD will begin medication therapy. The nurse should prepare a

plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Tricyclic antidepressants c. Antipsychotics d. Anxiolytics ANS: A

CNS stimulants, such as methylphenidate (Ritalin) and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 456

TOP: Nursing process: Planning

12. A nurse assesses a 3-year-old child diagnosed with autistic disorder. Which finding is most

associated with the child’s disorder? a. Toilet training complete b. Inability to identify colors c. Failure to develop interpersonal skills d. Anxiety when separated from a parent ANS: C

Autistic disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers nearly always mention the child’s failure to develop interpersonal skills. The distracters are expected behaviors for a 3-year-old child.

DIF: Cognitive level: Applying

REF: p. 452

TOP: Nursing process: Assessment

MSC: NCLEX: Psychosocial Integrity

13. A 14-year-old is sent to a residential program after arrests for truancy and assault. At the

program, the teen refused to participate in scheduled activities and pushed a staff member, causing a fall. Which strategy by nursing staff is indicated? a. Begin social skills training. b. Coax to gain compliance. c. Neutrally allow refusals. d. Establish firm limits.

ANS: D

Firm limits are necessary to ensure physical safety and emotional security. Limit-setting will also protect other patients from the teen’s thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 456

TOP: Nursing process: Planning

14. Which assessment finding would cause the nurse to consider a child to be most at risk for the

development of mental illness? a. The child has been raised by a parent with chronic major depression. b. The child’s best friend was absent from the child’s birthday party. c. The child was not promoted to the next grade one year. d. The child moved to three new homes over a 2-year period.

ANS: A

Statistics indicate that childreNn raRisedIbyGa dB ep.reCsseM d parent have an increased risk of U S N T developing an emotional disorder. The chronicity of the parent’s depression means it has been a consistent stressor. The other factors are not as risk enhancing.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 449-450 MSC: NCLEX: Psychosocial Integrity

15. The child most likely to receive risperidone (Risperdal) to manage symptoms is one diagnosed

with: a. ADHD. b. PTSD. c. anxiety disorder. d. autistic disorder.

ANS: D

Risperidone (Risperdal) is useful for relieving irritability and labile affect demonstrated by some autistic children. It is not indicated in any of the other disorders.

DIF: Cognitive level: Applying MSC: NCLEX: Physiologic Integrity

REF: p. 456

TOP: Nursing process: Planning

16. A child complains to the school nurse about painful verbal bullying by an aggressive

classmate. What is the nurse’s best first action? a. Give notice to the chief administrator at the school regarding the events. b. Support the victimized child to share feelings about the experience.

c. Encourage the victimized child to ignore the bullying behavior. d. Discuss the events with the aggressive classmate.

ANS: B

The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the child’s complaints and validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 453 MSC: NCLEX: Psychosocial Integrity

17. An adolescent in a residential program threatens to throw a pool ball at another adolescent.

Which comment by the nurse would set limits? a. “You will be taken to seclusion if you throw that ball.” b. “Do not throw the ball. Put it back on the pool table.” c. “Attention everyone: We’re all going to the gym.” d. “Please do not lose control of your behavior.”

ANS: B

Setting limits uses clear, sharp statements about which behavior is not allowed and guidance for performing a behavior that is expected. The distracters represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the child’s developing self-control that may be ineffective.

DIF: Cognitive level: Applying TOP: Nursing process: ImplemNentR ationI

REF: p. 456 M : N G SBC. CCLMEX: Psychosocial Integrity

U S N T

O

MULTIPLE RESPONSE 1. Which behaviors are indicative of bullying by a child? Select all that apply. a. Recruits other children to avoid a child who wears glasses b. Consistently calls another child “fat” and “stupid” c. Accidentally trips another child, resulting in a fall d. Repeatedly steals another child’s lunch money e. Plays a practical joke on another child ANS: A, B, D

Bullying can be verbal, relational, or physical. It is repetitive and intentionally produces harm or pain in another person. Playful teasing, one-time aggression, and joking do not meet the criteria for bullying.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 453-454 MSC: NCLEX: Psychosocial Integrity

Chapter 35: Mental Disorders of Older Adults MULTIPLE CHOICE 1. A patient living in community housing for older adults says, “I don’t go to the senior citizens

club. They play cards and talk about the past, because that’s all they can do.” The nurse analyzes that these remarks 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 using ageism as younger individuals. The other options are not substantiated by the information given in the scenario.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 461, 477 MSC: NCLEX: Psychosocial Integrity

2. A community health nurse visits an older adult whose spouse died 6 months ago. Three vodka

bottles are in the trash. The person says, “I get lonely and drink a little to help me forget.”

Select the nurse’s most therapeutic intervention. a. Teach the person about alcoholism, and suggest other coping strategies. b. Request a mental health consultation to assess for alcohol dependency. c. Advise the person not to drink alone, because the risks for injury increase. d. Arrange for the person toN aU tteR nS d aInNAGlT coB ho.liC csOAnonymous (AA) meeting for older adults.

ANS: D

This patient needs help with alcohol abuse as well as social involvement. The AA meeting for older adults will provide an opportunity for peer bonding and reminiscing as well as strategies for coping with stress without abusing alcohol. The other options are unnecessary or ineffective.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 469-470 MSC: NCLEX: Psychosocial Integrity

3. A nurse plans a staff education program for employees of a senior living community. Which

topic has priority? a. Late-onset schizophrenia b. Depression and suicide c. Dementia 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.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: pp. 464-465

TOP: Nursing process: Planning

4. A resident in a senior community has lost weight, feels depressed, and has lost interest in

former social activities. The nurse asks, “When you last saw your doctor, did you share these problems?” The resident replies, “Yes, but the doctor said I shouldn’t expect to feel good every day.” Which barrier to mental health care is evident? a. Legislative failures to provide services for older adults b. The physician’s inadequate mental health assessment c. The resident’s inadequate description of symptoms d. Economic obstacles to adequate programming ANS: B

Primary-care physicians are often hurried and have little time to spend with patients. In addition, they are more attuned to and more comfortable treating physical problems than mental disorders. They often miss depressive symptoms in older adults, thus creating a barrier to effective treatment. The patient’s description of symptoms was adequate. Economic and legislative policies are not discussed in the scenario.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 463

TOP: Nursing process: Evaluation

5. Select the best plan for assessing an older adult. a. Decrease anxiety by obtaining answers from the family whenever possible. b. Ask direct questions, limit the focus on past events, and use a loud voice volume. c. Ensure privacy, explain the purpose, use open-ended questions, and allow time for

answers. d. Speak loudly, keep the pace of the interview brisk, and politely interrupt to terminate long stories.

ANS: C

The general rules of interviewing apply. In addition, older adults respond better to open-ended questions than to a barrage of direct questions. Because it might take the older adult longer to formulate an answer, the nurse should allow time for the patient to answer. Making sure that the patient uses his or her glasses and hearing aid is advisable. Information should be obtained directly from the patient if possible. Direct questions might seem intrusive. Speaking loudly is necessary only if the patient has a hearing deficit. Setting a brisk pace and interrupting might frustrate the patient.

DIF: Cognitive level: Applying REF: pp. 471-472 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

6. An older adult patient is severely suicidal. The patient has not eaten for a week and today

began refusing fluids. The patient’s physical condition is declining. The nurse should prepare for which intervention? a. Insertion of a feeding tube b. Electroconvulsive therapy (ECT) c. Behavior modification d. Bright-light therapy ANS: B

ECT is the treatment of choice for severe depression in older adults when a rapid response is necessary. Bright-light therapy and behavior modification will take too long. The patient does not have assessment findings that indicate enteral feeding is needed.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 465

TOP: Nursing process: Planning

7. When assessing older adults, the nurse should pay particular attention to which demographic

group with the highest suicide risk? a. Hispanic men b. Caucasian men c. Caucasian women d. African-American women ANS: B

The suicide rate for Caucasian male older adults is higher than for any of the groups listed in the other options. Although women make more suicide attempts, men have a higher suicide attempt-to-completion ratio than women.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 465 MSC: NCLEX: Psychosocial Integrity

8. Which information is most important to obtain during assessment of an older adult with a

mental disorder? a. Functional ability and emotional status b. Chronologic age and sexual functioning c. Economic status and sources of income

NteUrR d. Developmental history, in esS t sI , aN ndGaTcB tiv.itC ieO sM ANS: A These data provide an overview of patient problems and ability to function. They guide the selection of interventions and services to meet identified needs. The other options reflect information of relevance, but are not of highest priority.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 471-472 MSC: NCLEX: Psychosocial Integrity

9. A high priority for assessment by nurses caring for older adults who self-administer

medications is: a. use of stimulants. b. overuse of benzodiazepines. c. misuse of antihypertensive medications. d. trading medications with acquaintances.

ANS: B

Benzodiazepines are among the most widely prescribed medications. They are often prescribed in high doses and for prolonged periods, leading to tolerance, physical dependence, and psychologic dependence. The other options are relevant but are not of the highest priority.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: p. 476 MSC: NCLEX: Psychosocial Integrity

10. The health care provider prescribes buspirone (BuSpar) for an older adult patient with

generalized anxiety disorder and alcohol abuse. What is the nurse’s expectation about the effects of this drug? a. Buspirone is associated with psychologic dependence. b. Buspirone manages anxiety without causing sedation. c. Buspirone is associated with physical dependence. d. Buspirone has a rapid onset of action.

ANS: B

Buspirone, which has a slow onset of action, is effective in relieving anxiety and is suitable for long-term use, because dependence does not develop. Two advantages are that it has no additive effect with alcohol and it is not sedating. The other options are incorrect.

DIF: Cognitive level: Understanding MSC: NCLEX: Physiologic Integrity

REF: p. 476

TOP: Nursing process: Planning

11. A 65-year-old patient is diagnosed with late-onset schizophrenia. Both positive and negative

symptoms of the disorder are present. The patient has a history of atrial fibrillation. The nurse should prepare patient education materials related to: a. chlorpromazine (Thorazine). b. risperidone (Risperdal). c. thioridazine (Mellaril). d. haloperidol (Haldol).

ANS: B

Atypical antipsychotics such as risperidone are effective against both positive and negative symptoms of schizophrenia and have the most favorable side effect profile. The distracters are RaSzI typical antipsychotics. ChlorN prU om inN eG anT dB th. ioC riO daM zine may cause cardiovascular side effects. Haloperidol may cause neurologic side effects.

DIF: Cognitive level: Analyzing MSC: NCLEX: Physiologic Integrity

REF: p. 476

TOP: Nursing process: Planning

12. A major nursing responsibility in milieu management of a unit for older adults diagnosed with

psychiatric disorders is to: a. provide cognitive-behavior therapy (CBT) for all patients. b. provide unconditional acceptance of all behavior. c. prevent isolation, withdrawal, and deterioration. d. limit time spent in reminiscence.

ANS: C

Nurses have a responsibility to facilitate optimal function. Attention to the milieu can increase psychologic functioning and prevent deterioration resulting from withdrawal and disuse of skills. Unconditional acceptance of the individual is appropriate, but not all behavior must be accepted. It would be impractical to provide CBT for all patients. Reminiscence is a positive activity that should be encouraged and integrated into a plan of care.

DIF: Cognitive level: Understanding REF: p. 476 MSC: NCLEX: Safe, Effective Care Environment

TOP: Nursing process: Planning

13. Reducing aggressive outbursts on a unit for older adults with mental disorders can be best

achieved by:

a. b. c. d.

liberal use of antipsychotic medication. practicing redirection and diversion. restricting diversional activities. limiting personal space.

ANS: B

Redirection and diversion are effective techniques to prevent and/or manage aggressive outbursts. Liberal use of medication will result in oversedation. Diversional activity can provide constructive outlets, so it should not be restricted. Control over one’s personal space reduces aggression. Real or imagined threats to personal space might incite aggression.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 477 MSC: NCLEX: Psychosocial Integrity

14. An 80-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins

the assessment, which action should occur first? a. Move the interview to a darkened room to reduce stimulation. b. Ask if the patient can hear clearly as the nurse speaks. c. Ask the patient to rate the level of pain. d. Initiate a neurologic assessment.

ANS: B

Before proceeding with any further assessment, the nurse should assess the patient’s ability to hear questions. Impaired hearing could lead to inaccurate answers.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 472 MSC: NCLEX: Psychosocial Integrity

N R I G B.C M

U Sfour N patients T O 15.1 A community health nurse assesses between ages 70 and 80. Which patient has 5 the highest risk for alcohol dependence? . a. Patient with no history of alcohol-related problems until retirement but now drinks alcohol daily to distract himself from arthritis pain b. Patient who drank socially throughout adult life and continues this pattern, saying

“I’m old enough to drink if I want to” c. Patient who abused alcohol between ages 30 and 45 but now abstains and occasionally attends AA meetings. d. Patient with intermittent problems of alcohol misuse early in life. Now drinks one glass of wine nightly with dinner.

ANS: A

Alcohol dependence can develop at any age, and the geriatric population is particularly at risk.

The geriatric problem drinker is defined as someone who has no history of alcohol-related problems but develops an alcohol abuse pattern in response to the stresses of aging.

DIF: Cognitive level: Analyzing TOP: Nursing process: Assessment

REF: pp. 469-470 MSC: NCLEX: Psychosocial Integrity

16. An older adult patient with depression is prescribed a selective serotonin reuptake inhibitor

(SSRI). Nursing assessment should include careful collection of information regarding: a. other prescribed medications and over-the-counter remedies used. b. evidence of pseudo-parkinsonism or tardive dyskinesia. c. history of psoriasis and other skin disorders.

d. history of diarrhea and electrolyte imbalances.

ANS: A

Drug interactions, both prescription and over-the-counter, can be problematic for the geriatric patient taking an SSRI. Careful collection of information is important. The distracters do not pose problems with SSRI drugs.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: pp. 469-470 MSC: NCLEX: Physiologic Integrity

MULTIPLE RESPONSE 1. Which remarks by a 72-year-old patient should prompt the nurse to assess for depression?

Select all that apply. a. “Lately I have had a lot of aches and pains and just haven’t felt very well.” b. “My appetite is better than usual, and I am sleeping about 9 hours a night.” c. “People are in and out of my room all day and all night taking my things.” d. “Don’t ask me to eat. I can’t because my stomach is upset all the time.” e. “Life is more organized now that I don’t live in my own home.”

ANS: A, C, D

Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The other options do not suggest symptoms of mental disorder.

DIF: Cognitive level: Applying

REF: p. 465

TOP: Nursing process: AssessN mU enR t SINGMTSB C. : C NC OLMEX: Psychosocial Integrity 2. Which assessment findings related to a 68-year-old patient should be identified as risk factors

for late-onset alcohol abuse and dependence? Select all that apply. a. Chronic obstructive pulmonary disease b. Insomnia c. Male gender d. Boredom and loneliness e. Recent loss of spouse ANS: A, B, D, E

Insomnia or chronic medical illness might lead the individual to use alcohol to self-medicate.

Loss of a spouse, boredom, and loneliness often result in alcohol use to escape emotional distress. Statistics show that more women than men develop late-onset problem drinking.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 464 MSC: NCLEX: Psychosocial Integrity

Chapter 36: Soldiers and Veterans MULTIPLE CHOICE 1. A soldier was diagnosed with post-traumatic stress disorder (PTSD). The soldier’s spouse

reports that when a telephone rings during the night, the soldier rolls out of bed and assumes an aggressive stance. How will the nurse document this finding? a. Flashback b. Avoidance c. Hyperarousal d. Reexperiencing ANS: C

Hyperarousal includes exaggerated responses to noises and other environmental stimuli. It is part of the constellation of problems that impair sleep for persons with PTSD. Flashbacks are an aspect of reexperiencing. Avoidance is another criterion for PTSD. DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 485 MSC: NCLEX: Psychosocial Integrity

2. Which social event would likely be most disturbing for this soldier diagnosed with PTSD? a. Halloween festival with neighborhood children b. Picnic and fireworks display on July 4th c. Singing carols around a Christmas tree d. A family outing to the seashore ANS: B

The exploding noises associated with fireworks are likely to provoke exaggerated responses from this soldier. The distracters are not associated with offensive sounds.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 485

TOP: Nursing process: Evaluation

3. A nurse counsels an 87-year-old veteran of World War II who tearfully shares memories of

sights associated with Nazi concentration camps. Which term will be most familiar to this veteran? a. Shell shock b. Battle fatigue c. Soldier’s heart d. PTSD ANS: B

Consequences of exposure to traumatic events associated with war have been addressed by different terms over generations. Battle fatigue was the term used in World War II. Soldier’s heart was the term used after the Civil War. Shell shock was the term used in World War I. PTSD was the term used beginning with the Vietnam War. DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 484

TOP: Nursing process: Planning

4. When is it most important for the nurse to screen for signs and symptoms of post-combat

PTSD? a. Screening should be ongoing b. Before departing to return to the United States c. Immediately upon return from the combat zone d. One year after returning from the combat experience ANS: A

PTSD can have a very long lag time; in some instances, it can be 20 years or more. Screening should be ongoing. The other options are too limited.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 485 MSC: NCLEX: Psychosocial Integrity

5. A nurse assesses soldiers in a combat zone. When is it most important for the nurse to screen

for signs and symptoms of traumatic brain injury (TBI)? a. After exposure to a blast b. Before departing to return home. c. One year after returning from combat d. Immediately upon return to the United States ANS: A

TBI manifests shortly after the injury and usually resolves in days or weeks. It would be most important to screen after exposure to an explosion and before returning to the United States.

PTSD can have a very long lag time; in some instances, it can be 20 years or more.

DIF: Cognitive level: Understanding TOP: Nursing process: AssessN menR t I

REF: p. 487

: C NCLMEX: Psychosocial Integrity U S NGMTSBC. O

6. General George Patton led U.S. troops in Europe and Africa during World War II. His career

was marred by an incident of scolding a distressed, frightened soldier as “a coward” and “yellow.” Patton’s behavior embodied which phenomenon associated with symptom delay in PTSD? a. Stigma b. Lag time c. Obscuration d. Co-morbidity ANS: A

Many soldiers and veterans fight the symptoms of mental illness associated with combat.

They fear appearing weak or inadequate. These phenomena contribute to the stigma associated with war-related psychiatric illnesses.

DIF: Cognitive level: Analyzing MSC: NCLEX: Psychosocial Integrity

REF: p. 485

TOP: Nursing process: Evaluation

7. A soldier in a combat zone tells the nurse, “I saw a child get blown up over a year ago, but I

keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind.” The soldier is describing which phenomenon associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance

d. Psychosis ANS: A

The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 485 MSC: NCLEX: Psychosocial Integrity

8. A soldier who served in a combat zone tells the nurse, “I saw a child get blown up over 2

years ago, but even now when I see something red, the visions race back to my mind and I smell burnt flesh.” How should the nurse document this experience? a. Thought intrusion b. Repetitive dreams c. Hallucinations d. Flashbacks ANS: D

The soldier describes an event while awake related to reexperiencing the trauma. The description applies to flashbacks, which are common in PTSD. The statement is not associated with the remaining options.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 485 MSC: NCLEX: Psychosocial Integrity

9. A soldier who served in a combat zone returned home to the United States. The soldier’s

spouse reports to the nurse, “We had planned to start a family right away, but now he won’t talk about it. He won’t even lN ookRat cIhildGrenB .” The spouse is describing which symptom U S N T .C M associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis ANS: C

Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence that this soldier is having hyperarousal or reexperiencing war-related traumas.

Psychosis is not evident.

DIF: Cognitive level: Applying TOP: Nursing process: Assessment

REF: p. 485 MSC: NCLEX: Psychosocial Integrity

10. A soldier returned home last year after deployment to a war zone. The soldier’s spouse

reports, “We had planned to start a family right away, but now he won’t talk about it. He won’t even look at children. I wonder if we’re going to make it as a couple.” Select the nurse’s best response. a. “PTSD often changes a person’s sexual functioning.” b. “I encourage you to continue to participate in social activities where children are present.” c. “Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior.” d. “PTSD often strains relationships. Here are some community resources for help.”

ANS: D

PTSD precipitates changes that often lead to divorce. It’s important to provide support to both the veteran and spouse. Confrontation will not be effective. While it’s important to provide information, ongoing support will be more effective.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 485-487 MSC: NCLEX: Psychosocial Integrity

11. A nurse manages a program providing day treatment services to combat veterans diagnosed

with PTSD. During breaks between activities, which type of music would be most appropriate? a. Rap b. Jazz c. Rock d. Hip-hop ANS: B

Hypervigilance is a common symptom of PTSD and leads to difficulty with relaxation. Music can soothe if it is not overpowering. Jazz is mellow and would not contribute to hyperarousal.

Rap, rock, and hip-hop would be overstimulating.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: p. 485 MSC: NCLEX: Psychosocial Integrity

12. A soldier experienced a TBI associated with acceleration–deceleration forces. Which part of

the neuron was most likely damaged? a. Axon b. Dendrite c. Telomere d. Cell body ANS: A

Acceleration–deceleration forces cause shearing of axons not dendrites, which result in TBIs. The cell body is not believed to be traumatized. Telomeres are part of DNA, not neurons.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 488 MSC: NCLEX: Physiologic Integrity

13. A veteran with a suspected TBI is scheduled for diffusion tensor imaging (DTI). What

information should the nurse provide? a. “This test will help show whether tracts in your central nervous system are damaged.” b. “This test will measure changes in chemicals that transmit messages between your brain and spinal cord.” c. “This test will help predict what types of medication will be effective for treating your symptoms.” d. “This test will help your health care provider decide whether or not a computed tomography (CT) scan is needed to further diagnose your injuries.”

ANS: A

DTI is a form of magnetic resonance imaging that produces detailed microscopic images of neural tracts and related injuries. It provides better imaging of subtle injuries than CT scans. It does not measure neurotransmitters.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 488 MSC: NCLEX: Physiologic Integrity

14. A combat veteran diagnosed with a mild TBI returned to college after discharge from the

armed forces. The veteran began tutoring after scoring poorly in three courses. Which strategy can the tutor use to assist the veteran’s academic achievement? a. Decrease extraneous stimuli to improve attention span. b. Practice deep breathing to increase the brain’s oxygen supply. c. Increase caffeine intake to counteract drowsiness and fatigue. d. Play background music while studying to improve concentration.

ANS: A

TBI produces multiple cognitive problems that are likely to interfere with memory and learning. Many persons with these injuries have difficulty excluding sensory stimuli, which impairs concentration and attention span. Background music would further impair concentration. Caffeine would increase stimulation but not improve cognitive processing.

Deep breathing is helpful for producing relaxation for anyone, but it would not support memory and learning.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: pp. 485, 488 MSC: NCLEX: Physiologic Integrity

15. Excitotoxicity in persons diagnosed with TBIs is associated primarily with which

neurotransmitter? a. Norepinephrine b. Glutamate c. Dopamine d. Serotonin ANS: B

Excitotoxicity is associated with overfiring of neurons secondary to activation of glutamate.

The remaining options are not associated with this reaction.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 488 MSC: NCLEX: Psychosocial Integrity

16. A combat veteran with TBI, depression, and anxiety begins new prescriptions for sertraline

(Zoloft) and lorazepam (Ativan). In recognition of potential long-term repercussions, the nurse should provide teaching related to which topic? a. Nonpharmacologic strategies for managing anxiety b. Identifying signs and symptoms of hepatotoxicity c. Recognizing evidence of tardive dyskinesia d. Strategies for preventing obesity ANS: A

Lorazepam is a benzodiazepine, which has a high probability of causing dependence if taken long term. The nurse should teach nonpharmacologic strategies for managing anxiety to facilitate the patient’s readiness to discontinue the lorazepam. Tardive dyskinesia is associated with antipsychotic drugs. Weight gain is associated with atypical antipsychotic drugs.

Hepatotoxicity is not a likely complication.

DIF: Cognitive level: Applying TOP: Nursing process: Implementation

REF: p. 490 MSC: NCLEX: Psychosocial Integrity

17. A nurse talks with the caregiver of a combat veteran with severe traumatic brain injury. The

caregiver says, “I don’t know how much longer I can do it. My whole life is consumed with taking care of my partner.” Which resource should the nurse suggest? a. Al-Anon b. Pastoral care c. Meals on Wheels d. Multifamily support group ANS: D

A multifamily support group will provide education, support, and socialization. These services support the needs of this caregiver. Pastoral care will offer support but not education and socialization. There is no indication of substance abuse or problems with meal preparation.

DIF: Cognitive level: Analyzing TOP: Nursing process: Planning

REF: p. 491; Box 36-3 MSC: NCLEX: Psychosocial Integrity

18. A combat veteran diagnosed with moderate traumatic brain injuries is agitated and aggressive.

Which pharmacologic interveNnU tioRnSwIoN ulG dT thB e. nuCrO seMexpect to be effective? a. Bupropion (Wellbutrin) b. Benztropine (Cogentin) c. Propranolol (Inderal) d. Buspirone (BuSpar) ANS: C

Beta blockers such as propranolol (Inderal) effectively manage agitation and aggression in persons with TBIs. A dopamine-norepinephrine reuptake inhibitor such as bupropion would increase agitation. Anxiety is not the central problem for this patient. The patient does not have extrapyramidal side effects or Parkinson’s disease.

DIF: Cognitive level: Applying MSC: NCLEX: Psychosocial Integrity

REF: p. 490

TOP: Nursing process: Planning

MULTIPLE RESPONSE 1. A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a

priority for signs and symptoms of which health problems? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. PTSD

ANS: C, E

TBI and PTSD each occur in approximately 20% of soldiers returning from Afghanistan.

Some soldiers have both problems. The incidence of disorders identified in the distracters would be expected to parallel the general population.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: pp. 484, 487 MSC: NCLEX: Psychosocial Integrity

2. Which terms have historically been applied to soldiers suffering psychiatric distress related to

exposure to the horrors of war? Select all that apply. a. Shell shock b. Battle fatigue c. Soldier’s heart d. Cyclothymic disorder e. PTSD ANS: A, B, C, E

Soldier’s heart, shell shock, battle fatigue, and PTSD are terms that have been used over time to describe psychiatric distress related to exposure to the horrors of war. Cyclothymic disorder is an affective disturbance not related to traumatic experiences.

DIF: Cognitive level: Understanding TOP: Nursing process: Assessment

REF: p. 484 MSC: NCLEX: Psychosocial Integrity

3. A combat veteran diagnosed with moderate traumatic brain injury (TBI) will begin

pharmacologic therapies that include psychotropic medication. What information should the nurse provide? Select all thatNappRly. I G B.C M a. “We will monitor you closeUly fS or hNowTeach mO edication affects you.” b. “Medications can be expected to dramatically improve your symptoms.” c. “Please be patient as your health care provider identifies the best drugs for your problems.” d. “The blood levels of most medications you take will need to be checked with laboratory testing.” e. “Be prepared for frequent dose changes as your health care provider adjusts the dose to meet your needs.”

ANS: A, C, E

Patients with TBIs are frequently overly sensitive to psychotropic medications, so close monitoring is important. However, TBI can also create drug resistance. As a consequence of both dynamics, medication adjustments are frequent and frustrating for the patient. Very few of the medications need serum monitoring; it would be misleading to say “most” do. It’s important not to make promises related to how effective the drugs may or may not be.

DIF: Cognitive level: Analyzing TOP: Nursing process: Implementation

REF: pp. 489-490 MSC: NCLEX: Physiologic Integrity