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Fortinash Psychiatric Mental Health Nursing TB 5th Edition
nursing (Chamberlain University)
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Fortinash: Psychiatric Mental Health Nursing, 5th Edition
Chapter 01: Psychiatric Nursing: Theory, Principles, and Trends
1. Which understanding is the basis for the nursing actions focused on minimizing
mental health promotion of families with chronically mentally ill members?
a. Family members are at an increased risk for mental illness.
b. The mental health care system is not prepared to deal with family crises.
c. Family members are seldom prepared to cope with a chronically ill individual.
d. The chronically mentally ill receive care best when delivered in a formal setting.
ANS: A
When families live with a dominant member who has a persistent and severe mental
disorder the outcomes are often expressed as family members who are at increased risk
for physical and mental illnesses. The remaining options are not necessarily true.
DIF: Cognitive Level: Application
REF: Page 3
2. Which nursing activity shows the nurse actively engaged in the primary prevention of
mental disorders?
a. Providing a patient, whose depression is well managed, with medication on time
b. Making regular follow-up visits to a new mother at risk for post-partum
depression
c. Providing the family of a patient, diagnosed with depression, information on
suicide prevention
d. Assisting a patient who has obsessive compulsive tendencies prepare and
practice for a job interview
ANS: B
Primary prevention helps to reduce the occurrence of mental disorders by staying
involved with a patient. Providing medication and information on existing illnesses are
examples of secondary prevention which helps to reduce the prevalence of mental
disorders. Assisting a mentally ill patient with preparation for a job interview is tertiary
prevention since it involves rehabilitation.
DIF: Cognitive Level: Application
REF: Page 4
3. Which intervention reflects attention being focused on the patient’s intentions
regarding his diagnosis of severe depression?
a. Being placed on suicide precautions
b. Encouraging visits by his family members
c. Receiving a combination of medications to address his emotional needs
d. Being asked to decide where he will attend his prescribed therapy sessions
ANS: D
A primary factor in patient treatment includes consideration of the patient’s intentions
regarding his or her own care. Patients are central to the process that determines their
care as their abilities allow. Under the guidance of PMH nurses and other mental health
personnel, patients are encouraged to make decisions and to actively engage in their
own treatment plans to meet their needs. The remaining options are focused on specifics
of the determined plan of care.
DIF: Cognitive Level: Application
REF: Page 5
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4. When a patient’s family asks why their chronically mentally ill adult child is being
discharged to a community-based living facility, the nurse responds:
a. “It is a way to meet the need for social support.”
b. “It is too expensive to keep stabilized patients in acute care settings.”
c. “This type of facility will provide the specialized care that is needed.”
d. “Being out in the community will help provide hope and purpose for living.”
ANS: D
Hospitalization may be necessary for acute care, but, when patients are stabilized, they
move into community-based, patient-centered settings or are discharged home with
continued outpatient treatment in the community. Concentrated efforts are made to
reduce the patient’s sick role by providing opportunities for the development of a
purposeful life and instilling hope for each patient’s future. Although social support is
important, such a living arrangement is not the only way to achieve it. Although acute
care is expensive, it is not the major concern when determining long-term care options.
Community-based facilities are not the only option for specialized care.
DIF: Cognitive Level: Application
REF: Page 5
5. What is the best explanation to offer when the mother of a chronically ill teenage
patient asks, “Under what circumstances would he be considered incompetent?”
a. “When you can provide the court with enough evidence to show that he is not
able to care for himself safely.”
b. “It is not likely that someone his age would be determined to be incompetent
regardless of his mental condition.”
c. “He would have to engage in behavior that would result in harm to himself or to
someone else; like you or his siblings.”
d. “If the illness becomes so severe that his judgment is impaired to the point where
the decisions he makes are harmful to himself or to others.”
ANS: D
When a person is unable to cognitively process information or to make decisions about
his or her own welfare, the person may be determined to be mentally incompetent.
Providing self-care is not the only criteria considered. Age is not a factor considered. The
decision is often based on the potential for such behavior.
DIF: Cognitive Level: Application
REF: Page 6
6. Which psychiatric nursing intervention shows an understanding of integrated care?
a. A chronically abused woman is assessed for anxiety.
b. A manic patient is taken to the gym to use the exercise equipment.
c. The older adult diagnosed with depression is monitored for suicidal ideations.
d. A teenager who refuses to obey the unit’s rules is not allow to play video games.
ANS: A
The majority of health disciplines now recognize that mental disorders and physical
illnesses are closely linked. The presence of a mental disorder increases the risk for the
development of physical illnesses and vice versa. Assessing a chronically abused
individual for anxiety call should attention to the psychiatric disorder that could develop
from the abuse. The remaining options show interventions that are appropriate for the
mental disorder.
DIF: Cognitive Level: Application
REF: Page 6
7. What reason does the nurse give the patient for the emphasis and attention being
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paid to the recovery phase of their treatment plan?
a. Recovery care, even when intensive, is less expensive than acute psychiatric
care.
b. Effective recovery care is likely to result in fewer relapses and subsequent
hospitalizations.
c. Planning for recovery care is time consuming and involves dealing with many
complicated details.
d. Recovery care is usually done on an outpatient basis and so is generally better
accepted by patients.
ANS: B
Much attention is paid to recovery care since effective recovery care helps improve
patient outcomes and thus minimize subsequent hospitalizations. Recovery care is not
necessarily less expensive than acute care. Although effective recovery care planning
may be time consuming and detail oriented, that is not the reason for implementing it.
Recovery care is not necessarily well accepted by patients.
DIF: Cognitive Level: Application
REF: Page 7
8. The nurse is attending a neighborhood meeting where a half-way house is being
proposed for the neighborhood when a member of the community states, “We don’t
want the facility; we especially don’t want violent people living near us.” The
response by the nurse that best addresses the public’s concern is:
a. “In truth, most individuals with psychiatric disorder are passive and withdrawn
and pose little threat to those around them.”
b. “The mentally ill seldom behave in the manner they are portrayed by movies;
they are people just like the rest of us.”
c. “Patients with psychiatric disorder are so well medicated that they do not display
violent behaviors.”
d. “The mentally ill deserve a safe, comfortable place to live among people who
truly care for them.”
ANS: A
A major reason for the existence of the stigma placed on persons with mental illness is
lack of knowledge. The main fear is of violence, although only a small percentage of
patients with mental illness display this behavior. Providing the public with accurate
information can help reduce stigma. The remaining options do not directly address the
concerns stated.
DIF: Cognitive Level: Application
REF: Pages 13-14
9. Which activity shows that a therapeutic alliance has been established between the
nurse and patient?
a. The nurse respects the patient’s right to privacy when visitors are spending time
with the patient.
b. The patient is eagerly attending all group sessions and working independently on
identifying their personal stressors.
c. The patient is freely describing their feelings related to the physical and
emotional trauma they experienced as a child with the nurse.
d. The nurse dutifully administers the patient’s medications on time and with
appropriate knowledge of the potential side effects.
ANS: C
A primary aspect of working with patients in any setting and particularly in the
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psychiatric setting is the development of a therapeutic alliance with the patient. Such an
alliance is established on trust. It is a professional bond between the nurse and the
patient that serves as a vehicle for patients to freely discuss their needs and problems in
the absence of the nurse’s criticism or judgment. Any nurse has an obligation to respect
the patient’s rights and administer care effectively. The patient’s willingness to
participate in the plan of care reflects self motivation.
DIF: Cognitive Level: Application
REF: Page 9
10. Mental health care reform has called for parity between psychiatric and medical
diagnoses. Which is an example of such parity?
a. Depression treatment is not paid for as readily as is treatment for asthma.
b. The mentally ill patient will be protected by law against social stigma.
c. Medical practitioners are trained to be proficient at treating mental disorders.
d. Psychiatric service reimbursement will be equivalent to that of medical services.
ANS: D
The term parity as used here refers to payments for mental health services that equal
payment schedules for medical or surgical conditions. The remaining options(B and C) do
not relate to financial reimbursement or funds allocated for mental health care being
equal to those of medical diagnoses.
DIF: Cognitive Level: Application
REF: Page 15
1. Which assessment findings suggest to the nurse that this patient has characteristics
seen in an individual who has reached self-actualization? Select all that apply.
a. Reports to have, “found peace and security in my religious faith”
b. Effectively “changed occupations” when a chronic vision problem worsened
c. Has consistently earned a six-figure salary as an architect for the last 10 years
d. Has been in a supportive, loving relationship with the same individual for 15
years
e. Provides free literacy tutoring help at the local homeless shelter 3 evenings a
week
ANS: A, B, D, E
Characteristics of self actualization would include: spiritual well-being, open and flexible,
relationally fulfilled, and generosity toward others. Salary doesn’t necessarily reflect selfactualization.
DIF: Cognitive Level: Application
REF: Page 4
2. Which nursing activities represent the tertiary level of mental health care? Select all
that apply.
a. Providing a depression screening at a local college
b. Helping a mental-challenged patient learn to make correct change
c. Reporting an incidence of possible elder abuse to the appropriate legal agency
d. Regularly assessing a patient’s understanding of their prescribed antidepressants
e. Providing a 6-week parenting class to teenage parents through a local high school
ANS: B, D
Tertiary prevention reduces the residual effects of the disorder such as depression and
mental retardation. There is no quaternary level of prevention. Primary prevention
reduces occurrences of mental disorders such as screenings and parenting classes, and
secondary prevention reduces the prevalence of disorders as evidenced by assessing
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knowledge.
DIF: Cognitive Level: Application
REF:
Page 4
3. Which nursing actions indicate an understanding of the priority issues currently
facing psychiatric mental health nursing today? Select all that apply.
a. Working on the facility’s ‘Safe Use of Restraints Policy’ revision committee
b. Advocating for increased salaries for all levels of psychiatric mental health nurses
c. Attending a political rally for increased state funding for mental health service
providers
d. Offering an in-service to facility staff regarding the cultural implications of caring
for the Hispanic patient
e. Joining the state nursing committee working on the role and scope of practice of
the advanced practice psychiatric nurse
ANS: A, C, D, E
Priority issues include funding, safety issues in psychiatric treatment centers—
particularly the use of patient restraints, quality-of-care issues, access to health care for
minority populations, and standardization of advanced practice nurse roles.
DIF: Cognitive Level: Application
REF: Page 9
4. Which assessment findings describe risk factors that increase the potential risk for
mental illness? Select all that apply.
a. Possesses high tolerance for stress
b. Is very curious about ‘how things work’
c. Admits to being a member of an ethnic gang
d. Only practicing Jew among school classmates
e. Has a younger sibling who is mentally challenged
ANS: C, D, E
Risk factors are internal predisposing characteristics and external influences that
increase a person’s vulnerability and potential for developing mental disorders. Types of
risk factors and examples include the following: having a mentally-challenged family
member in the home; belonging to a punitive gang; and being the object of reject or
bullying. The remaining options are protective factors.
DIF: Cognitive Level: Application
REF: Page 11
5. Which nursing actions show a focus on the fundamental goals that guide psychiatric
mental health nurses in providing patient care? Select all that apply.
a. Offering an informational session of identifying signs of depression at a local
senior center
b. Attending a workshop on evidence practice interventions for the chronically
depressed patient
c. Keeping strict but appropriate boundaries with a patient diagnosed with a
personality disorder
d. Asking a parent who has just experienced the death of a child if they could
consider talking with a grief counselor
e. Identifying what help a patient diagnosed with Alzheimer’s disease will need with
instrumental activities of daily living (IADLs)
ANS: A, B, D, E
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Standard objectives guide PMH nurses and members of related disciplines in the care of
patients (individuals, families, communities, and organizations). The objectives and
criteria are as follows: the promotion and protection of mental health, the prevention of
mental disorders, the treatment of mental disorders, and recovery and rehabilitation.
Keeping appropriate boundaries is a generalized nursing responsibility.
DIF: Cognitive Level: Analysis
REF: Page 3
Chapter 02: Nursing Practice in the Clinical Setting
1. Which nursing action is a reflection of Hildegard Peplau’s theoretic framework
regarding psychiatric mental health nursing?
a. Basing patient outcomes on expected instinctual responses
b. Discussing a patient’s feelings regarding parents and siblings
c. Providing the patient with clean clothes and wholesome food
d. Centering professional practice in a state run psychiatric facility
ANS: B
Peplau’s pioneering endeavors and contributions were largely influenced by
interpersonal psychotherapy. She believed that disorders evolved in the social context of
interpersonal interactions. (i.e., what went on between people). Instinctual responses are
more related to intrapersonal interactions. Florence Nightingale was instrumental in the
holistic approach to nursing care, whereas Linda Richards’ practice was centered on
institutional care of the mental ill.
DIF: Cognitive Level: Application
REF: Page 18
2. The nurse is attempting to provide a safe environment for a patient at great risk for
self-harm. Which intervention shows an understanding of evidence-based practice
(EBP)?
a. Using physical restraints only after all other options have been proven ineffective
b. Referring to the facility’s policies manual for guidelines for applying physical
restraints
c. Collecting data regarding the short-term effects of using physical restraints on an
aggressive patient
d. Requiring constant monitoring of a patient whose inability to self-regulate anger
has required the use of physical restraints
ANS: B
Health care systems are participating in the shift in nursing practice by encouraging
research in their facilities and by implementing interventions that increase nurses’
knowledge about EBP. Nurses are participating to make evidence-based nursing
practices available for their use, and they are helping to determine the outcomes that
will benefit patients. The remaining options are examples of long-standing practice
related to the use of physical restraints.
DIF: Cognitive Level: Application
REF: Page 19
3. Which statement by the patient reflects patient education that was based on the
concept of integrated patient care?
a. “I know I’m anxious when I get a tension headache.”
b. “My anxiety is a result of stressors I don’t cope well with.”
c. “Medication has helped me tremendously with anxiety control.”
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d. “Anxiety runs in my family; my entire family is trying to deal with it.”
ANS: A
Integrated patient care is the recognition of the interplay between physical and mental
health. In integrated care, these disorders are not treated as separate illnesses; rather,
they are treated together. The remaining options make no mention of a relationship
between mental and physical illness.
DIF: Cognitive Level: Application
REF: Page 19
4. The nurse demonstrates objective patient care when:
a. Being sympathetic to the patient’s recent loss of a spouse
b. Protecting the anxious patient by eliminating stressors in the milieu
c. Responding to the patient by stating, “I know exactly how you feel.”
d. Facilitating the patient’s exploration of various stress reduction techniques
ANS: D
The nurse demonstrates objectivity by helping the patient to process and organize
thoughts that are directed toward the solving of his or her own problems. With
sympathy, the nurse loses objectivity and moves into his or her own personal feelings.
Removing all stress does not allow the patient to develop necessary coping skills.
DIF: Cognitive Level: Application
REF: Pages 21- 22
5. Which nursing intervention would be appropriately addressed during the orientation
phase of the nurse–patient relationship?
a. Self reflection by the nurse regarding personal biases and prejudices regarding
the patient
b. Patient works at prioritizing personal needs and develops realistic expected
outcomes
c. Establishing the contract between the nurse and the patient regarding mutual
needs and expectations
d. Patient commits to the reinforcement of positive personal characteristics while
working on problems and concerns
ANS: C
A contract or agreement is established during the orientation phase of the relationship.
The contract defines limits and expectations of both the patient and the nurse. Self
Reflection occurs during the pre-orientation phase while the remaining options are
addressed during the working phase of the relationship.
DIF: Cognitive Level: Analysis
REF: Page 22
6. Which action on the part of a novice psychiatric mental health nurse shows a need
for future development of altruism?
a. Excusing a patient from attending group because, “all that talking makes me so
anxious”
b. Not permitting two patients who are physically attracted to each other to engage
in public displays of affection
c. Placing a physically aggressive patient in restraints when they are unable to
internally calm their anger
d. Self-reflecting on “why I continue to work with patients who are so emotionally
damaged they will never be normal”
ANS: A
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This option shows a misguided kindness that will ultimately have a negative impact on
the patient’s treatment. The remaining options show responsible nursing interventions
that include self-reflection of personal motivation for such work.
DIF: Cognitive Level: Application
REF: Page 24
7. The greatest negative outcome resulting from a nurse’s fear of a mentally ill patient
is that the:
a. Nurse will reinforce negative stereotyping of the mentally ill.
b. Patient will experience increased bias against the nursing staff.
c. Public’s fearfulness of the mentally ill will continue to be exaggerated.
d. Therapeutic alliance between the nurse and patient will not develop effectively.
ANS: D
Unrealistic preconceived images, stereotyping, and biases have an effect on nurses that,
when resulting in fear, will negatively impact the therapeutic effectiveness of the nurse
and the care provided. The remaining options do not have the priority that providing
quality patient care has.
DIF: Cognitive Level: Application
REF: Page 26
8. Which action on the part of a novice mental health nurse will best minimize fear
related to effectively working with the psychotic patient?
a. Be knowledgeable about psychotropic medications and their affect on psychosis.
b. Always arrange for staff support when working one-on-one with a psychotic
patient.
c. Take advantage of opportunities to attend workshops devoted to the care of the
psychotic patient.
d. Recognize that the psychotic patient is not in control of their behaviors due to
their altered though processes.
ANS: C
Fear breeds avoidance, but knowledge and preparation diminish fear and bring
confidence. Being prepared before entering the psychiatric setting includes having
knowledge and understanding of mental disorders. The remaining options do not provide
confidence but rather means of controlling or avoiding the psychotic patient.
DIF: Cognitive Level: Analysis
REF: Page 26
9. Which response by the nurse manager to a novice mental health nurse is most
effective when the nurse asks, “How do I justify not keeping a patient’s secret?”
a. “Never promise the patient that you will keep a secret for them.”
b. “Always stop the patient from telling you something as a secret.”
c. “Let the patient know that you will not keep a secret that could ultimately cause
harm or affect their treatment.”
d. “Keep reminding yourself that you are not the patient’s friend but rather a
professional mental health provider.”
ANS: C
Nurses and other healthcare professionals do not keep secrets or make promises to
patients when the secret may interfere with the patient’s treatment or put them or
others at risk for harm. The remaining options offer appropriate nursing actions but do
not effectively answer the nurse’s question.
DIF: Cognitive Level: Analysis
REF: Page 30
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10. The nurse is effectively facilitating the nurse-patient relationship when:
a. Sharing with an angry patient who is verbally abusive that, “Although I can
accept that you are angry, I cannot and will not accept your verbal abuse.”
b. Focusing on the patient’s life experience without relating to the similarities of
one’s own experiences
c. Objectively providing constructive criticism that is directed to helping the patient
identify inappropriate behaviors
d. Refraining from abandoning the patient regardless of the frustration the
interaction causes
ANS: A
Accepting the patient’s feelings is essential; however, it is not necessary to accept all of
the patient’s behaviors. Assist the patient by setting limits on patient behaviors that are
self-defeating or that threaten the patient or others in any way. Setting these limits
allows for mutual respect in the therapeutic alliance. The remaining options enhance the
patient’s clinical experience rather than the nurse-patient relationship.
DIF: Cognitive Level: Application
REF: Page 35
11. An often expressed intrinsic reward of psychiatric mental health nursing is:
a. Seeing the seriously ill recover their health
b. Working with patients of all ages and walks of life
c. Working with well-trained, caring health care providers
d. Having time to really focus on the human who is the patient
ANS: D
Psychiatric mental health nurses are able to spend the time to know the patient not only
as a patient but as an individual. This is an opportunity most nurses whose practice is
based on the physical care of the patient is not afforded. The remaining options are not
necessarily unique to psychiatric nursing.
DIF: Cognitive Level: Application
REF: Page 36
12. Which statement is an example of an inference?
a. “He is an alcoholic because his wife nags a lot.”
b. “He states he binges after arguing with his wife.”
c. “You say your alcohol intake exceeds a quart a day.”
d. “So you are saying that you were drinking earlier today.”
ANS: A
An inference is an interpretation of behavior that is made by finding motive and forming
conclusions without having all the necessary information. The nurse interprets the
patient’s behavior, decides on a reason, assigns a motive, and forms a conclusion. The
remaining options are validations of observations.
DIF: Cognitive Level: Application
REF: Page 34
1. Which interactions are likely outcomes of a well-established therapeutic alliance?
Select all that apply.
a. The nurse states, “I’m not here to judge but rather to help.”
b. The patient states, “I really think I can handle this problem now.”
c. The patient asks his abusive father to attend counseling with him.
d. The nurse sets boundaries for a patient who has few social skills.
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e. The patient with anger issues voluntarily goes into the seclusion room.
ANS: A, B, C, E
The alliance serves as a vehicle that provides patients with an opportunity to freely
discuss their needs and problems in the absence of judgment and criticism, to gain
insight into their abilities, to practice new coping skills, and to heal emotional wounds.
Setting boundaries is not an outcome of such an alliance.
DIF: Cognitive Level: Application
REF: Page 19
2. Which nursing interventions are directly related to the principles on which a
therapeutic alliance is based? Select all that apply.
a. Graciously declining to, “Come visit when I get discharged.”
b. Establishing the topic to be discussed at each group session
c. Explaining to the patient the purpose of terminating the alliance
d. Sharing how the nurse also has experienced the same problems
e. Providing subjective feedback to the patient’s efforts at therapy
ANS: A, B, C
The principles that focus on the development and maintenance of a healthy alliance
include: the relationship is therapeutic rather than social; the focus remains on the
patient’s needs and problems rather than on the nurse; the relationship is purposeful
and goal directed; the relationship is objective rather than subjective in quality; and the
relationship is time-limited rather than open-ended. The sharing of experiencing is not
patient centered.
DIF: Cognitive Level: Application
REF: Page 20
3. The nurse is attempting to minimize the group’s display of resistance during a
therapy session. Which patients are at risk for displaying such behavior? Select all
that apply
a. The patient who is cognitively impaired
b. The patient who is older and well educated
c. The patient who is aggressive and attention seeking
d. The patient who has attended similar therapy groups in the past
e. The patient who has been diagnosed with paranoid schizophrenia
ANS: A, D, E
A patient who redirects the focus away from himself or herself by changing the subject is
engaging in resistance behavior. Patients divert the topic for one or more of several
reasons: a fear of being judged; avoiding the repetition of material that has been
previously discussed; or the inability to stay cognitively focused. The attention-seeking
patient may attempt to monopolize the discussion but not necessarily be at risk for
resisting the topic. Age and education are not risk factors.
DIF: Cognitive Level: Application
REF: Pages 20-21
Chapter 03: The Nursing Process and Standards of Practice
1. The patient asks the nurse, “I’ve heard the student nurses talk about the nursing
process. Why is there so much emphasis on using the nursing process?” The
response that explains the need for nurses to understand and use the nursing
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process is:
a. “Do you think you have a better method we might use?”
b. “The nursing process is a systematic problem-solving method encompassing all
components necessary to care for patients.”
c. “Using the nursing process is a way of legitimizing our profession and placing us
on an equal footing with the pure sciences.”
d. “The nursing process is a unidimensional, static, linear approach used to guide
nurses as they make clinical judgments.”
ANS: B
This response best explains the importance of the nursing process by description and
relationship to patient care. Suggesting that the patient may have a better method is
challenging and does not address the question posed by the patient. Providing
legitimacy to the profession is a very limited explanation for use of the nursing process.
The nursing process is not one-dimensional, static, or linear.
DIF: Cognitive Level: Knowledge
REF: Page 40
2. When preparing to conduct a nursing history and assessment on a patient
transferred from the emergency department (ED) whose family believes the patient
to be a questionable historian due to cognitive impairment, the nurse initially begins
the interview by:
a. Reviewing the ED chart
b. Contacting the admitting physician
c. Directing the questions to the family members
d. Establishing a line of communication with the patient
ANS: D
The nurse should begin establishing the nurse–patient relationship by initially directing
the questions to the patient. The nurse can confirm information and/or obtain
supplementary information from the sources identified by the other options.
DIF: Cognitive Level: Application
REF: Page 40
3. The nurse shows the ability to effectively state a nursing diagnosis reflective of the
implications of depression on a patient’s life processes when stating in the patient’s
plan of care that:
a. Patient outcomes were partially attained. Implementation of present plan to
continue.
b. Patient will initiate and support conversation with nurse therapist by (date 3
weeks in future).
c. Oral medication for anxiety should be administered when depression is assessed
to be at the moderate level.
d. Impaired verbal communication r/t impoverished thoughts secondary to
depression as evidenced by monosyllabic responses.
ANS: D
This statement contains the various components of a nursing diagnosis while expressing
the existence of an altered life process. The remaining options reflect other steps, such
as evaluation and intervention planning.
DIF: Cognitive Level: Application
REF: Pages 47-48
4. When engaging in outcomes identification, the nurse:
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a. Interviews and collects patient-focused data
b. Re-assesses the patient’s physical and emotional status evaluation
c. Reviews the patient’s existing problems and projects the results of the nursing
care
d. Considers the patient’s presenting symptoms and identifies nursing-related
problems
ANS: C
Outcomes are projections of expected influence that nursing interventions will have on
the patient. Interviewing and collecting data is involved in the assessment process, reassessing is involved in the evaluation process, and identifying related nursing problems
is involved in determining appropriate nursing diagnoses.
DIF: Cognitive Level: Application
REF: Page 49
5. While discussing assessment of suicidal patients, a novice nurse mentions, “I was
taught to always base my care on concrete, evidence-based scientific reasoning and
never to rely on intuition.” Which response by the experienced nurse shows
understanding of intuitive reasoning?
a. “That’s wise, because intuition went out of favor with the scientific revolution.”
b. “Critical thinking and intuition are at opposite poles. Keep relying on your
expertise.”
c. “It’s possible that intuition about suicidality is generated by transfer of feelings
from the patient to the nurse.”
d. “It’s been determined that intuition is nothing more that extrasensory perception,
so some folks have it, and some don’t.”
ANS: C
A “strong hunch” or a “gut feeling” is an example of intuitive reasoning that is believed
to come from the therapeutic relationship’s sharing of feelings between nurse and
patient. Most nurses agree that intuition is compatible with scientific reasoning, because
both are likely linked to practice and experience. A nurse learns intuitive reasoning
through clinical practice rather than from school or books.
DIF: Cognitive Level: Application
REF: Page 45
6. A nurse shows effective critical thinking skills directed towards nursing care of a
cognitively impaired patient who continues to socially isolate by:
a. Clearly stating that the patient must socially interact once daily
b. Documenting that the patient continues to resist socialization
c. Asking the patient to identify which unit activity they are willing to attend
d. Suggesting that staff take the patient with them when running errands off the
unit
ANS: D
Critical thinking in this case involves the creation of alternative solutions to a problem
that was not resolved by conventional methods. The remaining options, although not
inappropriate, do not show critical thinking skills
DIF: Cognitive Level: Application
REF: Page 45
7. A depressed patient shares with the nurse that he, “has been thinking about ending
it all”. Based on NANDA recommendations, the nurse:
a. Implements suicide precautions for this patient
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b. Includes ‘Risk for Self Harm’ to the patient’s care plan
c. Documents regarding the patient’s safety every 15 minutes
d. Reviews the patient’s chart for references to past incidences of hopeless
ANS: B
NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a
risk diagnosis if the problem has not occurred yet. The remaining options, although not
inappropriate, do not related to NANDA.
DIF: Cognitive Level: Application
REF: Page 48
8. The nurse shows an understanding of the appropriate use of nursing outcomes
regarding triggers for a patient diagnosed with chronic alcohol abuse when stating:
a. "Can you work on identifying three situations that cause you to abuse alcohol?”
b. ”I’ll help you to identify three triggers for your drinking during today’s session.”
c. ”I’m pleased you’ve identified three situations that trigger your abuse of alcohol.”
d. “Do you think you will be able to avoid the three triggers that cause you to
drink?”
ANS: C
Outcomes sometimes referred to as behavioral goals are used to describe and evaluate
the effectiveness of nursing interventions. The correct option shows that the patient was
successful at accomplishing an outcome inferring the nursing interventions were
successful. The remaining options do not indicate an evaluation of success or failure.
DIF: Cognitive Level: Application
REF: Page 49
9. When a patient experiencing acute depression asks what the difference is between a
medical and a nursing diagnosis, the nurse responds best when stating:
a. Actually they are very similar in that they both are concerned with helping you
get better and lead a happier life.
b. Medical diagnoses are focused on why you are depressed whereas nursing
diagnoses are concerned about making your life less sad.
c. Nursing diagnoses are more directed at caring for you, unlike medical diagnoses
that focus on finding the cause for your problem.
d. The medical diagnosis identifies that you are experiencing depression whereas
the nursing diagnosis identifies how the depression is affecting you.
ANS: D
The medical diagnosis involves identifying a mental or physical problem that results in
the symptoms that negatively affect a patient’s life. Although the nurse is
knowledgeable about the disorders and their treatments, the nursing diagnosis focuses
mainly on the patient’s responses to the disorder and the effects that the disorder has on
the patient. The types of diagnoses have different foci that result in different actions and
concerns.
DIF: Cognitive Level: Application
REF: Page 49
10. A nurse best shows an understanding of the role of evidence-based research in
achieving therapeutic patient care outcomes when:
a. Subscribing to and reading a monthly psychiatric research nursing journal
b. Working on a committee to revise current facility policies regarding the use of
chemical restraints
c. Registering to attend a psychiatric workshop on newly developed psychotropic
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medication therapies
d. Asking an experienced staff member to review the interventions being proposed
for a newly admitted patient
ANS: B
Evidence-based practice is based on evidence and scientific principles that have been
developed through research. The more closely clinical practice reflects relevant research,
the more likely it is that patients will receive the best available care. The option that
infers action directed at implementing the research is the one that shows best
understanding. Reliance only on experience is not reflective of quality nursing care.
DIF: Cognitive Level: Application
REF: Page 51
11. When caring for a patient admitted with a diagnosis if bipolar disorder, managed care
regulations is the driving force behind the nurse’s use of:
a. NANDA nursing diagnoses
b. Short-term stress management therapy
c. A specialized clinical pathway for such patients
d. Generic instead of brand name medications
ANS: C
Managed care regulations have brought about the use of clinical pathways (also called
critical pathways or a care maps) which are standardized multidisciplinary planning tools
that monitor patient care through projected caregiver interventions and expected patient
outcomes with a projected timeline of success. NANDA nursing diagnoses are not related
to regulations or payment concerns. The implementation of short-term stress
management therapy in an acute care psychiatric environment would not be driven by
managed care regulation or payment concerns. The use of generic medications when
appropriate is primarily cost driven.
DIF: Cognitive Level: Application
REF: Page 51
12. A benefit of the implementation of clinical pathways is evidenced when the patient
states:
a. “I know my doctors and nurses really care about me.”
b. “My medication has really helped lessen my symptoms.”
c. “I have hopes that I will be able to lead a productive, healthy life.”
d. “My care team has really helped me manage most of my problems.”
ANS: D
Clinical pathways are tools that among other things promote interdisciplinary care thus
providing for holistic care of the patient. The remaining options do not involve the
additional recognized benefits of clinical pathways that include cost effectiveness and
access to patient status reports.
DIF: Cognitive Level: Application
REF: Page 54
13. A nurse shows the best understanding of the legal importance of the patient’s chart
when stating:
a. “You always document in ink and never erase or use “white out” in the nursing
notes.”
b. “It’s a document that shows proof that the patient received care that met the
expected standards.”
c. “Patient charts are carefully protected from unlawful access by inappropriate
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individuals or institutions.”
d. “The patient has a legal right to the information contained in the chart but not
the original documentation itself.”
ANS: B
The patient’s chart is a legal document that effectively communicates patient outcomes,
medications, treatments, responses, and unusual incidents reflecting the healthcare
systems attempts at meet the standard of care appropriate for this patient. The other
options are not as inclusive in describing the legal status of the chart.
DIF: Cognitive Level: Application
REF: Page 56
14. The nurse best fulfills the obligation to be accountable for providing care that meets
the expected standards of care when:
a. Developing a therapeutic relations with the patient
b. Applying evidence-based nursing practice to the plan of care
c. Providing appropriate discharge planning to meet the patient’s needs
d. Evaluating the effectiveness of interventions through achievement of outcomes
ANS: D
Evaluation of the patient’s progress and the nursing activities involved are critical
because nurses are accountable for the standards of care in each discipline. Although
the other options reflect appropriate and expected nursing interventions, they are not
the primary means of assuring that standard of care has been met.
DIF: Cognitive Level: Application
REF: Page 56
15. The nurse assesses a patient’s judgment by asking:
a. "Why did you run away?"
b. "When did you first start hearing voices?"
c. “What would you do if you smelled smoke in your home?”
d. "Do you believe you hear voices, or do you think it is in your mind?"
ANS: C
Judgment is the ability to assess and evaluate situations, make rational decisions,
understand consequences of behavior, and take responsibility for actions. Judgment may
be assessed by asking a question that has a common-sense answer. The other options
ask about motivation, elicits historical information about the illness or seeks information
about insight.
DIF: Cognitive Level: Application
REF: Page 43
16. The nurse responsible for the care plan of a patient diagnosed with cognitive
impairment includes rationales for the nursing interventions primarily to:
a. Provide a means for outcome evaluation
b. Account for the reasoning that drives the nursing action
c. Support the patient’s success in achieving the expected outcome
d. Provide information to aide in the implementation of the nursing action
ANS: B
Rationales primarily reflect nurses’ accountability for their actions by explaining why the
action is necessary and expected to positively impact the patient’s condition. Rationales
are not used to support or evaluate the success of the intervention nor to educate how
the action should be preformed.
DIF: Cognitive Level: Application
REF: Page 56
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17. A patient who has a nursing diagnosis of ineffective coping related to ineffective
problem solving has been involved in treatment for 6 months. The nurse determines
that the planned interventions require revision when the patient states:
a. “I really don’t think my psychiatrist actually helps me.”
b. “I can’t decide if I should get my own apartment or not.”
c. “I can’t accept that I will never be able to comfortably make decisions.”
d. “I don’t think I’m liked well enough to seek election as a committee chairperson.”
ANS: B
Nursing interventions describe a specific course of action or a therapeutic activity that
helps the patient to move toward a more functional state; in this case problem solving.
The statement indicates indecision and suggests that problem solving is still a patient
problem. Showing dislike of the physician actually shows a decision. Not accepting the
realization of ineffective decision making is not related to ineffective coping but rather
shows focus on affecting the problem. Expressing the perception that one is not liked
concerns self-esteem.
DIF: Cognitive Level: Application
REF: Page 54
18. To best facilitate interdisciplinary communication regarding the plan of care for a
patient diagnosed with paranoid schizophrenia, the nurse:
a. Requires weekly meetings of the care team
b. Ensures the team includes members from all appropriate disciplines
c. Uses the standardized NIC classification system of care interventions
d. Recognizes the need for team access to patient records and makes them
available
ANS: C
The Nursing Interventions Classification (NIC) is the first comprehensive standardized
classification of interventions. The NIC states that one should not change intervention
labels and definitions so that there is no confusion across settings. Although not
inappropriate, the remaining options do not directly minimize confusion related to
communication.
DIF: Cognitive Level: Application
REF: Page 55
19. When reviewing the history of a newly admitted patient diagnosed with severe
chronic depression, the nurse is most concerned about patient safety issues when
noting:
a. The patient’s Axis II includes a diagnosis of mental retardation
b. Documentation that the patient has been noncompliant regarding medications
c. The patient’s current Global Assessment of Functioning (GAF) Scale rating is 9
d. Reference to a recent physical injury resulting from the patient’s impulsive
behavior
ANS: C
The Global Assessment of Functioning (GAF) Scale is one of the tools use to assess
patient functioning and possible prognosis. It is coded on a numerical continuum, with 1
indicating little danger and 10 indicating severe or persistent danger, and possible
suicidal potential. Mental deficiency may contribute to issues of safety but it is not a
significant risk factor. Noncompliance may contribute to the patient’s depression but it is
not the greatest concern identified. Although past history is considered a predictor of
future behavior, this is more related to the safety of others than to the patient.
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DIF:
Cognitive Level: Application
REF:
Page 49
20. An appropriate nursing diagnosis for a patient who manifests a psychological
problem through frequent expressions of unfounded or excessive guilt or shame,
states that he is unable to deal with situations, and has a hesitation to try new things
would be:
a. Hopelessness
b. Powerlessness
c. Ineffective coping
d. Chronic low self-esteem
ANS: D
The behaviors mentioned in the situation are congruent with criteria for the diagnosis of
chronic low self-esteem. The patient’s symptoms go beyond powerlessness.
Hopelessness does not involve feelings of guilt and shame. The data is not consistent
with a diagnosis of ineffective coping.
DIF: Cognitive Level: Application
REF: Page 47
21. A well-stated outcome criteria for a patient with a nursing diagnosis of risk for
loneliness related to social isolation would include “The patient will:
a. No longer experience loneliness by the end of the fifth day of hospitalization.”
b. Agree to attend two on-unit, staff-directed group sessions daily.”
c. Continue to maintain social solitude 50% of the time.”
d. Interact with a peer on a daily basis by discharge.”
ANS: D
Outcome criteria for a risk diagnosis are developed from the risk factors—in this case,
social isolation. Outcomes meet criteria when they are measurable, specific, and present
a timeline for completion. The correct option meets all criteria. There is no stated means
by which to measure loneliness. Agreeing to attend is not specifically directed at
affecting social isolation since interaction is not an expectation. Social solitude promotes
social isolation.
DIF: Cognitive Level: Application
REF: Page 49
22. Care planning for a patient diagnosed with paranoid schizophrenia will include:
a. Analyzing effectiveness of care provided
b. Determining the patient’s needs and problems
c. Establishing realistic patient-focused outcome criteria
d. Identifying priorities of care based on the patient’s condition
ANS: D
Establishing priority nursing diagnoses is part of the process of planning. Determining
needs is part of assessment. Analyzing effectiveness is an evaluation activity.
Establishing realistic expectations is part of outcome identification.
DIF: Cognitive Level: Application
REF: Page 51
23. The expert nurse is confident that the novice nurse understands the principles that
guide the planning of patient care interventions when the:
a. Novice nurse asks the patient to identify their primary concerns
b. Patient successfully achieves the agreed upon nursing outcomes
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c. Expert nurse requests that the novice nurse observe several care planning
sessions
d. Novice nurse includes interventions that are supported by evidence-based
practices
ANS: A
Working with the patient to determine treatment priorities is a characteristic of good
care planning. Although successful achievement of expected outcomes and inclusion of
EBP interventions reflect appropriate care planning, such success is influenced by many
different factors. Although appropriate, observing care planning sessions does not
necessarily affect successful care planning on the part of the novice nurse.
DIF: Cognitive Level: Application
REF: Page 51
Chapter 04: Therapeutic Communication
1. An example of an environmental factor that would cause a nurse to modify a planned
critical interaction occurs when the:
a. Patient expresses a personal dislike for the nurse
b. Patient is in total denial about her condition
c. Nurse lacks the degree of knowledge required for the interaction
d. Nurse learns that the patient’s mother has been hospitalized with a stroke
ANS: D
Environmental factors include timing. Timing of critical interventions is important. It
should occur when the individual can give full attention to the topic. It would be
inappropriate to continue with the plan in the face of the patient’s distress related to her
mother’s illness. The remaining options reflect other types of factors that influence
communication such as attitudes, knowledge, and relationships.
DIF: Cognitive Level: Application
REF: Page 63
2. The nurse suspects that the patient’s communication is being negatively influenced
by personal attitude when he is heard stating:
a. “They think I’m mentally ill but I’m not; I just get a little depressed at times.”
b. “I can’t concentrate on anything besides getting out of here and back to my
kids.”
c. “Obviously my therapist can’t understand where I’m coming from because our
lives are so different.”
d. “There isn’t anyone here in this hospital I can trust enough to talk to about why I
abuse alcohol and drugs.”
ANS: C
Attitude determines how one person responds to another. It includes one’s biases, past
experiences, and openness. People of different socioeconomic backgrounds may have
difficulty surmounting this barrier. The remaining options reflect factors that can
negatively influence communication but they are environmental, knowledge, and
relationship oriented.
DIF: Cognitive Level: Application
REF: Page 64
3. The nature of the communication characterized in this exchange between a nurse
and a chronically depressed patient is:
Nurse: Is it true that you enjoy knitting?
Patient: Yes, I’ve done it for years and am pretty good at it.
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Nurse: I’m just a beginner. Do you think you could give me some tips?
Patient: I guess so. What would you like to know?
a. Therapeutic
b. Collegial
c. Social
d. Intrapersonal
ANS: C
Although the conversation takes place between the nurse and a patient, it is of a social
nature. It is superficial and benefits both parties mutually by encouraging a relationship
based on mutual interest. No expectation of help exists. Therapeutic communication
promotes patient growth and is patient-focused. Collegial conversation occurs for the
purpose of professional collaboration. Intrapersonal communication takes place within
the individual.
DIF: Cognitive Level: Comprehension REF: Page 66
4. A patient expresses a sense of genuineness in the nurse providing care when sharing
with family members that:
a. “I believe the nurse can feel what I’m feeling.”
b. “I always know what the nurse expects of me; the explanations are always clear.”
c. “I can tell the nurse is sincere because the face supports what the mouth is
saying.”
d. “I may not always like what the nurse has to say but I can always depend on
what I’m told.”
ANS: C
Genuineness is demonstrated by congruence between verbal and nonverbal behavior.
Empathy is seeing things from the patient’s viewpoint. Clearly stating expectations is a
characteristic of clarity. Trustworthiness can be described as dependability.
DIF: Cognitive Level: Application
REF: Page 69
5. When providing discharge teaching to a patient for whom English is a second
language, what technique will the nurse use to assess the patient’s understanding of
the information being shared verbally?
a. Continuously evaluating the patient’s nonverbal cues
b. Periodically asking the patient if they have any questions
c. Asking the patient to repeat the information they are given
d. Providing the information in concise, written form
ANS: A
Individuals from different cultures or even different generations often misunderstand and
misinterpret an unfamiliar language. Being aware of and critically examining cues that
result from nonverbal responses is an excellent technique to check their interpretations.
Asking if they have questions is an ineffective technique in light of the language barrier.
Repeating the information is no guarantee that the patient understands the information.
Providing the information in written form reinforces the material but does not ensure
understanding especially if the patient has deficiencies related to reading the language.
DIF: Cognitive Level: Application
REF: Page 64
6. When communicating with a psychotic, schizophrenic patient, the nurse avoids the
use of slang phrases most importantly because:
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a. Such phrases have different meanings for different people.
b. Such phrases will likely trigger anxiety and frustration in the patient.
c. The use of such phrases is not appropriate when communicating therapeutically
with a patient.
d. This patient’s altered thought processes will serve to make understanding such
phrases very unlikely.
ANS: D
Precise verbal communication is important because spoken words often mean different
things to different people. Figures of speech, jokes, clichés, colloquialisms, and other
terms or special phrases carry a variety of meanings especially to individuals with
altered thought processes. A person with schizophrenia interprets concretely and literally
whereas psychosis generally brings about loose associations. Although all the options
are reasons to avoid the use of slang phrases, the primary reason in this case in to avoid
confusing the patient.
DIF: Cognitive Level: Analysis
REF: Page 64
7. The nurse is considering the need for both effective means of communication and
safety when caring for a patient with impulse control issues and poor social skills.
Which nursing intervention is most appropriate to address these needs?
a. Reminding the patient with each interaction what space boundaries are
considered safe and desired
b. Asking the patient to describe and set space boundaries that feel safe and
facilitate effective communication
c. Clearly setting space boundaries for the patient so both patient and staff feel
safe and can communicate more effectively
d. Discussing the need for space boundaries and how they help both the patient
and the staff feel safe and aide in communicating effectively
ANS: D
Space as a concept of boundaries and safety is important to understand because the
nurse and the patient need to respect the distance that each needs. For successful
communication to occur, both parties need to feel safe. Some patients have problems
with their boundaries and invade other patients’ own safe zones; patients who perceive
this as threatening react aggressively to such boundary violations. The nurse may need
to help the patient understand the need for appropriate distances in order for everyone
to feel safe and to communicate effectively. Reminding the patient of what the
boundaries are without first discussing the importance of space boundaries is not an
effective technique. Having the patient set the boundaries does not take into
consideration the needs of others, whereas staff setting the boundaries without patient
involvement ignores the needs of the patient and prevents the patient from
understanding of the situation.
DIF: Cognitive Level: Application
REF: Page 65
8. During the termination phase of the nurse-patient relationship with a dependent
patient, the nurse evaluates the effectiveness of coping techniques learned by:
a. Role playing with the patient in order to practice being assertive
b. Asking the patient to define the difference between being assertive and being
aggressive.
c. Discussing how her father effectively used both assertiveness and
aggressiveness to control her
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d. Asking, “When you used assertiveness to deal with your father during his visit,
how did it work?”
ANS: D
Evaluation is a task of the termination phase. Asking such a question encourages
patients to evaluate actions and look at the outcomes of behaviors. Role playing to
practice the technique, defining the relevant terms, and discussing the effects of the
father’s behavior would occur during the working phase of the relationship and does not
encourage evaluation of the newly learned skills.
DIF: Cognitive Level: Application
REF: Page 75
9. The nurse has developed a plan in which nursing interventions are used to reinforce
the patient’s healthy behaviors. Which statement by the nurse will positively
reinforce the patient’s efforts regarding the plan?
a. “How can a stress reduction plan help you at home?”
b. “It sounds like you have the incentive to make healthy choices.”
c. “When you tried to follow the plan, how well did it work for you?”
d. “It sounds as though making healthy choices is very important to you.”
ANS: B
This answer offers a positive response to a patient who is trying out new behaviors. This
nursing response will serve to encourage the patient’s efforts. The remaining options do
not provide positive reinforcement but rather are attempts to gather more information or
clarify the patient’s motivation to change.
DIF: Cognitive Level: Application
REF: Page 75
10. A patient indicates that he is about to share information about his illness that is
shocking and embarrassing. Which nursing intervention has priority in this situation
in facilitating the communication process?
a. Reassuring the patient that talking will be therapeutic
b. Assuring the patient the information will be kept confidential
c. Responding to the patient’s information in an accepting manner
d. Providing the patient with a private place for the discussion to occur
ANS: C
Responding to the patient’s information in a nonjudgmental, accepting manner will
encourage continued therapeutic communication. The remaining options, although
appropriate, will not have the same generalized affect on the communication process as
the correct option.
DIF: Cognitive Level: Application
REF: Page 67
11. A patient whose history includes physically abusing his spouse and children has been
admitted to the unit for alcohol and drug dependency. Which nurse will likely
experience difficulty establishing a therapeutic relationship with this patient?
a. The nurse who has experienced physical abuse
b. The novice nurse who has never cared for an abuser
c. The experienced nurse who has ‘seen too many abusers’
d. The nurse who has been in treatment for abusing a spouse
ANS: A
The therapeutic use of the self begins with knowing yourself. Knowing yourself is a
complex and lifelong learning process. At the core of self-knowledge is the nurse’s ability
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to correctly identify his or her own negative or unresolved issues including family
backgrounds, dynamic cultural and social issues, values, biases, and prejudices. Having
been a victim of physical abuse places this nurse in a situation that can be very harmful
to the development of an affective nurse-patient relationship. The novice nurse may lack
some of the knowledge and experience necessary to be effective but is not a likely to
have intruding biases and prejudices. The experienced nurse is more likely to have
worked on the ability to provide effective care in spite of such experience with this type
of diagnosis whereas, the nurse having been treated for the diagnosis is most likely to
show empathy and caring.
DIF: Cognitive Level: Application
REF: Page 68
12. A novice nurse asks, “What is so wrong about being sympathetic with a patient who
has also lost a parent like I did?” The psychiatric nurse manager responds:
a. “There is a fine line between empathy and sympathy that when crossed makes
you less able to be therapeutic.”
b. “Rather than discussing the loss of your parent with the patient, you can talk to
me about it whenever you need to.”
c. “I’ll provide you with some excellent materials that I’m sure will help you to
understand why sympathy is less therapeutic.”
d. “Sympathy indicates that you are sharing your personal feelings and that
changes the focus of the communication from the patient to you.”
ANS: D
Empathy should not be confused with sympathy. Sympathy is overinvolvement and
sharing your own feelings after hearing about another person’s similar experience. It is
not objective, and its primary purpose is to decrease one’s own personal distress.
Although substituting sympathy for empathy does lessen the ability to be therapeutic,
that is not the best explanation for avoiding it. Offering to discuss the nurse’s loss is a
kind gesture but does not address the nurse’s question. Providing materials on the
subject would be an appropriate reinforcement but does not address the question well.
DIF: Cognitive Level: Application
REF: Page 70
13. A nurse has for the past 4 weeks been working with a psychotic patient who has
been mute and very withdrawn. The patient suddenly encroaches on the nurse’s
personal space by touching inappropriately. What is the most therapeutic response
by the nurse to address this behavior?
a. Ignore it this time because the patient is, at last, responding.
b. Firmly communicate acceptable boundaries to the patient.
c. Gently touch the patient’s head and then observe the reaction.
d. Smile while telling the patient that people don’t like being touched like that.
ANS: B
The therapeutic response is to clearly communicate appropriate boundaries. There are
times when patients misinterpret the nurse’s nurturing as an invitation to an intimate
relationship. In these instances, boundaries must be firmly, but neutrally, explained. The
behavior should not be ignored since doing so may well result in the patient repeating
the behavior with others, perhaps with disastrous results. Touch is often misinterpreted
by psychotic patients and in this case has no therapeutic value. Nonverbal
communication should always be congruent so as to avoid confusing the patient.
DIF: Cognitive Level: Application
REF: Page 75
14. Which statement indicates that a novice nurse understands the purpose of
therapeutic communication? “My goal for communication with any patient is to:
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a. maintain relationships.”
b. mutually share information.”
c. promote growth and change.”
d. offer advice and make suggestions.”
ANS: C
Therapeutic communication is intended to assist the patient to grow and change. The
other options are characteristics of social communication.
DIF: Cognitive Level: Application
REF: Page 67
15. The expected outcome of conducting a periodic self-evaluation of one’s own
responses to patients is for the nurse to continue:
a. Recognizing the nurse’s need for therapy
b. Recognizing personal problems and strengths
c. Maintaining distance from the patients’ problems
d. Maintaining professional boundaries with the patients
ANS: B
Self-evaluation of responses to patients will reveal whether the nurse is responding with
objectivity versus subjectivity, acceptance or rejection, calmly or with anger, and with
sympathy or anxiety. The goal is not identify the nurse’s need for therapy or to maintain
distance for patient problems, but rather to remain objective about them. The purpose of
a self-evaluation is to recognize the nurse’s responses, not to maintain boundaries.
DIF: Cognitive Level: Application
REF: Pages 68-69
16. Which nursing response would indicate an empathetic approach to a patient who is
depressed over recent losses in her life?
a. “Losing a job isn’t always a bad thing.”
b. “I lost my parents last year and still feel sad.”
c. “Please tell me more about what you are feeling.”
d. “Let’s not focus on what’s sad but rather what is good about life.”
ANS: C
Empathy or empathic understanding is the nurse’s ability to see things from the
patient’s viewpoint and to communicate this understanding to the patient. This response
focuses on the patient’s feelings and encourages further discussion. Minimizing the loss
or suggesting a change in focus sounds judgmental or patronizing and will likely cut off
communication. Although self-disclosure can be therapeutic, this focuses on the nurse’s
feelings.
DIF: Cognitive Level: Application
REF: Page 70
17. A nurse is considering the therapeutic value of touch when planning care for an
anxious patient. What is the initial question the nurse should answer before initiating
this technique?
a. “How comfortable am I with touching this patient?”
b. “Will the patient find therapeutic touch supportive?”
c. “Does research support the use of therapeutic touch?”
d. “Has therapeutic touch proven to be therapeutic with anxious patients?”
ANS: A
Touch will only communicate warmth and thus be therapeutic if the nurse is comfortable
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with it. Although the other options are all appropriate, they do not have priority in this
situation.
DIF: Cognitive Level: Application
REF: Page 76
18. The nurse mentions, “I like to use open-ended questions and statements because
they result in fuller, more revealing responses by the patient, and they stimulate
discussion.” What statement would the nurse ask to best stimulate conversation with
a patient about their family?
a. “Where does your family live?”
b. “Tell me about your family.”
c. “Do you have a family nearby?”
d. “Would you like to talk about your family?”
ANS: B
This broad opening will encourage discussion as well as allow the patient to decide what
to include about his or her family. The remaining options can all be answered with a “yes
or no” response and so do not stimulate communication.
DIF: Cognitive Level: Application
REF: Page 72
19. A patient is struggling to explore and solve a problem. The nurse determines that it
would be therapeutic to offer alternatives. Which verbal introduction should the nurse
incorporate in order to achieve this objective?
a. “Have you thought of...”
b. “You should...”
c. “Why don't you...”
d. “I think you need to...”
ANS: A
This encourages the patient to consider alternatives without giving advice. The other
options are preludes to giving advice, which is not considered therapeutic.
DIF: Cognitive Level: Application
REF: Page 74
20. A nurse is contemplating the use of self-disclosure. The expected outcome of this
strategy is that the patient will:
a. be informed about expected behaviors
b. express previously withheld feelings
c. foster a mutually supportive relationship with the nurse
d. recognize that the nurse can empathize through shared experiences
ANS: B
Self-disclosure should serve one or more of the following purposes: to model and
educate; to build the therapeutic alliance; to provide concrete reflection that encourages
reality testing. The nurse does not use self-disclosure foster a interdependent
relationship that in any way gives support to the nurse. Empathy does not rely upon
shared experiences.
DIF: Cognitive Level: Application
REF: Page 76
21. The novice nurse is learning about the appropriate use of touch with patients
experiencing psychiatric disorders. Which statement about touch will provide the
nurse with the best basis for successful practice in psychiatric nursing situations?
a. Touch carries a different meaning for different individuals.
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b. Touch is rarely misinterpreted by patients because of its universal appeal.
c. It is seldom inadvisable to touch a patient to convey interest and warmth.
d. Paranoid patients accept procedural touch best when combined with humor.
ANS: A
The meaning of touch is highly individualized and is influenced by the length of the
touch, the part of the body touched, the way the patient is touched, and the frequency
of touch. Touch is often misinterpreted and not universally accepted. It may be highly
inappropriate to use touch with certain patients to convey warmth and interest.
Suspicious patients often do not have a sense of humor and regardless would likely find
touch unacceptable.
DIF: Cognitive Level: Application
REF: Page 76
22. A patient who has shown good progress with treatment has shown great resistance
to being discharged to an outpatient program. Based on an understanding of the
underlying pathology of resistance, the nurse:
a. Recognizes that the behavior will cease when discharge has occurred
b. Refers back to the patient’s progress as an indication of the patient’s strengths
c. Assures the patient that outpatient therapy services will continue to be
supportive
d. Shares that although scary, discharge to outpatient therapy is a sign of
improvement
ANS: B
Resistance to change is part of human nature that both the nurse and the patient need
to address and manage so that positive growth will occur. The nurse helps patients to
overcome resistance by pointing out their progress and strengths.
DIF: Cognitive Level: Application
REF: Page 78
23. The nurse manager suspects that a novice nurse is experiencing countertransference
regarding a chronically ill, psychotic patient. Which response is most effective at this
time?
a. “I realize this is a difficult situation but it will occur again if you don’t manage it
now.”
b. “I want you to see our hospital counselor so that you can regain your professional
attitudes.”
c. “I believe you are no longer able to be therapeutic so I’m changing your patient
assignment.”
d. “I’d like to help you begin to self-reflect on the feelings you seem to have for this
patient.”
ANS: D
Countertransference is an emotional response on the part of the nurse that is a result of
certain qualities in a specific patient. The response is dramatic, irrational, and
inappropriate. The initial response would be for the nurse to engage in a self-assessment
that focuses on why these feelings are occurring. It is true that the nurse needs to
manage the situation but will need some guidance regarding how to accomplish that. If
self-reflection isn’t successful, then professional counseling would be the appropriate
step. Changing the nurse’s assignment is not an effective means of managing the
problem because it is a situation that reoccurs in nursing practice.
DIF: Cognitive Level: Application
REF: Page 78
24. Which of the following nursing responses is an example of the therapeutic technique
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of empathizing?
a. “I think you may be finding this very difficult.”
b. “I see you have been crying since your wife left.”
c. “Help me to understand how this is affecting you.”
d. “It sounds as if this is important to you.”
ANS: A
In an empathetic response the nurse exhibits warmth and acknowledges the patient’s
feelings. Commenting on the patient’s crying is an example of the technique of making
observations. Asking for help to understand is an example of seeking clarification.
Finding importance is an example of reflection.
DIF: Cognitive Level: Application
REF: Page 70
1. A nurse is discussing unit expectations with a newly admitted patient diagnosed with
poor impulse control. The nurse shows an understanding of the use of body language
to convey feelings when documenting that the patient is angry and resistant to
authority based on which of the following? Select all that apply.
a. Patient’s reluctance to make eye contact
b. Crossed-arm posture the patient assumes
c. Quizzical expression on the patient’s face
d. Sharp rapping of the patient’s fingers against the table
e. Patient’s tendency to lean forward when seated in the chair
ANS: B, D
Body language includes facial expressions, reflexes, body posture, hand gestures, eye
movement, mannerisms, touch, and other body motions. Body posture and facial
expressions, including eye movements, are two of the most important cues to determine
how a person is responding to the message. This patient’s crossed-arm posture and
sharp finger rapping are indicators of anger. Poor eye contract is recognized as poor selfesteem or guilt cues, whereas a quizzical expression is likely an indication of confusion.
Leaning forward in the chair is generally viewed as a positive sign of interest and/or
cooperation.
DIF: Cognitive Level: Application
REF: Page 65
2. The nurse is planning approaches to use to begin the establishment of the nursepatient relationship. Which therapeutic communication techniques will be most
useful to achieve this goal? Select all that apply.
a. Attentively listening as the patient describes their obsessive compulsive rituals
b. Asking the anxious patient if they have a plan for controlling their current anxiety
c. Encouraging the depressed patient to “come and talk with me whenever you
want”
d. Sitting quietly in the room while the non-communicating patient unpacks their
belongings
e. Responding to the patient’s feelings of loss by stating, “I know that must have
made you very sad.”
ANS: A, C, D, E
Attentive listening, offering self, silence and empathy are all therapeutic communication
techniques that are appropriate for use in the orientation stage of the nurse-patient
relationship. Encouraging plan formulation is reserved for the working phase of the
relationship.
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DIF:
Cognitive Level: Analysis
REF:
Page 73
3. The nurse has been working for several weeks with a single mom who has been both
verbally and physically abused by her children’s father. Which nursing actions are
appropriate for this stage of treatment? Select all that apply.
a. Asking, “How does it make you feel when he hits you?”
b. Providing information regarding women’s shelters in the local area
c. Assuring the patient that her children can visit when she wants to see them
d. Sharing that, “I know leaving him is difficult but you need a plan if he abuses you
again.”
e. Responding, “You’ve certainly become more assertive; don’t be afraid to stand up
for yourself.”
ANS: A, B, D
The working phase of the nurse-patient relationship involves evaluating the affects of the
abuse, providing information that will help formulate a plan to end or manage the effects
of the abuse, and encouraging the patient to confront the problem even when it is
stressful. Assuring the patient that her children may visit is something that would
happen in the orientation phase of the relationship when making the patient comfortable
and responsive to treatment occurs. Positively reinforcing behaviors occurs in the
termination phase as preparations are being made for discharge.
DIF: Cognitive Level: Analysis
REF: Pages 74-75
4. The nurse shows an understanding of an essential purpose of therapeutic
communication when (select all that apply):
a. Asking the patient, “How did it make you feel when your son died?”
b. Encouraging the patient to assume responsibility for the problems he or she has
c. Attentively listening as the patient describes the reasons he or she is seeking
help
d. Providing the patient with feedback regarding how he or she is implementing
stress relief techniques
e. Sharing with the patient the details of several extremely stressful personal events
and how they were managed
ANS: A, C, D
Therapeutic communication has three essential purposes: (1) to allow the patient to
express thoughts, feelings, behaviors, and life experiences in a meaningful way to
promote healthy growth; (2) to understand the significance of the patient’s problems and
the roles that the patient and the significant people in his or her life play in perpetuating
those problems; and (3) to assist with the identification and resolution processes of the
patient’s health-related behaviors. Encouraging the patient to assume responsibility for
his or her problems may not be appropriate in all cases and it is not appropriate for the
nurse to share personal information even if it relates to a problem similar to the
patient’s.
DIF: Cognitive Level: Analysis
REF: Page 68
5. What statements indicate that the patient has an understanding of assertive
behavior? Select all that apply.
a. “Always stand up for your own rights.”
b. “I say what it takes to make my wishes known.”
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c. “Talking really loud seems to get the focus on me.”
d. “I’m not uncomfortable telling someone ‘No’ when I need to.”
e. “You don’t have to ignore the rights of others to stand up for yourself.”
ANS: A, D, E
The assertive person defends their personal rights while respecting the rights of others
and is not uncomfortable saying no when they are feeling oppressed. The remaining
options are more characteristic of aggressive behavior.
DIF: Cognitive Level: Application
REF: Page 71
6. The nurse is working on the inclusion of therapeutic humor in interactions with a
chronically ill schizophrenic patient who was hospitalized after an attempted suicide.
Which outcomes are realistic expectations for this patient? Select all that apply.
a. Improved cognition
b. Decreased interest in self-harm
c. Increased ability to experience pleasure
d. Decrease in the expression of fear and anxiety
e. Appropriate expression of emotions through affect
ANS: B, C, D, E
In two studies, researchers found that humor-based group activities provided to patients
with chronic schizophrenia showed that they had a significant reduction in negative
symptoms, self-injury, self-reported anger, anxiety, and depression. Although the results
may be preliminary, they suggest that humor-based interventions may be beneficial for
patients with chronic mental illness. There is no supporting evidence that cognitive
abilities improve with the introduction of therapeutic humor.
DIF: Cognitive Level: Application
REF: Page 77
Chapter 05: Adaptation to Stress
1. Although stress may result from either a positive or a negative event, the physical
effects are similar. Which statement best describes the long term effects of stress?
a. Eustress is likely to result in short term stress.
b. Chronic distress can take a toll on the individual.
c. Stress usually manifests in physical symptoms first.
d. Distress generally results in more effective coping skills.
ANS: B
Distress is damaging to an individual whether it is a result of either positive or negative
stress. This stressor can become chronic if the conflict is not resolved. Distress can take
a toll on an individual’s body as well as on his or her emotional state. Eustress occurs as
a result of a positive stress such as from anticipation of a child’s birth but such stress is
not necessarily short term and can result in the same symptoms as distress. Distress is
less likely to occur if previous stress has brought about good coping skills.
DIF: Cognitive Level: Application
REF: Pages 89-90
2. When explaining the fight-or-flight response to stress, the nurse identifies that the
role of the pituitary gland is to:
a. Minimize the secretion of cortisol.
b. Facilitate the conservation of energy.
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c. Secrete adrenocorticotropic hormone.
d. Encourage fleeing from the stressor.
ANS: C
The pituitary gland secretes adrenocorticotropic hormone, which stimulates the adrenal
cortex to release cortisol. Cortisol is involved in helping the entire body to react to the
stress by mobilizing the energy reserves so that the body can rapidly respond to the
stressors by either fighting or fleeing.
DIF: Cognitive Level: Comprehension REF: Page 90
3. It is believed that an individual’s locus of control has a major role to play in how
stress will be handled. Which statement characterizes an internal locus of control?
a. “I’ll need to manage my money better in order to get out of debt.”
b. “The economy has really caused my finances to be in a real mess.”
c. “I don’t think I’ll ever be able to save enough to pay off my bills.”
d. “Having a family makes being able to stay out of debt really difficult.”
ANS: A
Individuals who demonstrate an internal locus of control view their capability to have
personal success or failure as having to do with their own efforts and their ability to
complete a task. An individual with an external locus of control views task completion as
having to do with circumstances beyond his or her control. The options involving the
economy, never being able to pay off the bills, and having a family exhibit external
control locus.
DIF: Cognitive Level: Application
REF: Page 91
4. A nurse manager is attempting to address issues of work-related stress and
dissatisfaction on the unit. Which administrative intervention has been identified
through research as providing the most positive impact on staff morale even when
job demands are high?
a. Scheduling so that all staff gets two weekends off a month
b. Arranging for extra staff when patient activity is above the unit average
c. Offering a paid vacation day to anyone who has no absents for six months
d. Assuring that no staff will be mandated overtime more than twice monthly
ANS: C
Workplaces with positive social interactions involve less stress, even when the job
demands are high. When there is competition among workers, negative interactions
among staff members, and no assistance when the workload becomes overwhelming,
job dissatisfaction and stress is evident. The nurse manager will best impact the stress
and resulting dissatisfaction by arranging for help with patient care when the need
exists. Although the other options are not inappropriate, they do not address the issue
research has identified as the primary cause of stress in the workplace.
DIF: Cognitive Level: Application
REF: Page 92
5. The nurse suggests that a patient help manage the stressors that are triggering
generalized anxiety by implementing compartmentalization. Which activity provides
proof that the patient is employing this healthy defense mechanism?
a. Attends a meditation class 3 times a week right after work
b. Uses chocolate as a reward when keeping stress under control
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c. Counts to 10 before responding to a coworker who is a source of stress
d. Shares with the office manager the situations that regularly cause increased
stress
ANS: A
The person who uses compartmentalization learns to leave the stressor in a designated
space. An example of this mechanism would be regularly attending a class that serves to
separate the stressful work environment from one’s private life. Using food as a reward
may not be healthy and as with the remaining options, it is not examples of
compartmentalization.
DIF: Cognitive Level: Application
REF: Page 93
6. The spouse of a patient exhibiting symptoms of chronic stress asks how they can
help their spouse. Which suggestion by the nurse shows an understanding of a family
member’s role in the management of stress?
a. Offer to discuss the problem with the person who is most responsible for causing
their spouse’s stress.
b. Listen attentively when their spouse talks about the stressors and provide hugs
to show your support.
c. Help the spouse limit the amount of time each day they devote to discussing and
otherwise dwelling on the stress.
d. Provide the spouse with a variety of options and techniques for dealing with the
stressors and the resulting physical symptoms.
ANS: B
People need people to prevent isolation to promote their ability to deal with stress. In a
study, it was found that individuals who had significant relationships that involved an
expression of affection had a reduction in the fight-or-flight response when stressed.
Those who regularly received hugs from their romantic partners had a decrease in
resting heart rate and a healthy functioning limbic-hypothalamic-pituitary-adrenal axis.
Conversely, individuals who lacked such support showed a higher level of stress and an
increased possibility of developing an illness. Offering to confront the source of the stress
is not supporting the spouse in learning to manage stress. Limiting time to dwell on
obsessive thoughts may be therapeutic, but when a spouse implements this technique
too often, it suggests a lack of patience and understanding of the problem. The spouse
may not be qualified to provide such therapeutic options; that is the role of a mental
health professional.
DIF: Cognitive Level: Application
REF: Page 93
7. The patient is being introduced to mindfulness-based stress reduction to help
manage chronic stress. The patient is first taught to focus on:
a. What is causing the stress
b. Both inhaling and exhaling
c. Relaxing each major muscle group
d. Visualizing their life without the stress
ANS: B
It is helpful to teach individuals a generic method of relaxation by first concentrating on
the rhythm of breathing. Paying attention to each breath as one takes in a respiration
and releases an expiration provides a focus for the meditation. The remaining options
are not steps included in mindful mediation.
DIF: Cognitive Level: Application
REF: Page 94
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1. What is the role of the brain in producing the fight-or-flight stress response? Select all
that apply.
a. The medulla oblongata increases heart rate.
b. Blood flow is increased by the medulla oblongata.
c. The hypothalamus is stimulated via the limbic area.
d. The reticular formation coordinates the brain’s sensory and motor tracks.
e. Adrenocorticotropic hormone production is increased in the hypothalamus.
ANS: A, B, C, D
The brain (specifically the medulla oblongata) is responsible for the heart rate, the blood
pressure rate, and the respiration rate. When a stressor is detected, the autonomic
nervous system tells the medulla oblongata to increase the blood flow to certain organs
(e.g., the muscles) to allow the individual to prepare for fight-or-flight. The brain receives
an increase in oxygenated blood to increase awareness and the ability to think and
respond to the stressor. The blood in the brain has an increase in glucose, epinephrine,
and norepinephrine to assist the individual with reacting to the stressor. The reticular
formation supports the coordination of the sensory and motor tract of the individual’s
brain. This provides the individual with the ability to fight or flee. The limbic area of the
brain communicates with the hypothalamus that the stress is occurring. The pituitary
gland secretes adrenocorticotropic hormone which stimulates the adrenal cortex to
release cortisol.
DIF: Cognitive Level: Application
REF: Page 90
2. Nursing interventions appropriate to the generalized adaptation syndrome (GAS)
exhaustion state include which of the following? Select all that apply.
a. Planning care to best conserve the patient’s energy
b. Assessment for respiratory disorders such as asthma
c. Monitoring of exacerbation of compulsive ritual behaviors
d. Frequent assessment of pain management related to headaches
e. Planned periods to reinforce effective relaxation techniques
ANS: A, B, D, E
If the individual’s body does not adapt and the stressor continues to be prominent, then
the third stage, called the exhaustion stage, occurs. The exhaustion stage can manifest
itself in the form of illnesses such as infections, headaches, hypertension, asthma
attacks, chronic fatigue syndrome, depression, anxiety disorders, and many other
chronic conditions.
DIF: Cognitive Level: Application
REF: Page 90
3. Which are expected outcomes for a patient who is effectively implementing a
decision tree to enhance their problem-solving abilities? Select all that apply.
a. A large, complex problem will be turned into a series of smaller, manageable
problems.
b. The patient will not be overwhelmed and made to feel powerless by the problem.
c. The problem and the resulting stress will be clearly and concisely defined.
d. All resulting stress will be eliminated and the patient will feel empowered.
e. Several different options for resolving the problem will be formulated.
ANS: A, B, C, E
A decision tree enhances the person’s ability to think through a problem without getting
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stuck in a pattern of feeling overwhelmed and therefore unable to determine ways to
reduce the effect of the stressful situation. The decision tree provides individuals with
opportunities to problem solve by breaking down a problem or a stressor into smaller
increments. Defining a problem clearly and determining options for solving it can help a
person to think about more than one way to work on the problem or stressor. The use of
a decision tree will not remove all stress but rather empower the individual to strive to
solve the problem causing the stress.
DIF: Cognitive Level: Application
REF: Page 92
4. The patient has been taught to use the stop, divert, and reframe method to deal with
stress. Which responses indicate that the patient can affective utilize the technique
when preparing to take a written examination? Select all that apply.
a. Is heard declaring that, “It’s only a test; if I fail this one I will just study harder for
the next one..
b. Is observed opening a notebook and focusing on a family picture taken during a
recent vacation
c. Is heard stating, “Stop thinking that you can’t correctly answer the question. You
can and you will.”
d. Is observed asking the test monitor to be allow to sit somewhere “quiet and away
from other people
e. Is heard saying, “I will read the question thoroughly, find the key word, and then
look at the options I’m given.”
ANS: B, C, E
Stop interrupts the negative train of thought. Divert allows focus on something that will
rapidly reduce the stress. Reframe reinforces what you can do to reduce the stressor. The
remaining options do not address any of the identified steps in this stress management
method.
DIF: Cognitive Level: Application
REF: Page 94
Chapter 06: Neurobiology in Mental Health and Mental Disorder
1. A patient with depression mentions to the nurse, “My mother says depression is a
chemical disorder. What does she mean?” The nurse’s response is based on the
theory that depression primarily involves which of the following neurotransmitters?
a. Cortisol and GABA
b. COMT and glutamate
c. Monamine and glycine
d. Serotonin and norepinephrine
ANS: D
One possible cause of depression is thought to involve one or more neurotransmitters.
Serotonin and norepinephrine have been found to be important in the regulation of
depression. There is no research to support that the other options play a significant role
in the development of depression.
DIF: Cognitive Level: Comprehension REF: Page 104
2. A patient has experienced a stroke (cerebral vascular accident) that has resulted in
damage to the Broca area. Which evaluation does the nurse conduct to reinforce this
diagnosis?
a. Observing the patient pick up a spoon
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b. Asking the patient to recite the alphabet
c. Monitoring the patient’s blood pressure
d. Comparing the patient’s grip strength in both hands
ANS: B
Accidents or strokes that damage Broca’s area may result in the inability to speak (i.e.,
motor aphasia). Fine motor skills, blood pressure control, and muscle strength are not
controlled by the Broca area of the left frontal lobe.
DIF: Cognitive Level: Application
REF: Page 100
3. The patient diagnosed with schizophrenia asks why psychotropic medications are
always prescribed by the doctor. The nurse’s answer will be based on information
that the therapeutic action of psychotropic drugs is the result of their effect on:
a. The temporal lobe; especially Wernicke’s area
b. Dendrites and their ability to transmit electrical impulses
c. The regulation of neurotransmitters especially dopamine
d. The peripheral nervous system sensitivity to the psychotropic medications
ANS: C
Medications used to treat psychiatric disorders operate in and around the synaptic cleft
and have action at the neurotransmitter level, especially in the case of schizophrenia, on
dopamine. The Wernicke’s area, dendrite function, or the sensitivity of the peripheral
nervous system are not relevant to either schizophrenia or psychotropic medications.
DIF: Cognitive Level: Comprehension REF: Page 104
4. A student nurse mutters that it seems entirely unnecessary to have to struggle with
understanding the anatomy and physiology of the neurologic system. The mentor
would base a response on the understanding that it is:
a. Necessary but generally for psychiatric nurses who focus primarily on behavioral
interventions
b. A complex undertaking that advance practice psychiatric nurses frequently use in
their practice
c. Important primarily for the nursing assessment of patients with brain trauma–
caused cognitive symptoms
d. Necessary for planning psychiatric care for all patients especially those
experiencing psychiatric disorders
ANS: D
Nurses must understand that many symptoms of psychiatric disorders have a neurologic
basis, although the symptoms are manifested behaviorally. This understanding facilitates
effective care planning. The foundation of knowledge is not used exclusively by
advanced practice psychiatric nurses nor is it relevant for only behavior therapies or
brain trauma since dealing with the results of normal and abnormal brain function is a
responsibility of all nurses providing all types of care to the psychiatric patient.
DIF: Cognitive Level: Comprehension REF: Page 98
5. A patient asks the nurse, “My wife has breast cancer. Could it be caused by her
chronic depression?” Which response is supported by research data?
a. “Too much stress has been proven to cause all kinds of cancer.”
b. “There have been no research studies done on stress and disease yet.”
c. “Stress does cause the release of factors that suppress the immune system.”
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d. “There appears to be little connection between stress and diseases of the body”
ANS: C
Research indicates that stress causes a release of corticotropin-releasing factors that
suppress the immune system. Studies indicate that psychiatric disorders such as mood
disorders are sometimes associated with decreased functioning of the immune system.
Research does not support a connection between many cancers and stress. There is a
significant amount of research about stress and the body. Research has shown that there
are some connections between stress and physical disease.
DIF: Cognitive Level: Application
REF: Page 107
6. A patient who has a parietal lobe injury is being evaluated for psychiatric
rehabilitation needs. Of the aspects of functioning listed, which will the nurse identify
as a focus of nursing intervention?
a. Expression of emotion
b. Detecting auditory stimuli
c. Receiving visual images
d. Processing associations
ANS: D
The parietal lobe is responsible for associating and processing sensory information that
allows for functions such as following directions on a map, reading a clock, dressing self,
keeping appointments, and distinguishing right from left. Emotional expression is
associated with frontal lobe function. Detecting auditory stimuli is a temporal lobe
function. Receiving visual images is related to occipital lobe function.
DIF: Cognitive Level: Application
REF: Page 101
7. At admission, the nurse learns that some time ago the patient had an infarct in the
right cerebral cortex. During assessment, the nurse would expect to find that the
patient:
a. Demonstrates major deficiencies in speech
b. Is unable to effectively hold a spoon in the left hand
c. Has difficulty explaining how to go about using the telephone
d. Cannot use his right hand to shave himself or comb his own hair
ANS: B
The cerebral hemispheres are responsible for functions such as control of muscles. The
right hemisphere mainly controls the motor and sensory functions on the left side of the
body. Damage to the right side would result in impaired function on the left side of the
body. The motor cortex controls voluntary motor activity. Broca’s area controls motor
speech. Cognitive functions are attributed to the association cortex. The right side of the
body’s motor activity is controlled by the left cerebral cortex.
DIF: Cognitive Level: Application
REF: Page 99
8. A patient with chronic schizophrenia had a stroke involving the hippocampus. The
patient will be discharged on low doses of haloperidol. The nurse will need to
individualize the patient’s medication teaching by:
a. Including the patient’s caregiver in the education
b. Being careful to stress the importance of taking the medication as prescribed
c. Providing the education at a time when the patient is emotionally calm and
relaxed
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d. Encouraging the patient to crush or dissolve the medication to help with
swallowing
ANS: A
The hippocampus plays a major role in short-term memory and, hence, in learning.
Taking the medication as prescribed and providing the education at a time when the
patient is calm and relaxed is information or considerations that all patients should be
given. The medication does not necessarily need to be crushed or dissolved since the
stroke would not have caused difficulty with swallowing.
DIF: Cognitive Level: Application
REF: Page 102
9. The physician tells the nurse, “The medication I’m prescribing for the patient
enhances the g-aminobutyric acid (GABA) system.” Which patient behavior will
provide evidence that the medication therapy is successful?
a. The patient is actively involved in playing cards with other patients.
b. The patient reports that, “I don’t feel as anxious as I did a couple of days ago.”
c. The patient reports that both auditory and visual hallucinations have decreased.
d. The patient says that, “I am much happier than before I came to the hospital.”
ANS: B
GABA is the principle inhibitory neurotransmitter. The medication should provide an
antianxiety effect. Alertness, psychotic behaviors, and mood elevation are not generally
affected by g-aminobutyric acid.
DIF: Cognitive Level: Application
REF: Page 105
10. The patient’s family asks whether a diagnosis of Parkinson’s disease creates an
increased risk for any mental health issues. What question would the nurse ask to
assess for such a comorbid condition?
a. “Has your father exhibited any signs of depression?”
b. “Does your father seem to experience mood swings?”
c. “Have you noticed your father talking about seeing things you can’t see?”
d. “Is your dad preoccupied with behaviors that he needs to repeat over and over?”
ANS: A
Serotonin and its close chemical relatives, dopamine and norepinephrine, are the
neurotransmitters that are most widely involved in various forms of depression. Most
researchers agree that the immediate cause of parkinsonism is a deficiency of dopamine
and so a patient with Parkinson’s disease should be monitored for depression, The other
mental health disorders (bipolar disorder, hallucinations, and obsessive compulsive
disorder) have not been connected to Parkinson’s disease.
DIF: Cognitive Level: Analysis
REF: Pages 106-107
11. Which explanation for the prescription of donepezil (Aricept) would the nurse provide
for a patient in the early stage of Alzheimer’s disease?
a. It will increase the metabolism of excess GABA.
b. Excess dopamine will be prevented from attaching to receptor sites.
c. Serotonin deficiency will be managed through a prolonged reuptake period.
d. The acetylcholine deficiency will be managed by inhibiting cholinesterase.
ANS: D
Decreased levels of acetylcholine are thought to produce many of the behavioral
symptoms of Alzheimer’s disease. The inhibiting action the drug has on cholinesterase
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will slow down the breakdown of acetylcholine and so delay the onset of symptoms. The
other neurotransmitters (GABA, dopamine, and serotonin) are not currently believed to
play a role in Alzheimer’s disease.
DIF: Cognitive Level: Application
REF: Page 107
12. There remains a stigma attached to psychiatric illnesses. The psychiatric nurse
makes the greatest impact on this sociological problem when:
a. Providing educational programming for patients and the public
b. Arranging for adequate and appropriate social support for the patient
c. Assisting the patient to achieve the maximum level of independent functioning
d. Regularly praising the patient for seeking and complying with appropriate
treatment
ANS: A
Much of the stigma attached to psychiatric illness is due to a lack of understanding of
the biologic basis of these disorders. Therefore, effective patient, family, and public
teaching is an important function of the role of the psychiatric mental health nurse.
While the remaining options are appropriate, they are not directed towards eliminating
social stigma but rather empowering the patient.
DIF: Cognitive Level: Comprehension REF: Page 112
13. The wife of a patient with paranoid schizophrenia tells the nurse, “I’ve learned that
my husband has several close relatives with the same disorder. Does this problem
run in families?” The response based on recent discoveries in the field of genetics
would be:
a. “Your children should be monitored closely for the disorder.”
b. “Research tends to support a familiar tendency to schizophrenia.”
c. “There is no concrete evidence; it is just as likely a coincidence.”
d. “Only bipolar disorder has been identified to have a genetic component.”
ANS: B
Familial tendencies appear with several psychiatric disorders including schizophrenia. To
insinuate that the children are at such risk would not be supported by research.
DIF: Cognitive Level: Application
REF: Page 108
14. A patient whose symptoms of mild depression have been managed with
antidepressants is concerned about the affect of accepting a promotion that will
require working the night shift. What will be the basis of the response the nurse gives
to address the patient’s concern?
a. The connection between a new job and possible depression does exist.
b. The medication can be adjusted to manage any increase in depression.
c. The interruption in normal wake-sleep patterns can influence mood disorders.
d. The change in sleep routine can be managed with a healthy sleep hygiene
routine.
ANS: C
Many psychiatric and medical disorders occur more frequently or are exacerbated when
sleep patterns and biologic rhythms are disrupted. While the remaining options contain
true information regarding the management of depression that is a result of sleep
disruption, they do not effectively address the patient’s concern.
DIF: Cognitive Level: Application
REF: Page 108
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15. The nurse is discouraged because the patient exhibiting negative symptoms of
schizophrenia has shown no improvement with the planned interventions to reduce
the symptoms. The mentor’s remark that helps place the problem in perspective is:
a. “You aren’t responsible for the behavior of any other person.”
b. “Patients can be perverse and cling to symptoms despite our efforts.”
c. “Negative symptoms have been associated with genetic pathology.”
d. “It will take several ‘trail and error’ attempts to get the right combination care.”
ANS: C
A complex disorder, such as schizophrenia, most likely has multiple contributing factors,
including genetic predisposition, prenatal development, and the environment. Nurse
frustration can be alleviated by helping the nurse realize that negative symptoms may
be the result of actual brain dysfunction, rather than psychologically determined
behaviors; thus the remaining options are not appropriate since they do not address the
complexity of the problem.
DIF: Cognitive Level: Application
REF: Page 106
1. What assessment data would reinforce the diagnosis of temporal lobe injury in
patient who experienced head trauma? Select all that apply.
a. Inability to balance a checkbook
b. Uncharacteristically aggressive
c. Affect fluctuates dramatically
d. Increased interest in sexual behaviors
e. Difficulty remembering the names of family members
ANS: C, D, E
The temporal lobe is involved with memory as well as increased sexual focus and altered
emotional responses. Personality and intellectual function is not centered in the temporal
lobe.
DIF: Cognitive Level: Application
REF: Page 101
2. A patient has begun experiencing dysfunction of the hypothalamus. What nursing
interventions will the nurse include in the patient’s plan of care? Select all that apply.
a. Reinforcing clear physical boundaries
b. Assisting the patient with completing daily menus
c. Learning about healthy sleep hygiene habits
d. Monitoring and recording temperature every 4 hours
e. Monitoring and recording blood pressure every 4 hours
ANS: B, C, D
The hypothalamus is responsible for regulation of sleep-rest patterns, body temperature,
and physical drives of hunger. Social appropriateness and blood pressure is not
controlled by the hypothalamus.
DIF: Cognitive Level: Analysis
REF: Page 102
3. The nurse is preparing a patient for a positron emission tomography (PET) scan.
Which instructions will the nurse include? Select all that apply.
a. There will likely be a 30 to 45 minute wait between the injection and the
beginning of the scan.
b. A blindfold and earplugs may be used to help decrease reaction to the
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environment during the scan.
c. Make every attempt to lie still during the scan because movement will affect the
imaging produced.
d. No food or fluids are to be ingested for at least 8 full hours before the scan and
none during the scan.
e. Staying awake during the scan is important since the results are altered when the
patient is in any phase of the sleep state.
ANS: A, B, C, E
Appropriate patient preparation for a PET scan would include information regarding the
time interval between injection of the isotope and the actual scan, the fact that steps will
be taken to minimize the effects of sights and sounds during the scan, lying still is critical
to achieving a quality image, and that being asleep during the scan will alter the results.
It is not necessary to fast before or during the scan.
DIF: Cognitive Level: Application
REF: Page 110
4. A patient with schizophrenia is described as “having difficulty with executive
functions.” What patient dysfunction can the nurse expect to assess behaviorally?
Select all that apply.
a. Invades the personal space of others frequently
b. Consistently fails to bring money when going to buy snacks
c. Cannot remember the names of staff who often provide care
d. Requires repeated reinforcement on how to make a sandwich
e. Frequently speaks of hurting himself or of hurting other patients
ANS: A, B, D
Executive functions include reasoning, planning, prioritizing, sequencing behavior,
insight, flexibility, judgment, focusing on tasks, responding to social cues, and attending
in appropriate ways to incoming stimuli. Memory is not considered an executive function
and risk for harm to self and others is not generally a diagnosis appropriate for such a
patient.
DIF: Cognitive Level: Application
REF: Page 100
5. The unit physicians have ordered magnetic resonance imaging (MRI) tests for the
following patients. For which patients would the nurse decline to make test
arrangements without further discussion with the physician? Select all that apply.
a. A patient who is claustrophobic
b. A patient who is breastfeeding
c. A patient who has an allergy to iodine
d. A patient who had a total knee replacement
e. A patient who is taking a neuroleptic medication
ANS: A, D
Patients with claustrophobia are often unable to complete this type of study, because the
MRI machine is enclosed, and patients are required to remain motionless. Metal implants
are contraindications for MRIs since metal affects the scan. Breastfeeding, iodine
sensitivity, and neuroleptic medication therapy are not contraindications for an MRI.
DIF: Cognitive Level: Application
REF: Page 111
Chapter 07: Human Development Across the Life Span
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1. The nurse leading parent education classes bases instruction on Erikson’s
developmental stages. It follows that the nurse will plan to instruct the parents that a
helpful strategy to foster a child's initiative would be to:
a. Offer several different options for dressing and encourage the child to select one
of them.
b. Allow the child to help wash the unbreakable dishes used to serve breakfast.
c. Provide one-on-one parent–child time each evening before bed.
d. Enroll the child in a weekend, age-appropriate sports program.
ANS: B
This strategy will allow the child to demonstrate initiative by washing dishes without
worrying about breakage. Making clothes selections is a strategy related to development
of autonomy. Providing one-on-one time promotes trust. Age appropriate sports program
is related to competence.
DIF: Cognitive Level: Application
REF: Page 117
2. Which of the following responses would the nurse expect from a 12-year-old
regarding stealing?
a. “You are never allowed to steal.”
b. “You go to jail is you steal someone else’s things.”
c. “My parents would punish me if I was caught stealing.”
d. “Stealing food when you don’t have anything to eat is alright.”
ANS: D
Before the ages of 10 or 11 years, children consider moral dilemmas differently from
older children. For younger children, rules are absolute and come from an authority
figure. Older children learn that rules are changeable in certain situations. According to
Piaget, younger children base moral judgment on consequences, whereas older children
base judgment on motives.
DIF: Cognitive Level: Application
REF: Page 121
3. A nursing diagnosis of hopelessness would be considered for an individual who:
a. Was consistently overprotected by family members
b. Was raised by parents who were strict disciplinarians
c. Had inconsistent, unpredictable physical care as an infant
d. As a teenager always felt unaccepted by his social peers
ANS: C
A sense of hope is the outcome of Erikson’s stage of trust versus mistrust. Inconsistent,
unpredictable, and discontinuous care would lead to hopelessness and to a mistrust of
self and the world. No data are given to support any of the other diagnoses.
DIF: Cognitive Level: Application
REF: Page 117
4. An adolescent has been a consistently, poor academic student due to a learning
disorder. Which statement overheard by the nurse would support the possibility of a
problem with the developmental stage competence versus inferiority?
a. “It’s too hard to get good grades.”
b. “I’ll never be able to get into a good college.”
c. “My parents are disappointed that I do so poorly in school.”
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d. “I don’t want people to know I can barely read or write.”
ANS: B
According to Erikson and the stage of competence versus inferiority, during school years
(6 to 12 years of age), children gain new knowledge, learn new skills, and grow more
competent. If they lack successes in learning or productivity, children may develop a
sense of inferiority. The other options reflect problems with autonomy and guilt.
DIF: Cognitive Level: Application
REF: Page 117
5. A parent is concerned with the interpersonal skills of her 12-year-old son. Based on
interpersonal theory, the nurse asks:
a. “Does your son belong to team or club with friends or classmates?”
b. “Does he feel bad when he does something he knows he shouldn’t do?”
c. “How does he tend to act when he doesn’t get exactly what he wants?”
d. “How confident is he in situations that are generally unfamiliar for him?”
ANS: A
According to Sullivan, the expected development of the preadolescent permits him or
her to work with peers toward a common goal and to develop a sense of “oneness.”
Development of a social conscience is not related to interpersonal skill development.
Coping with frustration develops in late adolescence. Confidence is suggested as a
developmental issue of 12- to 18-year-olds in Erikson’s model.
DIF: Cognitive Level: Application
REF: Page 118
6. The parents of an 8-year-old are attempting to help their child comprehend new
information. Which intervention suggested by the nurse shows an understanding of
the cognitive development theory for this age group?
a. The use of drawing and illustrations
b. Comparing the child’s experiences to the new material
c. Encouraging the child to talk about this new information
d. Asking the child to give a reason for how they feel about new information
ANS: B
Comparing a known to an unknown will help this age group understand new information.
Drawings and illustration as well as talking about new information are effective methods
for the younger aged child. Providing rationales is too advanced for this age group.
DIF: Cognitive Level: Application
REF: Page 119
7. According to Piaget, which of the following would the nurse consider normal when
assessing a 6-year-old?
a. Playing with an “imaginary friend”
b. Talking about their “best friend”
c. Enjoying putting puzzles together
d. Knowing its wrong to tell a lie
ANS: A
Preoperational stage (2-7 years) children begin to exhibit pretend play. The need to make
friends and the development of a conscious are observed in the concrete operations
stage (7-11 years). The ability to problem solve is seen in the formal operations stage
(11-16 years).
DIF: Cognitive Level: Application
REF: Page 118
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8. Which developmental level would be characterized by a child being able to focus, to
coordinate, and to imagine a series of events?
a. Preoperational
b. Concrete operational
c. Formal operational
d. Postoperational
ANS: B
In the concrete operational level, the child can focus and coordinate and imagine a
series of events. In the preoperational stage, the child is unable to relate two
classifications at one time and is present-oriented. At the formal operations level, the
child can think abstractly and in future orientation. Postoperational is not a stage of
cognitive development.
DIF: Cognitive Level: Application
REF: Page 118
9. Which strategy will the nurse include in the plan of care for a 6-year-old child for
whom operant conditioning has been recommended?
a. Periodically asking the child to attempt to solve increasingly difficult puzzles
b. Consistently offering praise when the child puts his dirty clothes in the hamper
c. Expecting the child to rinse and to place his dirty dishes in the sink
d. Conditioning the child to expect punishment when he misbehaves
ANS: B
A 6-year-old can learn to comply with requests when adults reinforce compliance with
positive reinforcement. The remaining options do not reinforce compliance but rather
state expectations.
DIF: Cognitive Level: Application
REF: Page 120
10. A child who has been physically abused becomes emotionally distorted when told
that the parent will no longer be allowed to visit. Which principle of social learning
theory is most likely for the child’s response?
a. The child views the abuse to be more desirable than the parent leaving.
b. The parent has fostered a fear in the child that increases when they are apart.
c. The child believes that he is responsible for the parent now being punished.
d. The parent has likely told the child that he deserved the abuse as a punishment.
ANS: A
Social theory states that reinforcement value is subjective and influenced by past
experiences. For most children, parental punishment is a negative outcome with low
reinforcement value. However, for some children who suffer from parental abuse, the
abuse has a high reinforcement value, because it is more desirable than abandonment.
The remaining options are not supported by the social theory.
DIF: Cognitive Level: Application
REF: Page 120
11. Which nursing intervention supports the principles on which the cross-links theory of
aging is based?
a. Applying an elastin sustaining moisturizer to an adult patient’s skin
b. Assessing a patient’s family history for genetic diseases and disorders
c. Questioning a patient regarding long-term exposure to environmental toxins
d. Assisting an adult patient is selecting foods that are high in vitamins A, C, and E
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ANS: A
Cross-links form in elastin in connective tissue. Elastin is similar to collagen in that it
maintains tissue flexibility and permeability. The effects of cross-linking in elastin fibers
are most pronounced in the changes that occur in facial skin with aging. Skin becomes
brittle, dry, and saggy, and it appears translucent. Applying appropriate moisturizes
helps minimize the effects. Genetic history is relevant to the genetic theory of aging.
Exposure to environmental toxics applies to the biological theory of aging. Vitamin A, C,
and E consumption related to the free-radical theory of aging.
DIF: Cognitive Level: Application
REF: Page 128
12. The nurse determines that a patient is showing a decline in explicit memory. Which
characterizes such a deficiency?
a. Inability to remember how to operate a common kitchen appliance
b. Difficulty remembering the name of a place visited 20 years ago
c. Being unsuccessful at retaining new information
d. Forgetting the ingredients of a favorite recipe
ANS: B
Explicit memory, which is the ability to recall a specific name or place, tends to decline
with aging. Working memory, which is the type of memory that is needed to perform
daily activities, does not show an aging decline.
DIF: Cognitive Level: Analysis
REF: Page 133
13. A patient is experiencing distress with midlife transition. Which statement provides
support that the patient is successfully managing this stressor?
a. “I won’t give up on my dream to be rich.”
b. “Being rich doesn’t necessarily make a person happy.”
c. “I’ll never be rich but I can save enough to live comfortably.”
d. “I wasn’t being realistic when I set being rich as my life’s goal.”
ANS: C
The midlife transition occurs between the ages of 40 and 45 years. Individuals face the
realization that the failure to accomplish all of life’s goals leads first to disappointment
and then to the reformulation of earlier goals. The remaining options do not show a
reforming of original goals.
DIF: Cognitive Level: Application
REF: Page 124
14. According to Maslow’s hierarchy of needs, the nursing strategies a psychiatric nurse
would use to assist in meeting self-esteem needs of elderly patients would include:
a. Providing privacy when spouses are visiting
b. Arranging for the spouses to dine with the patients when visiting
c. Including both the patients and spouses in all educational sessions
d. Attending to patient hygiene and dress in preparation for spousal visits
ANS: D
Promoting an attractive physical appearance will assist patients in meeting the need for
self-esteem. Patients receive positive feedback when appearance is attractive. The
remaining options are not directly focused on self-esteem but rather belonging and
safety.
DIF: Cognitive Level: Application
REF: Page 124
15. A patient is involved in a smoking cessation program that encourages self-control
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therapy interventions. Which intervention would the nurse suggest to this patient?
a. Limiting the act of smoking to certain times of the day
b. Keeping a behavioral diary that tracks when the patient smokes
c. Identifying the factors that initially encouraged the patient to start smoking
d. Making plans that involve spending the money saved when the smoking stops
ANS: B
Self-control therapy is based on self-regulation concepts, for example, keeping track of
one’s smoking behaviors with the use of a behavioral diary helps to identify cues
associated with the habit. Taking steps to then remove or avoid some of the cues is a
way to alter the environment. The remaining options are more reflective of behavior
modification therapy.
DIF: Cognitive Level: Application
REF: Page 121
16. A 70-year-old male has the nursing diagnosis situational low self-esteem related to
forced retirement. Using Maslow’s hierarchy of human needs, the nurse is confident
the patient is meeting the outcome of experiencing self-worth when the patient:
a. Moves to a secure apartment building
b. Exercises regularly with friends at the gym
c. Attends his grandchildren’s school functions
d. Volunteers at the local homeless shelter each week
ANS: C
Feelings of worth, self-confidence, and adequacy are desired outcomes for a patient with
low self-esteem. Security is associated with Maslow’s need for safety and security and
would be an appropriate outcome for a patient experiencing fear. Self-fulfillment is
related to self-actualization needs and might be associated with a wellness diagnosis.
Acceptance is related to love and belonging needs and could be associated with a social
isolation diagnosis.
DIF: Cognitive Level: Application
REF: Page 124
17. The spouse of a patient recently diagnosed with early stage Alzheimer’s disease
asks, “
Is there anything I can do to help delay the progression of this disease?” Which strategy
has the greatest potential for preserving the protective abilities of immune cells related
to the disease?
a. Minimize contact with the public during cold and flu season.
b. Enroll the patient in an exercise program that meets regularly.
c. Provide supplements to enhance the patient’s immune system.
d. Identify creative ways to keep the patient mentally challenged.
ANS: D
Research has demonstrated links between creative activities and the consequential
positive feelings with the increased production of protective immune cells. Creativity is
also possibly linked to delaying the onset of Alzheimer’s disease. Continually challenging
oneself mentally is a way to build up reserves of neurologic structures and connections.
The remaining options, although related to the immune system, are more directly
focused on the physical affects rather than the cognitive ones.
DIF: Cognitive Level: Application
REF: Page 138
1. A nurse is using Piaget’s model to assess a child’s developmental stage. Which
behaviors would determine that a child is successfully achieving the skills required of
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the formal operations level of development? Select all that apply.
a. Becomes sad when the family pet dies
b. Plans a trip to attend a basketball game
c. Identifies two different bowls that hold 1 cup
d. Selects the appropriate clothing for a ski trip
e. Enjoys solving “what if” types of word problems
ANS: B, D, E
The formal operations level includes the ability for future thinking and for problemsolving complex issues. The remaining options reflect concrete operations level abilities.
DIF: Cognitive Level: Analysis
REF: Page 119
2. The nurse is assessing a child according to Kohlberg’s developmental theory. Which
statement would support the belief the child is showing appropriate behaviors of the
pre-conventional state? Select all that apply.
a. “If I pick up my toys, can I get an ice cream cone?”
b. “I can’t watch cartoons when I don’t pick up my toys.”
c. “I always pick up my toys because mommy needs my help.”
d. “When I pick up all of my toys I make mommy very happy.”
e. “If I don’t pick up my toys, mommy could trip on them and fall.”
ANS: A, B, E
The pre-conventional stage (4-10 years) involves a punishment-obedience orientation as
well as an instrumental relativist orientation. The remaining options are reflective of a
higher level of development.
DIF: Cognitive Level: Analysis
REF: Page 121
3. Which activities should the nurse evaluate in an assessment of an older patient’s
functional status? Select all that apply.
a. Possessing the ability to prepare nutritious meals independently
b. Having the financial resources available to live independently
c. Performing regular, simple maintenance on their primary residence
d. Effectively toileting themselves for both bowel and bladder elimination
e. Safely moving around their residence without an increased risk for falls
ANS: A, D, E
Functional assessment usually consists of evaluating two areas. The first area, ADLs,
includes categories of personal care such as bathing, grooming, toileting, and
transferring. The second area, IADLs, addresses activities that are important for the
individual to be able to function in the community. IADLs include shopping, preparing
meals, and getting around. Financial resources and maintenance skills are not included
in such an assessment.
DIF: Cognitive Level: Application
REF: Page 131
4. Which older adult patient’s medical conditions appear to support the hypothesis
upon which the immunologic theory of aging is based? Select all that apply.
a. Has, at age 64, been diagnosed with type 2 diabetes
b. Has been treated for multiple sclerosis since age 30
c. Is managing a 36-year history of chronic Graves’ disease
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d. Has begun to experience symptoms of rheumatoid arthritis
e. Is experiencing a flare up of celiac disease, which was diagnosed at age 26
ANS: A, D
Immune function significantly declines with aging. Rheumatoid arthritis and matureonset diabetes are two diseases that are commonly experienced during older age that
are caused by alterations to the immune system. Although the remaining options reflect
disease processes associated with the immune system, they manifested in early
adulthood.
DIF: Cognitive Level: Application
REF: Page 128
5. The nurse manages the care for several older adult patients. Which strategies shows
an understanding of the effects of aging on cognitive function? Select all that apply.
a. Allowing ample time for completion of patient activities
b. Breaking complicated patient activities into single tasks
c. Planning patient activities that can be completed rather quickly
d. Excluding complex problem-solving patient activities in the daily routine
e. Planning for complex patient activities to be introduced early in the day
ANS: A, B, C
With aging, the ability to maintain the attention span through the completion of complex
tasks diminishes. Another segment of attention that shows some decrements with aging
is vigilance, which is the ability to sustain attention over longer periods of time.
Increased reaction time that results in decreased speed of performance is an obvious
change that occurs with normal aging. Problem-solving ability is a higher cognitive
function. There is little knowledge regarding normal changes in higher cognitive
functioning during aging and so the remaining options are not based on evidenced-based
practice.
DIF: Cognitive Level: Analysis
REF: Page 133
6. According to most biological theories of aging, predisposing factors create the affects
seen in aging. Which behaviors are considered predisposing factors regarding aging?
Select all that apply.
a. Diagnosis of a chronic genetic disease
b. Lack of healthy diet and regular exercise
c. Family history of several different cancers
d. Occupation that involved working with toxins
e. Radiation exposure from numerous diagnostic studies
ANS: A, C, D, E
One method of classifying biologic theories of aging relates to categorizing predisposing
factors as intrinsic or extrinsic to the organism. Intrinsic or genetic theories focus on the
process of aging as internal to the organism. Certain genetic diseases, including several
types of cancers and high-cholesterol syndromes that lead to heart disease, have a
negative impact on life expectancy. Extrinsic or nongenetic theories propose that aging
occurs as a result of environmental factors that act on the organism, such as radiation,
ozone, drugs, and toxic substances which, researchers have theorized, damage cellular
structures, thereby leading to aging and death. Diet and exercise are not considered
either intrinsic or extrinsic factors to biological theories of aging.
DIF: Cognitive Level: Application
REF: Page 128
7. The nurse is preparing to educate a group of middle-aged adults on longevity
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strategies. Which behaviors would the nurse stress? Select all that apply.
a. Having warm and caring people in your life
b. Engaging in age-appropriate exercise on a regular basis
c. Accepting the fact that aging negatively impacts your life
d. Seeking help if changes of aging cause depression or anxiety
e. Avoiding retirement for as long as possible in order to keep active
ANS: A, B, D
A Harvard study identified factors of middle adulthood that promote longevity and
include experiencing a warm and caring relationships, having effective adaptive or
coping strategies, and getting adequate exercise. Aging does not necessarily affect life
negatively and there are numerous ways to remain both physical and mentally active
after retirement.
DIF: Cognitive Level: Application
REF: Pages 124-125
8. A nurse is working with a group of older adults attending a seminar on the physical
and emotional effects of aging. Which patient statements are good predictors of
positive well being and perceived mortality? Select all that apply.
a. Being “satisfied with growing older”
b. Feeling “younger than my birthdays say I should”
c. Retirement “gives me time to do the things I’ve put off doing.”
d. Not having “to deal with the stress of any major chronic illnesses”
e. “At least I don’t have to worry about having enough money to retire.”
ANS: A, B, C
A research study of more than 400 older adults between the ages of 70 and 100
examined how satisfaction with aging is an indicator of positive well-being and possible
predictor of death. Researchers found that feeling older and being dissatisfied with how
one is aging are related to an increased mortality risk over time. Persons who were
satisfied with their aging or who felt “younger than their years” generally had longer
survival. Self-perception of aging predicted mortality even after controlling for known
mortality predictors such as illness, old age, gender, and socioeconomic status.
DIF: Cognitive Level: Application
REF: Page 125
Chapter 08: Culture, Ethnicity, and Spirituality
1. To include a cultural focus in patient care planning, which belief about faith will the
nurse incorporate? Faith is a:
a. Belief of body and mind
b. Manner of expressing spirituality
c. Use of spiritual resources without empiric proof
d. Search for the sacred, transcendent, or universal
ANS: C
Faith is the ability to draw on spiritual resources without having physical and empiric
proof. Body and mind refer to psychosomatic concepts. A manner of expressing
spirituality refers to religion. A search for the sacred, transcendent, or universal refers to
spirituality.
DIF: Cognitive Level: Comprehension REF: Page 151
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2. A culturally diverse patient refuses to participate in a group because of the presence
of a person who “can put spells on.” The nurse recognizes a priority need to explore
this patient’s:
a. Economic status
b. Home environment
c. Health-illness beliefs
d. Educational background
ANS: C
Culture influences beliefs about health and illness, including causes of illness. What the
nurse might label as delusional might be a culturally determined belief about illness
causation. The other assessments do not relate to the situation as directly.
DIF: Cognitive Level: Application
REF: Page 143
3. An Asian-American patient diagnosed with depression explains to the nurse that
eating two specific foods will restore the balance of hot and cold and she will be
cured. The nurse should:
a. Explain that foods cannot cure mental disorders.
b. Arrange for the patient to talk with the dietitian.
c. Change the subject to focus on medication compliance.
d. Accept that cultural beliefs about illness die slowly.
ANS: B
Culturally determined beliefs about health and illness should be respected. If there are
no contraindications to the patient eating the foods mentioned, the nurse should
facilitate obtaining them. Attempt to explain the flaw in the patient’s belief is an attempt
to negate culturally determined beliefs. Changing the subject does not address patient
concerns. Assuming that the belief is inflexible suggests the patient’s beliefs have no
merit.
DIF: Cognitive Level: Application
REF: Page 160
4. When working with a patient newly emigrated from Asia who has been assessed as
having xenophobia, the nurse could anticipate making the assessment that the
individual:
a. Resists sharing food with others
b. Would be reluctant to ride an elevator
c. Is unlikely to talk with nonfamily members
d. Fears the consequences of going out of doors
ANS: C
Xenophobia is defined as a morbid fear of strangers. The xenophobic individual would
not necessarily resist sharing food (fear of germs), riding in elevators (fear of closed
spaces), or going out of doors (fear of open spaces).
DIF: Cognitive Level: Application
REF: Page 146
5. The nurse plans to use pamphlets to teach a newly immigrated Vietnamese patient
about diabetes mellitus. Before initiating this education, the priority information for
the nurse to obtain is the patient’s:
a. Ability to read and understand English
b. Readiness and ability to learn this material
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c. Previous knowledge and interest in the subject
d. Willingness to participate and follow instructions
ANS: A
Pamphlets are useful only if the patient can read and understand the language in which
the material is written. The other options are secondary to this priority concern.
DIF: Cognitive Level: Analysis
REF: Pages 147-148
6. A nurse is planning to incorporate a culturally sensitive focus in her nursing care.
Which of these underlying principles concerning cultural heritage will be included?
a. A group is formed from among individuals who share similar ancestral origins.
b. A condition of belonging to a group is that all members share a unique heritage.
c. Learned patterns of behavior and thinking are shared by members of a cultural
group.
d. The classification of humans into cultural groups is generally based on physical
characteristics.
ANS: C
Cultural heritage is learned patterns of behavior and thinking shared by a particular
group that is transmitted over time to other members. Ancestral origins, a similar
heritage, and physical characteristics may be shared traits but alone do not constitute
cultural heritage.
DIF: Cognitive Level: Comprehension REF: Page 143
7. A patient diagnosed with paranoid schizophrenia is describing religiously-based
delusions that other patients find offensive. Which nursing intervention will the nurse
implement to provide a therapeutic milieu?
a. Engaging the delusional patient in prayer in order to redirect the problematic
behavior
b. Explaining to the delusional patient that such talk is offensive to some of the
milieu and will not be allowed
c. Asking for the pastoral counselor to visit the unit and talk with both the
delusional patient as well as the rest of the milieu
d. Removing the delusional patient from the milieu when staff is unable to
successfully refocus the conversation to a non-religious topic
ANS: C
Occasionally, individuals with serious mental disorders experience delusions that are
spiritual or religious in nature. Certified pastoral counselors are skilled with regard to
counseling patients and consulting with staff about these problems, and they assist the
health care team in ways that address the particular concerns of individual patients.
Challenging or debating the truth of a person’s delusions is not therapeutic, and spiritual
delusions are no exception. Engaging in spiritual or religious practice with individuals on
a psychiatric unit is also inappropriate. Removing the patient from the milieu is seldom
therapeutic and done only to maximize milieu safety.
DIF: Cognitive Level: Application
REF: Page 152
8. A patient confides to the nurse that she feels guilty about the poor relationship she
had with her mother-in-law, who is now deceased. The patient tells the nurse that
she is sure God will punish her for this and that she needs to confess her sins to
someone. Which of the following is the best response by the nurse?
a. “Would you like to speak to the chaplain when he comes later today? In the
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meantime, we could talk about your relationship with your mother-in-law.”
b. “It sounds as if you need to talk about this. Let’s sit down in a private area. I’d
like to know more about your relationship with your mother-in-law.”
c. “We all have trouble with our in-laws occasionally. God doesn't punish us for
that.”
d. “What’s done is done. We need to focus on your positive qualities.”
ANS: A
The patient has identified a specific spiritual problem that a chaplain would be equipped
to handle, so a referral is appropriate. The nurse, in the meantime, is equipped to
discuss relationship issues. Offering to talk about the relationship without addressing the
patient’s expressed spiritual needs is not therapeutic. Suggesting that the patient’s
relationship issues are not uncommon minimizes the patient’s feelings. Attempting to
refocus the patient dismisses the patient’s needs.
DIF: Cognitive Level: Application
REF: Page 152
TOP: Nursing Process: Implementation
MSC:
NCLEX: Psychosocial Integrity
9. A patient is dealing with the loss of a spouse. Which response shows an
understanding of the role spirituality plays in the management of grief?
a. “He’s in a better place; my faith tells me that is true.”
b. “I find that my faith is stronger now that I’m alone.”
c. “I’m told that a sense of spiritual connection will help me go on with life.”
d. “My faith helps me deal and gives me renewed hope; I rely on it to help me heal.”
ANS: D
Spirituality allows one to cope with these feelings by providing a sense of hope and
meaning to experiences that would otherwise be crippling. Spirituality is often a key
component in the healing process, and it is an integral part of the patient’s treatment
plan. The remaining options do not as directly deal with the patient’s personal loss and
the progression to healing.
DIF: Cognitive Level: Application
REF: Page 151
10. The nurse identifies a patient as being in spiritual distress. Which patient statement
supports this nursing diagnosis?
a. “I’ve never felt so alone before in my entire life.”
b. “I don’t know if I could get through this without faith in God.”
c. “I’ve always relied on my faith in God but now I feel I’ve been abandoned.”
d. “Why do bad things happen to good people? I’ve always been a good person.”
ANS: C
Spiritual distress is a nursing diagnosis that is defined as a disruption in the value and
belief systems that pervades the person’s state of being and that transcends the
physical and psychosocial self. Feeling abandoned when one has always relied on faith is
an indication of spiritual distress. Feeling alone and questioning why something has
occurred is not necessarily spirit based, and not an indication of spiritual distress.
Questioning one’s ability to manage an emotion without one’s faith is a testimony to the
faith, not an expression of despair.
DIF: Cognitive Level: Application
REF: Pages 151-152
11. Assessment of interpersonal relationships of Asian and Asian-American patients is
dependent on the nurse’s understanding that the culture of these patients is
identified as high context and will therefore value:
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a. Privacy; family is not routinely included in health discussions
b. Their right to make independent decisions about their care
c. Sharing their opinions and wishes with healthcare team
d. Their role and place in their family structure
ANS: D
Asian and Asian-American patients have been socialized into high-context cultures in
which there is collective identity, group decision making, emotional dependence,
deference to those of higher status and age, and use of indirect language to
communicate. The remaining options are characteristic of low-context cultures.
DIF: Cognitive Level: Application
REF: Page 149
12. Which communication behavior would be considered uncharacteristic for a patient
from a high-context culture?
a. Little direct eye contact
b. Use of global messages
c. Use of nonverbal symbolization
d. Arguing points with the physician
ANS: D
Arguing to get a point across is more characteristic of the communication of a person
from a low-context culture. A person from a high-context culture would not be expected
to dispute a person with authority. The person from a high-context culture would be
expected to use global communication and nonverbal symbolization but to make little
direct eye contact.
DIF: Cognitive Level: Application
REF: Page 149
13. An Asian-American patient is referred to the mental health clinic. He has many
somatic complaints for which no physical basis has been found. The patient tells the
nurse that he does not believe this clinic can help him. Based on knowledge of the
beliefs common to this culture, what can the nurse hypothesize about the patient?
a. Because of the cultural stigma attached to mental illness, he may be expressing
psychological distress via somatic symptoms.
b. Acculturation has occurred because feelings of hopelessness are alien to his
native culture.
c. Suicide is not a present danger because suicidal impulses are rarely associated
with feelings of helplessness among Asian-American patients.
d. The patient has rejected both family care and traditional healing methods in favor
of health care practices of the new culture.
ANS: A
The following facts are known about beliefs commonly held by members of this culture:
there is a stigma attached to mental illness; mental illness is often described in somatic
terms; members of this culture come into treatment late and often have feelings of
hopelessness upon entry into the system; families tend to care for their members with
mental illness; and traditional healing has usually been tried and failed before the
patient attempts to access the mental health system.
DIF: Cognitive Level: Application
REF: Page 156
14. The nurse determines which patient is at the greatest risk for a spiritual crisis?
a. A patient, whose religion opposes the use of blood products, has a severely
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bleeding ulcer
b. A single parent who must decide to terminate life support for a terminally ill child
c. A newlywed whose spouse has died in an automobile accident caused by a drunk
driver
d. A patient who denies the need for spiritual support when given the diagnosis of
terminal cancer
ANS: A
A spiritual crisis may occur when religious or spiritual beliefs conflict with a necessary
procedure or a treatment protocol, such as permitting a blood transfusion. Although the
remaining options all present with a serious emotional situation, there is no evidence to
support that the patient’s beliefs are being challenged.
DIF: Cognitive Level: Application
REF: Page 151
15. The nurse believes that a patient is exhibiting internal locus of control related to
spiritual development. Which patient statement supports this conclusion?
a. “Praying gives me tremendous comfort.”
b. “I pray because my church says that prayer is the way to God”
c. “I will ask that my fellow church members pray for me to get better.”
d. “My mother prayed daily and she was such a good and kind person.”
ANS: A
During development, one’s sense of faith, meaning moral values, and judgment moves
from an external locus of control to an internal locus of control. An example of such
internal control is the expressed feeling of comfort derived from prayer. The remaining
options reflect external locus of control since each is an expression of how beliefs about
prayer are provided by others; church doctrine and the faith of others.
DIF: Cognitive Level: Application
REF: Pages 153-154
16. A novice nurse has identified impaired verbal communication for an older Asian
patient who recently immigrated to the United States based on the patient’s
reluctance to maintain eye contact and engage in a conversation with staff. In order
to assure that the diagnosis is appropriate, the nurse manage asks:
a. “Have you asked the patient why communication is difficult for them?”
b. “Could you be misdiagnosing common shyness for a communication issue?”
c. “Have you noticed the patient communicating differently with family when they
visit?”
d. “Do you think the patient’s cultural traditions have a part to play in their
communication behaviors?”
ANS: D
Misunderstanding occurs when the nurse fails to take into account culture-specific
interaction patterns. Silence, infrequent eye contact, shame, fear, and language barriers
all affect a patient’s ability to interact. In light of the patient’s cultural diversity, the
other options are less likely to be pertinent.
DIF: Cognitive Level: Application
REF: Page 149 | Page 163
17. As a nurse assesses culture factors with patients, the subculture that poses the
greatest risk to a patient’s mental health is:
a. Poverty
b. Female gender
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c. Advanced age
d. Cultural ethnicity
ANS: A
Many people in poverty suffer discrimination and stigma which places them at risk for
depression and other anxiety-related illnesses. The other subcultures do not present with
the same or greater degree of risk.
DIF: Cognitive Level: Application
REF: Page 144
1. The nurse is addressing the possibility that a family of newly emigrated Hispanics
may experience cultural shock. Which statements are truisms concerning this
cultural adaptation issue? Select all that apply.
a. Most primitive cultures embrace the lifestyle of the industrialized ones.
b. It may take generations for family members to become acculturated.
c. The most resistant to adaptation are children and young adults.
d. Typical responses include fear and distrust of strangers.
e. Family members are at high risk for anxiety disorder.
ANS: B, E
Many immigrants experience culture shock, a sudden or violent disturbance of emotions
that involves a sense of anxiety, fear, and distrust. Children and young adults usually
adapt to their new surroundings more quickly. It takes approximately three generations
or longer for members of a minority group to integrate into the dominant cultural
environment.
DIF: Cognitive Level: Application
REF: Page 143
2. A nurse works in a mental health clinic serving many Southeast Asian individuals.
Which statements by the nurse would validate a striving toward cultural
competence? Select all that apply.
a. “It’s a challenge to plan treatment that is culturally congruent.”
b. “My dream is to be accepted by the Southeast Asian patients I care for.”
c. “There is so much to learn about the Southeast Asians and their problems.”
d. “Psychiatric care tends to be similar for those of Southeast Asian cultures.”
e. “I always try to be sensitive to the uniqueness of my culturally diverse patients.”
ANS: A, B, C, E
Culturally competent health care requires the development of interpersonal skills,
communication skills, and awareness and sensitivity to the uniqueness of individuals. It
is also an ongoing process, because each new encounter presents the opportunity to
gain additional knowledge and skills. Psychiatric care should be tailored to the individual
and not to cultural stereotypes.
DIF: Cognitive Level: Application
REF: Page 147
3. A patient’s cultural background is identified as being sociologically low context.
Which nursing interventions would be appropriate for such a patient? Select all that
apply.
a. Asking the patient to contribute suggestions to include in the care plan
b. Providing the patient with privacy during visits with their religious leaders
c. Instructing the patient on how to select foods within their prescribed diet plan
d. Waiting to provide medication education until family members are visiting
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e. Facilitating the family in assuming responsibility for the patient’s physical needs
ANS: A, B, C
Behaviors and communication styles of cultural societies referred to as low context
(individualistic) are those in which people care for themselves. Low-context societies
emphasize thinking and values that are centered on the individual: autonomy, individual
initiative, the right to privacy, and emotional independence. Facilitating family in
assuming responsibility for the patient’s physical and educational needs is not
compatible with the characteristic needs of the low-context society.
DIF: Cognitive Level: Application
REF: Pages 148-149
4. Guidelines for communicating with a patient whose ability to speak and understand
English is questionable include (select all that apply):
a. Use interpreters whenever possible.
b. Allow sufficient time for patient to formulate response.
c. Recruit a family member as an interpreter whenever possible.
d. Use nonverbal communication whenever it is considered appropriate.
e. Maintain eye contract if such interaction is accepted by the patient’s culture.
ANS: A, B, D, E
Interpreters are preferred to translators since they are trained to decode the message
behind the patient’s verbal response. The patient needs time to formulate their
responses especially if they are attempting to speak in English. Nonverbal
communication is a good source of information when effectively interpreted. Eye contact
when accepted by the patient’s culture encourages interaction and allows for
interpretation of nonverbal communication. Family members should not be used if other
options are available since they are not always objective in their translations.
DIF: Cognitive Level: Application
REF: Page 150
5. A patient experiencing depression over the loss of a loved one shares that, “I’m not a
religious person but I need something to help me cope with this.” The nurse shows
an understanding to the need for an outlet for the expression of emotions when
(select all that apply):
a. Asking, “Does dancing make you feel good?”
b. Encouraging the patient to talk about the feelings
c. Offering to arrange for a consult with the music therapist
d. Asking, “Can you think of ways to express your emotions in a healthy way?”
e. Suggesting the patient draw a picture of what it feels like to experience such a
loss
ANS: A, C, E
Religious practices are often beneficial for patients, but for those who do not have a
formal religion, other spiritual interventions are useful. Group therapies that encourage
patients to extend themselves and to find meaning in life are helpful. In addition, several
other creative forms of expression such as art, music, and dance therapy often address
patients’ spiritual needs. Although the other options are not inappropriate, they do not
provide interventions but rather reflect assessment questions.
DIF: Cognitive Level: Application
REF: Page 152
Chapter 09: Legal and Ethical Aspects in Clinical Practice
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1. An advanced practice nurse evaluates a patient for emergency commitment because
of the likelihood the patient will do serious harm to others. Which statement best
reflects the nurse’s role as patient advocate during the assessment process?
a. “Tell me about any delusions you are experiencing.”
b. “I understand you have had some difficulty today.”
c. “Tell me why you need to threaten or hurt others around you.”
d. “Threatening to hurt others will require that you be committed to the hospital.”
ANS: B
The advocacy role of nurses to help patients to obtain, maintain, and fully make use of
mental health benefits is critical. Assessment for commitment requires data collection
from the patient. This statement is the most neutral of the options given and the most
open ended; therefore it will be most likely to elicit a response. It is an unfounded
assumption that the patient is delusional. “Why” questions will usually elicit
rationalizations from the patient. Making a statement about the resulting hospitalization
is not information gathering.
DIF: Cognitive Level: Application
REF: Page 169
2. A patient was placed in restraints for 2 hours in order to help manage impulsive,
destructive, unsafe behavior. Which statement made by the charge nurse during a
meeting to discuss the incident shows an understanding of the need to use restraints
only as a last resort?
a. “How did this situation get so out of control?”
b. “You all know that restraints are used only as a last resort.”
c. “Can anyone tell me why restraints were used on this patient?”
d. “Let’s review what exactly happened that led to the use of restrains.”
ANS: D
To facilitate an open, honest review of the incident that will permit learning to take place,
the charge nurse must not place the staff on the defensive. Reviewing the events leading
up to the patient being restrained in a nonaccusatory manner shows an understanding of
proper restraint use. The other options imply the nurse manager does not believe the
situation was handled in an appropriate way.
DIF: Cognitive Level: Application
REF: Page 173
3. The nurse is explaining the advantage of advanced directives to a patient diagnosed
with schizophrenia. Which psychiatric outcome is a result of such preplanning?
a. Allows healthcare providers to manage the patient’s mental health care
b. Decreases the possibility that the patient will be committed involuntarily
c. Directly impacts the type of care the patient will receive as the disease
progresses
d. Assures that the patient will retain continued autonomy and independence of
living
ANS: B
The implementation of psychiatric advance directives significantly decreases involuntary
commitments. Healthcare management and treatments are not affected by psychiatric
advanced directives. The patient’s continued autonomy and independence is more
related to the condition not the directives.
DIF: Cognitive Level: Application
REF: Page 170
4. A patient is being treated in the inpatient unit for paranoid delusions that his wife is
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unfaithful resulting in threats to “get her for this whenever I get out.” Which
intervention to assure his wife’s safety will his primary therapist include in the
discharge plan?
a. Sharing the threats he has made with his wife
b. Requiring mandatory day hospital attendance
c. Advising the patient that he needs continued outpatient services
d. Informing the patient of the consequences of harming his wife
ANS: A
The Tarasoff ruling established the necessity for a mental health professional treating a
patient who threatens to harm another individual to warn the person against whom the
threat is made. The remaining options are not directly related to affecting his wife’s
safety.
DIF: Cognitive Level: Application
REF: Page 172
5. A patient who has schizoaffective disorder is being treated with lithium carbonate. He
repeatedly resists his medication based on his fine hand tremors as proof of drug
poisoning. Which nursing intervention addresses both the patient’s need to comply
with treatment and patient rights?
a. Informing staff that the patient is exhibiting manipulative behavior
b. Providing the patient with effective education regarding medication side effects
c. Assuring the patient the tremors are a result of the disorder, not of the
medication
d. Providing an assessment to determine if the patient is exhibiting paranoia as well
ANS: B
Although the patient has a legal right to refuse medication, medication compliance is
vital to successful treatment. Patient and family medication education by nurses and a
reassuring therapeutic relationship will greatly assist with medication adherence while
preserving the patient’s rights. Identifying manipulative behavior or paranoia does not
address compliance or patient rights. The assurance about the tremors is not true.
DIF: Cognitive Level: Analysis
REF: Page 174
6. A patient diagnosed with schizophrenia is hospitalized under an emergency
commitment. Which nursing explanation is most effective when the patient asks,
“Why am I being kept here?”
a. “The court believed you needed mental health care.”
b. “Your mental condition became unstable and you relapsed.”
c. “You couldn’t stop doing things that could likely have hurt you.”
d. “I’d suggest that you exercise your patient right to speak to a lawyer.”
ANS: C
When the effects of the patient’s mental illness result in an immediate risk of self-harm
or harm to others, an emergency commitment is appropriate. While it is correct that
such a commitment is court ordered and may be a result of a relapse, these options do
not appropriately respond to the patient’s question. The patient does have a right to a
lawyer, but this option fails to answer the patient’s question as well.
DIF: Cognitive Level: Application
REF: Page 170
7. A patient has been hospitalized and is now being mandated outpatient mental health
treatment as a condition for discharge. Which intervention best addresses the
nurse’s role of patient advocate when this patient resists the recommendation?
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a. Helping the patient identify advantages of outpatient versus inpatient therapy
b. Sharing that outpatient therapy is less expensive than inpatient hospitalization
c. Stressing that outpatient therapy can minimize the need for future hospitalization
d. Discussing the patient’s opposition to outpatient treatment with the treatment
team
ANS: C
The purpose of mandating outpatient mental health treatment is to break the cyclic
pattern of patients who, when discharged from an inpatient treatment facility,
subsequently require readmission to the acute psychiatric care setting. While the other
options reflect the nurse as advocate, they do not best address this patient’s situation.
DIF: Cognitive Level: Evaluation
REF: Page 170
8. A patient admitted for treatment of symptoms related to paranoid schizophrenia
refuses to sign a consent form allowing the nurse to discuss any aspect of his
hospitalization with his parents. Which statement by the nurse best respects the
patient’s rights while providing effective care?
a. Reminding the parents that, “I can’t discuss your son even though I want to.”
b. Asking the patient to, “please talk with me about why you don’t trust your
parents?”
c. Telling the patient that, “Keeping your parents uninvolved in your care is very
painful for them.”
d. Telling the parents that, “While I can’t discuss his care with you, you can tell me
anything you think I need to know.”
ANS: D
This option provides the family the ability to communicate important medical or
behavioral history to the treatment facility without the nurse releasing any information
about the patient without that patient’s permission. It is inappropriate for the nurse to
express such personal feelings about the patient’s wishes. Challenging the patient’s
decision in these manners does not fulfill the nurse’s role as advocate.
DIF: Cognitive Level: Application
REF: Page 171
9. Electroconvulsive therapy (ECT) has been prescribed for a patient diagnosed with
chronic depression. Which statement by the patient helps assure the nurse that the
patient’s right to informed consent has been respected?
a. “ECT treatment will cure my depression.”
b. “ECT is dangerous but I’m almost out of treatments.”
c. “I may not remember things that happened just before the ECT treatment.”
d. “I’m likely to permanently lose memory of things like dates and numbers.”
ANS: C
A potential side effect is memory loss that is usually temporary but that can rarely be
irreversible. It is not true that ECT either cures depression or that the treatment is
considered physically dangerous.
DIF: Cognitive Level: Application
REF: Page 174
10. A 15-year-old who shows poor impulse control and resistance to authority is
prescribed outpatient therapy. The parents are insistent that the treatment include
commitment to an inpatient facility. Which response by the nurse best supports the
outpatient treatment modality?
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a. “Your child has a right to receive treatment in the least restrictive manner.”
b. “Outpatient therapy is better accepted by teens that are authority resistant.”
c. “This form of treatment is less expensive and usually covered by insurance.”
d. “Short-term therapy like this is usually done in an outpatient environment
setting.”
ANS: A
An important concept related to the location and nature of mental health treatment is
the concept of the least restrictive alternative; this involves providing mental health
treatment in the least restrictive environment with the use of the least restrictive
treatment. The remaining options do not reflect the criteria upon which appropriate care
is based upon.
DIF: Cognitive Level: Application
REF: Page 169
11. A patient, who has been charged with assault with intent to commit murder, has
been hallucinating. Which question when answered correctly by the patient would
show competency to stand trial for the crime?
a. “Can you describe your hallucinations?”
b. “Were you ever sexually abused as a child?”
c. “Can you describe for me the charges against you?”
d. “Can you explain why you wanted to assault your brother?”
ANS: C
Competency to stand trial is a narrow concept based on the person’s awareness of the
legal process and the understanding of the criminal charges. The remaining options are
concerned with the individual’s symptoms, past experience, and motives rather than his
ability to understand the legal processes.
DIF: Cognitive Level: Application
REF: Page 177
12. A patient diagnosed with paranoid schizophrenia has been charged with murder. The
patient’s mother asks, “What will happen if my son is found not guilty by reason of
insanity?” Which response shows that the nurse understands the outcome of this
plea?
a. “Your son will not receive the death penalty.”
b. “He will receive the mental treatment he deserves.”
c. “The court will order that he be involuntary committed for treatment.”
d. “He is considered innocent and will be released to the care of his physician.”
ANS: C
After a person is found not guilty by reason of insanity, he or she is usually hospitalized
and sent to a psychiatric unit for evaluation of commitability. Although they have been
found
not guilty, they have committed a criminal act and that will require appropriate
punishment.
DIF: Cognitive Level: Application
REF: Page 178
13. After the nurse discovered a medication error had been made, the patient was
carefully observed and effectively treated for symptoms of a headache. What
element of malpractice is most critical in determining the nurse’s liability?
a. The nurse owed a legal duty to the patient.
b. The nurse breached the recognized duty.
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c. The patient suffered harm as a result of the act.
d. The harm was a direct result of the nursing act.
ANS: D
Malpractice cannot be established unless the nurse’s action was the direct cause of the
observed injury. A headache is not generally seen as an outcome of such a medication
error. The remaining options reflect elements that are already recognized as being true.
DIF: Cognitive Level: Application
REF: Page 178
1. Upon voluntary admission, the nurse will ensure that the patient’s rights are
preserved. Which interventions are directly related to a patient’s civil right? Select all
that apply.
a. Arranging for the patient to vote in city election by absentee ballot
b. Respecting the patient’s right to refuse a dose of a prescribed medication
c. Arranging for the patient to have a private area in which to visit with friends
d. Deferring to a patient’s expressed wish to “not share a room with anyone else”
e. Changing the assignment because a patient “doesn’t like” a particular staff
member
ANS: A, B, C
When individuals enter a mental health facility, they usually retain their civil rights,
unless such rights are clearly restricted via the use of due process to certify that an
individual lacks the capacity or competence to have them. These individuals retain the
right to vote, refuse medication, and to have visitors. A private room and selecting of
staff are not civil rights that all patients are entitled to.
DIF: Cognitive Level: Application
REF: Page 172
2. Which nursing interventions are required by The Joint Commission (TJC) when the
decision is made that a patient will benefit from the use of physical restraints? Select
all that apply.
a. The patient’s family is telephoned and told that restraints were applied.
b. The restraints are removed when the patient agrees to cooperate with staff.
c. A staff member is assigned to sit next to the patient until the restraints are
removed
d. The nurse provides the patient with a timetable that identifies when the
restraints will be removed.
e. The nurse notifies the patient’s mental health care provider that a face-to-face
assessment is needed
ANS: A, C, D
The Joint Commission (TJC) standards require that the patient’s family and legal
representatives be notified when restraints are used, and the licensed independent
practitioner (LIP) is required to assess the patient within 1 hour of the application of the
restraints. The staff is also now required to perform continuous in-person observation of
any patient in restraints for the duration of the restraint procedure. The criteria for
removal of the restraints is not based exclusively on the patient’s stated willingness to
cooperate or is the nurse required to provide the patient with a specific time when the
restraints will be removed.
DIF: Cognitive Level: Application
REF: Page 173
3. Privileged communication is a legal concept that in some states protects the
confidentiality of the nurse-patient relationship. Which information is not protected
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by this statute? Select all that apply.
a. A threat to “kill that man if he even thinks about leaving me”
b. The patient’s admission to having a sexually transmitted disease
c. The fact that a patient knows who was responsible for her brutal rape
d. The discussion about how the patient sold his prescription drugs to friends
e. Suspicion by the nurse that the patient has been physically abused by a spouse
ANS: A, B, E
Privileged communication allows certain information given to professionals by patients to
remain secret during any litigation. These statutes exclude the mandatory reporting of
violence against a child, an older adult, an impaired adult, and (in some instances) a
domestic partner; some communicable diseases that affect public safety; and
information that will prevent a felony (e.g., murder) from occurring. Only the patient can
give the information regarding her rape and the privilege prevents the nurse from
sharing information such as illegal selling of drugs to be used against the patient in a
court of law.
DIF: Cognitive Level: Application
REF: Page 171
4. Which statement helps assure the nurse that the patient has an understanding of
how their health information is managed to assure their right to confidentiality?
Select all that apply.
a. “I had to sign a paper saying my information could be released.”
b. “My records will be released to only people who really need to know.”
c. “All the doctors will have access to my medical records when I’m here.”
d. “No one can see my information unless I say it’s okay for them to see it.”
e. “My insurance company will get what they need in order to cover the bill.”
ANS: A, B, D, E
At the time of admission to a mental health facility, admission staff often request that
patients sign a release-of-information document. The release of information usually
includes the information that will be released; the persons or parties that the information
will be shared with, such as other health care providers and insurance providers; the
purpose of the release of the information; and the period of time during which the
information will be released. Only the professionals who are involved with the care will
have access to the patient’s medical records.
DIF: Cognitive Level: Application
REF: Page 171
5. A chronically depressed patient has been asked to participate in a research project
focusing on effectiveness of alternative therapies. The nurse determines that the
patient has an appropriate understanding of the guidelines that directs a research
project when he states (select all that apply):
a. “I hope they find a treatment that doesn’t involve drugs.”
b. “I plan to use all the money I get to pay off some of my bills.”
c. “Helping to find a treatment for depressed people is a good thing.”
d. “My doctor told me that I had a responsibility to get involved in this.”
e. “I’m confident that this research project has very little risk involved.”
ANS: A, C, E
Guidelines for informed consent require that the patient understands the purpose of the
research, any risks and possible discomforts to the subject, and possible benefits to the
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individual or to others. It is most important to note that the research is voluntary and
that it clearly reflects autonomy on the participants’ part. Research subjects seldom
receive payment for their involvement in the project.
DIF: Cognitive Level: Application
REF: Page 175
6. Which actions show the nurse has an understanding of the role documentation plays
in minimizing the risk of malpractice? Select all that apply.
a. Including patient quotes to document subjective symptomology
b. Supporting documentation with personal opinions of the patient’s behaviors
c. Being mindful to use correct spelling and punctuation in the documentation
d. Using common abbreviations in order to keep documentation brief and concise
e. Documenting the nursing evaluation of the patient’s understanding of all
instructions
ANS: A, C, E
Adequate and legible documentation is the best means of defense against a lawsuit and
the best way to validate that the nurse adhered to their scope of practice and to a safe
standard of care. It is important to be specific and to document symptoms by writing in
quotes how the patient expresses them. The reliability of the documentation is in
question if spelling and punctuation is neglected. Documentation of all patient outcomes
shows affective nursing care. Documentation should not include personal opinions or
abbreviations not approved by the health care facility.
DIF: Cognitive Level: Application
REF: Page 179
7. What actions by a nurse identify an understanding of the nursing responsibility to
treat the patient with consideration to the ethical component of beneficence? Select
all that apply.
a. Frequently self-reflecting on whether the nursing interventions are actually
helping the patient
b. Evaluating whether the intervention is causing the patient unacceptable levels of
anxiety or pain
c. Recognizing that the moral rule of primum non nocere does not apply to the
mentally ill patient
d. Being willing to influence the patient in making decisions concerning the need for
unpleasant treatments
e. Consistently setting boundaries to effectively deflect a patient’s inappropriate
sexually-oriented behaviors
ANS: A, B, E
Individuals who work in the health care field have a special duty and responsibility to act
in a manner that is going to benefit rather than harm patients. The term beneficence
refers to bringing about good. Self-reflection concerning interventions and frequent
evaluation of the effects of treatment on the patient is critical to beneficent care.
Maintaining a therapeutic environment by providing an appropriate nurse-patient
relationship is a vital component to fulfilling the obligation to act in a beneficent manner.
The moral rule of primum non nocere (“first do no harm”) is vital in clinical interventions
with persons with mental illnesses. The nurse should not influence patient decisions but
rather provide information to support an educated decision whenever possible.
DIF: Cognitive Level: Application
REF: Page 182
Chapter 10: Anxiety and Anxiety Disorders
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1. A patient who was savagely attacked by a bear has no memory of the event. Which
statement best explains the patient’s inability to remember the attack?
a. The woman lost consciousness and was not cognitively aware of what happened
during the attack
b. The brain has produced a chemical anemia that will repress the memories of the
attack indefinitely.
c. The patient is unconsciously using a defense mechanism to protect against the
repeated memory of the attack.
d. It is a temporary suppression of the attack; her memory will return when she is
physically and emotionally ready to handle the memories.
ANS: C
Defense mechanisms are used unconsciously to protect us from threats to the physical,
mental, and social aspects of ourselves. The memory of the event may or may not come
back but this is not generally related to the patient’s ability to handle the memories.
Memory may be lost or impaired as a result of brain trauma but not as likely from a
chemical alteration.
DIF: Cognitive Level: Application
REF: Page 187
2. Which assessment finding exhibited by a patient being assessed for posttraumatic
stress disorder (PTSD) would be considered a defining behavior and support such a
diagnosis?
a. Can describe the attack in great detail
b. Experiences dramatic swings in affect
c. Describes vivid “flashbacks” of being attacked
d. Is preoccupied with the need to “tell someone about the attack”
ANS: C
One defining behavior that is seen when an individual has PTSD is that the person reexperiences the traumatic event. This takes place by having recurrent and intrusive
disturbing recollections of the trauma, including thoughts, images, or perceptions about
the incident. The person sometimes experiences recurrent dreams of the incident and
acts or feels as though the event was recurring in the present (flashback). Generally the
PTSD patient cannot remember all the details of the trauma nor are they particularly
interested in re-telling the events of the trauma. The patient generally has a very limited
range of affect.
DIF: Cognitive Level: Application
REF: Page 196
3. What is the basis for assessing a male patient who is agoraphobic for panic attacks?
a. Men are more likely to experience panic attacks.
b. An overwhelming number of agoraphobic patients also have panic attacks.
c. Patients are often unaware that the symptoms they are experiencing are those of
panic.
d. Panic attacks are generally the cause of a patient developing phobias like
agoraphobia.
ANS: B
Almost all patients who present with agoraphobia in clinical samples have a current
diagnosis or history of panic disorder. Males are not more likely than females to
experience panic attacks. Patients are not usually unaware of panic attack symptoms.
Panic attacks don’t cause, but are often triggered by, phobias.
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DIF:
Cognitive Level: Application
REF:
Page 193
4. Discharge preparation for a patient includes the administration of the Hamilton
Anxiety Scale (HAS). When asked by the patient to explain the purpose of the
assessment the nurse responds:
a. “It is an assessment tool used to evaluate the symptoms of anxiety.”
b. “The tool is used to help confirm the diagnosis of anxiety disorder.”
c. “This tool helps determine if your symptoms have improved with treatment.”
d. “It helps identify the presence of any other disorder associated with anxiety.”
ANS: C
The HAS is a valid and time-tested tool that gives the most objective measure of the
degree to which anxiety has been effectively treated. The HAS does not evaluate for
symptoms of anxiety or act as a diagnosis tool for anxiety or another other associated
disorder.
DIF: Cognitive Level: Application
REF: Page 202
5. A patient is admitted for treatment for persistent, severe anxiety. Which nursing
diagnosis would help effectively direct patient care?
a. Disturbed sensory perception related to narrowed perceptual field
b. Risk for injury related to closed perception
c. Hopelessness related to total loss of control
d. Risk for other-directed violence related to combative behavior
ANS: A
A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should
be considered. Data are not present to support the other diagnoses.
DIF:
Cognitive Level: Analysis
REF:
Page 189
6. The patient was an awkward child who was ridiculed by his father for his inability to
catch a ball. As an adult, the patient developed panic attacks at the time his
company established after-work team sporting activities. Which data discussed
during the nursing interview provides insight to the possible cause of this anxiety
disorder when applying the behavioral model?
a. He always avoids sports because “I’m short and not the least bit athletic.”
b. When in fifth grade, the patient caused his team to “lose the big softball game.”
c. The company he works for places tremendous emphasis of successful team work.
d. As a child he wore a leg brace that prevented him from participating in school
sports.
ANS: A
In behavioral models that are based on learning theory, the etiology of anxiety
symptoms is a generalization from an earlier traumatic experience to a benign setting or
object. As a result, he associates embarrassment and shame with sports events and
develops panic attacks. The same kinds of cognitive operations that link embarrassment
with sporting events link the cognition of the expectation of embarrassment with the
idea of a sporting event, and the individual begins to experience panic attacks while
merely thinking about being involved. The remaining options are not as likely to bring
about the embarrassment and shame that would produce such a response.
DIF: Cognitive Level: Application
REF: Page 192
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7. The nurse is working with the family of a patient with obsessive-compulsive disorder
(OCD). Which concept should the nurse incorporate in the teaching plan?
a. The thoughts, images, and impulses are voluntary.
b. The family should pay immediate attention to symptoms.
c. The thoughts, images, and impulses tend to worsen with stress.
d. OCD is a chronic disorder that does not respond to treatment.
ANS: C
Stress is known to increase the intensity of OCD symptoms. Families should be taught
this relationship and the need to reduce stress in the patient’s life as much as possible.
The symptoms are not under the patient’s voluntary control. It is nontherapeutic to
immediately focus on the symptoms, since to do so contributes to secondary gain. OCD
responds well to medication and therapy.
DIF: Cognitive Level: Application
REF: Page 198
8. Which question would assist the nurse in determining whether the patient has been
experiencing anxiety?
a. “Have you had difficulty concentrating lately?”
b. “Have you been feeling sad and especially lonely?”
c. “Do you have a history of failed personal relationships?”
d. “Do you frequently experience difficulty controlling your anger?”
ANS: A
Concentration difficulties occur when moderate or greater levels of anxiety are present.
Loneliness is more related to mood. A failed personal relationship is more related to poor
self-esteem. Inability to control anger is related to poor impulse control.
DIF: Cognitive Level: Application
REF: Page 197 | Page 199
9. The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD)
is aware of the need to intervene early in order to de-escalate a patient’s increasing
anxiety level. Which patient behavior is likely an early indication of escalating
anxiety?
a. Talking rapidly
b. Pacing around the unit
c. Staring out the window
d. Refusing to go to therapy
ANS: B
Recognize the patient’s use of relief behaviors (e.g., pacing, wringing of hands) as
indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more
likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant
patients.
DIF: Cognitive Level: Application
REF: Page 200
10. The nurse has been working with a patient who experiences anxiety. Which
intervention should the nurse implement initially when the patient is observed pacing
and wring her hands?
a. Asking how she has managed anxiety effectively in the past
b. Distracting her by offering to help her make a telephone call
c. Asking her what she believes is causing her increased anxiety
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d. Teaching her to take deep, relaxing breaths to manage the anxiety
ANS: A
First help the patient to build on the coping methods that the patient used to manage
anxiety in the past. Coping methods that were previously successful will generally be
effective in subsequent situations. Distraction is not usually successful initially. Assessing
for the cause of the anxiety will not, in this situation, be helpful in managing it; often
times patients are not aware of the cause. Teaching will not be effective while the patient
is experiencing anxiety but should be done when the patient is relaxed and able to focus.
DIF: Cognitive Level: Analysis
REF: Page 200
11. The nurse is working with a patient with an anxiety disorder whose treatment
includes cognitive behavioral therapy. Which statement by the patient gives the
nurse reason to assume that the patient has an understanding of the basis of this
type of therapy?
a. “My abusive childhood has resulted in my overreaction to stress.”
b. “My delusional thoughts of extreme anxiety are what cause my panic attacks.”
c. “My brain chemistry causes me to overreact to common stress by getting so
anxious.”
d. “I’ve learned to react to my daily stress by having anxious thoughts and panic
attacks.”
ANS: D
The success of this approach centers on the patient’s understanding that the symptoms
are a learned response to thoughts or feelings about behaviors that occur in daily life.
Cognitive therapy helps patients identify target symptoms and change the cognitions
associated with them. This is a psychodynamic model explanation. Anxiety disorders
have no relationship to delusions. Brain chemistry is not a usual cause of anxiety but
rather can be altered by anxiety.
DIF: Cognitive Level: Application
REF: Page 201
12. Which verbal intervention would the nurse use when helping a patient who is
experiencing severe to panic-level anxiety?
a. “I will stay with you to make sure you remain safe.”
b. “First, you must stop pacing and wringing your hands.”
c. “How can I help you get control of yourself and this anxiety?”
d. “Can you tell me what was happening just before you got upset?”
ANS: A
A patient who is experiencing severe to panic-level anxiety requires brief, directive
verbal interchanges aimed at increasing feelings of safety and security. It is not likely the
patient will be able to stop the physical behaviors. Severely anxious patients are not able
to evaluate their situation and give direction to the nurse or are they able to relate
antecedent events to increasing anxiety.
DIF: Cognitive Level: Application
REF: Page 200
13. The nurse notes that a patient being treated for an anxiety disorder is becoming
more anxious sitting in a congested, noisy room waiting to see the therapist. Which
intervention will the nurse implement initially to assist the patient in de-escalating
his anxiety?
a. Offering to reschedule the patient’s appointment
b. Taking the patient to an unoccupied interview room
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c. Notifying the therapist of the need to see the patient stat
d. Requesting oral prn anxiolytic medication for the patient
ANS: B
A congested, noisy environment is not conducive to maintenance of low anxiety. Moving
the patient to a less stimulating environment may be all that is needed for the patient to
lower his anxiety level. The other options may not be necessary if the nurse intervenes
effectively.
DIF: Cognitive Level: Application
REF: Page 201
14. A patient is ordered medication therapy to manage the symptoms of anxiety
disorder. Which statement by the patient indicates an understanding of the typical
classification of medication prescribed for this disorder?
a. “Tricyclic antidepressants are particular good for panic attacks.”
b. “I have to give up beer while taking monamine oxidase inhibitors (MAOIs).”
c. “Selective serotonin reuptake inhibitors (SSRIs) help with panic attacks as well.”
d. “Benzodiazepines are usually effective when taken for chronic anxiety like mine.”
ANS: C
SSRIs are the most widely prescribed medication to treat panic disorder. They are
effective and have a low side-effect profile. Tricyclic antidepressants are not effective for
panic attacks and have more side effects than SSRIs. MAOIs are effective but require
knowledge of and compliance with a special diet and are not the first choice in this
situation. Benzodiazepines are effective but produce alterations in sensorium and other
side effects and are not used for long-term management.
DIF: Cognitive Level: Application
REF: Page 201
15. A patient with OCD tells the nurse, “Thinking these thoughts and doing all my rituals
is beyond being silly. I have few friends and I know others laugh behind my back. I
sometimes think I can control things, but I always find I can’t. I don’t know if I can
continue to live this way.” Which assessment question shows the nurse has an
understanding of this patient’s priority risk?
a. “Are you feeling hopeless?”
b. “Do you think you are socially isolated?”
c. “Have you been thinking about hurting yourself?”
d. “Do the rituals affect how you feel about yourself?”
ANS: C
Patients with anxiety disorders should always be assessed for the presence of depression
and suicidal ideation, the priority risk to safety. This patient has admitted feeling
powerless to control the symptoms, in addition to wondering if she can continue to live
the way she has been. There is ample reason for asking about suicidal ideation. The
remaining options address hopelessness, social isolation, and low self-esteem. While
appropriate nursing concerns, they don’t have the priority self-harm has for this patient.
DIF: Cognitive Level: Analysis
REF: Page 199
16. The head nurse in the ED has received word that a major fire in a high-rise office
tower will result in many injured persons being brought to the hospital within the
next few minutes. The head nurse tells the staff, “You will need to assess for acute
stress reactions as well as treating physical problems.” Which patient is exhibiting
symptoms characteristic of acute stress reaction?
a. A male whose moods swing between mania and depression
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b. A female who reports still hearing her daughter’s pleas for help
c. A male who keeps repeating “I don’t understand what’s going on?”
d. A female who is rocking her young son and repeating “it will be okay.”
ANS: C
Acute stress reactions are characterized by indications of dissociation, such as
dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory
hallucinations would be consistent with re-living a traumatic event. Comforting and
reassuring a child in this manner is not characteristic of an acute stress reaction.
DIF: Cognitive Level: Application
REF: Page 196
17. A nurse is reprimanded by the nurse manager. Shortly thereafter, a patient’s family
member reports that the nurse curtly told them “You can’t come in now. You know
you need to wait until visiting hours.” The incidence should be discussed based on
the knowledge that the defense mechanism the nurse used was:
a. Displacement
b. Projection
c. Sublimation
d. Suppression
ANS: A
Displacement is transferring a response or feeling toward one person onto another less
threatening person. Projection is attributing strong faults to another and is not displayed
in this scenario. Sublimation is channeling maladaptive thoughts into socially acceptable
behaviors. Suppression is intentionally avoiding thinking about problem areas.
DIF: Cognitive Level: Comprehension REF: Page 188
18. During a nursing assessment, a teenage patient smiles and states, “I don’t care what
you say. I want to be just like Mike, the leader of our gang.” The nurse understands
the defense mechanism being used is:
a. Denial
b. Humor
c. Splitting
d. Identification
ANS: D
Identification is wishing or trying to be like someone else. Denial is an unconscious
refusal to acknowledge some reality. Humor is not being used. Splitting is viewing
oneself and others as all bad or all good.
DIF: Cognitive Level: Comprehension REF: Page 188
19. A young, married female patient is attracted to a male nurse. When the nurse sets
clear boundaries, the patient falsely accuses him of sexual harassment. The nursing
supervisor recognizes the defense mechanism of:
a. Projection
b. Splitting
c. Suppression
d. Displacement
ANS: A
Projection is attributing strong conflicting feelings to another person. Splitting is seeing
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others and oneself as all good or all bad. Suppression is incorrect because the person
avoids thinking about problem areas. Displacement, or transferring a feeling to a less
threatening person, is not being used in this scenario.
DIF: Cognitive Level: Comprehension REF: Page 188
20. A college-aged patient complains that, “when I begin to take a test, I freeze up and
my mind goes blank.” The nurse will react based on the understanding that this
patient’s anxiety level is:
a. Mild
b. Moderate
c. Severe
d. Panic
ANS: C
In severe anxiety, a person may freeze and problem solving is difficult. A person is
relatively relaxed and comfortable in mild anxiety. A person in moderate anxiety may
feel energized and focused. A person at panic level has total loss of control.
DIF: Cognitive Level: Comprehension REF: Page 189
21. A college student diagnosed with high levels of anxiety is being prepared for
discharge. Which discharge criteria is appropriate for this patient?
a. The patient will avoid situations that cause anxiety.
b. The patient will use learned anxiety-reducing strategies.
c. The patient will return to living at home with supportive parents.
d. The patient will state, “I know medication is what I need to control my anxiety.”
ANS: B
Using anxiety-reduction strategies will promote maximal functioning. Trying to avoid
stressful situations is impractical and encourages avoidance, therefore limiting activities
and not supporting the development of coping mechanisms. Moving back into the
parent’s home promotes dependency, and medication therapy is not necessarily the only
treatment for anxiety.
DIF: Cognitive Level: Application
REF: Page 198
1. A patient is being evaluated for a possible diagnosis of panic disorder with
agoraphobia. Which nursing assessment findings support this diagnosis? Select all
that apply.
a. Patient states, “I’ve had these fears for more than 6 years.”
b. Patient describes having a “panic attack” several times a month.
c. Patient is embarrassed by the limitations the disorder causes.
d. Stated, “I never even think about going shopping in a crowded mall.”
e. Condition began after beginning treatment for a chronic intestinal problem.
ANS: A, B, C, D
To meet the first DSM-IV-TR criterion for panic disorder with agoraphobia, the person
must experience recurrent, unexpected panic attacks, with at least one attack followed
by one of the following for a month: (1) persistent concern about having additional
attacks; (2) worry about the implications of the panic attacks; or (3) a significant change
in behavior as a result of the attacks. The second criterion is that the individual
experiences agoraphobia. Agoraphobic fears typically involve being in a crowd. The third
criterion is that the person avoids agoraphobic situations or has anxiety about having a
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panic attack. This person will not go to an area or event where he or she has
experienced an agoraphobic reaction. The fourth criterion states that panic attacks are
not caused by the direct effects of a substance, a medication, or a medical condition.
DIF: Cognitive Level: Analysis
REF: Page 195
2. The nurse has identified a nursing diagnosis of disturbed thought processes for a
patient with obsessive-compulsive disorder. What abilities displayed by the patient
would be related to an appropriate outcome for this problem? Select all that apply.
a. Can identify when obsessions are worsening
b. Speaks of obsessions as being embarrassing behaviors
c. Describes lessening anxiety when compulsive rituals are interrupted
d. Plans to ignore obsessive thoughts and so minimizes resulting stress
e. Limits time focusing on obsessive thoughts to 15 minutes, 4 times a day
ANS: A, C, E
It is desirable for the patient to experience a sense of being able to identify and control
the obsessive thinking and the resulting anxiety. Identifying the behaviors as
embarrassing is not showing control nor is ignoring the behaviors.
DIF: Cognitive Level: Application
REF: Page 200
3. Which lifestyle changes should the nurse incorporate in the nursing care plan for a
patient with generalized anxiety disorder? Select all that apply.
a. Stop smoking.
b. Limit caffeine intake.
c. Eliminate stress from your life.
d. Practice a relaxation technique daily.
e. Limit worrying to specific times each day.
ANS: A, B, D, E
CNS stimulants, including caffeine and nicotine, increase anxiety symptoms such as
heart rate and muscle tension. Relaxation techniques are invaluable in the management
of stress and anxiety. Limiting the time to allow worrying will help control the invasive
thoughts. One cannot avoid stressful situations and attempting to do so does not help in
managing its affects.
DIF: Cognitive Level: Application
REF: Page 200
4. A nursing interview for a patient being admitted for depression reveals that the
patient has been taking a benzodiazepine for anxiety for 3 years. Which actions by
the nurse reflect an understanding of the effects of this classification of drugs? Select
all that apply.
a. The nurse asks how much of the drug the patient takes daily.
b. The admitting physician is notified of the patient’s medication history.
c. The nurse prepares to discuss the process of detoxification with the patient.
d. The nurse suggests to the patient that the dosage is likely to be increased.
e. The patient is interviewed regarding how well the anxiety has been controlled.
ANS: A, B, C
Benzodiazepines are relatively safe and effective for short-term use to control the
debilitating symptoms of anxiety. However, longer-term treatment with these drugs
raises issues of tolerance, abuse, and dependence. The medication dosage would not be
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increased. The effectiveness of the medication is irrelevant but rather the length of the
therapy is the prime concern.
DIF: Cognitive Level: Application
REF: Page 201
5. A patient comes to the ED exhibiting severe physical and emotional symptomology.
When no physical cause can be found for the symptoms, the patient is diagnosed
with severe anxiety with panic attack symptoms. Which assessment data supports
this diagnosis? Select all that apply.
a. Blood pressure 158/90; 15 minutes later 130/80
b. Claims that she feels like she going to die
c. Random but controlled thoughts
d. Unable to follow instructions
e. Dry, flushed skin
ANS: A, B, D
Blood pressure will begin to drop in a panic attack as the sympathetic nervous system
release occurs; the patient may express an emotional sensation of doom and the patient
will not be able to concentrate and so will be unable to follow instructions. Thoughts
during a panic attack are uncontrolled and the skin is diaphoretic.
DIF: Cognitive Level: Analysis
REF: Page 193
6. Which considerations should a nurse include when conducting a mental health
assessment on a culturally diverse patient Select all that apply.
a. Men and women are equally likely to seek psychiatric health care.
b. The role that spirits and magic play in a patient’s belief system is cultural based.
c. Rituals are only deemed obsessive when applied to the patient’s cultural
standards.
d. Agoraphobia is more difficult to assess in cultures that restrict female
socialization.
e. The nurse should consider the universal application of the Diagnostic and
Statistical Manual (DSM-IVTR).
ANS: B, C, D
Some cultures restrict women’s participation in public activities; thus agoraphobia is less
commonly diagnosed. Fears of magic and spirits are present in many cultures and are
pathologic only when they are deemed excessive in the context of that culture. Many
cultures have rituals to mark important events in people’s lives. The observation of these
rituals is not indicative of OCD unless it exceeds norms for that culture, is exhibited at
times or places that are inappropriate for that culture, or interferes with social
functioning. Most research that supports the development of the Diagnostic and
Statistical Manual, ed 4, text revision (DSM-IVTR) classification occurred in the United
States; consequently, symptoms that define disorders are representative of U.S. culture.
Overall, women are more likely than men to present for treatment or to come in contact
with health care providers.
DIF: Cognitive Level: Application
REF: Page 193
Chapter 11: Somatoform, Factitious, and Dissociative Disorders
1. Which question would the nurse performing an admission interview for a patient with
suspected dissociative amnesia disorder identify as a priority?
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a. “What help would you like us to give you?”
b. “Are you experiencing a high level of anxiety?”
c. “Do you find rituals make you feel more comfortable?”
d. “How would you describe your childhood memories?”
ANS: D
Due to a recent increase in reported cases of dissociative amnesia involving previously
forgotten early childhood memories, assessing such memories would have priority with
this patient. Obsessive-compulsive disorder is not generally viewed as a co-morbid
disorder of dissociative amnesia. The remaining options would not provide much specific
information for this patient’s condition.
DIF: Cognitive Level: Application
REF: Page 209
2. Which nursing assessment finding would support a diagnosis of somatoform
disorder?
a. Patient reports a family history of depression
b. The onset of symptoms beginning at age 38
c. An abnormality of the patient’s left heart ventricle
d. Complaints of diarrhea and an erratic menstrual cycle
ANS: D
The diagnosis of somatization disorder requires that symptoms indicate there is
involvement of multiple organ systems (e.g., gastrointestinal, reproductive, neurologic).
Structural anomalies would indicate a medical problem exists. An early onset of
symptoms (prior to age 30) is not recognized as a criterion for the diagnosis. A family
history of depression is not a criterion for the diagnosis.
DIF: Cognitive Level: Application
REF: Page 209
3. To differentiate between somatoform and conversion disorders, the nurse will direct
the assessment to determine the presence of the critical defining factor associated
with conversion disorder. Which is true about a conversion reaction?
a. Symptoms are generally associated with pain or sexual function.
b. Symptoms are not accounted for by a medical condition.
c. Symptoms are precipitated by psychological factors.
d. Symptoms are under the patient’s voluntary control.
ANS: C
Symbolic psychological factors are identified as being related to the onset or
exacerbation of a conversion symptom. An absence of a medical cause is present in both
the case of conversion and somatization disorders. The conversion symptom is not
limited to pain or sexual function nor is not under voluntary control.
DIF: Cognitive Level: Application
REF: Page 210
4. A diagnosis of dissociative identity disturbance has been identified for a patient who
has stated that he is unable to distinguish between himself and his surroundings.
What is an appropriate outcome for this patient?
a. Refers to himself as “the patient”
b. Identifies the onset of increasing anxiety
c. Uses manipulative behaviors to meet needs
d. Displays ability to suppress feelings of dissatisfaction
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ANS: B
Dissociative identity disturbance is exacerbated when the patient’s anxiety escalates.
Identification of increasing anxiety permits the patient to exercise anxiety-management
strategies and prevent dissociation. The patient should be expressing such feelings to
others. The patient should refer to himself in the first person. Use of manipulative
behavior is not desirable in this or any other patient.
DIF: Cognitive Level: Application
REF: Page 215
5. A patient comes to the ED stating that he suddenly became deaf. It is determined
that his wife has recently asked for a divorce. What is the basis for the possibility that
this patient is experiencing a conversion disorder?
a. Inventing the symptom helps in diverting attention from the marital problems.
b. Such a traumatic life change is likely to result in some form of mental illness.
c. The loss is a protective mechanism to help deal with overwhelming anxiety.
d. Men often exhibit this disorder since it is more accepted than showing sadness.
ANS: C
The scenario suggests that the patient is experiencing symptoms of conversion disorder,
an anxiety disorder in which the symptom affects voluntary sensory or motor function
and mimics a neurological disorder as a result of extreme anxiety, such as learning of his
wife’s desire to divorce him. There is no organic basis for the hearing loss but it is not
under the patient’s voluntary control. Most traumas are not dealt with by developing a
mental illness but by rather coping effectively. Males are as likely as females to display
conversion disorder symptoms.
DIF: Cognitive Level: Application
REF: Page 208
6. A patient reports severe pain during intercourse since being sexually assaulted three
years ago. What is the first step in confirming the diagnosis of a pain disorder?
a. Evaluating the patient’s understanding of the emotional effects of the assault
b. Asking the patient to keep a journal of her feelings regarding the assault
c. Assessing the patient for posttraumatic stress disorder
d. Ruling out a physical cause of the pain
ANS: D
While psychological factors have an important role in the onset, severity, exacerbation,
or maintenance of the pain, initially the presence of a physical cause of the pain must be
ruled out. The assessment of the patient’s understanding of the disorder or recording of
feelings regarding the trauma are not priorities until a diagnosis of pain disorder is made.
Posttraumatic stress disorder is not generally characterized with reports of sustained
pain.
DIF: Cognitive Level: Application
REF: Page 210
7. A patient has developed an acute loss of hearing and is diagnosed with a conversion
disorder. Which nursing diagnosis would be most appropriate?
a. Hearing impairment
b. Panic-level anxiety
c. Disturbed sensory perception
d. Denial due to a medical condition
ANS: C
The diagnosis of conversion disorder in this case results in a disruption of the patient’s
ability to perceive sensations, not a true loss or impairment of hearing. There is no
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evidence to support panic-level anxiety or a medical condition causing denial.
DIF: Cognitive Level: Application
REF: Page 210
8. A patient experiencing the sudden onset of blindness is diagnosed with a conversion
disorder. Which nursing intervention would be most therapeutic?
a. Suggesting to the patient that this is possibly malingering
b. Assisting him to make an appointment with an ophthalmologist
c. Providing nursing care in a supportive but matter-of-fact manner
d. Providing an occupational therapy consult to address the needs of a blind person
ANS: C
Interacting in a supportive but matter-of-fact way reduces the potential for any
secondary reward on the part of the patient. The patient is not feigning illness, so is not
a malingerer. An appointment with an eye doctor is not needed since the source of the
blindness is not physical. The person is not permanently blind, so occupational therapy
at this point is not a priority.
DIF: Cognitive Level: Application
REF: Page 210
9. A patient is being evaluated for the diagnosis of hypochondriasis. Which assessment
observation of the patient would serve to confirm this diagnosis?
a. Reports, “Pain in my back is certainly from a spinal tumor.”
b. Patient expresses no concern over her sudden loss of hearing.
c. Patient shows insight into the role stress plays in the illness.
d. Reports, “I don’t like doctors and so I haven’t been to one in years.”
ANS: A
With this disorder, the individual focuses on fears of having or the idea of having a
serious medical disorder on the basis of his or her misinterpretation of bodily symptoms
such as assuming pain is the result of a tumor. La belle indifference, showing little or no
concern, occurs with conversion disorders. Individuals with hypochondriasis make
multiple visits to physicians with health concerns. Showing insight into the condition
would not be displayed at the time of diagnosis, since such improvement is a result of
appropriate treatment.
DIF: Cognitive Level: Application
REF: Pages 210-211
10. A patient who inaccurately believes he has stomach cancer is recommended
cognitive theory to help address this false believe. Which intervention is most
consistent with a cognitive theory approach?
a. Continuing to challenge the patient about the rationality of his belief
b. Assisting him to reinterpret the meaning of the sensations his body is creating
c. Urging him to have a ‘second opinion’ consult with another medical specialist
d. Rewarding him with praise and acceptance when he states, “I do not have
cancer.”
ANS: B
Cognitive theorists believe that patients with somatic symptoms misinterpret the
meaning of body functions and sensations and become overly alarmed by them and so
help patients to reinterpret the meaning of body sensations. Continuing to challenge the
patient regarding the belief is not therapeutic and should be avoided. Reinterpretation of
thoughts is an appropriate cognitive approach. Rewarding appropriate behavior is a
behavioral technique. Encouraging a second opinion is not helpful at this point since it is
not likely to change his belief.
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DIF:
Cognitive Level: Application
REF:
Page 208
11. The ED nurse is caring for a patient with a dissociative fugue. Which assessment
finding would support this diagnosis?
a. Reports of pain in both legs and abdomen
b. An inability to recall how and when he arrived in this city
c. Change in voice and attitude suggesting two distinct personality states
d. Inability to see since witnessing an accident that resulted in two deaths
ANS: B
The inability to recall the past is indicative of a fugue disorder. The remaining options are
not characteristics of dissociative fugue.
DIF: Cognitive Level: Application
REF: Page 213
12. A nurse interviews a 17-year-old patient and notes these assessment data: excessive
grooming, checking in the mirror, and preoccupation with perceived physical
imperfections. The nurse suspects:
a. Hypochondriasis
b. Factitious disorder
c. Somatoform disorder
d. Body dysmorphic disorder
ANS: D
These symptoms are indicative of a body dysmorphic disorder.
DIF: Cognitive Level: Application
REF: Page 209
13. The nurse reinforces the recommendation of group therapy for a patient with a
somatization disorder. What knowledge is this recommendation based upon?
a. Group therapy is the one therapy of choice for this anxiety disorder.
b. Group therapy is therapist driven and managed to eliminate stress on the
patients.
c. The group will support the patient in all complaints of physical illness as well as
emotional distress.
d. This therapy allows the patient to learn what has successfully worked for other
patients with the disorder.
ANS: D
An advantage of group therapy is that it is an opportunity for the patient to learn from
the successes and failures of others with similar symptoms. The group therapist will not
allow members to support dysfunctional verbalizations. This disorder is treated with a
variety of treatment modalities. This therapy is done with cooperation between therapist
and patients.
DIF: Cognitive Level: Application
REF: Page 216
14. A family member asks the nurse about possible medications to treat somatization
disorders. Which statement by the nurse shows an understanding of the recognized
medication therapy for this disorder?
a. “Hypnotics, taken appropriately will help with your major complaints.”
b. “Lithium will require regular monitoring to assure therapeutic blood levels.”
c. “Antidepressant therapy may take several weeks to bring about symptom relief.”
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d. “Anticonvulsants are often used to treat the side effects of these type of
disorders”
ANS: C
Pharmacologic therapy for somatization disorders commonly include antidepressants,
which can take weeks of administration before positive effects are noted. The remaining
classifications are not generally used to treat somatization disorders.
DIF: Cognitive Level: Application
REF: Page 216
TOP: Nursing Process: Implementation
MSC:
NCLEX: Psychosocial Integrity
15. A patient has a somatization disorder. Which statement by the patient would indicate
a need for additional patient teaching?
a. “I have learned that my family can be a support system.”
b. “I will let my therapist know if I think suicidal thoughts.”
c. “Drinking strong coffee really helps me combat my fatigue.”
d. “Nicotine makes my heart race, so I need to stop smoking.”
ANS: C
Educating the patient about the importance of limiting caffeine, nicotine, and other
central nervous system stimulants is important since these substances can increase
physical symptoms of anxiety (e.g., rapid heart rate, jitteriness) that may cue other
somatic concerns. Drinking strong coffee each day may cause physical symptoms that
could cue other somatic concerns; this statement indicates a need for more teaching.
The remaining options are all positive thoughts or actions for a patient.
DIF: Cognitive Level: Application
REF: Page 216
16. A patient is diagnosed with body dysmorphic disorder. Which question assesses for
the presence of a common co-morbid mental disorder?
a. “Do you every have suicidal thoughts?”
b. “Do you worry about being terminally ill?”
c. “Do you see yourself as having problems controlling your anger?”
d. “Do you engage in repetitive, ritualistic behaviors to help control anxiety?”
ANS: A
Anxiety and depression are common comorbid mental health conditions seen in patients
diagnosed with body dysmorphic disorder due to their constant dissatisfaction with their
appearance. Obsessive-compulsive disorder, poor impulse control, and somatization
disorders are not generally seen in such patients.
DIF: Cognitive Level: Application
REF: Page 211
17. Which adult patient is most likely a candidate for the diagnosis of factitious disorder?
a. An educated African immigrant
b. A health care facility employee
c. A cognitively challenged female
d. A middle-aged American male
ANS: B
The adult patients diagnosed with factitious disorder are often knowledgeable regarding
medical terminology, and many work in the health care. The other options are not
commonly associated with the disorder.
DIF: Cognitive Level: Application
REF: Page 212
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1. A patient is being treated for somatoform disorder with psychotherapy and
medication therapy. Which interventions are appropriate for the patient’s plan of
care? Select all that apply.
a. Instructing the patient in use of imagery to distract themselves when feeling
anxious
b. Educating the patient on the identification of side effects related to anxiolytic
therapy
c. Monitoring the patient’s vital signs to assess for the side effects of
benzodiazepine administration
d. Discussing the need for long-term cognitive therapy in order to eliminate the
symptoms of the disorder
e. Asking the patient to explain the role serotonin selective reuptake inhibitors
(SSRIs) play in the management of his symptoms.
ANS: A, B, C, E
Pharmacologic interventions are symptom oriented and include anxiolytics for associated
anxiety, antidepressants for associated depression, and short-term benzodiazepine
therapy. Monitoring for orthostatic hypotension is recommended when benzodiazepines
are prescribed. Instructing the patient to perform visual imagery (guided imagery) will
reduce anxiety by distracting his or her focus on somatic concerns. When used, cognitive
therapy is implemented short term.
DIF: Cognitive Level: Application
REF: Page 216
2. What discharge criteria would be appropriate for a patient with a somatization
disorder? Select all that apply.
a. Increased willingness to relinquish the “sick role”
b. Decreased anxiety related to possible health issues
c. Increased caloric intake and demonstrated weight gain
d. Decrease the use of laxatives, sleeping pills, and diuretics
e. Experiencing decreased frequency of auditory hallucinations
ANS: A, B
Minimization of the use of sickness to gain control and decreased anxiety related to
health and wellness are the outcomes that relates specifically to somatization disorder.
The remaining options are not typically associated with this disorder.
DIF: Cognitive Level: Application
REF: Pages 213-214
3. The nurse is evaluating a patient diagnosed with a dissociative disorder for discharge
criteria. Which statements made by the patient indicate that discharge criteria have
been met? Select all that apply.
a. “I’ve learned to identify my personal stressors.”
b. “Meditation is a wonderful support in managing my stress.”
c. “It’s getting better; I’m sleeping about 5 hours most nights.”
d. “I know I have to rely on myself to get this problem under control.”
e. “I’ll talk with my doctor before making any changes to my medicines.”
ANS: A, B, E
Discharge criteria would include behaviors and attitudes that show insight and some
control over the disorder. Compliance with medication therapy, identification of stressors
and using learned stress-reducing strategies such as mindfulness meditation are
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examples of such behaviors. There is a need for more nightly sleep and a willingness to
seek help and support are important unmet criteria with this patient.
DIF: Cognitive Level: Application
REF: Pages 213-214
Chapter 12: Mood Disorders: Depression, Bipolar, and Adjustment Disorders
1. The nurse learns at report that a newly admitted manic patient is demonstrating
grandiosity. Which statement would be most consistent with this symptom?
a. “I can’t do anything anymore.”
b. “I’m the world’s most astute financier.”
c. “I can understand why my wife is upset that I overspend.”
d. “I can’t understand where all the money in our family goes.”
ANS: B
An individual who is demonstrating grandiosity has an exaggerated view of his abilities.
The other options are more moderate statements and lack that element of exaggeration.
DIF: Cognitive Level: Application
REF: Page 233 | Page 235
2. The nurse will base a discussion of dysthymia on the fact that the condition:
a. Typically has an acute onset
b. Involves delusional thinking
c. Is chronic low-level depression
d. Does not include suicidal ideation
ANS: C
Dysthymia is identified as a chronic low-level depression frequently lasting over a period
of several years without remitting. Dysthymia has a slow, insidious onset. Delusional
thinking is not a common manifestation of dysthymia. Suicidal thoughts are seen among
dysthymic patients.
DIF: Cognitive Level: Comprehension REF: Pages 232-233
3. What is the priority nursing diagnosis for a patient exhibiting signs of acute mania
that include exaggerated physical activity, agitation, insomnia, and anorexia?
a. Risk for injury
b. Chronic low self-esteem
c. Noncompliance
d. Insomnia
ANS: A
Risk for injury is the priority diagnosis. Possible injuries include dehydration, which may
result from not drinking and trauma, which may result from bumping into objects or from
physical altercations. The other options are valid diagnoses, but not of highest priority.
DIF: Cognitive Level: Analysis
REF: Page 242
4. A patient has been admitted with a diagnosis of atypical depression. In planning
interventions, the nurse would expect to consider the characteristic symptom of:
a. Seasonal episodes
b. Leaden paralysis
c. Psychomotor agitation
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d. Increased depression in the morning
ANS: B
Behavioral characteristics of atypical depression include the feeling that one’s limbs are
so heavy they cannot be lifted or moved (leaden paralysis). Seasonal mood changes are
characteristic of seasonal affective disorder. Psychomotor agitation and depression that
is greater in the morning than in the evening are characteristics more likely to be
observed in patients with melancholic depression.
DIF: Cognitive Level: Application
REF: Page 237
5. An inappropriately dressed patient has not slept for 3 days while making excessive,
expensive long-distance phone calls. When the patient can be heard singing loudly in
the examining room, the nurse makes initial plans to focus on:
a. Assessing needs for food, liquids, and rest
b. Setting strict limits on dress and behavior
c. Conducting an in-depth suicide assessment
d. Obtaining a complete psychosocial assessment
ANS: A
Patients with mania frequently ignore their basic physiologic needs, as evidenced by not
sleeping for 3 days, thus making these assessments the priority. Limits, although
appropriate to consider, are not the priority. The manic state precludes a thorough
assessment initially. Suicide assessment is not a priority at this time but reckless
behavior could result in personal injury.
DIF: Cognitive Level: Application
REF: Page 245
6. Which statement by the patient would indicate the need for additional education
regarding the prescribed lithium treatment regimen?
a. “I will restrict my daily salt intake.”
b. “I will take my medications with food.”
c. “I will have my blood drawn on schedule.”
d. “I will drink 8 to 12 glasses of liquids daily.”
ANS: A
Patients taking lithium must maintain a normal sodium intake or risk symptoms of
lithium toxicity. The patient should have 2 to 3 liters of fluid daily. Taking lithium with
food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is
important to prevent toxicity.
DIF: Cognitive Level: Application
REF: Page 246 | Page 250
7. The nurse would evaluate that patient education regarding lithium therapy for an
individual with bipolar disorder as effective if the patient states:
a. “I can stop my lithium when I feel better.”
b. “I can continue with my diuretic and cardiac medications.”
c. “I will probably need to take the lithium for the rest of my life.”
d. “I will taper my lithium when a therapeutic serum level is achieved.”
ANS: C
Most patients with bipolar disorder require long-term maintenance on lithium or other
antimanic medication. Patients should never stop medication without consulting the
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physician. When a therapeutic level is achieved, the patient will continue on
maintenance doses of lithium. Diuretics are contraindicated for the patient on lithium.
DIF: Cognitive Level: Application
REF: Page 246
8. A patient who has been taking lithium carbonate 300 mg tid comes to the Outpatient
Department with a list of medications he is taking. Which of the medications on the
list would require re-evaluation of lithium dosage?
a. HydroDIURIL daily
b. Navane bid
c. Ativan at bedtime
d. Cefobid daily
ANS: A
Diuretics alter fluid and electrolyte balance, increasing risk for lithium toxicity; therefore
HydroDIURIL is correct. Antipsychotic medications are frequently prescribed concurrently
with lithium to manage acute symptoms of mania, so no re-evaluation of lithium dose is
necessary for Navane. Antianxiety drugs are not contraindicated with concurrent lithium
use, so no lithium dose re-evaluation is necessary for Ativan. Antibiotics do not alter fluid
and electrolyte balance, so readjustment of lithium dosage is not required for Cefobid.
DIF: Cognitive Level: Analysis
REF: Page 246 | Page 250
9. Which outcomes would be appropriate to determine early favorable response to
antidepressant medication?
a. The patient will complete own self-care activities.
b. The patient will demonstrate assertive communication skills.
c. The patient will describe signs and symptoms of major depression.
d. The patient will make plans to attend one community social activity a week.
ANS: A
Ability to manage basic ADLs demonstrates improvement in major depression.
Understanding the disorder may occur later when patient cognition has improved
enough to be able to process information. Initiation of community social activity occurs
when the patient has increased energy. Assertive communication is learned and
practiced after the depression lifts.
DIF: Cognitive Level: Application
REF: Page 253
10. Prior to initiating medication therapy with phenelzine (Nardil), the nurse should plan
to determine the patient’s:
a. Mood and affect
b. Activity level
c. Cognitive ability to understand information about the medication
d. Support network and its members’ willingness to participate in treatment
ANS: C
Phenelzine (Nardil) administration requires strict adherence to a restricted diet. The
patient must have the cognitive ability to understand the food and medication
interactions that may cause a serious reaction.
DIF: Cognitive Level: Application
REF: Page 248
11. A patient who has a history of bipolar disorder recently underwent orthopedic surgery
and was discharged to return home. When visited by the home care nurse, the nurse
documented the following: slow and soft speech; sad facial expression; and patient
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crying when describing extreme fatigue, low mood, and the feeling that he will never
get well. He has refused to bathe and perform ADLs for several days. Which nursing
diagnosis would be appropriate?
a. Self-care deficit secondary to possible depression
b. Situational low self-esteem related to immobility
c. Deficient knowledge related to depression and surgery
d. Disturbed thought processes related to bipolar disorder
ANS: A
Refusal to perform tasks of bathing, grooming, and other ADLs provides evidence of a
self-care deficit. The other symptoms documented by the nurse are characteristic of
depression. No data are present to suggest the diagnoses given in the other options.
DIF: Cognitive Level: Application
REF: Page 245
12. The nurse caring for an extremely withdrawn patient with depression wants to assist
her to become more interactive. The best approach would be to say:
a. “I know you’ll feel better if you leave your room.”
b. “You look so gloomy sitting here all by yourself.”
c. “Let’s explore how it feels to sit alone here all day and feel sad.”
d. “I need another person for a card game and I’d like you to be my partner.”
ANS: D
This direct approach invites the patient to participate in a kind, but firm manner. The
patient is not given an option to simply say “yes” or “no.” It is not therapeutic to give
false reassurance. The remaining options focus too intensively on negative thoughts and
feelings.
DIF: Cognitive Level: Application
REF: Page 245
13. Which nursing diagnosis would relate to the primary nursing concern related to a
recently written prescription for amitriptyline (Elavil) 50 mg tid?
a. Anxiety
b. Ineffective coping
c. Risk for self-injury
d. Chronic low self-esteem
ANS: C
Patients with depression are at increased risk for suicide when they have been on
antidepressant medication for 2 weeks, because they are regaining some energy but
may not have achieved full therapeutic effect with mood improvement. Poor coping is
important but it is not the priority. Evidence of noncompliance is lacking. The medication
is not prescribed for anxiety disorders.
DIF: Cognitive Level: Analysis
REF: Page 246
14. What information concerning amitriptyline (Elavil) 50 mg tid would the nurse give the
patient regarding the expected outcome of this medication therapy?
a. “Complying with this therapy will cure your depression.”
b. “This medication is expected to improve brain chemical imbalance.”
c. “Amitriptyline will help re-establish your ability to think clearly again.”
d. “Elavil will be particularly effective at assisting you in regaining your
independence.”
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ANS: B
Antidepressant medication works by re-establishing the balance of neurotransmitters in
the brain, particularly serotonin and norepinephrine. Antidepressants do not promise a
cure for depression. Cognitive therapy, rather than antidepressants, addresses thinking
issues. Learned helplessness is addressed by cognitive therapy.
DIF: Cognitive Level: Application
REF: Page 246
15. Which principle should the nurse apply when planning nursing care for a patient who
was voluntarily admitted after a suicide attempt?
a. Patients who attempt suicide and fail will not try again.
b. The more specific the plan, the greater the risk for suicide.
c. Patients who talk about suicide are less likely to attempt it.
d. Patients who attempt suicide and fail do not really want to die.
ANS: B
Patients whose suicidal ideation includes a vague, diffuse plan or no plan at all are not at
as high a risk for attempting suicide as an individual who has a well-developed plan and
the means to carry it out. The nurse will need to continually reassess the patient. None
of the remaining options are true statements concerning suicide attempts.
DIF: Cognitive Level: Application
REF: Page 244
16. An appropriate nursing strategy to assist a patient who was involuntarily admitted
after a suicide attempt is::
a. Avoiding any focus on the topic of suicide
b. Encouraging patient to verbalize personal feelings
c. Supporting patient focus on others rather than self
d. Discussing the impact of suicidal thoughts on the family
ANS: B
Verbalization helps relieve pent-up feelings and emotional pain. Avoidance of the topic is
nontherapeutic for a suicidal patient. The remaining options may serve to increase the
patient’s feelings of guilt.
DIF: Cognitive Level: Application
REF: Page 244
17. Which principle should the nurse apply when planning care for a patient who is
diagnosed with bipolar disorder and currently in the manic phase?
a. Manic patients respond well to peer pressure.
b. Decreasing stimulation tends to diminish symptoms.
c. Increasing stimulation tends to encourage the patient to focus.
d. Detailed activities will facilitate the patient’s ability to self control behavior.
ANS: D
The only statement that is a valid principle is the option related to activity and its impact
on controlling behavior. The other statements are inaccurate.
DIF: Cognitive Level: Application
REF: Page 246
18. Which nursing intervention is most therapeutic when the nurse is managing the
aggressive, disruptive behaviors of a manic patient whose attempts to control the
milieu has been rejected by the other patients?
a. Advising that the patient to accept the wishes of the group
b. Suggesting that the patient either quiet down or leave the room
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c. Accompanying the patient to a quieter part of the unit
d. Ignoring the patient’s outbursts because they are surly related to the mania
ANS: C
Escorting the patient to a less stimulating environment will assist the patient to remain
in control of behavior. It is unlikely that the patient would respond to verbal suggestions
to leave the area unaccompanied or accept the group’s wishes and would likely see the
suggestions as a threat that would further escalate the impending loss of control. The
behavior cannot be ignored since it will likely lead to an acceleration of the mania.
DIF: Cognitive Level: Application
REF: Page 246
19. What information would serve as the basis for the nurse’s reply when asked whether
the cycling of moods from depressed to manic is a constant pattern seen in bipolar
disorders?
a. Clinical observation tells us that mood disorders tend to remit and recur.
b. Most cyclic behavior can be managed with the appropriate forms of therapy.
c. Mood disorders generally see a decrease in cyclic affecting within 5 years of
onset.
d. Persons with higher cognitive abilities will generally exhibit fewer cyclic episodes.
ANS: A
Mood disorders tend to remit and recur throughout the patient’s lifetime. There is no
current research to support the other options.
DIF: Cognitive Level: Application
REF: Page 223
20. The individual who displays the history and symptoms most consistent with a
medical diagnosis of seasonal affective disorder (SAD) is:
a. 26 years of age and complains of 3 consecutive years of depressed mood
beginning in November and remitting in April
b. 64 years of age and complains of anhedonia, early morning awakening,
psychomotor retardation, weight loss, and excessive feelings of guilt
c. 46 years of age and complains of dysphoric mood for 3 years, poor
concentration, loss of interest in social activities, indecision, low energy, and low
self-esteem
d. 38 years of age and complains of sadness, loss of ability to react to positive
stimuli, weight gain, hypersomnia, leaden paralysis of limbs, and sensitivity to
interpersonal rejection
ANS: A
Marked seasonal changes in mood typify seasonal affective disorder. Depression begins
in October or November and lifts in March or April and must occur for at least 2
consecutive years. The other options are lacking in the identifying period of time when
the symptoms are exhibited.
DIF: Cognitive Level: Application
REF: Page 230 | Page 237
21. A patient with suspected seasonal affective disorder asks the nurse, “I’ve been
feeling down for 3 months. Will I ever feel like myself again?” The response that
builds on an understanding of this disorder is:
a. “Spontaneous improvement usually comes in 6 months to a year.”
b. “Can you tell me what you mean when you say ‘feel like myself’?”
c. “People who have seasonal mood changes often feel better when spring comes.”
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d. “Usually patients with this disorder see improvement during the fall and winter.”
ANS: C
Seasonal affective disorder is a condition in which the patient experiences depression
beginning in the fall, lasting throughout the winter, and remitting in spring in the
northern hemisphere. Fall and winter is not reflective of any diagnostic category of mood
disorder. Spontaneous improvement occurs only with the change of seasons and
available sunlight. Questioning is a response that does not address the point of
understanding SAD.
DIF: Cognitive Level: Application
REF: Pages 230 | Page 237
22. A Chinese-American patient comes to the mental health clinic after referral by her
primary care physician. She complains of nervousness, headaches, fatigue, and
vague GI symptoms for which no organic basis has been established. The symptoms
began about 9 months ago when her favorite aunt died. The most appropriate
independent nursing action would be to:
a. Prescribe a trial course of antianxiety medication.
b. Plan strategies for cognitive behavioral therapy.
c. Arrange admission to the inpatient unit for a complete workup and psychologic
testing.
d. Confer with the psychiatrist about the cultural association between depression
and somatic symptoms.
ANS: D
Expression of symptoms is influenced by ethnicity and culture. When depressed, Asian
and Asian-American patients describe somatic symptoms, whereas patients of Western
cultures may focus on mood and cognitive symptoms. Option d is an appropriate
independent intervention the nurse should take. Options a, b, and c would be considered
collaborative, rather than independent, interventions.
DIF: Cognitive Level: Application
REF: Page 228
23. A patient with melancholic depression paces and wrings her hands for hours at a
time while repeating, “I’m a bad person.” Staff members have been unsuccessful in
their attempts to promote rest. Which intervention is most appropriate in promoting
rest?
a. Instructing the patient to lie down for 15 minutes of every hour
b. Asking the patient to fold and stack bath towels and washcloths
c. Making the patient aware of the negative effects of fatigue on mood
d. Reassuring the patient that she is accepted and not considered a “bad” person
ANS: B
The psychomotor energy of agitation must be expended; it may be channeled into
simple, repetitive activity. Standing in one place to fold towels is an improvement over
pacing. This patient will be unable to comply with the request to lie down. A severely
depressed patient will not be able to cognitively process this sort of information.
Reassurance will not appreciably affect the need for psychomotor activity.
DIF: Cognitive Level: Application
REF: Page 246
24. What measure will facilitate communication with a patient who is depressed and
evidencing psychomotor retardation and withdrawal?
a. Ask the patient to indicate yes or no with finger signals.
b. Arrange to spend time with the patient at prearranged intervals.
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c. Give concrete and concise directions rather than asking questions.
d. Speak loudly and rapidly to the patient to focus his or her attention.
ANS: B
This measure will promote the establishment of rapport and demonstrate respect and
acceptance of the patient. It will facilitate patient willingness to communicate thoughts
and feelings without making unnecessary demands on the patient; a headshake or nod
would work as well. Patients should not simply be ordered about; they should be asked to
respond without placing excessive demands. Patients with psychomotor retardation have
the ability to hear, but their ability to process information may be slowed, requiring wellpaced simple communication.
DIF: Cognitive Level: Application
REF: Page 244
25. Which measure consistent with the use of cognitive therapy could the nurse
incorporate into the treatment plan of a chronically depressed patient?
a. Approach the patient with cheerful affect and optimistic remarks.
b. Ignore the patient’s pessimistic statements; give attention for positive thinking.
c. Identify negative evaluations and challenge pessimistic beliefs.
d. Seek to uncover unconscious conflicts about significant relationships.
ANS: C
Cognitive therapy addresses symptom removal by identifying and correcting distorted
negative thinking. An overly cheerful mannerism is an insensitive nontherapeutic
approach that will reinforce patient negative thinking about self. To ignore negative
statements while reinforcing positive thinking is considered a behavioral approach.
Seeking to uncover unconscious conflicts is a psychodynamic approach.
DIF: Cognitive Level: Application
REF: Page 251
26. Which symptom related to thought-flow disturbance is the nurse most likely to assess
in a newly admitted patient who is diagnosed with bipolar disorder, manic episode?
a. Slow, halting speech
b. Flight of ideas
c. Schemata
d. Anhedonia
ANS: B
Flight of ideas is a continuous rapid flow of speech marked by jumping from topic to
topic. It is a manifestation of thought disorder associated with inability to filter stimuli
causing increased distractibility. Slow speech would be seen in depression. Neither
schemata or anhedonia are symptoms of a thought-flow disorder.
DIF: Cognitive Level: Application
REF: Page 233
27. Therapeutic interactions between the nurse and a manic patient will be facilitated
when the nurse:
a. Uses a calm, matter-of-fact approach to structuring
b. Focuses primarily on enforcing rigid limits on behaviors
c. Implements a laissez-faire approach to the patient’s symptoms
d. Encourages the patient to use humor and wit to redirect energy
ANS: A
A calm, matter-of-fact approach minimizes patient need for defensiveness and minimizes
power struggles. The use of rigid limit setting leads to power struggles and escalation of
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patient hyperactive, aggressive behavior. Structure and judicious limit setting are more
therapeutic. A laissez-faire approach is nontherapeutic; manic patients usually need
structure. Encouraging humor and wit is generally ineffective since patients with mania
cannot maintain control of emotions and may shift from witty to angry in seconds.
DIF: Cognitive Level: Application
REF: Page 245
28. A patient who is experiencing a manic episode approaches the nurse and with
pressured speech states, “I hate oatmeal. Let’s get everybody together to do
exercises. I’m thirsty and I’m burning up. Get out of my way; I have to see that guy.”
The priority nursing action is to:
a. Measure the patient’s temperature and pulse.
b. Offer to have the dietitian visit to discuss his diet.
c. Tell the patient he can lead exercises at the community meeting.
d. Show relief when the patient ends the interaction and walks away.
ANS: A
During a manic episode, the patient may be inattentive to physical needs or illness. The
brief remark about “burning up” could suggest fever. Thirst may accompany fever, be a
sign of dehydration, or be related to lithium administration. More information is needed.
Because hyperactive patients have difficulty remaining still, taking the temperature and
pulse will give priority information. If necessary, BP can be taken later. A nutritional
consult is not a priority intervention. It is not appropriate to foster increased
hyperactivity. To show relief would be disrespectful on the part of the nurse.
DIF: Cognitive Level: Application
REF: Page 242
29. A patient with bipolar disorder reveals to the clinic nurse that she may be 4 weeks’
pregnant. Which action will the nurse take?
a. Confer with the physician about ordering a pregnancy test and discontinuing
lithium.
b. Educate the patient to the risk to the fetus as a result of exposure to the lithium
in her blood.
c. Suggest to the physician that the lithium dose should be increased for better
symptom control.
d. Remind the patient that barrier birth control methods should be used to prevent
pregnancy during lithium therapy.
ANS: A
The first need is to learn whether the patient is pregnant. Lithium ingestion by the
mother can cause fetal damage. Lithium should be discontinued, not increased, if
pregnancy is confirmed. It is premature to discuss fetal malformations before the
pregnancy is confirmed. Options b and c are inappropriate and harmful. Birth control
information has no value unless the pregnancy test is negative.
DIF: Cognitive Level: Application
REF: Page 250
30. Which nursing measure would be relevant to protecting the physiologic integrity of a
patient during a manic episode when marked hyperactivity is present?
a. Provide appropriate attire for patient to wear.
b. Set firm limits on behavior injurious to others.
c. Monitor the patient’s weight at the same time daily.
d. Use genuineness to develop a therapeutic alliance with the patient.
ANS: C
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Hyperactivity expends huge amounts of calories and interferes with caloric intake, thus
resulting in rapid weight loss. Monitoring weight daily protects the patient’s physiologic
integrity. The other options are concerned with psychosocial integrity.
DIF: Cognitive Level: Analysis
REF: Page 245
31. Care planned for a patient with adjustment disorder will be most effective if the nurse
knows adjustment disorders are a group of disorders that:
a. Involve psychotic thinking in adolescents
b. Address issues of anxiety and depression
c. Include behaviors that are seen primarily in the child and adolescent population
d. Manifest as transient episodes of dysfunction in response to specific stressors
ANS: D
Adjustment disorders are short-term disturbances in mood or behavior resulting from
identifiable stressors. Psychotic features are not present. Adjustment disorders can occur
in any age group. Anxiety and depression may be present, but emphasis is on identifying
and resolving the specific issue.
DIF: Cognitive Level: Comprehension REF: Page 238
32. The nurse manager, teaching a class to new staff members about working with
patients with adjustment disorders, will specify that the intervention most helpful in
working with patients with this diagnosis is:
a. Entering pertinent data in the patient’s medical record
b. Including family members in the interdisciplinary treatment plan
c. Identifying the precipitating stressful event and current problems
d. Reducing the patient’s level of anxiety to prevent behavioral escalation
ANS: C
Identification of the precipitating stressful event and interpretation of the existing
problem are fundamental to working with the patient to reduce symptoms. Including
family in treatment planning is secondary to identification of the stressor and the
problem. Anxiety will remain high until the problem and the stressor are identified. Data
entry is not directly related to the question posed.
DIF: Cognitive Level: Application
REF: Page 238
33. When a father states, “I don't understand what the doctor means by saying my
daughter has an adjustment disorder.” The nurse explains that this disorder often
results from:
a. Failure of existing coping skills
b. Lack of stable emotional support
c. Denial that a problem truly exists
d. Overcompensation to present a controlled appearance
ANS: A
When existing coping skills are not adequate to deal with a stressor, and new coping
skills have not been developed, symptoms appear. These symptoms may fit the DSM-IVTR criteria for adjustment disorder. The lack of emotional support is not applicable to the
situation. The disorder does not result from use of denial since patients usually recognize
that a problem exists. Overcompensation is not related to the onset of adjustment
disorder.
DIF: Cognitive Level: Application
REF: Page 228
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34. Which question would be most effective in helping a patient with an adjustment
disorder identify the event that triggered the maladaptive response?
a. “Can you tell me about your support system?”
b. “Have you ever been in psychotherapy before?”
c. “Did you experience any stressful events recently?”
d. “How do you usually handle problems in your life?”
ANS: C
This question will determine whether the patient is able to identify a particular stressor
that has affected her life recently. Asking about support systems will help gain
information about important persons in the patient’s life. History of psychotherapy will
provide information about mental health. Previous methods will provide information
about use of coping strategies.
DIF: Cognitive Level: Application
REF: Page 238
35. A teenager is admitted to the adolescent unit with a diagnosis of adjustment disorder
with depression. Which information collected from the assessment interview will be
given highest priority when planning the patient’s care?
a. Patient frequently disregards curfew.
b. Patient’s parents were divorced 8 years ago.
c. Patient states she finds no pleasure in living.
d. Patient is failing most of her high school classes.
ANS: C
Finding no pleasure in living should suggest the need for further assessment of suicide
potential. Safety needs take priority over problems suggested by other data collected.
DIF: Cognitive Level: Analysis
REF: Page 238 | Page 246
36. The nurse has been working with a patient who has adjustment disorder with
depressed mood. Which finding would permit the nurse to accurately evaluate that
the crisis has been resolved?
a. Absence of presenting symptoms
b. Decreased need for medications
c. Increased socialization with peers
d. Significant increase in the patient’s appetite
ANS: A
When the presenting symptoms are absent, the nurse can evaluate the problems as
resolved. Most patients with adjustment disorders do not require medication, so this is
not a good indicator. Data do not substantiate that the patient is experiencing problem
socializing. This could indicate the patient is overeating as a means of dealing with
stress.
DIF: Cognitive Level: Application
REF: Page 253
37. Which of the following statements would correctly serve as a basis for teaching a
family the usual outcome of an adjustment disorder?
a. The symptoms will likely resolve completely.
b. The patient may continue to be in danger of self-harm.
c. Medications are frequently used to mask the symptoms.
d. Relaxation is an effective tool to decrease and manage stress.
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ANS: A
The prognosis for most patients with adjustment disorders is good. In the majority of
cases, identification of the stressor and use of effective coping strategies result in
resolution. Continued self-harm is not a usual outcome for an adjustment disorder.
Medications are not used routinely to treat adjustment disorders. Relaxation techniques
are interventions rather than outcomes.
DIF: Cognitive Level: Application
REF: Page 238
38. Which activity would be a constructive outlet for tension and anxiety while enhancing
self-esteem for a patient with adjustment disorder with anxious mood?
a. Knitting scarves for a homeless shelter
b. Painting a "paint-by-number" scenic picture
c. Working on a large, colorful picture puzzle
d. Engaging in regular, age-appropriate physical exercise
ANS: D
Physical exercise may assist in relieving tension and promoting feelings of well-being.
Knitting is tedious and requires steadiness, which the patient may not have if symptoms
of anxiety include jitteriness. Painting requires fine motor coordination, not always
present if a patient is anxious. Some patients find puzzles frustrating and become even
more tense while working on one.
DIF: Cognitive Level: Application
REF: Page 246
39. The major rationale for careful ongoing assessment of a patient with adjustment
disorder is:
a. Characteristic symptoms abate but take at least 6 months to do so.
b. The disorder may be a precursor to a more serious mental health problem.
c. Practitioners become less discerning as they become more familiar with the
patient.
d. Patients with adjustment disorders have a high risk for self-harm, especially
suicide.
ANS: B
Adjustment disorders usually improve with identification of the stressor and development
of coping strategies to relieve stress. If symptoms worsen, new treatment strategies
must be developed to treat the more serious mental health disorder that has become
apparent. There is no research to support the remaining options.
DIF: Cognitive Level: Application
REF: Page 238
1. When assessing a patient diagnosed with a mood disorder, which abnormal
diagnostic tests would be considered a possible factor in the manifestation of the
disorder? Select all that apply
a. RBC (red blood cell)
b. ECG (electrocardiogram)
c. BUN ( blood urea nitrogen)
d. TSH (thyroid stimulating hormone)
e. Blood glucose
ANS: A, D, E
Anemia, hyper- or hyperthyroidism, and diabetes mellitus are all medical conditions that
can occur simultaneously with mood disorders. There is no research to support a strong
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connection between renal or cardiac disorders with mood disorders.
DIF: Cognitive Level: Analysis
REF: Page 236
2. Which statements regarding a hypomanic episode are true? Select all that apply.
a. Behavior has been observed in the patient for at least 4 days.
b. Patient appears unaware of potentially dangerous situations.
c. Hospitalization is generally required to stabilize the behavior.
d. Patient is engaging in behaviors that are normally uncharacteristic of them.
e. Primary difference between mania and hypomania is the nature of the activity.
ANS: A, B, D
Manic and hypomanic episodes share symptom criteria, and they differ primarily with
regard to their severity and duration but not the nature of the activity. Hypomanic
episodes are not severe enough to cause significant impairment in social and
occupational functioning or to require hospitalization. However, for diagnosis, it must be
evident that the mood and behavioral disturbances of hypomania represent a definite
change in the person’s usual functioning that lasts for at least 4 days. As judgment
declines, patients sometimes fail to recognize the consequences of their actions and the
presence of possible danger.
DIF: Cognitive Level: Application
REF: Page 236
Chapter 13: Schizophrenia and Other Psychotic Disorders
1. A newly admitted patient has the diagnosis of catatonic schizophrenia. Which
behavior observed in the patient supports that diagnosis?
a. Uses a rhyming form of speech
b. Refuses to eat any unwrapped foods
c. Laughs when watching a sad movie
d. Maintains an immobilized state for hours
ANS: D
Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging
from frenzied behavior to immobilization and may include echopraxia and posturing.
Paranoid thinking is characteristic of paranoid schizophrenia. Inappropriate affect and
clanging are seen in disorganized schizophrenia.
DIF: Cognitive Level: Application
REF: Page 274
2. What would be an appropriate short-term outcome for a patient diagnosed with
residual schizophrenia who exhibits ambivalence?
a. Decide their own daily schedule.
b. Decide which unit groups they will attend.
c. Choose which clinic staff member to work with.
d. Choose between two outfits to wear each morning.
ANS: D
An early step would be to make choices about nonthreatening matters when presented
with limited alternatives. The remaining options represent decisions that are too
complicated for the patient to make initially.
DIF: Cognitive Level: Application
REF: Page 285
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3. What is the priority nursing diagnosis for a catatonic patient?
a. Ineffective coping
b. Impaired physical mobility
c. Impaired social interaction
d. Risk for deficient fluid volume
ANS: D
The highest priority for the patient is maintenance of basic physiologic needs, such as
hydration. Mobility is of lesser physiological importance than fluid volume. The remaining
options do not have priority over a physiological need.
DIF: Cognitive Level: Application
REF: Page 275
4. Which nursing diagnosis is appropriate for a patient who insists being called “Your
Highness” and demonstrates loosely associated thoughts?
a. Risk for violence
b. Defensive coping
c. Impaired memory
d. Disturbed thought processes
ANS: D
Delusions and loose associations suggest disturbed thought processes. The other options
are not supported by data in the scenario.
DIF: Cognitive Level: Application
REF: Page 278
5. Which initial short-term outcome would be appropriate for a patient who was
admitted expressing delusional thoughts?
a. Accept that delusion is illogical.
b. Distinguish external boundaries.
c. Explain the basis for the delusions.
d. Engage in reality-oriented conversation.
ANS: D
Delusions are not reality oriented; thus an appropriate outcome would be that patient
will engage in reality-oriented conversation rather than discussing delusional beliefs.
Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute
them. Data are not present to suggest boundary disturbance. Explaining the delusion is
not progress; it suggests the patient still holds to the belief.
DIF: Cognitive Level: Application
REF: Page 286
6. Which of the following interventions should the nurse plan to use to reduce patient
focus on delusional thinking?
a. Confronting the delusion
b. Refuting the delusion with logic
c. Exploring reasons the patient has the delusion
d. Focusing on feelings suggested by the delusion
ANS: D
Focusing on feelings suggested by the delusion will help meet patient needs and help
the patient stay based in reality. This technique fosters rapport and trust while
discouraging the belief without challenging or refuting it.
DIF: Cognitive Level: Application
REF: Page 286
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7. Which assessment observation supports a patient’s diagnosis of disorganized
schizophrenia?
a. Reports suicidal ideations
b. Last relapse was 6 years ago
c. Consistent inappropriate laughing
d. Believes that “the government is out to get me”
ANS: C
The presence of disorganization and inappropriate affect identifies this disorder as
disorganized schizophrenia. The symptoms of residual schizophrenia have long periods
of remission. Schizoaffective disorder presents with severe mood disorders along with
symptoms of schizophrenia. Paranoid schizophrenia is characterized by persecutory or
grandiose delusions.
DIF: Cognitive Level: Application
REF: Page 274
8. A patient tried to gouge out his eye in response to auditory hallucinations
commanding, “If thine eye offends thee, pluck it out.” The nurse would analyze this
behavior as indicating:
a. Derealization
b. Inappropriate affect
c. Impaired impulse control
d. Inability to manage anger
ANS: C
Command hallucinations may be so intense that the patient cannot control the impulse
to do what the hallucination tells him to do; thus the patient has impaired impulse
control. This is not an anger management problem. Derealization is a feeling that the
environment is distorted or unreal and not suggested in the scenario. No evidence of
inappropriate affect is given.
DIF: Cognitive Level: Application
REF: Page 278
9. An appropriate intervention for a patient with an identified nursing diagnosis of
situational low self-esteem would be:
a. Providing large muscle activities to relieve stress
b. Attempting to determine triggers to hallucinations
c. Engaging patient in activities designed to permit success
d. Encouraging verbalization of feelings in a safe environment
ANS: C
All are useful interventions for a patient with schizophrenia; however, engaging the
patient in specifically designed activities is the only option that addresses improving selfesteem.
DIF: Cognitive Level: Application
REF: Page 285
10. A 19-year-old patient is admitted for the second time in 9 months and is acutely
psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone
rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes
and that the world is burning. The nurse assesses the primary deficit associated with
the patient’s condition as:
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a. Social isolation
b. Disturbed thinking
c. Altered mood states
d. Poor impulse control
ANS: B
The nurse interprets the patient’s statements that were not reality-based as indicating
disturbed thought processes. Social isolation is not the primary patient problem. No data
exist to support the other options.
DIF: Cognitive Level: Application
REF: Pages 278-279
11. A patient has been admitted with disorganized type schizophrenia. The nurse
observes blunted affect and social isolation. He occasionally curses or calls another
patient a “jerk” without provocation. The nurse asks the patient how he is feeling,
and he responds, “Everybody picks on me. They frobitz me.” The patient’s
communication exhibits:
a. A neologism
b. Loose associations
c. Delusional thinking
d. Circumstantial speech
ANS: A
A newly coined word having meaning only for the patient is called a neologism (meaning,
new word). It is associated with autistic thinking. The patient’s speech does not show
associative looseness or circumstantiality. The use of a neologism is not delusional in and
of itself, but it suggests delusional thinking may be present.
DIF: Cognitive Level: Comprehension REF: Page 278
12. A patient has been admitted with disorganized type schizophrenia. The nurse asks
the patient how he is feeling, and he responds, “Everybody picks on me. They frobitz
me.” The best response for the nurse to make would be:
a. “That”s really too bad that you are being treated that way.”
b. “Who do you mean when you say ‘everybody’?”
c. “What difference does frobitzing make?”
d. “Why do they frobitz?”
ANS: B
This response will help clarify the patient’s thinking and change the focus from global to
specific. In this situation, sympathizing with the patient is a nonproductive response. The
remaining options appear to accept the neologism thus supporting the patient’s
delusional thinking.
DIF: Cognitive Level: Application
REF: Page 286
13. Which patient behavior would support the diagnosis of residual schizophrenia with
negative symptoms?
a. Communicating using only rhyming phases
b. Claims that “worms are crawling in my brain”
c. Maintaining both arms suspended awkwardly overhead
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d. Shows no emotion when telling the story of a sister’s recent death
ANS: D
Blunted affect is considered a negative symptom. The other symptoms would be
classified as positive symptoms.
DIF: Cognitive Level: Application
REF: Page 274 | Page 280
14. By discharge, which outcome is appropriate for a patient who hears voices telling him
he is evil?
a. Respond verbally to the voices.
b. Verbalize the reason the voices say he is evil.
c. Identify events that increase anxiety and promote hallucinations.
d. Integrate the voices into his personality structure in a positive manner.
ANS: C
An appropriate outcome for a patient with hallucinations is recognition of events that
precede the onset of hallucinations. Trigger events or situations usually cause increased
feelings of anxiety. The remaining options are neither desirable nor appropriate.
DIF: Cognitive Level: Application
REF: Page 277
15. Which response by the nurse would best assist a patient in de-escalating aggressive
behavior?
a. “Tell me what’s going on.”
b. “Why are you getting so upset?”
c. “If you throw something, you will be restrained.”
d. “It’s time for group therapy. You can talk there.”
ANS: A
Using how, what, and when to gather information is a nonthreatening approach. It will
promote patient verbalization and explanation of events without causing the patient to
become defensive. Mentioning restraints sounds threatening even though it may be
meant to remind the patient of limits. Why questions are demanding and threatening to
patients. Sending the patient into group therapy sidesteps the problem.
DIF: Cognitive Level: Application
REF: Pages 292-293
16. A 34-year-old male admitted with catatonic schizophrenia has been mute and
motionless for several days while at home prior to admission. He still appears
stuporous in the hospital. Which nursing intervention would be an initial priority?
a. Orienting the patient to the unit
b. Reinforcing reality with the patient
c. Establishing a nonthreatening relationship
d. Assessing the patient for physical problems
ANS: D
Patients who are mute and motionless and inattentive to environmental stimuli are at
risk for a number of physical problems. Further, they are unable to communicate existing
problems. The nurse must make thorough and astute assessments before creating plans
to meet the patient’s needs. A patient who is stuporous may not be able to attend to
information given about unit rules and protocols. While establishing a therapeutic nursepatient relationship is an important intervention, it does not have priority according to
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Maslow’s hierarchy. Because the patient is mute, one can only suspect lack of reality
orientation. While an appropriate intervention, it is not the priority according to Maslow’s
hierarchy.
DIF: Cognitive Level: Application
REF: Page 275
17. Which response is appropriate when a patient’s mother expresses guilt over “causing
my child to be schizophrenic”?
a. “I can see how you would be upset over this turn of events.”
b. “New findings suggest this disorder is biological in nature.”
c. “Don’t be so hard on yourself; your daughter needs you to be strong.”
d. “It’s difficult to see what produces stress for the child at the time it’s occurring.”
ANS: B
Many individuals in the mental health field attribute the development of schizophrenia to
multiple causes centering on biological theories. The remaining options do little to
provide the mother with new information.
DIF: Cognitive Level: Application
REF: Page 265
18. Which response demonstrates both empathy and understanding of the relationship
genetics has to the development of schizophrenia in twins?
a. “In fraternal twins, the chance of the other twin developing the disorder is quite
small.”
b. “Studies show that 50% of twins develop schizophrenia when it is present in the
other twin.”
c. “No one can say what will happen, so we will hope for the best for you and both
of your sons.”
d. “You poor woman! I wish I could tell you that your other son he will be free of the
disorder.”
ANS: A
Current research supports the correct option, whereas the remaining options are not
factual and show expressed sympathy rather than empathy.
DIF: Cognitive Level: Application
REF: Page 266
19. The wife of a patient diagnosed with paranoid schizophrenia asks, “I’ve been told
that my husband’s illness is probably related to imbalanced brain chemicals. Can you
be more specific?” The response based on the dopamine hypothesis is:
a. “Breakdown of dopamine produces LSD, which in large amounts produces
psychosis.”
b. “An increase in the brain chemical dopamine explains the presence of delusions
and hallucinations.”
c. “Decreased amounts of the brain chemical dopamine explain the presence of
delusions and hallucinations.”
d. “An increase in the brain chemical dopamine explains the presence of lack of
motivation and disordered affect.”
ANS: B
The statement is correctly based on the dopamine hypotheses while the remaining
options are neither known to be true nor based on that theory
DIF: Cognitive Level: Comprehension REF: Page 266
20. What is the basis for the reduction in disturbed thought processes when a patient is
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administered haloperidol (Haldol)?
a. Reduction in the number of brain cells that crave dopamine
b. Dopamine receptors are blocked, making dopamine less available
c. Dopamine receptors are enhanced, making more dopamine available
d. Medication causes an increased cellular production of dopamine
ANS: B
Excess dopamine is responsible for symptoms of psychosis such as delusions and
hallucinations. Blocking dopamine receptors will result in reduction of primary
symptoms. The other options do not reflect the action of typical antipsychotic
medications.
DIF: Cognitive Level: Comprehension REF: Page 266
21. During a treatment team meeting, the point is made that a patient with
schizophrenia has recovered from the acute psychosis but continues to demonstrate
apathy, avolition, and blunted affect. The nurse who relates these symptoms to
serotonin (5HT2) excess will suggest that the patient receive:
a. Haloperidol (Haldol)
b. Chlorpromazine (Thorazine)
c. Olanzapine (Zyprexa)
d. Phenelzine (Nardil)
ANS: C
Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more
effective than typical antipsychotics in blocking serotonin receptors and reducing the
negative symptoms of schizophrenia. Haloperidol (Haldol) and chlorpromazine
(Thorazine) are typical antipsychotic medications while phenelzine (Nardil) is an MAOI
antidepressant.
DIF: Cognitive Level: Application
REF: Page 287 | Page 289
22. What response would be anticipated when a patient who received chlorpromazine
(Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)?
a. Development of pseudoparkinsonism
b. Development of dystonic reactions
c. Improvement in tardive dyskinesia
d. Worsening of anticholinergic symptoms
ANS: C
Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive
dyskinesia as well as improve both positive and negative symptoms of schizophrenia.
Pseudoparkinsonism and dystonic reactions are associated with typical antipsychotic
medication. Anticholinergic symptoms are not intense with the use of atypical
antipsychotic medication.
DIF: Cognitive Level: Application
REF: Page 287 |Page 289
23. A patient admitted with the diagnosis of schizophreniform disorder R/O organic
pathology. Based on this information, the nurse can expect that the patient will:
a. Be scheduled for a magnetic resonance imaging (MRI) test
b. See a mental health specialist for extensive psychological testing
c. Have an immunologic assay performed within 2 days of the admission
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d. Participate in a dexamethasone suppression test (DST) administered by the staff
ANS: A
The MRI will reveal structural changes in the brain that might be responsible for
symptoms of psychosis (e.g., abscess, tumor). Psychologic testing may be performed but
will be less definitive in ruling out organic pathology. Immunologic studies are not
indicated. The DST is related to depression.
DIF: Cognitive Level: Application
REF: Page 269
24. In planning aftercare for a patient with schizophrenia and whose insurance benefits
have been exhausted, the nurse who is concerned about overcoming negative
symptoms will make provisions for the patient to have stimulation, structure,
socialization, and support. Which option would best incorporate these factors?
a. Day hospitalization
b. Attending a psychosocial club
c. Living with his elderly mother
d. Spending free time in the mall
ANS: B
A psychosocial club is organized to provide the 4 S’s and is not costly to patients. Day
hospitalization would not be possible because of the lack of insurance benefits. Living
with his mother might fall short of stimulation and support. Spending time in the mall
lacks structure, socialization, and support.
DIF: Cognitive Level: Application
REF: Page 291
25. A patient with catatonic schizophrenia has been standing with his left arm upraised
and his right foot off the floor for the majority of the last 20 hours, eating only when
allowed to eat standing up. Which nursing intervention has priority for this patient?
a. Providing high-calorie drinks hourly
b. Assessing for lower extremity edema bid
c. Taking the patient to activities therapy once daily
d. Encouraging the patient to sit or lie down for 30 minutes hourly
ANS: B
Patients who maintain one position for long periods of time should be assessed for
dependent edema. In this case, the nurse would look for edema of the lower extremities
and would be concerned about the pressure exerted by standing on one foot for long
periods of time. Such encouragement would probably be met with resistance by the
patient. High-calorie drinks would be necessary if the patient failed to eat at meals. The
patient probably would not be able to cognitively process what is required to participate
in activities.
DIF: Cognitive Level: Application
REF: Page 275
26. Which nursing action best addresses the needs of a paranoid patient who believes
the food is poisoned?
a. Explaining that others eat the food and are not harmed
b. Allowing the patient to select food from vending machines
c. Encouraging the patient to discuss why someone would poison the food
d. Taking steps to prevent the patient from verbalizing the delusional thoughts
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ANS: B
Patients who think hospital food is being poisoned will sometimes eat wrapped foods that
have not been opened, and occasionally, they may eat food brought from the outside by
a trusted person. Delusions are fixed, false beliefs that cannot be refuted by logic. The
patient will probably state that the others have been given the antidote to the poison.
Encouraging discussion about the delusion is not therapeutic. Although it is wise to
minimize the amount of discussion about delusions, refusing to allow the patient to
speak about the delusions will not foster a therapeutic alliance.
DIF: Cognitive Level: Application
REF: Page 273
27. Prior to discharge, the nurse plans to teach the patient and family about relapse.
Which items will the nurse include in the teaching?
a. Recognizing warning signs of relapse
b. Using street drugs judiciously and only in small amounts
c. Lowering medication dosage to manage emerging side effects
d. Notifying the nurse of warning signs present for more than one month
ANS: A
The patient and family must be aware of signs of impending relapse. These signs are
usually similar to those that the patient experienced prior to hospitalization and will be
patient-specific. The nurse should be notified ASAP, rather than waiting two weeks.
Patients should never adjust medication dosage. Street drug use often precipitates
relapse since many street drugs are dopaminergic.
DIF: Cognitive Level: Application
REF: Page 277
28. Because of the cognitive disturbances associated with schizophrenia, which
technique will be useful as the nurse teaches a patient about self-management?
a. Use only verbal instruction.
b. Teach material in small segments.
c. Offer opportunities for making numerous choices.
d. Plan the teaching for a time when the patient has been recently medicated.
ANS: B
Patients with cognitive disturbances should be taught small blocks of information at a
time and given frequent reinforcement. Both verbal and visual materials should be used
since processing of verbal stimuli may be more impaired. Teaching should be scheduled
when the patient is most alert. A large number of choices may be confusing for the
person, but a few simple choices may be included.
DIF: Cognitive Level: Application
REF: Page 279
29. The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that
her husband “will be this sick for the rest of his life.” What information can the nurse
provide to the wife?
a. “This disorder generally responds well with treatment and follow-up.”
b. “All types of schizophrenia by their nature are chronic relapsing disorders.”
c. “Outcomes are related to the patient’s pre-hospital symptoms of
disorganization.”
d. “The typical outcome for this diagnosis is that total remission is not achievable.”
ANS: A
The prognosis for paranoid schizophrenia is good with appropriate treatment and
effective follow-up. The remaining options are not correct when considering this type of
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schizophrenia
DIF: Cognitive Level: Application
REF: Page 274
30. A patient is exhibiting auditory hallucinations in addition to being forgetful and easily
confused. Which diagnosis does the nurse base this patient’s interventions on?
a. Social isolation
b. Deficient knowledge
c. Situational low self-esteem
d. Impaired cognitive functioning
ANS: D
Schizophrenia may alter cognitive functioning, including memory, retention, attention,
and the processing of incoming information. Altered cognition accounts for many of the
symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can
adjust plans to take the deficits into account. The patient is not exhibiting symptoms that
would warrant any of the other options.
DIF: Cognitive Level: Application
REF: Page 263
31. A patient experiences intrusive, insulting auditory hallucinations. Which independent
behavioral technique can the nurse teach the patient to employ when the voices are
troublesome?
a. Introduce a distraction like reading.
b. Use positive talk to offset the insults.
c. Sing or whistle to compete with the voices.
d. Increase the daily dose of an antipsychotic medication.
ANS: C
This action provides an alternative to listening to the voices and gives the patient a
sense of control. The patient should not adjust medication independently. Reading will
not be particularly effective, because the voices are uncontested in a quiet atmosphere.
Positive talk is generally used to positively affect self-esteem.
DIF: Cognitive Level: Application
REF: Page 279
32. A patient with schizophrenia tells the nurse as they sit in the day room, “I hear voices
telling me bad things.” The most therapeutic response the nurse can make is:
a. “Tell me what the voices are saying.”
b. “I believe you hear voices, but I don’t hear them myself.”
c. “The voices are not real. They’re a product of your imagination.”
d. “Do you think the voices would go away if we went into your room to talk?”
ANS: B
By voicing his or her own reality related to the voices, the nurse does not deny the
patient’s experiences but helps the patient distinguish actual voices from those resulting
from internal stimulation. Discussing what the voices are saying serves only to validate
the reality of the voices. Challenging the voices will cause the patient to defend his
perceptions and thereby reinforce the importance of the hallucination. Asking to move
validates the reality of the voices and is not a helpful action since the voices go where
the patient goes.
DIF: Cognitive Level: Application
REF: Page 277 |Page 283
33. A patient tells the nurse, When I’m in the day room, I hear people whispering about
me, and that makes me want to punch them.” What direction will the nurse provide
the staff regarding interacting with this patient?
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a. “To minimize the need to whisper, utilize nonverbal techniques when possible.”
b. “Stay physically close to this patient and use touch as a tool to interact with
him.”
c. “Treat this patient matter-of-factly. Be direct; don’t talk about him or others in his
presence.”
d. “Interact with this patient only when necessary. The fewer interactions, the fewer
misinterpretations there will be.”
ANS: C
This approach is important when providing care for a patient who is misinterpreting
reality and is suspicious of the motives of others. Ostracizing the patient is nontherapeutic. Patients often misinterpret touch as threatening. This might promote loss of
control. Using nonverbal communication techniques would be nontherapeutic as it would
increase patient anxiety and promote loss of control.
DIF: Cognitive Level: Application
REF: Page 286
34. A patient with schizophrenia is medication compliant and has well-controlled
symptoms. He has, however, never been successful in holding a job because of poor
social skills and lack of understanding of basic job skills. The nurse case manager
should consider referring the patient:
a. For cognitive therapy
b. To assertiveness training
c. To a day hospital program
d. For psychosocial rehabilitation
ANS: D
Psychosocial rehabilitation helps patients readjust to community living by promoting
development of necessary skills. Social skills training and job skills training programs are
usually available. The patient does not need the more intensive services found in a day
hospital. Cognitive therapy will not offer the needed community living skills training.
Assertiveness training is only a small portion of the community living skills the patient
needs.
DIF: Cognitive Level: Application
REF: Page 288
35. A patient prescribed an antipsychotic medication develops a high fever, unstable
blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse
should:
a. Administer the medication and monitor the vital signs every 4 hours.
b. Give a lower dose of the medication for 24 hours and monitor the blood pressure.
c. Prepare to administer a prn dose of the anticholinergic drug benztropine
(Cogentin).
d. Hold the medication and immediately describe the patient’s symptoms to the
doctor.
ANS: D
These symptoms could be related to a possibly fatal disorder called neuroleptic
malignant syndrome (NMS), and the nurse should hold the medication and contact the
doctor immediately. The other options are inappropriate in light of the seriousness of the
situation.
DIF: Cognitive Level: Analysis
REF: Page 289
1. Which interventions will the nurse implement to preserve milieu safety when a
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patient becomes agitated? Select all that apply.
a. Project confidence and control.
b. Provide a show of force when appropriate.
c. Ask the agitated patient why they are feeling so aggressive.
d. Move to within 5 feet of the patient to help contain their movement.
e. Provide the patient with several options as means of de-escalating the crisis.
ANS: A, B, E
The correct options demonstrate that the staff is in control without unnecessarily
challenging the patient. Asking ‘why’ is often interpreted as being challenging and often
serves to future agitate the patient. Eight feet is considered to be the therapeutic
distance between patient and staff in this type of situation.
DIF: Cognitive Level: Application
REF: Page 293
2. Which interventions will the nurse implement to assure effective staff crises
management skills? Select all that apply.
a. Schedule regular staff crises simulations.
b. Encourage the staff to discuss the details of unit crises.
c. Attempt to identify staff who are ineffective during crises.
d. Review documentation that describe the details of unit crises.
e. Review unit crises management policies for needed updates.
ANS: A, B, D, E
The correct options empower the staff while improving/maintaining their crises
management skills. The failures of the process should be identified without blaming staff
for ineffective crises management.
Chapter 14: Personality Disorders
1. When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial
personality disorder, the nurse recognizes that which nursing diagnosis would be
pertinent to his care?
a. Risk for self-mutilation
b. Disturbed personal identity
c. Impaired social interaction
d. Social isolation
ANS: C
The patient with antisocial personality disorder is impulsive, manipulative, and
dishonest. Patients with this disorder are frequently involved in illegal matters. Selfmutilation and disturbed identity are more appropriate for patients with borderline
personality disorder. Social isolation would apply more readily to Cluster A disorders.
DIF: Cognitive Level: Comprehension REF: Page 306
2. Which observation is supportive of a diagnosis of avoidant personality disorder?
a. Talks about “my three failed marriages”
b. Cries loudly whenever requests are denied
c. Fears criticism from others, including staff
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d. Shows no remorse when accidentally breaking another patient’s bracelet
ANS: C
Symptoms suggesting an avoidant personality disorder include fear of rejection,
avoidance of relationships, and censorship of expression of thoughts and feelings
because of fear of a negative reaction. Borderline personality disorder presents with
unstable interpersonal relationships, labile affect, and complaints of emptiness. Patients
with histrionic personality disorders are overly dramatic, manipulative, and attentionseeking. Patients with schizoid personality disorder are indifferent to and lack concern for
interpersonal contacts.
DIF: Cognitive Level: Application
REF: Page 305 | Page 307
3. Which behavior is supportive of a diagnosis of dependent personality disorder?
a. Perceives personal behavior to be embarrassing
b. Believes they are incapable of functioning independently
c. Tends to exaggerate the potential dangers of ordinary situations
d. Demands excessive attention from others whenever in a group situation
ANS: B
The dependent person must rely on others to make decisions and assume responsibility
of major areas of his or her life. Low self-esteem and exaggeration are seen in avoidant
personality disorder. Attention seeking is seen in narcissistic personality disorder.
DIF: Cognitive Level: Application
REF: Page 307
4. When planning care for a patient with antisocial personality disorder, which
consideration has greatest importance?
a. Addressing the demand for constant attention
b. Teaching coping skills related to frustration tolerance
c. Identifying behaviors related to well-developed superegos
d. Managing the manipulative behaviors resulting from a charming persona
ANS: D
Patients with antisocial personality disorder are described as charming because of their
ability to size up and manipulate others. Narcissistic patients demand constant attention.
Patients with histrionic personality disorder do not tolerate delay of gratification or
frustration. Patients with personality disorder have poorly developed superegos.
DIF: Cognitive Level: Application
REF: Page 306
5. When a patient diagnosed with borderline personality disorder experiences the death
of a beloved parent, which characteristic response will the nurse anticipate?
a. Denies the death for a protracted period of time
b. Exhibits several different psychotic thought processes
c. Expresses extreme anger and rage by burning the parent’s clothes
d. Becomes uncharacteristically helpful and attends to the funeral arrangements
ANS: C
If a significant person in the patient’s life dies, the patient with borderline personality
disorder cannot mourn but often exhibits one or more of the six constituent states that
include anger and rage. The other options are not characteristically seen as mourning
behaviors in individuals with this diagnosis.
DIF: Cognitive Level: Application
REF: Page 304
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6. A 27-year-old woman diagnosed with borderline personality disorder displays a labile
affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry
feelings without self-injury. A priority nursing diagnosis for this patient is:
a. Anxiety
b. Risk for self-mutilation
c. Risk for other-directed violence
d. Ineffective coping
ANS: B
Patients with borderline personality disorder frequently engage in self-mutilation in an
attempt to manage chaotic feelings. The important clue to this diagnosis is that the
patient is having difficulty tolerating feelings without self-injuring. There is no data to
support anxiety or ineffective coping. The risk is greater for violence toward self.
DIF: Cognitive Level: Application
REF: Page 306
7. Which outcome has priority for a patient with borderline personality disorder being
discharged from an outpatient treatment environment?
a. Patient demonstrates control over self-destructive impulses.
b. Patient can identify symptoms that indicate a need for psychotherapy.
c. Patient demonstrates an understanding of the importance of medication
compliance.
d. Patient actively participates in a community 12-step group related to relevant
care.
ANS: A
The patient’s ability to control self-destructive impulses has priority over the other
options because doing so will affect patient safety.
DIF: Cognitive Level: Analysis
REF: Page 310
8. A patient who is diagnosed with schizoid personality disorder is isolative, does not
speak to her peers, and sits through the community meeting without speaking. Her
mother describes her as shy and having few friends. Which would be an appropriate
nursing diagnosis for this patient?
a. Anxiety related to a new environment as evidenced by isolation and not talking
with peers
b. Ineffective coping related to new environment as evidenced by isolation and
minimal interaction with others
c. Impaired social interaction related to unfamiliar environment as evidenced by
isolation and not talking with peers
d. Disturbed thought processes related to a new environment as evidenced by
isolation and minimal interactions with others
ANS: C
This nursing diagnosis relates directly to her symptoms and their underlying pathology.
Data are not present to support the other options.
DIF: Cognitive Level: Application
REF: Page 306
9. The nurse is careful to provide a quiet, comfortable, safe environment when
conducting an assessment interview. What is the reason this is particularly important
when working with a patient believed to be exhibiting characteristics of a personality
disorder?
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a. These patients are generally experiencing chronic depression and are severely
impaired socially.
b. A high stimulus environment will cause the patient to exhibit exacerbated
behaviors that are loud and attention seeking.
c. The patient is easily intimidated and may become so withdrawn that the
assessment will be difficult if not impossible to complete.
d. This disorder produces defensive, guarded, and impulsive behavior that is easily
provoked into anger when the patient feels threatened.
ANS: D
Individuals with these disorders are often withdrawn, defensive, guarded, and impulsive,
and may demonstrate an escalation of anger or make hostile or threatening comments.
The remaining options are specific to certain types of personality disorders.
DIF: Cognitive Level: Application
REF: Page 309
10. When facilitating change in the behavior of a patient diagnosed with a personality
disorder, which intervention will have the greatest impact on success?
a. Collaborating with the patient when establishing treatment goals
b. Educating the patient to the importance of complying with treatment
interventions
c. Evaluating the patient’s understanding of the etiology of the prescribed
medications
d. Conducting regular assessments so the treatment can be changed when
necessary
ANS: A
When planning interventions with a patient who has a personality disorder, it is
important to recognize that the person has disturbed values that do not reflect the views
held by the general population. Because of these disturbances, the nurse needs to
collaborate with the patient regarding the goals that are identified during treatment. The
remaining options although appropriate will not be attainable if the patient does not
recognize the interventions as being useful and personally applicable.
DIF: Cognitive Level: Analysis
REF: Page 312
11. A patient with antisocial personality disorder yells, “Shut up about that, or I’ll punch
you in the nose!” and shakes his fist at another patient in a group meeting after the
patient speaks negatively of illicit drug use. The nurse quickly determines that the
patient is at risk to act violently against others as evidenced by his aggressive
behavior, verbal threats, and a history of impulsivity. Which is the best approach for
the nurse to use?
a. Secluding the patient to protect the other patients and staff
b. Putting the patient in restraints to protect the entire milieu
c. Exploring alternate ways to handle frustrating topics in the group
d. Telling the patient to leave the group until he can behave appropriately
ANS: C
Discussing angry feelings in a group setting that is focused on exploring alternative
problem-solving options will both distract the patient from angry feelings and help to
focus energy on constructive activities. Seclusion and restraints are not necessary until
verbal interventions prove unsuccessful. Making the patient leave the group is not an
approach that will lead to meaningful learning.
DIF: Cognitive Level: Application
REF: Page 313
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12. A patient with borderline personality disorder is having difficulty with memories of
sexual abuse and reports vague, generalized pains, menstrual problems, and
headaches that severely impact her ability to function independently. Which
collaborative consult will have the greatest impact on the patient’s health and
wellness?
a. Occupational therapist exploring ways to reduce stress
b. Neurologist to evaluate the patient’s reports of headaches
c. Acupuncturist exploring ways to reduce the generalized pain
d. Gynecologist to assess the patient’s dysmenorrheal symptoms
ANS: A
An occupational therapist can determine ways to increase adaptive functioning and
independent living skills. Groups on stress reduction, self-awareness, and feelings are
often co-led by occupational therapists. Although appropriate, the remaining options are
all a result of unmanaged stress.
DIF: Cognitive Level: Analysis
REF: Page 314
13. Which intervention will best ensure a nonjudgmental evaluation of a patient’s
noncompliance with the treatment plan for management of his antisocial behaviors?
a. Re-evaluating the patient’s understanding of the goals of the prescribed
treatment plan
b. Asking questions that focus on his perception of why he can follow his treatment
plan
c. Expressing concern about the patient’s long-term prognosis if his noncompliance
continues
d. Re-assessing the patient for changes that may require the revision of his current
treatment plan
ANS: B
The nurse asking questions to determine possible reasons for the outcome criteria not
being met would exhibit a nonjudgmental approach to this patient’s assessment
interview. While appropriate, the remaining options are not nonjudgmental in nature.
DIF: Cognitive Level: Analysis
REF: Page 315
14. The nurse counsels a mother to allow her 2-year-old child to keep a blanket that he
uses to comfort himself. The basis for this counseling is:
a. Sullivan’s theory of “good me”
b. Freud’s developmental theory
c. Mahler’s theory of object relations
d. Kernberg’s conceptualization object constancy
ANS: C
Mahler’s theory of object relations suggests that the child at this age has a beginning
sense of object constancy and can use a representation of the mother for comfort. The
child may use a blanket or other object to remind himself of the mother. The other
theories mentioned are not as clearly related as Mahler’s.
DIF: Cognitive Level: Comprehension REF: Pages 303-304
15. Which behavior supports the failure to successfully achieve the oral stage of Freud’s
psychosexual stages of development?
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a. An adult’s excessive dependency on parents
b. A history of multiple, simultaneous sex partners
c. A need to ritualistically turn the lights off repeatedly
d. A lack of guilt when responsible for mistreating others
ANS: A
Individuals who have difficulty with the oral stage are often dependent. The other
options reflect behavior not grounded in this stage.
DIF: Cognitive Level: Application
REF: Page 302
16. A patient with borderline disorder tells the nurse, “It’s hard to figure out who I am.
Sometimes I’m sexually attracted to women and sometimes to men.” The nurse
using Freudian concepts can analyze this as a developmental problem related to:
a. Lack of separation-individuation
b. Isolation of affect during latency
c. Impaired development of sexual identity during the phallic stage
d. Overdevelopment of latency stage traits related to control issues
ANS: C
According to Freud, identifying one’s sexual identity takes place during the phallic stage
of development. When sexual identity is not clearly established, the individual may
express confusion in sexual preference. The other options do not relate to information
given in the scenario.
DIF: Cognitive Level: Comprehension REF: Page 303
17. The patient tells the nurse, “I thought my doctor understood me completely. Now, I
hate him! He doesn’t understand me at all.” The nurse assesses the patient’s
description of feelings about the physician as evidence of the use of:
a. Splitting
b. Dissociation
c. Isolation of affect
d. Projective identification
ANS: A
Splitting is the inability to synthesize the positive and negative aspects of self and
others. It manifests as idealization and devaluation. Definitions of the other defenses
listed do not fit the description of the behavior in the scenario.
DIF: Cognitive Level: Application
REF: Page 304
18. The nurse conducts milieu therapy based on the understanding that:
a. Therapy is grounded in the milieu routine.
b. The milieu is a substitute for the patient’s family.
c. Staff represents the authority within the milieu.
d. The milieu provides realistic community interactions.
ANS: D
The purpose of milieu therapy is to recreate a community setting on these units so that
the patient is able to interact with other patient peers to identify and problem-solve
issues that occur when relating to others. The milieu does not replace the patient’s
family. The remaining options are not true.
DIF: Cognitive Level: Application
REF: Page 315
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19. A patient with a borderline personality disorder tells the nurse, “My doctor tells me
there’s something wrong with the hard wiring of my brain, and that’s why I’m so
impulsive and get so many mood swings. He said he’s going to prescribe some
medication.” Being aware of current practice guidelines, the nurse will prepare a
teaching plan for:
a. Lithium (Lithobid)
b. Fluoxetine (Prozac)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
ANS: B
Fluoxetine is an SSRI. SSRIs are the medications of choice for patients with personality
disorder who have affect dysregulation and impulsivity. SSRIs have a low incidence of
side effects. Lithium may be used in instances of severe mood disorder. Lorazepam is
used to help manage high anxiety, while haloperidol is prescribed in cases of violent
behavior.
DIF: Cognitive Level: Application
REF: Page 315
20. Which self-reflective intervention is most appropriate for the nurse to engage in when
managing care for patients who exhibit characteristics of personality disorders?
a. Reinforcing the therapeutic boundaries between the nurse and patient as often
as needed
b. Requesting a temporary transfer to a medical unit periodically to help minimize
burn-out
c. Frequently self-assessing for biases and prejudices that result in patient care that
is compromised
d. Arriving at a personal decision regarding the use of both chemical and physical
restraints to assure milieu safety.
ANS: A
Patients with personality disorders have difficulty relating to others. As a consequence,
these individuals have difficulty defining boundaries between themselves and others.
Part of nursing care is to define boundaries within the therapeutic relationship in order to
develop safe, patient-centered therapeutic relationships. The use of chemical and/or
physical restraints is determined by institutional policies, not personal decision. The
remaining options are appropriate for all patient care, not specifically care of patients
with personality disorders.
DIF: Cognitive Level: Application
REF: Page 314
21. Which statement correctly describes the schizotypal personality disorder?
a. Psychotic behavior will require a long hospitalization.
b. There may be misinterpretation of events but not psychosis.
c. There is greater personality disorganization than in schizophrenia.
d. The patient will be outgoing, actively seeking interactions with others.
ANS: B
Patients with schizotypal personality disorder may have problems thinking and
accurately perceiving events, but symptoms of psychosis such as delusional thinking and
hallucinations will be absent. Personality disorganization is greater in schizophrenia.
Psychosis will require longer hospitalization. Patients with schizotypal personality
disorder are not generally outgoing and social.
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DIF:
Cognitive Level: Application
REF:
Page 306
22. A psychiatric technician remarks to the nurse, “That patient with dependent
personality disorder is so clingy!” The response by the nurse that will be helpful to
the technician is:
a. “I think everyone feels that way. It’s difficult to have someone clinging.”
b. “Patients with personality disorders have little regard for the rights of others.”
c. “The patient fears having to function independently without direction from
someone else.”
d. “The patient is so preoccupied with perfection and structure that she’s afraid to
do anything at all.”
ANS: C
Patients with dependent personality disorder have an all-encompassing need to be taken
care of. This need causes submissive, clinging behaviors. By helping the technician
understand that the patient’s behavior is need-based rather than purposely annoying,
the technician will be better able to respond with empathy and care. Validating the
remark shows neither acceptance nor empathy for the patient. The remaining options do
not provide accurate learning for the technician.
DIF: Cognitive Level: Application
REF: Page 307
23. Which behavior is of particular concern to the nurse when managing the care of a
patient diagnosed with a personality disorder?
a. Reporting a staff member for ‘wanting to hurt me’
b. Shoplifting two candy bars from the hospital’s gift shop
c. Asking much more frequently to be allowed to ‘smoke a cigarette’
d. Refusing for three days to either bathe or change into clean clothing
ANS: B
Patients with personality disorders often exhibit self-destructive behaviors that result in
getting themselves in trouble with the law, such as shoplifting. The remaining options
are not generally considered characteristic behaviors of the patient diagnosed with a
personality disorder.
DIF: Cognitive Level: Application
REF: Page 318
24. Which intervention will provide the most information regarding a patient’s selfperception of their role in their environment?
a. Asking the patient to keep a journal about things they enjoy doing
b. Observing the patient interact with family members at a unit picnic
c. Encouraging the patient to discuss the successes they have experienced
d. Helping the patient select appropriate, attractive clothing for family visitation day
ANS: B
How the patient interacts within the family system and the role that the patient takes
(e.g., victim, placater) will offer the nurse the most insight into the patient’s selfperception. The other options are focused on assessing and/or affecting self-esteem.
DIF: Cognitive Level: Application
REF: Page 313
25. A psychiatric technician mentions to the nurse, “All these patients with Axis II
problems! It makes me wonder how so many mothers could have been such poor
parents and messed up their kids so badly!” The response by the nurse that helps
put the development of personality disorders into perspective is:
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a. “Parenting is the responsibility of fathers, too, so don’t blame only mothers.”
b. “Personality disorder is often related to sexual abuse that occurs without parental
knowledge.”
c. “There is some evidence to suggest a biologic component to personality
disorders.”
d. “Peer interactions may be more important in child development than parental
involvement.”
ANS: C
Tests show that schizotypal and schizoid disorders may reflect neurointegrative or
neurochemical dysfunction and that affective dysregulation found in a number of
personality disorders may be a function of serotonin abnormalities and may be
implicated in impulsivity, aggression, and suicidal tendencies. The other options are
either untrue or unhelpful.
DIF: Cognitive Level: Application
REF: Page 305
26. Which behavior is supportive of a histrionic personality disorder?
a. Withholding of feelings and low self-esteem
b. Insistence on others conforming to own methods
c. Engaging in impulsive acts like unprotected sex
d. Initial charm dissolving into coldness and blaming others
ANS: C
Impulsive sexual activities are characteristic of histrionic personality disorder. Low selfesteem is more indicative of avoidant behaviors. Inflexible methods are usually seen in
obsessive-compulsive personality disorders. Alternating between charming and blaming
describes some behaviors commonly seen in antisocial personality disorders.
DIF: Cognitive Level: Application
REF: Page 306
27. A patient with a personality disorder asks the nurse, “Is it true I have an inherited
brain disorder?” The nurse replies, knowing that:
a. There is proof that personality disorders are inherited.
b. All persons with personality disorders display brain abnormalities.
c. Individuals with personality disorders manifest some biological markers.
d. Individuals with personality disorders show an error in brain glucose metabolism.
ANS: C
There is a need for more research relating genetics and brain dysfunction to personality
disorders. Although there are some biologic markers, none of the other options are true.
DIF: Cognitive Level: Application
REF: Page 305
1. Which assessment data is supportive of a diagnosis of antisocial personality
disorder? Select all that apply.
a. Was reprimanded to a juvenile correction facility at age 14
b. Mother reports characteristic behaviors as early as age 7
c. Is below age-appropriate norms for both weight and height
d. Patient states, “I don’t like school and skip whenever I feel like it.”
e. Has been admitted to a drug rehabilitation program twice in 4 years
ANS: A, B, E
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Patients diagnosed with antisocial personality disorder have a history of conduct
disorders before the age of 15 years, prison or juvenile detention experiences, and
substance abuse. There is no research that supports the remaining options as being
characteristic of this disorder.
DIF: Cognitive Level: Application
REF: Page 307
2. When implementing Freud’s theory of human psychosexual development, the nurse
observes for behaviors that are characteristic of successful completion of stages that
include (select all that apply):
a. Anal, where self-confidence is formed
b. Oral, where the ability to trust is developed
c. Latency, where a person learns inner control
d. Adjustment, where developmental failures are re-addressed
e. Phallic, where the ability to interact with others is grounded
ANS: A, B, C, E
Freud’s stages of psychosexual development include in order of completion: oral, anal,
phallic, latency, and genital. There is no adjustment stage in Freud’s theory.
DIF: Cognitive Level: Comprehension REF: Pages 302-303
Chapter 15: Substance-Related Disorders and Addictive Behaviors
1. When asked, “What causes alcoholism?” the nurse’s response will be based on the
fact that:
a. The response to alcohol is a result of a brain-based disorder.
b. Alcoholism is believed to be an allergic response to the alcohol.
c. Every individual has the same susceptibility for developing alcoholism.
d. It is a physical response to alcohol but it’s etiology is not fully understood.
ANS: A
It has been determined that alcoholism is not an allergy but rather it is recognized as a
partial brain-based disorder that some brains are more susceptible to than others.
DIF: Cognitive Level: Application
REF: Page 323
2. Which patient response would support the conclusion that the patient has moved into
the ‘dark side’ of a narcotic addition?
a. “I’ve been abusing drugs for at least 10 years.”
b. “Drugs makes me feel good; that why I use them.”
c. “I don’t like the way I feel when I don’t use drugs.”
d. “Drugs are something that I can either take or leave”
ANS: C
During beginning use (the light side), the “feel good” effects are dominant. As the
individual becomes habituated to the drug, tolerance and withdrawal symptoms develop;
this constitutes the dark side. The remaining options do not describe effects of drug use.
DIF: Cognitive Level: Application
REF: Page 325
3. A substance use disorder (SUD) is a likely comorbid mental illness in which patient?
a. The soldier diagnosed with posttraumatic stress disorder
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b. The teenager demonstrating symptoms of poor impulse control
c. The older adult diagnosed with early stage Alzheimer’s disease
d. The new mother exhibiting symptoms of postpartum depression
ANS: A
Posttraumatic stress disorder creates a risk for substance use or relapse. A total of 30%
to 60% of persons with SUDs meet the criteria for comorbid posttraumatic stress
disorder. The remaining options have not shown such a prevalence of comorbid
relationship with SUDs.
DIF: Cognitive Level: Application
REF: Page 327
4. Which group would be the target population for educational material on the dangers
of binge drinking?
a. Full-time college students
b. Blue-collared young adults
c. Older widows and widowers
d. High school juniors and seniors
ANS: A
The highest prevalence of binge and heavy drinking is among young adults between the
ages of 18 and 25 years, with the majority being full-time college students.
DIF: Cognitive Level: Application
REF: Page 329
5. Which social factor has the greatest impact on the changing nature of alcohol abuse
treatment?
a. Development of new pharmaceutical treatment options
b. Dramatic increase of alcoholism among young adult males
c. Raising cost of both inpatient and outpatient treatment programs
d. Women’s substance abuse only recently acknowledge by society
ANS: D
The existence of an alcohol abuse problem among women has only been recently
recognized and this has dramatically affected treatments and services being provided.
Although the other options are true, they do not have the impact on treatment
modalities as much as the correct option.
DIF: Cognitive Level: Application
REF: Page 330
6. Which assessment data poses the greatest risk for injury in a patient who abuses
alcohol?
a. Takes a baby aspirin each morning
b. Uses over-the-counter antihistamines for seasonal allergies
c. Has been taking a tricyclic antidepressant for more than 2 years
d. Took a narcotic for 1 week to manage post–dental surgery pain
ANS: C
Tricyclic antidepressants are strictly contraindicated with alcohol consumption because
of their potential effect on cardiac function. Although aspirin increases bleeding times
and antihistamines and narcotics increase sedation, the outcome of combining alcohol
and these drugs is not as dangerous as that of the correct option.
DIF: Cognitive Level: Analysis
REF: Page 335
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7. If an individual is admitted with a diagnosis of Wernicke-Korsakoff's syndrome, the
nurse would expect to assess:
a. Peptic ulcer
b. Vivid illusions
c. Cognitive deficits
d. Auditory hallucinations
ANS: C
Wernicke-Korsakoff’s syndrome includes a severe form of amnesia and an inability to
learn new skills which reflects a cognitive impairment. The other options are not
associated with the syndrome.
DIF: Cognitive Level: Comprehension REF: Page 338
8. Which sociological aspect, vital to relapse prevention, is greatly affected when a
patient is found to have a dual diagnosis of psychosis and alcoholism?
a. Ability to afford the cost of outpatient services
b. A supportive, reliable, accessible support system
c. Protection from both physical and emotional abuse
d. Access to reasonable housing and employment opportunities
ANS: B
Often individuals with this type of diagnosis have lost their support systems as a result of
chronic mistreatment of their family and friends and an inability to maintain and
recognize the importance of this aspect to their treatment plan. Although the remaining
options impact relapse prevention, they are generally available when the patient is being
supported appropriately.
DIF: Cognitive Level: Application
REF: Pages 335-336
9. Which nursing intervention best demonstrates an understanding of the relationship
between confirmed intravenous drug abuse and specific infections?
a. Screening the patient for hepatitis B virus (HBV)
b. Assessing the patient for potentially infected injection sites
c. Determining if the patient has ever been tested for human immunodeficiency
virus (HIV)
d. Evaluating the patient’s understanding of the increased risk for developing
sexually transmitted diseases
ANS: A
Injecting drug users have one of the highest HBV rates among all risk groups and
account for at least half of all new HCV cases, so screening for such infections
demonstrates that the nurse understands the severity of the problem. Although the
other options reflect potential infection risks, they are not as commonly seen in patients
with this diagnosis.
DIF: Cognitive Level: Application
REF: Page 336
10. Which assessment data would bring into question a patient’s statement that, “I have
only a few drinks on special occasions.”?
a. History of treatment for glaucoma
b. Fasting serum blood glucose level of 182 mg/dL
c. Patient reports numbness in hands and feet bilaterally
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d. Red rash observed over neck, shoulders, and upper chest
ANS: C
Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake.
Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking
causing the nurse to question the patient’s statement. The remaining options do not
reflect symptomology generally associated with alcoholism.
DIF: Cognitive Level: Application
REF: Page 338
11. Which intervention has priority when a nurse suspects a staff member of providing
patient care while being impaired by alcohol or drugs?
a. Asking the staff member to explain their suspicious behavior
b. Adjust the staff member’s assignment to minimize patient contact
c. Providing the staff member with material regarding alcohol abuse and treatment
d. Reporting the staff member’s suspicious behavior to the nursing supervisor on
duty
ANS: D
It is a professional obligation to report suspected impaired practice. The remaining
options do not have prior in this situation since the concern is patient safety.
DIF: Cognitive Level: Analysis
REF: Page 332
12. Which nursing intervention demonstrates an understanding regarding the primary
form of substance use disorder among older adults?
a. Assessing the patient’s hands and feet for the presence of both numbness and
tingling
b. Having the patient, “describe your relationship with you adult children, coworkers, and friends.”
c. Asking, “Please identify for me all the medications both prescribed and over the
counter you regularly take.”
d. Evaluate the patient’s understanding of the possible health risks that alcohol and
medication abuse has on one’s health
ANS: C
Misuse of prescription medications is the most common form of drug abuse among older
adults. This population is especially vulnerable because of the multiple drugs that are
often prescribed for medical conditions. The remaining options do not help identify the
presence of multiple medications.
DIF: Cognitive Level: Application
REF: Pages 334-335
13. Which assessment demonstrates the nurse’s understanding of the relationship
between substance abuse and the development of symptoms characteristic of
delirium?
a. Determining the patient’s age and gender
b. Evaluating the patient’s food and fluid intake over the last 48 hours
c. Observing the patient for fine tremors of the hands, especially the fingers
d. Determining the amount of caffeine the patient ingested in the last 24 hours
ANS: D
Some people who ingest large amounts of caffeine develop delirium. The remaining
options are not relevant to caffeine ingestion or the abuse of any other substance.
DIF: Cognitive Level: Analysis
REF: Page 340
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14. Which protocol should guide the nurse responsible for administering pharmacologic
interventions for a patient who is experiencing alcohol intoxication?
a. Medication interventions are based on the presence of withdrawal symptoms.
b. Medications are prescribed at appropriate intervals for at least one full week.
c. Symptoms are managed with medications for only the initial 24 hours of
hospitalization.
d. Medications are introduced to treat grand mal seizures that may accompany
withdrawal symptoms.
ANS: A
The course of intoxication is usually self-limiting to approximately 24 hours, after which
withdrawal symptoms can occur for a time period unique to each patient. Treatment is
directed by the symptoms the patient is experiencing, which generally emerge during
the withdrawal stage. Seizures are among several serious symptoms that can occur
during the withdrawal stage.
DIF: Cognitive Level: Application
REF: Page 350
15. A patient recently discharged from an alcohol rehabilitation program is brought to the
hospital in a state of prostration with severe throbbing headache, tachycardia, a
beet-red face, dyspnea, and continuous vomiting. The patient’s significant other
states the patient got sick about 15 minutes after drinking a glass of wine. The nurse
should be guided in assessment by the suspicion that the patient:
a. Is having a stroke
b. Has alcohol intoxication
c. Is reacting to disulfiram (Antabuse)
d. Is exhibiting symptoms of cross-dependence
ANS: C
The alcohol deterrent drug, Antabuse, commonly prescribed in recovering alcoholic
treatment, causes this reaction when taken in combination with alcohol. Alcohol
intoxication, stroke, and cross-dependence do not present with the listed prostration
symptoms.
DIF: Cognitive Level: Application
REF: Page 337
16. Which question is most appropriate when assessing a patient who is exhibiting
symptoms of a systemic infection including a fever of unknown origin?
a. “Are you an intravenous drug user?”
b. “Have you been told that you drink too much alcohol?”
c. “Have you been diagnosed with an acute bacterial infection before?”
d. “Are you familiar with an infection of the heart called endocarditis?”
ANS: A
Intravenous drug users are at risk for subacute bacterial endocarditis and other
circulatory compromise created by foreign substances introduced during the process of
intravenous use. Regardless of the setting, nurses need to ask about intravenous drug
use whenever a patient presents with fever of unexplained origin. Assessing the
patient’s knowledge related to bacterial infections and endocarditis will not address the
possible cause of the fever. Alcohol consumption is not relevant in this situation.
DIF: Cognitive Level: Application
REF: Page 341
17. Which observation seen in a teenage patient supports the suspicion of anabolic
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steroid abuse?
a. Lack of facial hair
b. Ritualized hand washing
c. Stealing and hiding a magazine belonging to another patient
d. Throwing a chair when told it was time to turn off the television
ANS: D
For all individuals abusing anabolic steroids, extreme mood swings occur, and these may
be accompanied by violent behaviors. Obsessive-compulsive behaviors and stealing are
not generally associated with this disorder. The increased hormone presence would
result not in a lack, but rather an increase, in facial hair.
DIF: Cognitive Level: Application
REF: Page 341
18. A patient’s wife has chronic alcoholism, and the husband is concerned about the
possibility that their children may develop the disease. He asks the nurse what the
risk is. The nurse’s best response is:
a. “The risk for developing alcoholism is increased if there is a family history of
alcoholism.”
b. “Studies have confirmed that individuals with dependent personality traits are at
high risk for this disease.”
c. “Cultures that include alcohol as part of the ritualized behavior have a higher rate
of alcoholism.”
d. “Twin studies have indicated that the environment of a person is more important
than the biologic influences of parents.”
ANS: A
Problems with alcohol increase with the number of relatives with alcoholism. No unique
personality profile is prone to addiction. Ritualized use of alcohol does not predispose to
alcoholism and twin studies indicate a significant genetic contribution to susceptibility to
alcoholism.
DIF: Cognitive Level: Application
REF: Page 327
19. Which observation best supports the patient’s success with achieving long-term
sobriety?
a. Asking a family member to, “get rid of all the alcohol before I come home”
b. Identifying all the problems alcoholism has caused the family over the years
c. Being able to discuss the importance of attending a support group for alcoholics
d. Promising to, “stop the drinking so I can be a good parent and raise a good child”
ANS: B
One of the most prominent factors that leads an individual to recovery is the patient’s
recognition that substance use has caused or influenced his or her life’s problems and
interrupted his or her functioning. The remaining options lack that element of selfreflection.
DIF: Cognitive Level: Application
REF: Pages 344-345
20. Which principle of recovery is the basis of the nurse’s response when a patient
relapses and is hospitalized for alcohol detox treatment?
a. Alcoholism requires a lifelong commitment to control.
b. Most people who are serious about treatment achieve sobriety.
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c. Relapsing is an expected occurrence for the patient diagnosed with alcohol
abuse.
d. Rehabilitation generally involves several relapses before true sobriety is
achieved.
ANS: D
Sobriety is the goal of complete abstention from drugs, alcohol, and addictive behaviors.
Sobriety often involves several attempts, and many patients relapse 9 or 10 times before
achieving and sustaining sobriety. This information is the basis for the physical and
emotional support provided by the nurse. Although citing that a relapse is not a failure
but an expected part of the recovery process, this option does not include the needed
information of the frequency of the possible relapses. The remaining options are not
focused on relapsing.
DIF: Cognitive Level: Application
REF: Page 345
21. Which assessment observation is the best support for a patient’s diagnosis of
alcoholism?
a. Reporting, “I messed up three marriages.”
b. Testing positive for hepatitis B virus (HBV)
c. Admission that, “I drink more than I should.”
d. A positive response to three items on the CAGE test
ANS: D
The CAGE questionnaire is a well-validated screening instrument. A positive response to
two of the four items of the CAGE questionnaire indicates a potential problem with
alcoholism. Although the remaining options are recognized red flags for possible
alcoholism, they lack the selectivity of the screening tool.
DIF: Cognitive Level: Analysis
REF: Page 347
22. Which factor has the greatest negative impact on the use of laboratory serum alcohol
results in determining legal intoxication?
a. The variable time it takes to metabolize alcohol in the body
b. States differs greatly in their definitions of legal intoxication
c. Legal issues with securing consent for the test from an impaired patient
d. The relatively short period of time alcohol can be detected in the blood
ANS: D
The major disadvantage of blood alcohol testing is the narrow window of time for the
detection of drugs in the blood stream. Although the variability of individual metabolism
rates may be considered a factor, they are stable enough to allow for testing timetables.
The legal issues related to consent and the definition of legal intoxication limits does not
impact the reliability of the test itself to determine intoxication.
DIF: Cognitive Level: Application
REF: Pages 347-348
23. Which intervention will the nurse caring for a patient suspected of phencyclidine
(PCP) abuse implement based on an understanding of the medication’s unique
properties?
a. Assessing for chronic renal failure
b. Focusing attention on providing patient safety
c. Implementing suicide precautions immediately
d. Monitoring for delayed development of psychotic symptoms
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ANS: D
Phencyclidine (PCP) is a hallucinogen, but it has its own set of CNS reactions. PCP has a
long duration of action that can result in delayed psychotic symptoms. Chronic renal
failure would not be immediately observable. Patient safety is a nursing responsibility
regardless of the diagnosis. Self-harm is not generally a characteristic of this type of
substance abuse.
DIF: Cognitive Level: Application
REF: Page 342
24. Which outcome would be appropriate for the detoxification phase of treatment for
alcoholism?
a. Adequate dietary protein intake
b. Re-connection with family and support system
c. Identification of triggers that cause alcohol abuse
d. Control over emotions resulting in aggressive behavior
ANS: A
When implementing any plan, patient safety and health are always the first priorities, so
the nurse focuses on nutritional support, including providing a protein-rich diet. The
remaining options are outcomes reserved for the later stages of the recovery process.
DIF: Cognitive Level: Application
REF: Page 349
25. Which intervention will the nurse plan for when managing the detoxification of a
patient diagnosed with chronic alcoholism?
a. Low-protein diet to minimize risk of kidney failure
b. Seclusion to help manage aggression towards others
c. Transporting patient to scheduled 12-step support group meetings
d. Administering Ativan (lorazepam) to manage alcohol withdrawal symptoms
ANS: D
During the process of detoxification, the nurse gives enough of a drug (or one to which
the person has cross-tolerance) to relieve the withdrawal symptoms. Benzodiazepines
like lorazepam (Ativan) have a cross-tolerance with alcohol, so they are used to manage
withdrawal symptoms. The detoxification diet would be high in protein. Seclusion would
not be initiated before less severe attempts to manage the behavior failed. Attending a
support group would not be appropriate for the detoxification stage of rehabilitation.
DIF: Cognitive Level: Application
REF: Page 350
1. Which behaviors would demonstrate a strong possibility for successful rehabilitation
for a patient with a substance abuse–related diagnosis? Select all that apply.
a. States that, “I promise I’ll never use drugs again.”
b. Has shown ability to use effective coping mechanisms
c. Expresses an understanding of the severity of their addiction
d. Plans to associate with old friends “only when they aren’t drinking”
e. Demonstrates an interest in staying involved in an appropriate support group
ANS: B, C, E
The correct options show an understanding of the disease process and examples of
needed skills as well as the commitment to maintain control over their addiction. The
remaining options reflect promises but not true insight into the severity of their problem
and the effects needed to manage it successfully.
DIF: Cognitive Level: Application
REF: Page 345
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2. A nurse engaged in primary prevention for substance abuse among adolescents
could advise parents to (select all that apply):
a. Watch for signs of depression.
b. Help the teen anticipate pressures.
c. Be a role model for effective coping skills.
d. Support the teen’s interest in hobbies and sports.
e. Require academic tutoring when grades begin to drop.
ANS: B, C, D
The correct options are proactive and focus on preventing the problem although the
remaining options intervene once there are indications that the problem may exist.
DIF: Cognitive Level: Application
REF: Page 334
3. When suspicious of possible fetal alcohol syndrome, which assessment findings
would support this diagnosis? Select all that apply.
a. Webbed toes
b. An enlarged head
c. Super sensitive hearing
d. A flattened bridge of the nose
e. Symptoms of a septal heart defect
ANS: A, D, E
The correct options are characteristics of FAS but one would not include hearing loss or a
small head in children with this disorder.
DIF: Cognitive Level: Application
REF: Page 331
4. A teen says to the school nurse, “Huffing is harmless. There are no reasons not to
sniff inhalants.” The nurse can reply knowing that (select all that apply):
a. Such behavior can result in irreversible hearing impairment.
b. There has been minimal research done on the effects in teens.
c. Long-term use can result in poor short- and long-term memory.
d. Irreversible kidney damage is often observed with even casual use.
e. Research indicates both central nervous system and bone marrow damage.
ANS: A, C, E
Research as shown that even teens who engage in sniffing high concentrations on
inhalants often experience hearing loss, CNS and bone marrow damage, and impaired
cognitive function. Kidney impairment is often seen as reversible.
DIF: Cognitive Level: Application
REF: Page 343
Chapter 16: Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders
1. A patient diagnosed with moderate dementia consistently appears to be distorting
the truth resulting in his wife asking, “What should I do when he lies to me about
unimportant things?” Upon what rationale should the nurse’s response be based?
a. Changing the topic provides diversion.
b. Delusions should be confronted to clarify thinking.
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c. Ignoring memory deficit avoids catastrophic reactions.
d. This isn’t lying but rather a way to fill in the memory gaps.
ANS: D
Confabulation is not lying but rather a method for filling in the memory gaps. Ignoring,
using confrontation, and changing the topic would not be as useful as gently reorienting.
DIF: Cognitive Level: Application
REF: Page 374
2. The nurse is to perform a complete assessment of a patient in her home, using the
Mini-Mental State Examination (MMSE) as one component. When the nurse arrives,
the patient is seated at the table with her husband, the TV is on, and several
grandchildren are visiting. The patient is quiet, but her hands are gripped tightly, and
she is staring at the ceiling. The best action for the nurse to take would be which of
the following?
a. Ask the husband to make an appointment to bring his wife to the clinic for
testing.
b. Explain to the husband that accurate data will be sought, and ask him to stay
with the grandchildren in another room.
c. Do not perform the test during the assessment (because it will not be valid) and
rely on observations and reports from the family.
d. Explain the importance of the testing process and make an appointment for
another day when the environment can be better controlled.
ANS: D
Testing the patient in her home under quieter, less distracting circumstances is the best
solution. Asking the husband to leave is likely to increase the patient’s anxiety and alter
test results. Use of the MMSE is an integral component of the assessment and must not
be deleted. Testing in the more familiar, comfortable surroundings of the home will yield
more reliable results.
DIF: Cognitive Level: Application
REF: Page 378
3. A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing
intervention is supported by this diagnosis?
a. Encouraging fluids to minimize constipation
b. Frequently assessing both visual and auditory hallucinations
c. Scheduling frequent changing of position to prevent skin breakdown
d. Dimming the lights to help control eye discomfort resulting from cataracts
ANS: C
Because of inactivity, hypoactive delirium patients are more likely to develop further
complications, including decubiti that could be minimized by frequent repositioning. The
remaining options identify interventions that are not generally a result of this diagnosis.
DIF: Cognitive Level: Application
REF: Page 377
4. Which of the following should the nurse use as a basis for explaining the etiology of
Alzheimer’s disease to the family of a patient with this disease?
a. It is a secondary dementia indicated by loss of recent memory and disorientation
to time and place.
b. It is a primary dementia that is incurable, irreversible, and fatal. It is caused by
the presence of a beta-amyloid protein in the neurons resulting in senile plaques.
c. It is a secondary dementia that is treatable with analysis of the diet and removal
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of toxic substances from the diet and environment.
d. It is a primary dementia characterized by stepwise decreases in cognitive
abilities. It is irreversible but treatable with antihypertensive medications.
ANS: B
This option provides accurate information about Alzheimer’s disease. Alzheimer’s
disease is not a secondary dementia nor is it treated with antihypertensive medications.
DIF: Cognitive Level: Application
REF: Pages 367-368
5. Which outcome is realistic for a patient with stage 1 Alzheimer’s disease?
a. Caregiver will assume role of decision maker for patient to reduce stress.
b. The patient will maintain the highest possible functional level to preserve
autonomy.
c. Arrangements will be made for appropriate long-term placement to minimize risk
of injury.
d. The patient will retain full physical functioning through cognitive and
occupational therapies.
ANS: B
This outcome addresses health maintenance (i.e., maintaining an optimal functional
level as determined by present capacity). Although long-term placement may be an
option, it is not necessarily appropriate during this stage. Patients in stage 1 are often
able to make simple decisions. Continuing to make decisions gives the patient a sense of
control. Although a patient in stage 1 does not appear markedly deteriorated, some
diminution of function may be present.
DIF: Cognitive Level: Application
REF: Page 382
6. The home care nurse is visiting a patient who was discharged to home after a
procedure at an ambulatory surgical center. The patient lives alone in a senior
retirement community. The nurse’s assessment documents mild dysphasia. The
patient repeatedly asks, “Why is there a bandage on my arm?” and is not able to
state the appropriate day and year. Appropriate planning for the patient should
include:
a. Assessing diet and meal preparation, assessing environment for safety problems,
referral to a dementia program
b. Attending English class to improve speech, transferring finances to a conservator,
employing an aide to help with medications
c. Arranging Meals on Wheels, attending speech therapy, relocation to a skilled
nursing facility if no improvement in 1 month
d. Arranging an appointment at a geriatric assessment program, OT referral for
swallowing therapy, teaching to manage public transportation
ANS: A
Further assessment is appropriate before making changes in the living environment.
Enrolling in a dementia program will provide stimulation and help the patient maintain
intellectual skills. English classes will not improve speech. The other plans might have
relevance, however. The remaining sets of options are either irrelevant or beyond the
patient’s abilities.
DIF: Cognitive Level: Application
REF: Page 383
7. A patient diagnosed with Alzheimer’s disease has a catastrophic reaction during an
activity involving simultaneous playing of music and working on a craft project. The
patient starts shouting “no, no, no” and rushes out of the room. The nurse should:
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a. Discontinue the activity program since it upsets the patients.
b. Follow the patient, reassure her, and redirect her to a quieter activity.
c. Isolate the patient until she is calm, and then direct her back to the activity.
d. Give the patient prn antianxiety medication and restrict her activity participation.
ANS: B
These actions will restore safety and self-esteem. Isolation will decrease self-esteem and
may increase confusion. It is only one patient that is distressed, not the entire group.
Behavioral interventions should be attempted prior to administering medication.
DIF: Cognitive Level: Application
REF: Page 376
8. Which behaviors would indicate that a therapeutic activity program for a patient with
Alzheimer’s disease had been successful?
a. Accurate recent memory, positive emotional response, and increased verbal
expression
b. Increased attention span, verbal expression of remote memory, and positive
emotional response
c. Positive use of perseveration, reduction in use of habitual skills, and improved
abstract reasoning
d. Positive emotional response, ability to remember multiple steps, and accurate
recent memory
ANS: B
These are all observations that would indicate that a therapeutic activity program has
kept the patient functioning at the highest level of which he is capable. The behaviors
described in the other options are not realistic expectations for this patient.
DIF: Cognitive Level: Application
REF: Page 387
9. A patient has been diagnosed with dementia secondary to cerebral disease. The
family members note the patient “has not been as sharp as he once was” and that
he has developed urinary incontinence and a gait disturbance. Which
pathophysiology can cause such symptoms?
a. Normal pressure hydrocephalus
b. Vitamin B12 deficiency
c. Hepatic disease
d. Tuberculosis
ANS: A
Normal pressure hydrocephalus is a disorder characterized by dementia, gait disorder,
and urinary incontinence. Dilation of ventricles in the absence of increased CSF is a
prominent manifestation. Early urinary incontinence is not seen in the disorders listed in
the other options.
DIF: Cognitive Level: Analysis
REF: Page 367
10. When asked about the prognosis for a patient diagnosed with a dementia secondary
to normal pressure hydrocephalus the nurse replies:
a. “Unfortunately the prognosis is for a downhill course ending in death.”
b. “There will be good days and bad days for the rest of the patient’s life.”
c. “The symptoms generally remit after a shunt is inserted to drain fluid.”
d. “We’ll try our very best, but only time will tell how successful we are.”
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ANS: C
By relieving the cause, the symptoms of secondary dementias are largely reversible. The
statements reflected in the other options do not reflect this fact.
DIF: Cognitive Level: Application
REF: Page 367
11. Which statement by an adult child concerning the behaviors of their parent supports
the diagnosis of Alzheimer’s disease?
a. “Mom forgot to pay her utility bills last month.”
b. “Mom isn’t as interested in keeping a neat house as she was.”
c. “Mom doesn’t seem interested in going out with friends anymore.”
d. “Mom refuses to stop driving even though her reaction time is very slow.”
ANS: A
Increased forgetfulness, particularly that involving former routine activities (such as bill
paying), is symptomatic of Alzheimer’s disease. The other options do not indicate
cognitive deficit.
DIF: Cognitive Level: Application
REF: Page 374
12. The daughter of an older patient with dementia tearfully tells the nurse that she
doesn’t know what’s wrong with her mother, who has begun accusing the family of
holding her prisoner. Which nursing diagnosis would be appropriate for this patient?
a. Powerlessness
b. Defensive coping
c. Ineffective coping
d. Disturbed thought processes
ANS: D
Paranoid thinking is common in patients with dementia. Inability to correctly interpret
environmental clues and to think logically leads to delusional thinking as the patient tries
to make sense of a confusing world. The remaining options are not supported by the
data in the scenario.
DIF: Cognitive Level: Comprehension REF: Page 382
13. The daughter of an elderly patient with dementia tearfully tells the nurse that she
doesn’t know what’s wrong with her mother, who has begun accusing the family of
stealing her money. The nurse assesses the patient’s stage of Alzheimer’s disease as
stage:
a. 1
b. 2
c. 3
d. 4
ANS: B
In stage 2, memory and cognitive deficits are worsening. The patient is less able to make
sense of a confusing world and makes faulty interpretations resulting in paranoid
delusional thinking. The patient in stage 1 does not usually have delusions. The patient
in stage 3 often is unable to communicate meaningfully. There is no stage 4 of
Alzheimer’s disease.
DIF: Cognitive Level: Comprehension REF: Page 375
14. An elderly patient was well until 12 hours ago, when she reported to her family that
in the middle of the night she awakened to see a man standing at the foot of her bed.
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There is no evidence that this situation ever happened. This series of events supports
which possible diagnosis?
a. Delirium
b. Anxiety
c. Paranoia
d. Dementia
ANS: A
Delirium is a disturbance of consciousness and cognition that develops over a short
period. It is secondary to a medical condition. The scenario does not fit the disorders
mentioned in the remaining options.
DIF: Cognitive Level: Comprehension REF: Page 371
15. A patient diagnosed with delirium has become agitated and fearful. Which nursing
intervention should the nurse implement to help prevent a catastrophic response?
a. Interact with the patient on an adult-to-child level.
b. Place the patient in a safe, nonstimulating environment.
c. Ask the patient to explain what is causing the agitation and fear.
d. Be prepared to apply physical restraints to minimize the patient’s risk for injury.
ANS: B
The safety of a patient with delirium is of primary importance. Symptoms of delirium
fluctuate and may worsen, especially at night. The greater the patient’s confusion and
disorientation, the greater the possibility for self-harm. The patient should be treated as
an adult; to do otherwise is demeaning. Asking for an explanation is inappropriate,
because delirious patients cannot formulate rational answers. Patients are never
restrained unless all other less restrictive measures have failed.
DIF: Cognitive Level: Application
REF: Page 376 |Page 383
16. A patient has been diagnosed with Alzheimer’s disease, stage 1. The nurse would
expect to help the family plan measures to assist the patient with:
a. Perseveration
b. Recent memory loss
c. Catastrophic reactions
d. Progressive gait disturbances
ANS: B
Recent memory loss is the only symptom listed in the options that would be expected in
stage 1 Alzheimer’s disease.
DIF: Cognitive Level: Comprehension REF: Page 375
17. An elderly patient with dementia has a nursing diagnosis of self-care deficit: bathing,
hygiene. She lives alone and the nursing assessment proves reason to believe she
has forgotten how to perform hygiene and bathing activities. Which intervention is
most appropriate for this patient?
a. Bathe daily with reminders.
b. Bathe twice weekly with assistance.
c. Patient will be provided with in-home nursing care.
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d. Patient will be transferred to an assisted living facility.
ANS: B
Bathing twice weekly would be a realistic goal. Assistance should be provided, both to
prevent falls and to regulate shower temperature. The elderly are advised not to bathe
daily because it is too drying to their skin. The remaining options are not supported by
the information given in the scenario.
DIF: Cognitive Level: Application
REF: Page 383
18. Which situation would be most likely to serve as a trigger to a catastrophic reaction
in a patient with stage 2 Alzheimer’s disease?
a. Participating in singing “Happy Birthday” to another patient at dinner
b. Being scolded by an aide for spilling a glass of milk
c. Listening to Big Band music from the 1940s
d. Eating cupcakes in the activities room
ANS: B
Catastrophic reactions are overexaggerated negative emotional responses initiated as a
result of a perceived failure at a task or change in the environment. Being scolded by the
aide presents a situation that would clearly be frustrating to the patient.
DIF: Cognitive Level: Application
REF: Page 376
19. Which theory of etiology of Alzheimer’s disease, suggested by current research,
might the nurse use to help a family understand that this disorder is not of
psychosocial origin? Alzheimer’s disease is associated with:
a. Abnormal serotonin reuptake
b. Prion infection of gray matter
c. ß-Amyloid protein deposits in the brain
d. Excessive acetylcholine in the frontal cortex
ANS: C
The prevailing theories of etiology of Alzheimer’s disease include the following:
angiopathy and blood-brain barrier incompetence; neurotransmitter and receptor
deficiencies of acetylcholine; abnormal proteins, specifically ß-amyloid and their
products; and genetic defects. Neither serotonin nor prions are implicated as problems in
Alzheimer’s disease.
DIF: Cognitive Level: Knowledge
REF: Page 368
20. The nurse is administering donepezil (Aricept) to a patient with stage 1 Alzheimer’s
disease. Based on this drug’s mechanism of action, the nurse will seek evidence of
improvement in the patient’s:
a. Social behaviors
b. Existing delusions
c. Ability to tolerate stress
d. Ability to remember recent events
ANS: D
Donepezil is a cholinesterase inhibitor that increases the concentration of acetylcholine.
Acetylcholine is needed for intact memory and for learning. This medication is not
prescribed for the conditions identified in the remaining options.
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DIF:
Cognitive Level: Comprehension REF:
Pages 385-386
21. A patient with dementia is unable to name ordinary objects. Instead, he describes the
function of each item (e.g., “the thing you cut meat with”). The nurse assesses this
as:
a. Apraxia
b. Agnosia
c. Aphasia
d. Amnesia
ANS: B
Agnosia is the failure to identify objects despite intact sensory function. Apraxia is the
inability to carry out purposeful, complex movements and use objects properly. Aphasia
refers to inability to speak (expressive) or inability to comprehend what is said or written
(receptive). Amnesia is inability to remember a significant block of information.
DIF: Cognitive Level: Comprehension REF: Page 373
22. Which intervention has highest priority for a patient with stage 3 Alzheimer’s
disease?
a. Cutting the patient’s food into bite size pieces
b. Providing fluids to the patient every hour while awake
c. Demonstrating to the patient how to put toothpaste on the brush
d. Assisting the patient in signing a birthday care for a granddaughter
ANS: B
The severe dementia characteristics of stage 3 renders the patient incapable of
independently meeting hydration and nutrition needs. These needs are basic to life, so
they are of highest priority. The remaining options are not applicable for such an
impaired patient.
DIF: Cognitive Level: Application
REF: Page 375
23. A patient was admitted to a dementia unit after persistently wandering away from
home. Which intervention will best address this patient’s risk for injury?
a. Place the patient in a geriatric chair with a tray across the lap.
b. Provide one-to-one supervision when the patient is ambulatory.
c. Reinforce verbal explanation to the patient concerning the dangers of wandering.
d. Activate alarm system that will alert staff to the patient’s attempt to open the
door.
ANS: D
Electronic alarms allow patients freedom of movement although still preventing them
from wandering off the unit. One-to-one supervision is not necessary in an environment
designed as a dementia unit. The geriatric chair would be an unacceptable form of
restraint for this patient. The patient would not be capable of processing the verbal
explanation.
DIF: Cognitive Level: Application
REF: Page 375
24. A patient with moderate dementia does not remember her son’s name. The son
repeatedly questions the mother asking, “Do you know my name?” The mother
invariably becomes agitated. The nurse can most effectively intervene by explaining
to the son:
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a. “Your mother is angry with you and is punishing you by ‘forgetting’ who you are.
Be patient and she’ll get over it.”
b. “Your mother’s dementia is preventing her from retaining information even for
short periods of time. She senses your distress and becomes agitated.”
c. “You will need to reorient your mother often during your visits with her. With
reinforcement, she may be able to begin to recall who you are.”
d. “Because you both become so distressed, it might be better if you come to see
your mother less frequently and stay for only shorter periods of time.”
ANS: B
When a patient with dementia is presented with a demand that exceeds their capacity to
function, the demand creates a high level of stress. Showing anxiety and disapproval
adds even greater stress. The son should be counseled to make every attempt to
demonstrate positive responses to his mother. The other options are not effective
interventions.
DIF: Cognitive Level: Application
REF: Page 383
25. The wife of a patient with moderate to severe dementia tells the nurse, “I’m
exhausted. He wanders at night instead of sleeping, so I get no rest. I’m afraid to
leave him during the day, so I have to take him with me wherever I go.” The nurse
recognizes the need to provide teaching for this caregiver. An appropriate outcome
for this teaching would include:
a. Experiences less stress indicated by improved sleep patterns
b. Feels comfortable leaving the patient in the care of others occasionally
c. No longer experiences resentment concerning the need to care for the patient
d. Feels at peace with the decision to admit the patient to an appropriate care
facility
ANS: A
Stress reduction allowing for better rest is an appropriate outcome. The other options are
not necessarily appropriate nor will they result in improvement for the caregiver.
DIF: Cognitive Level: Application
REF: Page 388
26. A teenager is admitted to the ED after being alternately hyperalert and difficult to
arouse. The symptoms started within the last few hours, during which time he
became disoriented, confused, and delusional. These symptoms support the
diagnosis of:
a. Amnesia
b. Delirium
c. Dementia
d. Depression
ANS: B
The symptoms are indicative of delirium. The other options are not supported by the
scenario.
DIF: Cognitive Level: Application
REF: Pages 371-372
1. Which interventions provided by the caregiver will help ensure effective care for the
patient diagnosed with dementia? (Select all that apply)
a. Taking the patient’s blood pressure regularly
b. Being alert to ways the patient might be hurt
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c. Keeping the patient on a predictable schedule
d. Assuming responsibility for meeting the patient’s needs
e. Providing the patient with nonstimulating, private time
ANS: B, C, E
These interventions take responsibility for areas in which the patient is incapable of
providing self-care and addressing the special needs this patient has. Taking the blood
pressure is not necessary unless there is a medical condition that requires doing so.
Although the patient’s ability to provide self-care will deteriorate, independence should
be encouraged as appropriate.
DIF: Cognitive Level: Application
REF: Page 383
2. For which medication will the nurse prepare material for the family of a patient
diagnosed with mild to moderate Alzheimer’s disease? (Select all that apply.)
a. Tacrine (Cognex)
b. Donepezil (Aricept)
c. Haloperidol (Haldol)
d. Rivastigmine (Exelon)
e. Galantamine (Razadyne)
ANS: A, B, D, E
The only drug that is not generally prescribed for Alzheimer’s disease is Haldol.
DIF: Cognitive Level: Comprehension REF: Page 386
Chapter 17: Disorders of Infancy, Childhood, and Adolescence
1. Which complaint is representative of anxiety in a 6-year-old child?
a. “I worry that my dad will get hurt at work.”
b. “I get a stomach ache when it’s my weekend at my dad’s house.”
c. “I can’t sleep when I stay at Grandma’s because I worry about my mom.”
d. “I’m not going to sports camp because I don’t like being away from my friends.”
ANS: A
Developmental differences exist with regard to the symptoms of anxiety. Children
between the ages of 5 and 8 years old most commonly report unrealistic worry about
harm to their parents. Between the ages of 9 and 12 years, children report excessive
distress during times of separation. Adolescents typically report somatic complaints.
DIF: Cognitive Level: Application
REF: Page 409
2. Which of the following meets the DSM-IV-TR criteria for moderate mental retardation?
a. Requires constant one-on-one supervision and total physical care
b. Advanced as far as the sixth grade and works at a warehouse every day and
supports himself
c. Advanced as far as the second grade and provides her own personal care with
supervision
d. Attends the local community college for developmental English and math courses
ANS: C
Individuals diagnosed as having moderate mental retardation acquire some
communication skills, but rarely advance academically beyond the second grade. With
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supervision they can provide for their own personal care. Persons requiring constant
supervision and total physical care would be considered profoundly retarded. Persons
achieving elementary or above learning skills would be considered mildly retarded.
DIF: Cognitive Level: Application
REF: Page 397
3. The nurse is assessing a child with autism. Which of the following behaviors would
the nurse expect to observe?
a. Referring to their imaginary friend, Skipper
b. Asking to telephone ‘my friends’ on the weekends
c. Repeating, ‘milk, milk, milk, milk’ until given a drink
d. Is insistent that a dim light be left on in the bedroom at night
ANS: C
Stereotyped and repetitive use of language or idiosyncratic language is one of the
characteristic behaviors seen in autism. The remaining options are normal
characteristics of a child in various developmental stages.
DIF: Cognitive Level: Application
REF: Page 398
4. Which behavior best supports the diagnosis of attention-deficit/hyperactivity disorder
in an 8-year-old child?
a. Cries when separated from his mother or father
b. Refuses to pick up toys as instructed by his parents
c. Is fascinated with spinning and moving toys and objects
d. Can concentrate on school work for only very short periods of time
ANS: D
Experiencing difficulty concentrating on tasks is a hallmark for ADHD. Crying is a
characteristic of separation anxiety. Disobedience as described may represent
oppositional behavior. Focusing on repetitious motion is characteristic of autism.
DIF: Cognitive Level: Application
REF: Page 402
5. Which behavior is most characteristic of a conduct disorder?
a. Frequently getting up and interrupting while being read to
b. Only apologizes for hitting a friend to avoid being punished
c. Finds it difficult to spend the night away from family members
d. Becomes extremely agitated when the television is turned off
ANS: B
Children or adolescents with conduct disorder generally do not empathize with other
people’s feelings and are unconcerned with other’s situations or needs. They exhibit
uncaring behavior, but they will often express words of guilt or remorse because they
have learned that it reduces or prevents punishment. ADHD is often characterized by
hyperactivity. Separation anxiety is often responsible for a child’s resistance to spending
time away from home. Autism can be the cause of exaggerated responses.
DIF: Cognitive Level: Application
REF: Pages 404-405
6. Which assessment finding should be considered a high risk factor for adolescent
suicide?
a. Being sexually abused
b. Having experienced panic attacks
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c. Being mildly cognitively impaired
d. Having a diagnosis of type 1 diabetes
ANS: A
Suicide risk factors include a history of sexual abuse. There is no current research to
support a strong relationship between suicide attempts and any of the other options.
DIF: Cognitive Level: Application
REF: Page 406
7. Planning for a patient with Asperger’s disorder will be facilitated if the nurse
understands that this disorder is different from autism. The nurse will base care on
knowledge that Asperger’s disorder is characterized by:
a. Repetitive patterns of behavior
b. Age-appropriate language development
c. Stereotypic movements and speech patterns
d. Obsession with objects that move in a spinning motion
ANS: B
Communication will be facilitated knowing that a patient with Asperger’s disorder has no
clinically significant delays in language or cognitive function. The remaining options are
characteristics of both disorders.
DIF: Cognitive Level: Application
REF: Page 399
8. Which behaviors would support a diagnosis of oppositional-defiant disorder?
a. Exhibits involuntary facial twitching and blinking and makes barking sounds
b. Negative, hostile, and spiteful toward parents and blames others for misbehavior
c. Displays high anxiety when away from parents, has nightmares, and fears being
kidnapped
d. Violates others rights, is cruel to people or animals, lies and steals, and is truant
from school
ANS: B
Children with oppositional defiant disorder argue with adults, actively defy adults’
requests, deliberately annoy adults, and refuse to take responsibility for their behaviors.
Lying, stealing, and animal cruelty describes a child with conduct disorder. Being afraid
of being kidnapped describes a child with separation anxiety. Facial twitching is
associated with Tourette’s disorder.
DIF: Cognitive Level: Application
REF: Page 404
9. Which child’s history is a risk for developing a reactive attachment disorder?
a. Father is a chronic alcoholic
b. Was born with a congenital cardiac disorder
c. Experienced head trauma at age 7 months of age
d. Spent first 12 months of life in an Asian orphanage
ANS: D
Reactive attachment disorder is a disorder that occurs in some children who are
institutionalized.
DIF: Cognitive Level: Application
REF: Page 399
10. Which intervention will best help a teenager manage aggressive behavior?
a. Administering prescribed medication as ordered
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b. Supporting the patient’s interest in writing poetry
c. Reenacting situations that may trigger aggression
d. Providing information on anger management techniques
ANS: C
Role-play situations that trigger aggressiveness explore and reinforce alternative
methods of coping. The other options although appropriate lack the opportunity to
reflect on the triggers and practice the coping skills.
DIF: Cognitive Level: Application
REF: Page 411
11. Which intervention will best help a child manage hyperactive behavior?
a. Arranging for the child to play basketball 4 times a week
b. Allowing the child to play a favorite video game as a reward
c. Using a favorite food and beverage to distract the child
d. Placing the child in a low stimulation environment for 30-60 minutes
ANS: A
Redirect disruptive behavior with recreational activities to channel excess energy. The
remaining options will have little positive effect on the child’s energy level.
DIF: Cognitive Level: Application
REF: Page 411
12. The nursing diagnosis that would be universally applicable for children with autistic
disorder would be:
a. Risk for constipation related to odd eating habits
b. Chronic low self-esteem related to negative social feedback
c. Impaired social interaction related to inability to relate to others
d. Disturbed thought processes related a neurological dysfunction
ANS: C
Children with autistic disorder display profoundly disturbed social relationships.
Essentially, they lack social reciprocity. They seem aloof and indifferent to others and
prefer inanimate objects to people. The remaining options are not necessarily true of this
mental illness.
DIF: Cognitive Level: Application
REF: Page 398
13. A child’s diagnosis of conduct disorder is supported by the fact that:
a. The child’s mother is a chronic alcoholic.
b. The child engages in ritualistic behaviors.
c. A brain scan shows structural abnormalities.
d. There is a family history of respiratory disorders.
ANS: A
Conduct disorder occurs more frequently when a biologic parent has alcohol dependency.
There is no research to support a connection between a conduct disorder and any of the
remaining options.
DIF: Cognitive Level: Application
REF: Page 404
14. Which intervention will best help minimize parental guilt in the family of a child
diagnosed with a psychiatric disorder?
a. Helping them to develop realistic expectations for their child
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b. Educating them on the need to provide the child with boundaries
c. Providing them with information regarding locally available services
d. Encouraging them to use respite care periodically to allow for downtime
ANS: A
Teach the parents about the patient’s disorder to minimize their guilt related to causing
or caring for the child. The remaining options although appropriate do not focus on the
potential for self guilt.
DIF: Cognitive Level: Application
REF: Page 412
15. Which behavior demonstrates that a child is achieving appropriate management of
separation anxiety?
a. Earned two As, three Bs, and one C this report card period
b. Falls asleep with a parent sitting outside the bedroom door
c. Sleeps on a chair in the parent’s bedroom rather than in their bed
d. Reports having only a ‘little stomach ache’ during breakfast on school days
ANS: A
Children with separation anxiety disorder demonstrate academic difficulties resulting
from a refusal to attend school or frequent absences resulting from somatic illnesses.
The other options show continued behaviors seen with this disorder.
DIF: Cognitive Level: Application
REF: Page 400
16. A 15-year-old has been diagnosed with major depression and admitted to the
adolescent unit. Which behavior would the nurse expect to observe in this patient?
a. Discussing repeated “run-ins” with the law
b. Being manipulative and callous towards others
c. Blaming “adults” for his admission to the adolescent unit
d. Reporting decreased enjoyment of school-related activities
ANS: D
Anhedonia, the absence of pleasure, is a common manifestation of depression. Legal
behavior and manipulative and uncaring behavior are characteristic of conduct disorder.
Seeing adults as the root of their problems is common in conduct disorder and
oppositional-defiant disorder.
DIF: Cognitive Level: Application
REF: Page 408
17. When discussing depression and suicide with parents of teenagers, the nurse is
accurate in reporting that the most common method used in late adolescent suicide
is:
a. Hanging
b. Firearms
c. Oral poisoning
d. Drug overdose
ANS: B
Statistics show the use of firearms is the most commonly used method of committing
suicide among adolescents. With this in mind, the nurse could counsel parents about the
importance of keeping firearms locked away from teens. The other options are less-often
used methods for attempting suicide.
DIF: Cognitive Level: Comprehension REF: Page 406
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18. Planning safety interventions for a teenager with a history of self-injurious behavior is
based on what research-based information?
a. Teenagers rarely entertain the idea of suicide.
b. Suicides can occur accidentally as a result of self-injurious behaviors.
c. Self-injury is always viewed as a risk factor for future suicidal attempts.
d. Assessment for suicidal ideations is a vital component of this child’s care.
ANS: B
Self-injurious behavior is not suicidal behavior and is not viewed as a risk factor for
suicidal ideations or attempts, but some teenagers accidentally commit suicide in the
process. Teenagers are acting on suicidal thoughts at an alarming rate.
DIF: Cognitive Level: Application
REF: Page 407
19. Which statement made by a teenage male hospitalized after a failed suicide attempt
is most concerning to the nurse?
a. “My uncle shot himself but he didn’t die.”
b. “I don’t know why I get so depressed and want to die.”
c. “The gun I got for my birthday is my most prized possession.”
d. “I hope I don’t ever get depressed enough to try and hurt myself again.”
ANS: C
Factors associated with suicidal behaviors include access to firearms providing the
teenage patient with the opportunity and means to harm himself if he again becomes
depressed. Although the remaining options represent possible risk factors, none provide
insight into opportunity and means.
DIF: Cognitive Level: Analysis
REF: Page 406
20. The mother of a child describes her child’s “annoying behavior” as not being able to
sit still or to stop jerking his arms when told to. Which disorder does the nurse
suspect?
a. Tourette’s disorder
b. Oppositional-defiant disorder
c. Pervasive developmental disorder
d. Attention-deficit/hyperactivity disorder
ANS: A
The parent describes simple motor tics that are involuntary behaviors and characteristic
of Tourette’s disorder. The child is not being defiant because he has no control of the tics.
Although the child displays repeated motor behaviors, they are unrelated to
hyperactivity because they are not generalized and occur only sporadically. These
involuntary tics are not seen in pervasive developmental disorders such as autism.
DIF: Cognitive Level: Comprehension REF: Page 401
21. Which response is most therapeutic when a parent whose child is diagnosed with
Tourette’s disorder voices concerns that their child’s facial contortions are merely
acts of defiance?
a. “Your child isn’t defiant but rather mentally ill.”
b. “What makes you think he is doing that out of defiance?”
c. “I think with the use of some behavior modification techniques, he can learn to
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control the facial tics.”
d. “Your son’s behavior is likely due to a neurological dysfunction that causes those
involuntary facial tics.”
ANS: D
Tourette’s disorder is most often thought to be a genetic neurologic disorder whose
characteristic behaviors are involuntary in nature. Referring to the child as mentally ill is
not a true description of the situation. Asking the parent to further discuss the idea that
the tics are an act of defiance is inappropriate since that is not true. Behavioral
modification is not effective on involuntary behaviors.
DIF: Cognitive Level: Application
REF: Page 401
22. Which description is characteristic of an impulsive child?
a. Pacing and speaking in a very loud, disruptive voice
b. Frequently talking about hearing voices telling him what to do
c. Running out into the street regardless of frequent instruction to look both ways
first
d. Having a difficult time concentrating on reading since his attention is easily
diverted
ANS: C
Running into the street is an example of impulsive behavior because it is clearly taking
action before considering consequences. Hyperactivity refers to such things as increased
pace and volume of activity. Thought disorders include such perceptual dysfunction as
auditory hallucinations. Distractibility is characterized by poor concentration.
DIF: Cognitive Level: Application
REF: Page 403
23. Which intervention would qualify as primary prevention of violent behaviors in
children and adolescents?
a. Forbidding the child to continue friendships with violent peers
b. Limiting exposure to violence on TV, video, and computer games
c. Seeking counseling for a child who has been experimenting with drugs
d. Showing a unified approach to parenting when dealing with a violent child
ANS: B
Studies suggest that an obsession with violence in video games, movies, music, and
writings increases aggressiveness in children and adolescents. The other options are
relevant only after the risk for violence has been established.
DIF: Cognitive Level: Application
REF: Page 407
24. A friend says to a nurse, “I am not going to get vaccines for my baby. I hear that
vaccines cause autism.” The nurse’s best reply is:
a. “The exact cause of autism is not really known”
b. “It’s believed that autism is really a result of birth trauma.”
c. “There is no conclusive evidence to connect autism to vaccinations.”
d. “Please tell me more about where you got that information about autism?”
ANS: C
There is no research to connect autism to a reaction to vaccinations or to birth trauma.
The exact cause of autism remains undetermined but that response doesn’t address the
patient’s statement nor does asking the patient to give additional information regarding
their original statement.
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DIF:
Cognitive Level: Application
REF:
Page 397
25. A 5-year-old girl on a behavior modification program is admitted to the unit. The
nurse would expect to participate in which activity based on this approach?
a. Firmly challenging the child’s irrational thoughts
b. Including the child in the creation of a behavioral contract
c. Family therapy with every member present for each session
d. Play therapy with dolls representing every member of the family
ANS: B
Behavior modification includes constructing a contract that outlines behavioral changes
that is a result of the input of therapists, family and the child. Family therapy, play
therapy, and thought challenging are not generally used with a behavior modification
program.
DIF: Cognitive Level: Application
REF: Page 414
26. A mother asks why the whole family needs to meet with the therapist because it is
her teenage stepdaughter who has the substance abuse problem. The nurse replies
with the knowledge that:
a. Mothers usually have insight into their children’s problem.
b. The parents are responsible for changing the teen’s behavior.
c. The family will probably use behavior modification with the teen.
d. Sometimes the teenaged patient is actually acting out family dynamics.
ANS: D
It is important to remember that children will often act out the underlying family
dynamics or family psychopathology. Mothers may not have an understanding of the
problems their children are experiencing. Behavior modification is not typically a
treatment for teen substance abuse. The teen is responsible for changing personal
behavior.
DIF: Cognitive Level: Application
REF: Page 409
1. The parents of a child diagnosed with ADHD ask the nurse what current medications
are available for their child. The nurse should list which of the following medications?
(Select all that apply.)
a. Methylphenidate (Concerta)
b. Zolpidem (Ambien)
c. Dextroamphetamine (Adderall)
d. Atomoxetine (Strattera)
e. Haloperidol (Haldol)
ANS: A, C, D
Ambien is a sleeping medication and not typically used to treat ADHD. Haldol is an
antipsychotic that is not specified for use for ADHD. The other medications are
sometimes used for ADHD.
DIF: Cognitive Level: Application
REF: Page 412
Chapter 18: Eating Disorders: Anorexia Nervosa and Bulimia Nervosa
1. The mother of a teen with an eating disorder expresses a concern that the family is
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responsible for the problem. Which question will best help the nurse identify another
influence that is likely to have played a role in the teenager’s eating disorder?
a. “Does she have an after-school job?”
b. “Does she have access to nutritious foods?”
c. “Is there a family history of underweight adults?”
d. “Is your daughter interested in clothes and fashion?”
ANS: D
Women in this culture are bombarded by the fashion industry and media messages
equating beauty with thinness. Although it is true that eating disorders are less common
in countries where food is not abundant, in this culture persons with eating disorders
tend not to choose nutritious foods. Workplace competition with men would be of greater
significance than this broad statement. The biologic tendency to be overweight may
influence some persons.
DIF: Cognitive Level: Application
REF: Pages 419-420
2. Long-term prognosis for eating disorders is improved dramatically when treatment
includes long-term cognitive-behavioral therapy. What statement provides the best
explanation to the patient for this component to the treatment plan?
a. “This will help you identify a healthy, weight restoration diet.”
b. “Medication alone will not help you from relapsing back to your old habits.”
c. “In order to manage your disorder, you have to understand the root problems.”
d. “Prognosis has been proven to be much better with both medication and
therapy.”
ANS: C
Individuals need to resolve the core problems related to their eating behavior as well as
the underlying psychological issues. Outcome literature indicates that long-term
cognitive-behavioral, family, or interpersonal therapy, often in combination with
antidepressant medication, results in the most sustained improvement. Long-term
outcome studies show a more promising prognosis for those patients who continue
treatment. Weight restoration is necessary but not sufficient for recovery. The options
that discuss the components of treatment do not sufficiently explain the reasoning
behind cognitive and behavior therapy.
DIF: Cognitive Level: Application
REF: Page 426
3. The nurse is identifying outcomes for a teenager diagnosed with anorexia nervosa.
Which outcome has the greatest impact on long-term prognosis?
a. Verbalize underlying psychological issues.
b. Demonstrate effective coping skills related to conflict management.
c. Demonstrate improvement in body imagine reflecting a realistic viewpoint.
d. Consume adequate calories appropriate for age, height, and metabolic needs.
ANS: B
Long-term prognosis is dependent on the patient’s ability to cope with the stressors that
are at the root of the emotional problems such as conflict with family. Verbalization of
underlying stressors is not a guarantee that there will be progress towards managing
them. Acceptance of one’s body and adequate calorie intake is possible only after coping
skills are learned and used.
DIF: Cognitive Level: Application
REF: Page 429
4. Which statement is the basis for the cross-cultural assessment practices of eating
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disorders?
a. Mediterranean cultures are more likely to exhibit symptoms.
b. Male-dominated cultures are more likely to accept this disorder.
c. Westernized cultures tend to have similar numbers of diagnosed cases.
d. Access to food is the primary factor in determining incidence of the disorder.
ANS: C
The incidence and prevalence of eating disorders around the world are similar among
European countries, the United States, Canada, Mexico, Japan, Australia, and other
Westernized
countries. Access to food is not necessarily a cultural factor.
DIF: Cognitive Level: Application
REF: Page 423
5. The nurse observes a distorted thinking pattern in a teenage patient diagnosed with
an eating disorder. Which statement characterizes personalization by the patient?
a. “I’ve got to be thin to get a good job.”
b. “There is no such thing as a healthy carbohydrate.”
c. “My mother and dad fight all the time because I’m fat.”
d. “My whole family will be disgraced if I don’t get into a good college.”
ANS: C
The basis of personalization of thinking is that an individual compare themselves
endlessly with others and perceive others’ behavior as a direct reaction to them.
Believing the problems the parents are experiencing is a direct result of the patient’s
weight is an example of such thinking. The thought that a job depends solely on weight
or that all carbohydrates are bad are examples of dichotomous thinking. Feeling
responsible for the family’s reputation is a reflection of control fallacy thinking.
DIF: Cognitive Level: Application
REF: Page 422
6. A 16-year-old patient has anorexia nervosa. Which term used to describe the
menstrual history is characteristic of this disorder?
a. Amenorrhea
b. Dysmenorrhea
c. Premenstrual syndrome
d. Heavy menstrual flow
ANS: A
Amenorrhea is common in patients with eating disorders, possibly due to altered
hypothalamic function. The remaining options are not usually related to changes
resulting from an eating disorder.
DIF: Cognitive Level: Comprehension REF: Page 426
7. A 14-year-old patient newly admitted to the eating disorders unit refuses to eat
meals and angrily shouts at the nurse, “You can’t make me eat! I’ll do whatever I
want to do.” Which nursing intervention demonstrates an understanding of the
priority safety issue for this anorexic patient?
a. Placing the patient’s favorite low calorie beverages in open view
b. Assigning a staff member to one-on-one observation of the patient
c. Unlocking the patient’s bathroom only at specific times during the day
d. Explaining to the patient that they will be required to keep an eating journal
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ANS: B
The patient, especially when stressed, is capable of self-mutilation and needs to be
protected from doing so. The issues of hydration, purging, and therapy work do not have
the priority that physical safety has.
DIF: Cognitive Level: Application
REF: Page 429
8. A nursing intervention that will be planned to occur early in the nurse-patient
relationship with a patient with an eating disorder is:
a. Using confrontation to attack denial
b. Placing the patient in a therapeutic group
c. Formulating a therapeutic nurse-patient alliance
d. Attacking enmeshment by separating patient and family
ANS: C
An alliance is formulated early to give the patient an opportunity to participate in
treatment and increase the patient’s sense of control, thus eliminating power struggles.
Confrontation is rarely used early in the relationship. Placement in a group and antienmeshment techniques would normally take place after the contract has been agreed
on.
DIF: Cognitive Level: Application
REF: Page 427
9. A patient is being assessed for a binge-eating–associated eating disorder. Which
assessment question is directed towards collecting data on the most commonly
abused substance among this patient population?
a. “How much alcohol do you drink on a weekly basis?”
b. “Do you use amphetamines to help control your weight?”
c. “Do you rely on laxatives to control your bowel movements?”
d. “How many packs of cigarettes do you smoke on a daily basis?”
ANS: A
Eating disorder symptoms predict the type of drug use, with bingeing associated more
with alcohol and tranquilizer abuse, purging associated more with the abuse of multiple
drugs, and restricting associated more with amphetamine.
DIF: Cognitive Level: Application
REF: Page 424
10. The nurse is caring for a patient who is being treated for comorbid eating and
affective disorders. For which medication would the nurse expect to prepare a patient
teaching plan?
a. Fluoxetine (Prozac)
b. Diazepam (Valium)
c. Lorazepam (Ativan)
d. Lithium
ANS: A
SSRIs are effective in treatment of depression and have been found to be useful in
treatment of eating disorders. Benzodiazepines like Valium and Ativan are used for
anxiety reduction. Lithium is used for bipolar disorder.
DIF: Cognitive Level: Comprehension REF: Page 432
11. A patient who is hospitalized with anorexia nervosa states during a one-to-one
session with the nurse, “I’m freaking out. I’m losing it.”" Which nurse response would
be most therapeutic at this time?
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a. “Would you feel better if I called your parents?”
b. “Just sit here and relax that will help you regain control.”
c. “May I sit with you while you think about what is happening?”
d. “Please tell me what thoughts are going through your head right now.”
ANS: D
Helping the patient identify thoughts will facilitate the learning of effective coping
mechanisms to deal with the stress. The patient needs to learn to bear and deal
effectively with her own discomfort. The nurse is taking control without allowing the
patient the opportunity to deal with her own issues. The nurse should encourage the
patient to deal with her feelings and issues, rather than sit passively with her.
DIF: Cognitive Level: Application
REF: Page 433
12. Accomplishment of which expectation should be considered most critical prior to
discharging a patient with anorexia nervosa?
a. Attainment of minimum normal weight
b. Resumption of normal menstrual cycle
c. Reduction of periods of active exercise to three times daily
d. Knowledge of nutritional value of foods required for a balanced diet
ANS: A
Attaining the desired weight is the priority discharge goal because it best indicates
patient compliance with the treatment plan. Resumption of the menstrual period may
take an extended time. Having knowledge of nutrition does not ensure that the patient
will apply it. Exercising three times a day is considered excessive.
DIF: Cognitive Level: Application
REF: Pages 426-427
13. Which patient statement demonstrates the expected emotional response to
bingeing?
a. “I know it’s bad but I can’t help bingeing.”
b. “Everyone indulges in bingeing some times.”
c. “After I binge I feel happy for a little while.”
d. “Bingeing isn’t bad if I do it only when I’m stressed.”
ANS: C
Serotonin levels and mood both improve with bingeing. This affect on serotonin would
not result in rationalization, denial, or a sense of guilt and hopelessness.
DIF: Cognitive Level: Application
REF: Page 421
14. Which intervention best monitors the health status of a patient newly admitted for a
diagnosis of bulimia nervosa?
a. Scheduling a bone mineral density screening
b. Performing a portable electrocardiogram (ECG)
c. Obtaining a urine sample for a urine analysis
d. Arranging for a serum potassium level to be drawn
ANS: D
Patients with bulimia nervosa require initial assessment for acute fluid and electrolyte
imbalances (particularly serum potassium) for the presence of life-threatening
imbalances. Bone mineral density screening for osteopenia and osteoporosis and
assessment is appropriate but it does not have priority over of the blood work to identify
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an acute life-threatening condition. The remaining options are not diagnostic tests that
are generally required of this diagnosis.
DIF: Cognitive Level: Application
REF: Page 432
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential: Diagnostic Tests
15. In an art therapy session, a patient with anorexia nervosa was asked to draw a
picture of herself. Which drawing would likely depict the patient’s view of herself?
a. A tall, slim girl with obvious muscle definition
b. A shapely figure of a model who she really admires
c. A malnourished teenager with thin, lanky extremities
d. A grossly obese figure lacking feminine characteristics
ANS: D
Patients with eating disorders have alexithymia (i.e., difficulty naming their feelings) and
they often have difficulty finding the words needed for talk therapy. Therefore, the use of
expressive arts therapy allows for nonverbal self-disclosure and the experiential
exploration of the inner experience. It also bypasses intellectual defenses and helps the
patient to be more present in his or her bodily experience. The patient would be able to
draw what she is unable to verbally describe. The other options do not reflect the
anorexic patient’s self-view of their body.
DIF: Cognitive Level: Analysis
REF: Page 433
16. A teenager admitted to the eating disorders unit has begun displaying behaviors that
reflect possible secondary gains related to the hospitalization. What is the basis for
this behavioral change?
a. The patient has moved into the guilt phase of the recovery process.
b. The attention has reinforced the initial food-focusing behaviors.
c. The medication therapy has not yet brought about the expected results.
d. The increase of calories had help clarify the patient’s thought processes.
ANS: B
Unfortunately, secondary gains, such as the attention generated from the
hospitalization, reinforce the behavior associated with the eating disorder. There is no
phase of the recovery identified with the expression of guilt. Clarity of one’s thinking nor
the expected effects of medication therapy would contribute to secondary gains.
DIF: Cognitive Level: Application
REF: Page 422
17. How does the mortality rate among patients diagnosed with eating disorders
compare to those with other psychiatric diagnoses?
a. More deaths are attributed to substance abuse than to eating disorders.
b. This disorder is associated with the highest death rate among all other disorders.
c. This disorder has fewer associated deaths that any other impulse control
disorder.
d. More related deaths are recorded compared to those associated with
schizophrenia.
ANS: B
The mortality rate with eating disorders is higher than that seen with any other
psychiatric diagnoses, and it has been reported at 4% to 20% of death among this
population.
DIF: Cognitive Level: Application
REF: Pages 423-424
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18. A patient being treated for an eating disorder is prescribed refeeding. Which outcome
is the primary reason a patient receiving this treatment is closely monitored by the
nursing staff?
a. Complies with treatment commendation made by treatment team
b. Regularly consumes and tolerates between 3000 to 4000 kcal/day
c. No physical signs or symptoms of an electrolyte imbalance are observable
d. Discharge depends on patient’s ability to demonstrate a gain of 3 pounds per
week
ANS: C
Although all options are outcomes requiring nursing assessment and monitoring, the
acute and serious nature of electrolyte imbalances has priority over the remaining
options.
DIF:
Cognitive Level: Analysis
REF:
Page 432
19. The interdisciplinary care team has suggested family-based therapy as a part of the
care plan of a teenager diagnosed with an eating disorder. Which statement is the
basis for this recommendation?
a. This approach encourages family involvement in the patient’s recovery.
b. The family is often dysfunctional, enmeshed, and in need of counseling.
c. This approach has shown a significant impact on successful long-term prognosis.
d. The family implements the behavioral contract as established by the plan of care.
ANS: C
Outcome studies of this approach to anorexia show a 90% improvement rate as
compared with an 18% improvement rate for those receiving individual therapy. Fiveyear follow-up studies show that 70% of patients remained in recovery with this type of
treatment. The remaining options are all correct but they do not directly address the
impact on long-term prognosis.
DIF: Cognitive Level: Comprehension REF: Page 434
20. A parent of a teenager being treated for anorexia nervosa asks the nurse what,
“Being an enmeshed family” means. Which question provides the best response to
the question?
a. “What do you think that statement means?”
b. “Who told you your family was enmeshed?”
c. “Are the members of your family expected to be independent and self-reliant?”
d. “Does your family place importance on being successful and accepted by
others?”
ANS: D
An enmeshed family often puts a lot of importance on body image, social acceptance,
and achievement. Expecting independence and self-reliance is not compatible with
enmeshed family dynamics. The remaining options do not address the parent’s question.
DIF: Cognitive Level: Application
REF: Page 422 | Page 436
21. A patient with severe weight loss as a result of anorexia nervosa has refused meal
trays and supplemental feedings for 3 days since being admitted to the hospital and
so refeeding has been ordered. Which intervention will initiate this treatment?
a. Scheduling a nutrition consult with the hospital dietitian
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b. Tube feedings until the patient eats 90% of all meals for 1 day
c. IV infusions beginning immediately and continuing for 48 hours
d. Placing the patient on suicide precautions and one-to-one observation
ANS: B
The priority is to begin refeeding, a procedure that involves tube feedings that are
continued until the patient is voluntarily eating sufficient quantities. Refeeding takes
place using foods and fluids via the GI tract, rather than by the parenteral route.
Although refeeding is very threatening to the patient, since they have no control over
the weight gain that will occur, suicide precautions are not indicated at this point, but
careful assessments will continue. A nutritional consult is not useful at this point in the
treatment since the patient is not making choices regarding eating.
DIF: Cognitive Level: Application
REF: Page 434
22. A patient’s plan of care is being managed by an interdisciplinary team familiar with
the etiology of eating disorders. Which team principle is most important to the
successful treatment of this patient population?
a. The team must preserve the patient’s sense of autonomy.
b. The patient must be an active member of the care planning team.
c. The patient’s family must be included in the decision-making process.
d. The plan of care must demonstrate collaboration and consistency by the team.
ANS: D
In order to best assure a good prognosis, the plan of care has to include consistent and
collaborative efforts by all members of the interdisciplinary team. Although the
remaining options are goals to be strived for, they do not have the importance that
collaborative and consistent care planning has for successful treatment.
DIF: Cognitive Level: Analysis
REF: Page 430
23. Which concern has the greatest priority for a patient admitted with a diagnosis of
bulimia nervosa?
a. Social isolation
b. Imbalanced fluid volume
c. Compromised family coping
d. Disturbed perception of body image
ANS: B
The physical harm that can result for a fluid imbalance has priority over any of the
psychological options presented.
DIF: Cognitive Level: Analysis
REF: Page 429
24. A patient diagnosed with bulimia nervosa is hospitalized for treatment of electrolyte
imbalance. Which response by the nurse to the patient’s request to use the bathroom
immediately after eating lunch is most therapeutic?
a. “No one is allowed to leave the dining room during meals.”
b. “Okay, but as you know I will accompany you to the bathroom.”
c. “We’ve discussed that there are other options than to induce vomiting.”
d. “I think I understand your plan, and I cannot permit you to carry it out.”
ANS: B
To best ensure a good prognosis, the plan of care has to include consistent and
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collaborative efforts by all members of the interdisciplinary team. The patient is most
likely attempting to purge to manage weight gain and the nurse must attempt to prevent
that behavior. Refusing to allow the request does not account for the fact that the
patient might actually need to void or defecate. Assuming the patient’s motivation in this
manner is confrontational and nontherapeutic, suggesting that other options are
available is not addressing the immediate request.
DIF: Cognitive Level: Application
REF: Page 430
25. After ignoring a unit rule regarding being weighed, a patient receiving treatment for
an eating disorder tells the nurse, “I can’t get weighed this morning, because I drank
a glass of juice a few minutes before breakfast.” Which statement by the nurse is
consistent with treatment principles?
a. “I’m pleased that you took in some calories.”
b. “This is weight day. Please step on the scale.”
c. “We need to discuss why you chose to ignore the rules about being weighed.”
d. “The rule is ‘weigh before eating’; now we have to put it off until tomorrow.”
ANS: B
The nurse needs to create a structured and supportive environment with clear,
consistent, and firm limits. This helps to establish a predictable routine and promotes
internal control that the patient currently lacks. This response is calm, matter-of-fact, and
firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a
situation in which a power struggle is likely to arise. The patient should not be praised for
behavior that broke the rules. Although the issue needs to be discussed, this is not the
time to address it. The remaining option suggests that the patient will not be weighed
according to schedule.
DIF: Cognitive Level: Application
REF: Page 430
1. A patient is being assessed for possible anorexia nervosa. Which behaviors are
supportive of such a diagnosis? Select all that apply.
a. Eats only red apples and green grapes
b. Exercises 3 times a day every day
c. Has lost 25 pounds but wears only pre-loss clothing
d. Becomes extremely agitated whenever expected to eat
e. Reports fantasies about being able to eat without gaining weight
ANS: A, B, C, D
The characteristic of anorexia nervosa do not include fantasies about eating.
DIF: Cognitive Level: Comprehension REF: Page 426
2. Which reports describe behaviors that meets the criteria for a diagnosis of binge
eating? Select all that apply.
a. Sister reports, “She is so sad after she finishes.”
b. Claims, “I can’t control myself when I get that way.”
c. The patient reports, “making myself vomit” at least twice a week.
d. Mother reports seeing the patient, “eat entire loaf of bread for lunch.”
e. Maintains that, “I look okay now but I do this so I don’t gain any weight.”
ANS: A, B, C, D
All described behaviors are characteristic of binge eating except for the belief that body
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image is currently acceptable.
DIF: Cognitive Level: Application
REF:
Page 425
3. Which assessment findings support a diagnosis of bulimia nervosa? Select all that
apply.
a. Loose watery stool
b. Red rash on extremities
c. Blood pressure of 88/58
d. A potassium level of 2.8 mEq/L
e. Reports of mild muscle cramping
ANS: A, C, D, E
A red rash on the extremities is not a characteristic of bulimia. All other options can be
related to the disorder.
DIF: Cognitive Level: Analysis
REF: Page 427
4. The mother of a teenager is concerned that the child may be anorexic. Which report
of the teenager’s behavior is support of such a diagnosis?
a. Insists she likes “really baggy clothes”
b. Will eat only lean protein, fruits, and vegetables
c. Has had one menstrual period in the last 2 years
d. Although she has grown 3 inches, she has gained no weight
e. Regularly claims that she will “eat later” but seldom does
ANS: A, C, D, E
A willingness to eat lean meats, fruits, and vegetables would not be characteristic of a
patient exhibiting anorexia. The remaining options could be seen in such a patient.
DIF: Cognitive Level: Application
REF: Page 425
Chapter 19: Sleep Disorders: Dyssomnias and Parasomnias
1. Which assessment observation would not support a diagnosis of narcolepsy?
a. Sleep study reports excessive, loud snoring.
b. Sleep study shows evidence of sleep paralysis.
c. Patient reports “needing to drink pots of coffee to stay awake at work.”
d. Patient reports, “When I get sleepy I actually see things that aren’t really there.”
ANS: A
Snoring is a characteristic obstructive sleep apnea, not narcolepsy. Classic symptoms of
narcolepsy include excessive daytime sleepiness, sleep paralysis, and hallucinations
DIF: Cognitive Level: Application
REF: Page 446
2. An adult patient diagnosed with narcolepsy is being educated on the medication
therapy that is prescribed. Which explanation is provided for the central nervous
system stimulant dextroamphetamine (Dexedrine)?
a. The apnea will be lessened by this medication.
b. It will help control the sporadic loss of muscle tone.
c. This medication will minimize the daytime sleepiness.
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d. Dexedrine will manage the inflammation that causes the snoring.
ANS: C
Central nervous system stimulants such as dextroamphetamine (Dexedrine, Dextrostat)
may be prescribed to manage excessive daytime sleepiness. This medication has no
affect on cataplexy, apnea, or snoring. Apnea and snoring are not symptoms of
narcolepsy.
DIF: Cognitive Level: Application
REF: Page 451
3. A pediatric patient has been diagnosed with obstructive sleep apnea (OSA). Which
statement would the nurse use as a basis for explaining the etiology of this disorder?
a. Melatonin is not being released in sufficient quantity.
b. This condition is often due to adenotonsillar hypertrophy.
c. Children have a high ratio of REM sleep that can result in frequent gasping.
d. This can be related to a sleep position which compromises chest movement.
ANS: B
When OSA is found in children, it is usually the result of adenotonsillar hypertrophy,
craniofacial abnormalities, and neuromuscular conditions, all of which result in airway
obstruction during sleep. There is no research on OSA related to melatonin insufficiency,
dreaming, or a particular sleep position.
DIF: Cognitive Level: Application
REF: Page 445
4. Which outcome is appropriate for an adult patient recently diagnosed with primary
insomnia?
a. Demonstrate an understanding of the cerebral stimulants prescribed.
b. Recognize that the prescribed flurazepam (Dalmane) can be used for up to 2
months.
c. Demonstrate the proper use of continuous positive airway pressure (CPAP)
ventilation.
d. Recognize physical and psychosocial stressors that exacerbate the sleep
disturbance.
ANS: D
The patient should identify physical and psychosocial stressors that exacerbate the sleep
disturbance in order to attempt successful self-management of the problem. Neither
stimulants nor CPAP therapy are prescribed for this disorder. The duration of flurazepam
therapy is considerably shorter.
DIF: Cognitive Level: Application
REF: Page 448
5. A 10-year-old is diagnosed with somnambulism as a result of frequent episodes of
sleepwalking. Which topic should be included when considering patient and family
education?
a. Medication therapy seldom prescribed for this disorder
b. Safety issues such as sleeping in the ground level bedroom
c. The likely connection between sleepwalking and narcolepsy
d. The need for short-term cognitive and behavioral therapy
ANS: B
Safety is a primary concern when managing sleepwalking since injury is quite likely as a
result of the patient’s inability to be aware of danger. Drugs that suppress stages 3 and 4
sleep, such as benzodiazepine hypnotics, have been used for the management of this
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disorder. There is no research to support a connection between this disorder and
narcolepsy. This disorder is not treated with either of these therapies.
DIF: Cognitive Level: Application
REF: Page 452
6. Which patient statement would support a diagnosis of a circadian rhythm sleep
disturbance?
a. “I just started on the night shift at work.”
b. “My mother was seriously depressed for years.”
c. “I wake up gasping for breath, and it is really scary.”
d. “I don’t think I drink any more than my buddies do.”
ANS: A
The shift work–type of circadian sleep disorder is usually the result of night shift work or
frequently rotating shift work. Depression, breathing problems, and drinking indicate
other types of sleep disturbances.
DIF: Cognitive Level: Application
REF: Page 447
7. Which physical assessment finding is supportive of a diagnosis of obstructive sleep
apnea?
a. Barrel chest
b. Raccoon eyes
c. Enlarged nasal nares
d. Large neck circumference
ANS: D
Persons with obstructive sleep apnea often have a large neck circumference that
appears to be related to pressure being applied to the trachea. Neither an enlarged
chest nor enlarged nostrils would cause the airway obstruction associated with this
disorder. Blackened eyes are related to trauma or allergies.
DIF: Cognitive Level: Application
REF: Page 446
8. When the family of a child diagnosed with a nightmare disorder asks the nurse about
prognosis, the nurse replies with the knowledge that:
a. The disorder is frequently self-limiting in children.
b. If the child is obese, it is likely the nightmares will continue.
c. High doses of diazepam (Valium) are needed to cure the disorder.
d. With the use of antipsychotic medication, the disorder will not worsen.
ANS: A
A child who is experiencing nightmares usually outgrows the disorder as he or she ages.
Medications are not generally prescribed for this disorder. There is no research to support
a correlation between obesity and nightmares.
DIF: Cognitive Level: Application
REF: Pages 445-446
9. Which of the statements made by the patient would be most indicative of
dyssomnia?
a. “I think I am seeing things when I wake up.”
b. “My wife says I snore and even stop breathing.”
c. “I go to sleep okay but then wake up several times at night.”
d. “My wife says I sit straight up in bed at 2 AM and then say strange things.”
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ANS: C
The dyssomnia known as insomnia is characterized by a predominant complaint of
difficulty initiating or maintaining sleep. Snoring is a characteristic of obstructive sleep
apnea. The other options are seen in narcolepsy.
DIF: Cognitive Level: Application
REF: Page 446
10. A patient with obstructive sleep apnea (OSA) is being discharged. What patient
statement indicates the need for further teaching?
a. “I hope to lose some weight.”
b. “My antidepressants seem to be helping.”
c. “I will try the oral appliance that the doctor suggested.”
d. “A glass of wine at bedtime will help relax my airways.”
ANS: D
Health care providers usually discourage patients with this disorder from using sedating
substances such as alcohol, because these types of sedatives often exacerbate the
problem by relaxing the airway, thus increasing the risk of longer apneic episodes
throughout the night. The remaining options are all positive strategies to help with OSA.
DIF: Cognitive Level: Application
REF: Page 452
11. Which statement indicates to the nurse that a patient requires additional education
regarding appropriate sleep hygiene?
a. “I will try to avoid daytime napping.”
b. “Relaxing music may help relax me for sleep.”
c. “Exercising before bed will make me good and tired.”
d. “I need to cut back on my four daily cups of coffee.”
ANS: C
Avoiding physical exercise or mental stimulation just before bedtime will usually support
healthy sleep patterns. The remaining options are all good sleep hygiene practices.
DIF: Cognitive Level: Application
REF: Page 452
12. A patient tells the nurse, “I take herbal products like melatonin and valerian to help
sleep.” Which response will the nurse make to the patient?
a. “My aunt uses them, and they help her a lot.”
b. “Studies show they are ineffective as sleep aids.”
c. “They can cause serious side effects and should be avoided.”
d. “Be aware that these products are uncontrolled, so preparations vary.”
ANS: D
Herbal products (e.g., melatonin, valerian) are not regulated by the U.S. Food and Drug
Administration, and preparation concentrations may vary. It is not appropriate to give
advice based on personal anecdote. There has not been systematic evaluation of the
products, so there is no proof to support statements regarding effectiveness or severity
of side effects.
DIF: Cognitive Level: Application
REF: Page 451
13. Which intervention will best assess a narcoleptic patient for a commonly recognized
comorbid psychiatric disorder?
a. Observing for signs of self-mutilation
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b. Observing the patient for ritualistic behaviors
c. Asking, “Do you consider yourself to be depressed?”
d. Asking, “Do you rely on alcohol to function socially?”
ANS: C
Research supports a link between insomnia and major depression.
DIF: Cognitive Level: Application
REF: Page 445
1. An adult patient diagnosed with insomnia is prescribed the antihistamine,
diphenhydramine. Which side effects does the nurse educate the patient about?
Select all that apply
a. Urinary retention
b. Blurred vision
c. Rhinorrhea
d. Dry mouth
e. Diarrhea
ANS: A, B, D
Such drugs as Sominex and Unisom contain diphenhydramine, which is an antihistamine
that has both sedative and anticholinergic effects (e.g., dry mouth, blurred vision,
constipation, nasal congestion, urinary retention) and prescribed for insomnia.
Rhinorrhea and diarrhea are not side effects of the anticholinergics.
DIF: Cognitive Level: Comprehension REF: Pages 450-451
2. During the assessment interview, a patient tells the nurse he has “sleep problems.”
Which question will assess for the use of substances that affect the quality of sleep?
Select all that apply.
a. “Do you follow a low-fat diet?”
b. “Are you a big coffee drinker?”
c. “Do you indulge in an evening alcoholic drink?”
d. “Have you been prescribed an opiate-based analgesic”?
e. “Are you currently taking antianxiety medication?”
ANS: B, C, D, E
Examples of substances that influence sleep includes alcohol, stimulants such as
caffeine,
sedatives such as opiates, and antianxiety medications. Fats are not thought to influence
sleep.
DIF: Cognitive Level: Application
REF: Page 444
3. Which suggestions would be included when educating a patient concerning the
management of a circadian rhythm sleep disorder? Select all that apply.
a. Darken the bedroom.
b. Go to sleep at the same time each night.
c. Keep the bedroom environment calm and serene.
d. Initially, retire 30 minutes earlier than usual.
e. Take a low-dose over-the-counter sleep aid.
ANS: A, B, C, D
The primary aim when managing a circadian rhythm sleep disorder is positively affected
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by establishing regularity in the sleep-wake cycle by synchronizing sleep-wake patterns
with typical daily schedules, identifying and managing external environmental factors
that interfere with sleep, and encouraging the patient to sleep earlier than the previously
established pattern. Sleep aids are not recommended.
DIF: Cognitive Level: Application
REF: Page 453
4. Which notations should be included in a sleep journal? Select all that apply.
a. Any regular bedtime rituals
b. Things that assist with sleep
c. Time when patient went to bed
d. Things that interfere with sleeping
e. Foods eaten at dinner or last meal
ANS: A, B, C, D
Information about when the patient went to bed, sleep rituals, aides, and barriers to
sleep should be included, but unless foods have been identified as an aid or barrier to
sleep, they need not be included.
DIF: Cognitive Level: Application
REF: Page 449
5. Which comorbid conditions have been associated with sleep deprivation? Select all
that apply.
a. Depression
b. Hypertension
c. Anxiety disorders
d. Gastric reflux disease
e. Coronary artery disease
ANS: A, B, C, E
Sleep deprivation is associated with mood disorders such as depression and anxiety as
well as stress-related medical conditions such as coronary artery disease and
hypertension. There is currently no research to support a connection with gastric reflux
disease.
DIF: Cognitive Level: Comprehension REF: Page 441
Chapter 20: Sexual Disorders: Sexual Dysfunctions and Paraphilias
1. Which of these individuals is experiencing a symptom of the DSM-IV-TR diagnosis
sexual aversion disorder?
a. The patient who has genital pain associated with intercourse
b. The patient who avoids genital sexual contact with a partner
c. The patient who has absence of desire to engage in sexual activity
d. The patient who has delayed orgasm following sexual excitement
ANS: B
Aversion disorder is characterized by avoidance of genital sexual contact with a partner.
Orgasmic disorder, male or female, is characterized by delayed orgasm following sexual
excitement. Hypoactive sexual desire disorder is characterized by absence of drive for
sexual activity. Dyspareunia refers to genital pain associated with intercourse.
DIF: Cognitive Level: Comprehension REF: Page 461
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2. A patient who has a sexual disorder mentions to the nurse, “I don’t know why I
bother looking for help. They don’t know much about sex problems.” Which
statement best describes the evolution of research on sexuality and should serve as
the basis for the nurse’s response?
a. Increased knowledge about sexual dysfunction has been available since the late
1960s.
b. Masters and Johnson were the first persons to explore the area of sexual
dysfunction.
c. Kaplan was instrumental in identifying the need for psychoanalysis in treating
sexual dysfunction.
d. Sigmund Freud, a sexologist, based his work on scientific data from studying
human sexual behavior.
ANS: A
In 1966, research conducted by Masters and Johnson described exactly what happens to
the body during erotic stimulation. Since then, there has been considerable research
concerning the subject of sexuality and sexual dysfunction. Kaplan identified the need
for using behavioral techniques in treating sexual disorders. Freud did not base his work
on scientific data. Freud, Newton, and Ellis preceded Masters and Johnson in studying
sexual dysfunction.
DIF: Cognitive Level: Application
REF: Page 459
3. A patient who is being treated at the community health clinic complains of lack of
sexual desire and mentions the problems this is causing in her marriage. Which of
the following data is likely related to her sexual dysfunction?
a. Being an adopted only child
b. Taking an antidepressant medication
c. Growing up in a dysfunctional family
d. Living in an isolated area in the country
ANS: B
Antidepressants, especially SSRIs, are known to decrease sexual desire. The other
options are not known to be closely related to development of sexual dysfunction.
DIF: Cognitive Level: Application
REF: Page 460
4. When a patient’s wife asks the nurse about fetishism, which example could the nurse
give as part of an explanation?
a. Being sexually aroused only by touching female shoes
b. Standing on the street corner exposing genitals to others
c. Feeling sexually attracted to a 10-year-old child who lives next door
d. Achieving sexual pleasure from rubbing against a stranger in an elevator
ANS: A
Fetishism refers to using various objects, not individuals, for sexual arousal. Exposing
genitals refers to exhibitionism. Rubbing against a stranger is termed frotteurism. Being
sexually attracted to children is an example of pedophilia.
DIF: Cognitive Level: Application
REF: Page 473
5. Which assessment question will be most informative when interviewing a Hispanic
female who reports having a sexual aversion?
a. “In your culture is the female expected to be subservient?”
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b. “How old were you when you first became sexually active?”
c. “What are your religious beliefs regarding sexual intercourse?”
d. “When did you first begin experiencing pain during intercourse?”
ANS: C
Many religions place restrictions on sexual behavior that is other than procreative and
this can result in sexual dysfunction. Although female roles and sexual history can play a
role in sexual disorders, they are not frequently viewed in the development of sexual
aversion. Painful sexual intercourse is not a symptom of sexual aversion.
DIF: Cognitive Level: Analysis
REF: Page 460
6. A sexual history begins with the nurse asking the patient when she experienced her
first menstrual period. What is the basis for beginning the assessment with this type
of question?
a. Medical history is the initial focus of all history assessments.
b. Female sexual dysfunction has its roots in pre-pubescent experiences.
c. Females are more comfortable discussing physical issues than emotional ones.
d. To minimize embarrassment, the history is begun with nonthreatening questions.
ANS: D
The sexual history is an important aspect of the assessment but the questions can be
embarrassing. It is suggested that the interview begin with the least awkward topic and
then working toward more difficult and personal topics. There is no proof that the
remaining options are true.
DIF: Cognitive Level: Application
REF: Page 463
7. What is the basis of the nurse’s response when a husband reports that, “Our problem
is that my wife never initiates sex?”
a. Initiation of sex is generally viewed as the male’s role.
b. Communication between partners is vital to satisfying sex.
c. Men often enjoy sex that is initiated by their female partners.
d. Some women may become aroused only after they experience foreplay.
ANS: D
Research as shown that in longer-term relationships, women did not initiate sex as often;
the desire for sex was generated after they were aroused accounting for this woman’s
apparent lack of sexual interest. The remaining options are not directly related to sexual
interest.
DIF: Cognitive Level: Application
REF: Page 462
8. Which comment would support the sexual diagnosis of dyspareunia?
a. “I experience genital pain during intercourse.”
b. “I do not enjoy sexual intercourse and try to avoid it.”
c. “I cannot maintain adequate lubrication during intercourse.”
d. “My perineal muscles contract at the wrong times during intercourse.”
ANS: A
Genital pain is a manifestation of dyspareunia. Ineffective muscle contractions are
consistent with female sexual arousal disorder. Avoiding sex is consistent with
hypoactive sexual disorder. Insufficient lubrication is consistent with vaginismus.
DIF: Cognitive Level: Application
REF: Page 461
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9. Which patient statement shows achievement of an expected outcome for a patient
being treated for a paraphilic disorder who is receiving Depo-Provera injections?
a. “The vaginal pain issue is almost totally resolved.”
b. “I don’t have those sexual fantasies nearly as often now.”
c. “Sex is more pleasurable now that I’m getting the injections.”
d. “I haven’t had a problem maintaining an erection since I started the medication.”
ANS: B
Depo-Provera given intramuscularly once a week has been prescribed with some success
for patients with paraphilic disorders provides external control that helps patients
develop their own internal controls to avoid relapses by lowering the frequency and
intensity of inappropriate sexual thoughts and fantasies. The remaining options do not
relate to paraphilic disorders. Because of the drug’s effects and side effects, the patient
must give written consent before the drug can be administered initially. The patient can
withdraw consent at any time.
DIF: Cognitive Level: Application
REF: Page 476
10. Which assessment question demonstrates knowledge of possible risk factors for the
development of a paraphilic disorder?
a. “When were you first diagnosed with schizophrenia?”
b. “Are you aware of a family history of obsessive-compulsive disorder?”
c. “When did you begin relying on printed pornography as a sexual stimulant?”
d. “Why do you find it difficult to take your prescribed antianxiety medication?”
ANS: C
Use of pornography during childhood and adolescence has been shown as a risk factor
for the development of inappropriate sexual thinking and behaviors in adulthood. The
remaining options have not been associated with being risk factors for this disorder.
DIF: Cognitive Level: Application
REF: Page 472
11. Which of these statements reflect achievement of discharge criteria for a patient
receiving in- hospital treatment for a paraphilic disorder?
a. “My wife is willing to attend counseling with me.”
b. “The medication I’m taking has helped me be less anxious.”
c. “I hope I will be able to know what causes me to think this way.”
d. “This injection I take will help me reach a pleasurable climax again.”
ANS: A
Identification of members of a personal support systems shows achievement of a
generally stated discharge criteria. The medication prescribed for this type of disorder is
not directed towards managing anxiety or improving performance. The patient should be
aware of triggers and causes of behavior prior to discharge.
DIF: Cognitive Level: Application
REF: Pages 473-474
12. A patient admits to fondling his 3-year-old and 5-year-old nieces. Which statement
best indicates that the patient lacks an understanding of the impact of this behavior?
a. “There is absolutely nothing wrong with me.”
b. “My babysitter used to do the same things to me.”
c. “Their mother is going to hate me and it’s your fault.”
d. “The children always want me to hold them in my lap.”
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ANS: B
Exhibiting a lack of empathy or ability to express regret is a clear sign of distorted
thoughts and lack of insight regarding the effects on the children. The other options
show denial and poor insight in general.
DIF: Cognitive Level: Application
REF: Page 474
13. Which finding would the nurse expect to assess in a 17-year-old patient who has
been diagnosed with Klinefelter’s syndrome?
a. Elevated sperm count
b. Decreased secretion of FSH
c. Gynecomastia in a teenage male
d. Hyperplasia of penis and scrotum
ANS: C
Having gynecomastia (enlarged breasts) at the time of puberty is a characteristic finding
in individuals with Klinefelter’s syndrome. Aspermatogenesis, an abnormally low sperm,
count is an expected finding. FSH level is expected to be elevated. Penile and scrotal
changes are not an expected finding.
DIF: Cognitive Level: Application
REF: Page 471
14. Which topic should be addressed when providing medication information to a patient
prescribed Depo-Provera injections for a sexual disorder?
a. Nutritional supplementation to offset weight loss
b. Techniques to minimize exposure to viral infections
c. Ability to self-monitor for elevated diastolic blood pressure
d. Safety measures to protect against injuries related to manic activity
ANS: C
Common side effects include weight gain, increased blood pressure, and fatigue. The
nurse may suggest a dietary consultation to help the patient maintain a healthy weight
and decrease the possibility of weight gain. There is no reason to expect an impaired
immune system.
DIF: Cognitive Level: Application
REF: Page 476
15. Which question would enable the nurse to assess for cognitive distortions during an
interview with a patient diagnosed as having pedophilia?
a. “Is there a family history of sexual dysfunction?”
b. “Were you sexually abused as a child or adolescent?”
c. “How do you think the child felt being your sexual partner?”
d. “Will you be willing to take medication to treat your disorder?”
ANS: C
If the patient does not respond with a statement showing empathy for the child,
cognitive distortion is present. Similarly, if the patient uses denial or rationalization as he
or she discusses the disorder, the nurse can assess the presence of cognitive disorder.
The other options, although valid questions, do not assess for cognitive distortion.
DIF: Cognitive Level: Analysis
REF: Page 474
16. A patient approaches a clinic nurse in the waiting room and states, “I’d like to talk
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with you about a sexual problem I’m having.” Which response demonstrates an
understanding on the nurse’s initial responsibility to this patient?
a. Offering, “Go ahead if you like. I have time to listen.”
b. Suggesting, “Would you prefer speaking to a sex therapist?”
c. Saying, “Let’s go into my office where there’s more privacy.”
d. Asking, “What type of sexual dysfunction are you experiencing?”
ANS: C
To facilitate a therapeutic nurse-patient alliance, preserve patient confidentiality, and
minimize embarrassment, the nurse initially ensures a private and quiet space for the
discussion. The nurse should not attempt to suggest another person to talk with the
patient since the patient has identified the nurse and assessment is a nursing
responsibility. Questions should initially be of a nonthreatening nature.
DIF: Cognitive Level: Application
REF: Page 463
17. Which intervention should the nurse suggest when a couple expresses the concern
that, “Neither of us is interested in sex at the same time.”
a. Scheduling a “sex date” at a time you both agree upon
b. Encouraging role playing to help minimize self-consciousness
c. Exploring new stimulation techniques to renew interest in sex
d. Learning communication techniques that facilitate open expression of feelings
ANS: A
Teaching couples to schedule sexual experiences at agreed upon times will help them
focus on sex at the same time. The other options although valid do not address the issue
of the timing of mutual interest.
DIF: Cognitive Level: Application
REF: Page 464
18. A patient is receiving Depo-Provera. He drinks two to three beers a day, smokes,
vacations in hot sunny climates, and is slightly overweight. The nurse knows that
essential patient teaching should include the fact that:
a. It is vital to use a sunscreen consistently.
b. Smoking may increase the risk for deep vein thrombosis.
c. Drinking alcohol could cause delusions and hallucinations.
d. Losing weight is essential for efficacy of the medication.
ANS: B
Smoking may increase the risk for deep vein thrombosis. There are no alerts about
alcohol, sunscreens, or losing weight with this medication.
DIF: Cognitive Level: Application
REF: Page 476
1. Which interventions would a nurse include in the teaching plan for a patient
diagnosed with a sexual dysfunction? Select all that apply.
a. Teach breathing techniques to encourage relaxation during sex.
b. Suggest positive imaging to improve body self-acceptance during sex.
c. Educate the patient regarding the affects of hormones on sexual functioning.
d. Instruct the patient on the use of progressive touch to facilitate sexual pleasure.
e. Suggest an external relaxant such as alcohol to promote self-confidence related
to sex.
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ANS: A, B, C, D
All the options with the exception of the use of external relaxants to promote selfconfidence are appropriate. Alcohol will provide a false sense of confidence and can
negatively affect one’s ability to perform sexually.
DIF: Cognitive Level: Application
REF: Page 464
2. Which topics should be included in a discussion on risk factors for developing a
sexually oriented dysfunction? Select all that apply.
a. Diabetes
b. Depression
c. Chronic pain
d. Gastric ulcers
e. Alcohol consumption
ANS: A, B, C, E
All the options reflect conditions that have known risk factors for sexual dysfunction
disorders with the exception of gastric ulcers. Currently there is no known connection
between the disorders.
DIF: Cognitive Level: Application
REF: Page 460
Chapter 21: Crisis: Theory and Intervention
1. Which patient statement is representative of those seen in Phase 2 of the crisis
response regarding financial problems?
a. “I can’t get evicted and live on the street; I’d kill myself first.”
b. “I need to get drunk and forget about money problems for a little while”
c. “I need to figure out a way to get enough money to meet my rent this month.”
d. “I’ve always been able to rely on my mother but she won’t give it to me this
time.”
ANS: B
Phase 2: Previous coping and problem-solving strategies fail to relieve the stressor.
Phase 1: The individual is exposed to a stressor. Phase 3: Resources from within and
outside of the individual are mobilized to resolve the problem and to alleviate the
discomfort caused by the stressor. Note that people may drop out of situations in
numerous ways, including self-medication with alcohol. Phase 4: The absence of crisis
resolution leads to major disorganization such as self-injurious behavior.
DIF: Cognitive Level: Application
REF: Pages 483-484
2. Which event has the potential for causing a situational crisis?
a. Losing one’s faith in God
b. Losing a job after 10 years
c. Leaving home to attend college
d. Retirement from teaching school
ANS: B
A situational crisis occurs when a specific, external event, such as job loss, disturbs one’s
psychologic equilibrium. The other options would be considered internal (subjective)
crises.
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DIF:
Cognitive Level: Application
REF:
Page 484
3. Which patient statement made by a spouse is representative of those seen in Phase
3 of the crisis response regarding the death of a loved one?
a. “I don’t know what I’ll do to fill my days now.”
b. “Life isn’t worth living if I have to live alone.”
c. “Prayer doesn’t seem to give me the peace it has in the past."
d. “Maybe going and spending time with my daughter will help.”
ANS: D
Phase 3: Resources from within and outside of the individual are mobilized to resolve the
problem and to alleviate the discomfort caused by the stressor. Phase 1: The individual is
exposed to a stressor. Phase 2: Previous coping and problem-solving strategies fail to
relieve the stressor. Phase 4: The absence of crisis resolution leads to major
disorganization such as self-injurious behavior.
DIF: Cognitive Level: Application
REF: Page 484
4. Which patient response demonstrates that the patient whose home was destroyed by
a fire is coping with the disaster?
a. Agreeing to see a grief counselor
b. Stating, “At least no one was hurt in the fire.”
c. Addressing the details regarding the rebuilding of the house
d. Stating, “I knew things were going along too well to be true.”
ANS: C
Coping does not imply mastery over the crisis; rather, it is the process that is used to
respond to the crisis and find resolution. Working on rebuilding the home is an example
of this process. The remaining option show varying degrees of attempting to justify or
minimize the crisis.
DIF: Cognitive Level: Application
REF: Page 498
5. Which factor will have the greatest impact on a patient’s ability to effectively respond
to the loss of a spouse?
a. The age of the patient
b. The years they were married
c. How the patient has handled other deaths
d. Availability of an effective support system
ANS: C
An individual’s interpretation of the crisis is based to a large degree on previous
outcomes to similar situations such as experiencing another death crisis. The remaining
options do not have the same degree of influence as does the correct option since they
are not an example of previous experience.
DIF: Cognitive Level: Analysis
REF: Page 490
6. What is the basis for a 1-month crisis intervention follow-up for individuals who have
survived a major hurricane?
a. Symptomology of acute stress disorder can occur within a month of experiencing
the trauma.
b. The patient generally has had time to reflect on the trauma and is now ready to
discuss its impact.
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c. Medications prescribed to help manage the initial anxiety caused by the trauma
will need to be re-evaluated.
d. Private insurance carriers require professional mental health follow-ups when
initial counseling has occurred.
ANS: A
An acute stress disorder (ASD) may manifest when a person is in crisis. ASD is an anxiety
disorder that is characterized by a cluster of dissociative and anxiety symptoms that
occur within 1 month of a major traumatic stressor. Although the patient may now be
receptive to counseling, there is no reason to believe this will happen within a month.
The remaining options are not necessarily true.
DIF: Cognitive Level: Application
REF: Page 485
7. What intervention has highest priority when a patient diagnosed with acute stress
disorder (ASD) reports difficulty sleeping and is observed to have an exaggerated
startled response 6 weeks after the trauma occurred?
a. Short-term therapy will be suggested.
b. Antianxiety medication will be prescribed.
c. The patient will be scheduled for a consult at the sleep patient.
d. The patient will be assessed for possible posttraumatic stress disorder (PTSD).
ANS: D
If symptoms of ASD persist for more than 1 month, an assessment for other diagnoses
may also be considered, such as posttraumatic stress disorder (PTSD). The remaining
options do not address the issue of a more complex diagnosis and would be treating only
isolated symptoms.
DIF: Cognitive Level: Application
REF: Pages 489-490
8. Several school-age children injured in a school bus accident were brought to the ED.
Family members and friends paced back and forth in the waiting room. Members of
the crisis team were called in for the primary purpose of:
a. Waiting with the families and friends
b. Facilitating understanding and providing support
c. Determining the level of individual family coping
d. Assisting the medical team with the physical injuries
ANS: B
A crisis team is able to provide immediate emotional support to friends and families who
are distressed over the event and the state of victims, and they are able to facilitate
understanding of the event by teaching. The remaining options do not reflect the
function of crisis intervention teams.
DIF: Cognitive Level: Application
REF: Page 492
9. Which behavior is observed in the honeymoon stage of a community’s adjustment to
a severe flood?
a. Individuals unselfishly share the limited resources.
b. The community’s shopping mall and theater reopen.
c. A community rally is held to show support for the rebuilding of the town.
d. Individuals protest the government’s plan to distribute flood recovery funding.
ANS: C
The honeymoon phase occurs 1 week to 3 to 6 months after the event, when feelings of
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community sharing and high social attachment exist demonstrated by a community rally.
The heroic phase occurs immediately after the event, and it is a time of altruism and
heroic behavior in the community such as selfless sharing. The disillusionment phase
occurs 2 months to 1 to 2 years after the event, and it is characterized by feelings of
disappointment, anger, resentment, and bitterness regarding the expectations of support
that were not met and often demonstrated through examples of community protest. The
reconstruction phase occurs 2 months to 1 to 2 years after the event, when physical and
emotional reinvestment take place as community resources are re-established.
DIF: Cognitive Level: Application
REF: Page 487
10. A worker has recently been involved in assisting with the cleanup from a flood that
washed away many homes in his area and caused loss of life. Which crisis
intervention would assist the worker in dealing with the traumatic experience?
a. Arranging for his minister to meet with him
b. Suggesting he be admitted to a mental health facility
c. Providing him the opportunity to talk about the experience
d. Encouraging him to leave the area in order to forget the experience
ANS: C
The worker needs to be able to express his feelings and deal with the pain associated
with the crisis event. Nurses can help facilitate understanding of the event by listening
and teaching. The remaining interventions are not considered crisis interventions.
DIF: Cognitive Level: Application
REF: Page 495
11. A patient who survived a tornado is without shelter and food, has lost his car, and
has learned that several friends sustained injuries. To tailor intervention to the
patient’s needs, the nurse would make it a priority to:
a. Offer antianxiety medication.
b. Explore earlier life experiences.
c. Explain computer-based crisis therapy.
d. Arrange for an agency to provide shelter and food.
ANS: D
Maslow’s hierarchy of need theory suggests that survival needs should be met first. Thus
arranging for food and shelter takes precedence over other concerns.
DIF: Cognitive Level: Analysis
REF: Page 492
12. A new nurse mentions, “I can understand a situational crisis upsetting a person’s
equilibrium, but I don’t understand how something positive, like getting married or
having a baby, can precipitate a crisis.” To explain, the mentor should answer, “You
need to think of a crisis as a(n):
a. Threat to survival.”
b. Threat to the familiar.”
c. Opportunity to learn.”
d. Psychiatric disorder.”
ANS: B
By viewing a crisis as a threat to the norm, it is possible to understand why even positive
events, such as winning the lottery, may provoke a crisis. Crises are not considered
discrete psychiatric disorders nor are they opportunities to learn. Crises are not always
threats to one’s physical survival.
DIF: Cognitive Level: Application
REF: Page 483
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13. At the crisis center a staff nurse tells the nurse clinician, “The patient is dealing with
an internal crisis situation.” Which situation would qualify as a trigger for that
designation?
a. Job loss
b. Marital breakup
c. Death of a friend
d. Loss of religious faith
ANS: D
Internal (subjective) crises are threats to a person’s well-being that are not so obvious to
the outside observer. Some are associated with phase-of-life events. Loss of faith in a
supreme being would exemplify an internal crisis. The other options are considered
external (situational) crises.
DIF: Cognitive Level: Analysis
REF: Page 484
14. Which behavior is observed in the disillusionment stage of a community’s adjustment
to a devastating hurricane?
a. Individuals opening their homes to those without shelter.
b. Nearby communities provide clothing and food for victims.
c. The community remembers the event with a rally in its newly rebuilt park.
d. State leaders attend a community meeting to discuss why funding is slow to
arrive.
ANS: D
The disillusionment phase occurs 2 months to 1 to 2 years after the event, and it is
characterized by feelings of disappointment, anger, resentment, and bitterness
regarding the expectations of support that were not met and often demonstrated
through examples of community protest meetings. The heroic phase occurs immediately
after the event, and it is a time of altruism and heroic behavior in the community such as
selfless sharing. The reconstruction phase occurs 2 months to 1 to 2 years after the
event, when physical and emotional reinvestment take place as community resources
are re-established.
DIF: Cognitive Level: Application
REF: Page 487
15. Which clinical picture can the nurse expect to see most frequently among patients
who have been in a bus-train collision and derailment?
a. Elation and hyperactivity
b. Denial of the incident and suspicion
c. Shock, numbness, confusion, and disorganization
d. Highly emotional displays, such as begging for help
ANS: C
Common immediate responses to a traumatic event include shock, numbness, denial,
dissociative behavior, confusion, disorganization, indecisiveness, and suggestibility. The
other options contain behaviors that may be observed, but they are far less common
than the behaviors given in the correct option.
DIF: Cognitive Level: Comprehension REF: Page 485
16. To plan effectively for an individual who is in crisis, the nurse must have an
understanding of:
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a. Methods to establish rapport
b. Family counseling techniques
c. The meaning of the crisis event to the individual
d. Posttraumatic stress disorder treatment modalities
ANS: C
Knowing the meaning to the individual is crucial, since the mitigating circumstances and
support a patient has may reduce the impact of the crisis event. For example, a property
loss is likely to be of greater concern to someone with few financial resources than to
someone who is wealthy or fully insured. Establishing rapport should occur prior to the
planning stage. An understanding of family counseling techniques is not necessary. Crisis
intervention may not depend on information about posttraumatic stress disorder.
DIF: Cognitive Level: Comprehension REF: Page 490
17. Which nursing intervention is vital to the effective management of a psychiatric
emergency resulting from a patient’s experience of extreme despair?
a. Suicide precautions
b. Introduction to a support group
c. Introducing new coping mechanisms
d. Assessment for obsessive-compulsive rituals
ANS: A
A psychiatric emergency involves a sudden and serious psychological disturbance that
results in a behavioral state that requires intervention to prevent a life-threatening or
psychologically damaging consequence. Despair is often associated with the patient’s
attempt at self-harm and so suicide precautions are vital to emergency management in
the situation. Obsessive-compulsive behavior is not generally seen as a response to
despair. The remaining interventions would not be considered during emergency
management.
DIF: Cognitive Level: Application
REF: Page 487
18. Which patient statement assures the nurse that the patient’s immediate psychiatric
emergency has been resolved?
a. “Will I ever be able to go back to my family and job?”
b. “I don’t ever want to feel so out of control ever again.”
c. “Will you please ask the doctor if I can have a pill for my nerves?”
d. “I will let you know if I start feeling the need to hurt myself again.”
ANS: D
The primary factor that distinguishes a psychiatric emergency from other types of crises
and medical emergencies is the presence or threat of danger to the self or others. When
the patient expresses the willingness to alert the staff when such feelings are occurring
there is reason to believe the immediate emergency has past. The other options do not
exhibit such a sense of willingness on the patient’s part.
DIF: Cognitive Level: Application
REF: Page 488
19. Which patient has the greatest risk for the development of a psychiatric emergency?
a. The schizophrenic older adult living on the streets
b. The anorexic young adult hospitalized for treatment
c. The orphaned teenager who lives with grandparents
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d. The teenager who has a problem with authority figures
ANS: A
Populations at high risk for psychiatric emergencies include those with chronic mental
pathologies, such as chronic schizophrenia, because their emotional stability can be
easily disrupted. The other patients lack that element of emotional and cognitive fragility
and have a responsible support system.
DIF: Cognitive Level: Analysis
REF: Page 488
20. The crisis nurse working with law enforcement is called to assist at a scene where an
overtly psychotic individual is threatening officers with a handgun. He shouts that
aliens dressed like police are pursuing him and he has to get away. The priority
intervention is:
a. Evaluate the patient for recent substance use.
b. Ensure the patient’s safety and develop rapport.
c. Screen for the level of psychiatric care needed.
d. Assist the patient to make sense of the experience.
ANS: B
Patients who feel threatened should be assured of their safety so that rapport building
can take place. When rapport has been developed, the nurse may be able to convince
the individual to give up any weapons. The patient is not capable of understanding the
experience at this point in the scenario. Although relevant, the remaining options do not
have the priority of the correct option since they depend upon a therapeutic nursepatient rapport.
DIF: Cognitive Level: Analysis
REF: Page 489
21. Which patient behavior assures the nurse that the primary goal of crisis intervention
has been achieved by a patient who experiencing extreme mania?
a. The patient has resumed a healthy sleep pattern.
b. The patient has asked that their family be allowed to visit.
c. The patient demonstrates an understanding of manic behaviors.
d. The patient is compliant with the medication therapy prescribed.
ANS: A
The goal of crisis intervention is to return the individual to their precrisis level of
functioning. Resuming healthy sleep patterns would indicate that the crisis had been
resolved. The remaining options fail to demonstrate a return to normal or precrisis
function or behavior.
DIF: Cognitive Level: Application
REF: Page 491
22. Which statement is the basis for the combination of both interactive therapy and
antidepressant medication for a patient whose chronic depression resulted in a
suicide attempt?
a. Therapy is seldom effective when not supported with appropriately prescribed
medications.
b. The suicide attempt was the deciding factor in determining the need to prescribe
an antidepressant.
c. Patients are more willing to attend therapy sessions when they are prescribed
medications to manage acute symptoms.
d. Research has shown that a combination of therapy and medications achieve
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expected outcomes more effectively than single interventions.
ANS: D
In general, when medications are indicated, the combination of medication and
interactive therapy is more effective than either modality alone. The remaining options
are not true statements.
DIF: Cognitive Level: Application
REF: Pages 491-492
1. Which statements are the basis for making counseling available to grade-school
children who have experienced the violent death of a classmate? Select all that
apply.
a. It is vital to foster each child’s sense of psychologically safety.
b. The fear of the unknown circumstances of the classmate’s death will serve to
increase their own anxieties.
c. Counseling will provide mental health professionals with the opportunity to
address all the children’s concerns.
d. The more appropriate information the children are given about their classmate’s
death, the better they will be able to understand why the death occurred.
e. Although the children may not be capable of understanding the information they
are given, the interaction with mental health providers will minimize their
anxieties.
ANS: A, B, D
Strategies to enhance a sense of psychological safety for children in crisis include talking
with the child about the crisis or trauma in terms that he or she can understand. The
more information that the child can be given about who, what, where, why, and how the
crisis occurred, the easier it is for the child to make sense of the situation. Fear of the
unknown will make a traumatized child more anxious and symptomatic. Although is may
not be possible to address or resolve all of the concerns, listening to the child, without
necessarily having good answers to his or her questions, can be very therapeutic.
DIF: Cognitive Level: Application
REF: Page 492
2. Which nursing interventions are implemented when using the ACT model to manage
a patient who has experienced a physical assault while visiting a vacation resort?
Select all that apply.
a. Assessing the patient’s need for medical attention
b. Performing a cultural assessment
c. Arranging for a social service consult
d. Offering to notify the patient’s family
e. Requesting a visit by the hospital clergy
ANS: A, B, C, D
The components of ACT include assessment for immediate medical needs as well as a
cultural assessment in order to provide culturally sensitive care. Facilitating connection
to support systems such as family and social services will help meet the patient’s need
for physical and emotional support. Requesting a clergy visit should not be done without
the first securing the patient’s consent.
DIF: Cognitive Level: Application
REF: Page 491
3. Which assessment observations will be most influential in determining whether a
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patient exhibiting signs of alcohol intoxication who was brought to the emergency
room by friends will be involuntarily admitted for psychiatric evaluation? Select all
that apply.
a. The patient’s earlier contact with a crisis hotline
b. Expressing a desire, “to just drive myself home”
c. Patient’s admission that, “I don’t want to keep living like this.”
d. Uncooperative and disrespectful behavior towards the hospital staff
e. Announcing that, “my girlfriend will pay for leaving me for my best friend.”
ANS: C, E
The decision to admit this patient involuntarily is based on whether the person poses a
danger to himself or herself, including sharing thoughts or threats of suicide, sharing a
suicide plan, or actively using a weapon or situation to injure himself or herself; and/or
whether the person poses a danger to others as evidenced by threatening another,
brandishing a weapon, or displaying erratic or unpredictable behavior. The remaining
options do not fulfill either of these conditions.
DIF: Cognitive Level: Application
REF: Page 488
4. Which situations would increase an individual’s risk for ineffective coping related to
stress? Select all that apply.
a. Being over 65 years of age
b. Being unmarried and female
c. Having been adopted as an infant
d. Having a history of chronic back pain
e. Being diagnosed with both depression and hypertension
ANS: D, E
Risk factors may limit an individual’s ability to cope or problem solve during stressful life
events or situations. These may include the presence of concurrent or multiple
biopsychosocial stressors, such as depression and hypertension, as well as chronic
physical or psychological pain. The other options are not known to negatively impact an
individual’s ability to cope or problem solve.
DIF: Cognitive Level: Application
REF: Page 484
5. Which characteristic makes a stressful event a crisis situation? Select all that apply.
a. The event was not expected.
b. The patient felt emotional or physically threatened.
c. The event resulted in physical trauma to the patient.
d. The patient showed immediate signs of anxiety or panic.
e. The patient has little or no social support system to rely upon.
ANS: A, B
Crises have defining characteristics that include being unexpected and creating the
perceptions of threat. The other options are not necessary characteristics of a crisis
situation.
DIF: Cognitive Level: Comprehension REF: Page 483
Chapter 22: Suicide Prevention and Intervention
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1. Which suicide is an example of Durkheim’s anomic suicide?
a. A Muslim who was disgraced by a family member
b. A woman whose life savings were embezzled from her
c. A suicide bomber who blows up a bus in the middle East
d. A convicted rapist who has been given a life sentence
ANS: B
Anomic suicides are acts of self-destruction by individuals who have become alienated
from important relationships in their groups, especially as this relates to their standard of
living. Durkheim characterized egoistic suicides as the self-inflicted deaths of individuals
who turn against their own conscience. Altruistic suicides are self-inflicted deaths on the
basis of obedience to a group’s goals rather than reflecting the person’s own best
interests. Durkheim defined fatalistic suicides as self-inflicted deaths that result from
excessive regulation.
DIF: Cognitive Level: Application
REF: Page 503
2. The nurse administering an antidepressant to a suicidal patient understands that the
brain abnormality the medication addresses is:
a. Atrophy of the brain
b. Enlarged lateral ventricles
c. Irregularities in the serotonin system
d. Abnormal electroencephalogram (EEG) readings
ANS: C
Antidepressants regulate serotonin levels, which is a chemical that is involved the
development of depression. There is no research to support brain atrophy or enlarged
lateral ventricles as being related to the development of depression. EEG readings are
designed to assess the electrical activity of the brain.
DIF: Cognitive Level: Comprehension REF: Page 504
3. A family member of a suicidal patient asks, “Are there any medications that can
prevent a person from committing suicide?” Which statement best answers the
question?
a. If people want to harm themselves, they eventually will.
b. Antipsychotic medications are used primarily for suicide prevention.
c. Antidepressants treat mood disorders that accompany suicidal ideation.
d. There are no medications available that specifically affect suicidal behavior.
ANS: C
Although there is no medication to prevent suicide, the most constructive answer
informs the family that mood disorders are often accompany by suicidal ideation, and
antidepressants can treat these. Antipsychotic medications are not generally used for
depression. The remaining option lacks empathy and does not accurately answer the
question.
DIF: Cognitive Level: Application
REF: Page 504
4. Which intervention would the nurse implement when a patient’s frontal lobe is
affected?
a. Educating the patient on the affects of dopamine
b. Helping the patient identify reasons for crying
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c. Assessing the patient for any suicidal ideations
d. Evaluating the affects of medication on motivation
ANS: C
Researchers believe that frontal lobe dysfunction is related to feelings of hopelessness
and worthlessness, both of which are signs of suicidal thoughts. The remaining options
are related to symptoms that are associated with the limbic system.
DIF: Cognitive Level: Application
REF: Page 504
5. Which approach listed in the plan of care of a suicidal patient is considered a
cognitive technique?
a. Intense psychotherapy to deal with childhood issues
b. Group therapy with patients with similar problems
c. Limitation of negative thought patterns and increase of realistic self-evaluation
d. Inclusion of significant others and family in the plan of care
ANS: C
Cognitive techniques use examination of thought patterns and challenges to irrational or
negative thoughts. The remaining options are not interventions that are supported
cognitive therapy.
DIF: Cognitive Level: Application
REF: Page 517
6. The nurse presenting a suicide prevention lecture would decide who the target
population is based on what fact?
a. Females have the highest risk for suicide.
b. Children are considered a high-risk group for committing suicide.
c. The highest suicide rate is among the Caucasian middle-age population.
d. Rates of suicide are highest among the older population, age 80 and older.
ANS: D
The highest rate of suicide is among the older adult population. The remaining options
are not true statements.
DIF: Cognitive Level: Application
REF: Page 502
7. Which statement by a young adult would alert the nurse to increased suicide risk?
a. “I have a necktie in my room that I can use to hang myself.”
b. “If I fail one more class, I’m going to have to think about ending it.”
c. “When I leave home to live on my own, I’m going to buy myself a gun.”
d. “When I took two bottles of Mom’s pills, I had to have my stomach pumped.”
ANS: A
Only the correct option states an intended method and indicates immediacy and
available means of enacting a successful suicide attack.
DIF: Cognitive Level: Analysis
REF: Page 510
8. An older adult is admitted to the hospital for severe depression. The nurse, gathering
data for a medical and psychiatric history, learns of a suicide attempt 4 years ago
after the death of a spouse. Based on this information, it is likely that the patient:
a. Will avoid attempting suicide again after the past experience
b. Will try to minimize the seriousness of the suicide attempt
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c. May express suicidal ideation or make a suicide attempt
d. Will report that he has recently written a will
ANS: C
The majority of persons who complete suicides have made previous suicide attempts.
The remaining options are not supported by research that indicates the increased risk of
suicide associated with a history of such behaviors.
DIF: Cognitive Level: Application
REF: Page 511
9. The nurse asks a patient admitted with a diagnosis of major depression, “Do you feel
like hurting yourself at this time?” What is the primary rationale for obtaining this
information when nothing in the referral note implied that the patient was suicidal?
a. It is likely that he is hiding the desire to harm himself.
b. This information must be reported to the patient’s physician.
c. Specific safety measures must be implemented when self-harm is a danger.
d. Patient safety is always the primary responsibility of the unit’s nursing staff.
ANS: C
Depression is a disorder linked to suicidal behavior, so it is imperative to ask and then
closely observe the patient if he says “Yes.” The remaining options although true are not
the primary rationale for assessing a depressed patient for suicidal ideations.
DIF: Cognitive Level: Analysis
REF: Page 510
10. The nurse working at the crisis center received a call from a patient who stated he
was depressed and wanted to die. Further investigation revealed that the patient had
within reach all of the items listed below that he could use “to get the job done.”
Which item would cause the nurse the most concern?
a. A garden hose
b. A loaded gun
c. Two bottles of Prozac
d. A bottle of an alcoholic beverage
ANS: B
Firearms are the most lethal form of weapons that are used to complete suicide, with
50.2% of all individuals who completed suicide in 2007 doing so with a firearm. Using a
firearm is a more lethal method of suicide than are medications, a garden hose, or a
bottle of alcohol. It does not allow time for rescue.
DIF: Cognitive Level: Application
REF: Page 502
11. Which statement made by a patient who attempted suicide 5 days ago would cause
the nurse to observe his behavior more closely?
a. “When I’m discharged, maybe my son will let me stay with him.”
b. “I’m not sure I will ever really enjoy the things we did before I lost her.”
c. “It puzzles me that anyone would want to kill themselves but I certainly did.”
d. “My wife and I would have celebrated our thirty-sixth wedding anniversary
today.”
ANS: D
Significant anniversary dates may be a time for future suicide attempts. The remaining
options do not have the same level of risk since they are not expressing despair or
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indicate an available means.
DIF: Cognitive Level: Application
REF:
Page 509
12. Which finding related to a teenager who has been diagnosed with depression is most
significant when planning care?
a. Her father recently remarried.
b. Her mother died from suicide 1 year ago.
c. She has expressed a dislike for her new stepmother.
d. She ran away from home twice during the past month.
ANS: B
Option b is correct because suicidal behavior can become a learned familial adaptation
to stressors. Running away, remarriage, and issues in stepfamilies can be important, but
they are not of primary importance.
DIF: Cognitive Level: Analysis
REF: Page 507
13. The nurse is planning care for a patient who was admitted to the hospital after
threatening to harm himself when he was stopped by the police for speeding. He was
intoxicated at the time of admission and was assessed as being depressed, anxious,
and hostile. Which patient outcome is the priority?
a. Patient will remain free from self-harm although hospitalized.
b. Patient will report suicidal ideation or desire to harm self to the staff.
c. Patient will accept referral to the hospital-based substance abuse program.
d. Patient will recognize and interrupt unconscious intentions to harm self.
ANS: A
The primary outcome is for the patient to be free from self-harm because the primary
issue for this patient is the high risk for self-harm. The remaining options are all actions
that will support this outcome.
DIF: Cognitive Level: Application
REF: Page 516
14. A patient was admitted and prescribed antidepressants for severe depression with
feelings of hopelessness, helplessness, and suicidal ideation. When would the patient
be at greatest risk for suicide during hospitalization?
a. Within the first hour after admission and when family leaves
b. At night after visitors leave and patients are allow in their room
c. Within the first 24 hours after admission and as discharge approaches
d. Within 48 hours of first expressing suicidal ideation and as therapy progresses
ANS: C
Statistics show that the most dangerous times for a hospitalized patient who has the
potential for self-harm is within the first 24 hours after admission and as the associated
stress of discharge nears.
DIF: Cognitive Level: Application
REF: Page 513
15. Which statement made by the patient who attempted suicide best indicates that the
criterion for discharge has been met?
a. “I know who to call if I get depressed again.”
b. “I’ve learned that there is hope and I don’t have to hurt.”
c. “I have good friends who are willing to help me with my problems.”
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d. “I do not feel like harming myself anymore and that feels so comforting.”
ANS: D
Denying a need to harm oneself is a clear statement from the patient that he or she is
feeling more positive. The remaining options although positive are not as good an
indicator for discharge because they do not address the issue of self-harm.
DIF: Cognitive Level: Analysis
REF: Page 514
16. The Emergency Department nurses were discussing a patient who seeks help almost
every holiday by expressing suicidal ideation or making a suicide gesture. One of the
nurses stated, “I don't think he is serious about hurting himself. Maybe we should not
see him the next time he comes.” Which response from the charge nurse is accurate
in dealing with the patient who may be using suicidal behavior as a ploy to enter the
hospital?
a. “He obviously needs the support he gets at the hospital.”
b. “We should avoid showing any warmth the next time he comes in.”
c. “Telling him we cannot see him may be the answer to stop this behavior.”
d. “Each episode must be individually evaluated, and all options must be explored.”
ANS: D
A patient who has a history of suicide gestures or attempts is at greater risk for using
this behavior style again. This is unsafe behavior that needs to be evaluated. It is true
that the patient is in need of support but that answer does not address the issue of the
misconception expressed by the nurse’s statement. The remaining options are
unprofessional and totally lacking in therapeutic understanding of suicide.
DIF: Cognitive Level: Application
REF: Page 511
17. A patient diagnosed with cancer of the prostate was admitted after his wife reported
he was trying to mix a lethal dose of medications and alcohol to drink. Which patient
outcome is a priority to this situation?
a. Patient will participate in all unit activities.
b. Patient will recognize that depression is treatable.
c. Patient will learn ways to handle his unresolved anger.
d. Patient will admit to suicidal thoughts when asked by staff.
ANS: D
Notifying staff of suicidal ideations has priority since it is directly related to the patient’s
safety. The other options lack the direct relationship to patient safety.
DIF: Cognitive Level: Application
REF: Page 516
18. On day 4 of hospitalization after a suicide attempt, the patient tells the nurse, “You
don’t have to worry about me any longer. Today was the turning point. You can stop
the suicide precautions.” Which action indicates the nurse’s use of intuition in
responding to this patient?
a. Reporting the patient’s statements and the nurse’s own feelings to the staff and
suggest increased vigilance
b. Reporting only the patient’s statements and evaluate the outcome, Patient will
report lack of suicidal ideation as attained.
c. Conferring with the patient’s family members to obtain their evaluation of the
patient and his behavior and follow their lead
d. Suggesting that the level of suicide precautions be lowered from one-to-one
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supervision to observing the patient every 30 minutes
ANS: A
It is unlikely that a highly suicidal patient would recover so quickly. Sometimes
hospitalization and medication allow a renewal of energy, enough to increase suicidal
resolve. The nurse should follow this intuition and suggest increased vigilance. Keeping
this concern to oneself is not helpful. Taking the lead from the family is not appropriate,
and lowering suicide precautions so soon is risky.
DIF: Cognitive Level: Application
REF: Page 514
19. A patient has been displaying advanced thought of suicide. Which action reflects this
behavior?
a. Acknowledging thoughts of dying
b. Expresses verbal expressions of ‘severe sadness’
c. Wrists are bleeding from cuts with a butter knife
d. Found unconscious with empty pills bottles nearby
ANS: C
A nonlethal suicide gesture is characteristic of this degree of suicide risk. Having suicidal
thoughts only is reflective of ideations although a verbal expression is a moderate risk
gesture. An actual attempt that was potentially lethal is the ultimate risk behavior.
DIF: Cognitive Level: Application
REF: Page 512
20. A patient who is a policewoman tells the nurse she is depressed and can no longer
deal with the stress of her job. She mentions that employee assistance counseling
failed to change her hopeless attitude. She states that she will use her police
revolver to shoot herself in the head during the day when no one is at home and the
home is locked. Which formulation by the triage nurse is correct?
a. Plan explicit. Imminence high. Method highly lethal and accessible. Rescue
potential low.
b. Plan vague. Imminence moderate. Method somewhat lethal and accessible.
Rescue potential moderate.
c. Plan complete. Imminence low. Method low lethality but accessible. Rescue
potential high.
d. Plan nebulous. Imminence low. Method low lethality but accessible. Rescue
potential high.
ANS: A
The correct option identifies that the plan is well thought out; the imminence is high
because the patient is ready to act; the gun is a highly lethal method, and she has the
weapon; and the rescue potential is low because a gun is the chosen method. The
remaining options do not show the proper assessment of these criteria.
DIF: Cognitive Level: Analysis
REF: Page 511
21. The health care team is planning care for a patient hospitalized following a suicide
attempt. Which statement by a team member should serve as a basis for planning?
a. “A patient who has made a recent suicide attempt is at low risk for another
attempt.”
b. “A patient who has made a recent suicide attempt is at very high risk for another
attempt.”
c. “A patient who has made a recent suicide attempt requires ongoing assessment
to determine the level of risk.”
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d. “A patient who has made a recent suicide attempt may be at risk for 24 hours
until medication takes effect.”
ANS: C
The correct option shows an understanding of the need for additional assessment in
order to develop an effective plan of care. Assessment is needed to determine whether a
patient is at high risk for another suicide attempt. The remaining options are incorrect.
DIF: Cognitive Level: Application
REF: Page 503
22. A suicidal patient agreed on day 2 of hospitalization to write and sign a “no self-harm
contract.” As a result of this contract, the health care team should plan to:
a. Discontinue suicide precautions.
b. Base the level of observation on staff assessment.
c. Reduce observation to observing the patient every hour.
d. Reduce one-to-one observation to observing the patient every 15 minutes.
ANS: B
Research suggests that no-harm contracts may not prevent self-harm; therefore any
reduction in suicide precautions is incorrect. Staff assessment needs to be continued and
based on observation.
DIF: Cognitive Level: Application
REF: Page 518
23. When assigning the suicidal patient to a room on the unit, the nurse should select a:
a. Single room near the exit
b. Double room near the exit
c. Single room near the nurse’s station
d. Double room near the nurse’s station
ANS: D
The correct option implements the helpful practice if having a roommate for the suicidal
patient and observation of the patient is easier if the room is close to the nurse’s station.
The remaining options lack both of those interventions.
DIF: Cognitive Level: Application
REF: Page 517
24. There are several suicidal patients on the psychiatric unit. When meal trays are
returned to the kitchen, a serrated-edge knife is missing. The nurse to whom the aide
reports this should:
a. Acknowledge the information and be watchful for the remainder of the shift.
b. Ask each of the patients on suicide precautions where the knife is hidden.
c. Report the information to the charge nurse and suggest a unit search.
d. Report the information to security and let them handle the matter.
ANS: C
This is an important safety issue. Although being watchful is appropriate, it is not
sufficient to ensure safety in this situation. Assuming that only the patients on suicide
precautions would know about the knives is not a proper assumption. Security does not
need to be called in at this time, so option d is incorrect. Searching the unit for the
missing knife would be the safest option.
DIF: Cognitive Level: Application
REF: Page 517
25. To maximize therapeutic care to a newly admitted suicidal patient on days 1 and 2 of
hospitalization, the nurse will:
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a. Select appropriate community resources for referral.
b. Identify patient areas of weakness and deficiency.
c. Encourage the patient to express psychological pain.
d. Refute delusional thinking by logical argument and reinforcement.
ANS: C
With a newly admitted patient, listening to expressions of pain will be one of the first
interventions for the nurse in order to support the assessment process. It is too soon to
consider community resources. Identifying weaknesses is not a helpful intervention for a
suicidal patient. There is no data supporting delusional thinking.
DIF: Cognitive Level: Application
REF: Page 518
26. A suicidal patient tells the nurse, “There’s no other way out for me. I have so many
problems that there’s nothing to do but cash it in.” Which statement by the nurse
would be a helpful approach?
a. “I can see that things are bad. It’s good you recognized your limitations.”
b. “Let’s look at the problem you consider most urgent to see about a solution.”
c. “We’ll begin problem-solving together as soon as you stop feeling suicidal.”
d. “Your thinking is flawed. I’ll teach you to think differently and be less depressed.”
ANS: B
The most effective intervention is to help the patient prioritize problems and work on
them one at a time. To affirm the negative is not therapeutic. Although a change in
thinking is appropriate, it does not deal with the patient’s statement about problems.
The remaining option places unrealistic demands on the patient.
DIF: Cognitive Level: Application
REF: Page 517
27. A newly admitted patient with depression has been determined as suicidal and in
need of one-to-one supervision. What is the best statement to inform the patient of
the plan of care?
a. “A staff member will be with you at all times to watch you for suicide gestures.”
b. “On this unit, a staff member stays with each new admission for the first 24
hours.”
c. “We understand the impulse to attempt self-harm may be strong, so someone will
stay with you to help you control the impulse.”
d. “We are not sure you would be willing to tell a staff member if the urge to commit
suicide becomes strong, so to prevent hospital liability someone will stay with
you.”
ANS: C
The correct option explains the intervention in terms of the patient’s needs. Basing the
intervention on the patient’s suicidal gestures is too threatening and intrusive. It is not
true that all patients are observed for 24 hours. Identifying liability indicates that the
staff is mostly worried about the hospital.
DIF: Cognitive Level: Application
REF: Page 517
Chapter 23: Violence: Anger, Abuse, and Aggression
1. A young child is being evaluated in the Emergency Department for injuries her
mother reports resulted from a fall down the stairs. Which of these findings indicates
that physical abuse may be a chronic problem for the child?
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a. The mother’s description of the child as being ‘clumsy’
b. Several fractures revealed on x-ray in varying degrees of healing
c. Clinging to her mother as she attempted to leave the examining room
d. Struggling with the staff when attempts to obtain a blood specimen were made
ANS: B
Unhealed fractures indicate both numerous injuries and that medical intervention was
not sought at the time of injury. Although unkind, the mother’s description of the child is
not reason to believe chronic abuse has occurred. The remaining options reflect normal
behavior, especially if pain or separation is suspected.
DIF: Cognitive Level: Application
REF: Page 539
2. A child was admitted to the children's unit, having been sexually abused by an
acquaintance of her family. The child refuses to talk and participate in unit activities,
choosing to stay in her room with her stuffed animals. Which therapeutic intervention
will best help the child release pent-up feelings about the abuse?
a. Family therapy
b. Play therapy
c. Individual communication with the nurse
d. Role-play with other children on the unit
ANS: B
Play helps communicate and release feelings about the child’s problems. A child may
have difficulty expressing feelings verbally. Family therapy may be useful, but it is not
designed for releasing feelings. Role-playing is more effective with older children or
adults.
DIF: Cognitive Level: Application
REF: Page 541
3. The nurse is leading a support group for women who have experienced interpersonal
violence. When a patient asks about the characteristics of the perpetrators of
interpersonal violence, the nurse accurately responds that they are:
a. Usually under the influence of alcohol
b. Most often someone the victim knows
c. A stranger to the victim in most cases
d. Often in a psychotic state during the act
ANS: B
Statistics show that interpersonal violence is usually committed by someone the victim
knows. Drugs and alcohol are not necessarily involved. The victim usually knows the
perpetrator. The perpetrators are aware of what they are doing.
DIF: Cognitive Level: Application
REF: Page 526
4. Which nursing intervention will assist a patient being treated in the Emergency
Department for extensive soft tissue injuries to disclose an experience of domestic
violence?
a. Allowing the patient to initiate the topic of violence
b. Speaking with the patient in the absence of her husband
c. Providing a safe, nonintimidating, and supportive environment
d. Interviewing her in the presence of another healthcare professional
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ANS: C
Providing a safe environment is the first step in assisting a patient who is a victim of
domestic violence. Including others in the conversation may increase anxiety and
reluctance to disclose. Isolating the husband is assumed in providing a safe,
nonintimidating environment. The patient may not disclose without prompting by the
nurse.
DIF: Cognitive Level: Application
REF: Page 534
5. A patient admits to having been battered by her live-in boyfriend several times over
the past 2 years. She states to the nurse, “We plan to get married next June, and I
think things will be better then. He is always so sorry afterward, that I think I can
trust him to change.” Which intervention should be included in the patient’s teaching
plan?
a. Discourage her hope that the battering will end after they are married.
b. Assist her in enrolling in a class to learn techniques of self-defense.
c. Assist her in developing an emergency plan, because the pattern of violence is
likely to continue.
d. Emphasize that the battering pattern usually remains the same in frequency and
severity over time.
ANS: C
Developing an emergency plan is critical for any battered woman. The battering is not
likely to cease unless the batterer seeks help but stating that fact is not therapeutic by
itself. This will not stop the violence, although it might afford her some protection.
Violence usually increases over time.
DIF: Cognitive Level: Application
REF: Pages 532-533
6. The nurse in the Emergency Department is taking a history from a family
accompanying a child with suspicious traumatic injuries. The nurse should:
a. Be open, concerned, and honest.
b. Obtain information as covertly as possible.
c. Avoid responding to hints that abuse has occurred.
d. Separate the family from the child during the interview.
ANS: A
The nurse serves as a role model for the parents and the child. Being open and honest
and showing appropriate concern for the child is the most appropriate approach. Direct
questioning is necessary to obtain the history. Concerns about the possibility of abuse
must be addressed in a sensitive manner. The family will be able to remain with the child
during history taking. It is helpful for the nurse to observe family interactions.
DIF: Cognitive Level: Application
REF: Page 541
7. When an elderly patient is brought into the Emergency Department by family
members who reported a fall the nurse became suspicious that the patient had
suffered physical abuse. The patient denied that she had been abused. Her denial is
most likely based on her:
a. Feeling that she deserved the physical abuse
b. Strong belief that nothing could be done to help her
c. Lack of trust that the situation could ever be changed
d. Fear of the possibility of being removed from her family
ANS: D
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Fear of being separated from family and institutionalized is a powerful motive that keeps
elders from revealing abuse. The other options may be factors in some cases but they
are not primary motivators of silence.
DIF: Cognitive Level: Analysis
REF: Page 544
8. A nurse planning a group to help batterers learn more effective ways to cope would
teach participants that the key component in wife battering is:
a. Their need for the batterer to control
b. The role of alcohol in the pattern of abuse
c. History of psychotic or paranoid behavior
d. Failure of the woman involved to assert herself
ANS: A
The batterer uses violence as a means of controlling his partner to meet his own needs.
Alcohol use is not the root cause of spousal abuse. There are no data to support mental
illness as a factor in abusive relationships. Assertive behavior may result in increased
abuse.
DIF: Cognitive Level: Application
REF: Page 528
9. The nurse caring for a school-age child who has been sexually abused by a close
family member demonstrates an understanding of communication barriers in this
situation by:
a. Realizing that repeated questioning by others will occur
b. Assuring the child that the story they are telling is believed
c. Reinforcing that the child will not be in trouble with the police
d. Promising to tell only those who need to know about the incident
ANS: B
Fear of being blamed or of being disbelieved is a powerful motivator of silence. When the
child fears that there will be no support, there is no reason to disclose the abuse. The
other options are much more remote.
DIF: Cognitive Level: Analysis
REF: Page 541
10. The nurse is considering making a child abuse or neglect report to protective
services. To make the report, the nurse needs to:
a. Have strong evidence that the abuse/neglect has occurred.
b. Obtain the supervisor’s permission to make the report.
c. Notify the parents of the intent to file the report.
d. Have suspicions that the abuse has occurred.
ANS: D
Suspicions are all that are required by state mandatory child abuse and neglect reporting
laws. The agency bears the burden of collecting evidence. As a mandated reporter, the
nurse does not need anyone’s permission to make the report. Only a suspicion is
required. Parent notification is unnecessary.
DIF: Cognitive Level: Application
REF: Pages 540-541
11. A community health nurse is working with a family in which an elderly woman was
neglected by her son and his wife but insists on remaining with the young couple
despite the threat of future neglect. Which intervention should be given highest
priority?
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a. Identifying community resources to decrease the caregivers’ stress
b. Establishing patient rights and consequences of abuse and monitoring
c. Providing stress management techniques for both of the caregivers
d. Educating the caregivers on the aging process and how to cope with it
ANS: B
Securing the patient’s safety is the priority for care. This option sets forth expectations
for the family and establishes the fact that the patient’s state will be monitored. The
other options are appropriate interventions but are not the highest priority.
DIF: Cognitive Level: Analysis
REF: Page 545
12. To provide nursing care to abused children and their families, the nurse must first:
a. Recommend removal of the children from the family.
b. Complete a comprehensive physical and mental assessment.
c. Refer each case to the appropriate social worker for follow-up.
d. Examine personal feelings regarding the trauma of child abuse and neglect.
ANS: D
Self-examination is required in order for the nurse to be objective and therapeutic in
providing care. Although important, an assessment is not the initial step in this situation.
Removal is not always recommended. A social service referral may not be required,
depending on the situation.
DIF: Cognitive Level: Application
REF: Page 537
13. According to statistical research data, which of these children currently being
followed by the pediatric nurse practitioner is at the greatest risk for fatal abuse?
a. A child who is 2 years old and has cerebral palsy
b. A child who is 5 years old and has chicken pox
c. A child who is 8 years old and has appendicitis
d. A child who is 11 years old and has a fractured humerus
ANS: A
At highest risk for fatal abuse are children under 3 years of age and those with
disabilities. The remaining options do not present children meeting the criteria.
DIF: Cognitive Level: Application
REF: Page 529
14. A patient has been physically abused by her boyfriend frequently since moving in
together. During her last discussion with the nurse, the patient stated, “I probably
should not keep going back to him, because he continues to abuse me.” The nurse is
aware that the final decision to leave a batterer is:
a. Usually a gradual process that occurs over time
b. Likely to occur after the victim suffers a serious injury
c. More likely if the patient has approval from her family
d. Made when the batterer gives her permission to do so
ANS: A
The victim usually moves slowly when making the decision to leave the batterer because
of many self-imposed constraints and many environmental factors that must be
considered. It is unlikely that a batterer will give permission for the victim to leave. The
remaining options are not supported by current research.
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DIF:
Cognitive Level: Application
REF:
Page 533
15. A patient has been chronically battered by her husband since they were married.
Until now she had avoided dealing with her situation, but she now expresses a desire
to deal with the problem since the attacks are occurring more frequently. Which
outcome is realistic for the patient?
a. Setting a goal date for divorcing her husband
b. Verbalizing an awareness of her increasingly dangerous situation
c. Citing possible ways she may have contributed to the abusive episodes
d. Employing methods of retaliating in order to gain experience being assertive
ANS: B
Because the abuse has been long-term and is increasing in intensity, the patient needs
to state her awareness of being in danger. When the patient accepts this fact, she may
be increasingly ready to make further plans to extricate herself. The victim is not at fault
for abuse. Setting a divorce date is not practical because she has not begun to pursue
litigation. Retaliation is not an effective means of resolving the problem.
DIF: Cognitive Level: Application
REF: Page 532
16. The nurse who sees a number of battered elderly females each year decides to put
together a set of guidelines for nurses. An appropriate guideline to include would be
to:
a. Make protective services aware of the abuse.
b. Take at least two photographs of each trauma area.
c. Begin the interview by asking the least sensitive questions.
d. Assess for the presence of sexually transmitted diseases.
ANS: C
During the assessment and when taking the woman’s history, it is recommended that in
all cases the nurse begins with the least sensitive questions and gradually progress to
the more sensitive ones. The remaining options may be appropriate but depend on the
circumstances.
DIF: Cognitive Level: Application
REF: Page 531
17. A nurse planning teaching for a parent group concerned with preventing family
violence can discuss the fact that exposure to violence in the media:
a. Desensitizes people to the violence around them
b. Has no effect on the increase of violence in society
c. Broadens the viewer’s knowledge about world happenings
d. Helps to distinguish appropriate behaviors from inappropriate behaviors
ANS: A
Violence in the media has been shown to desensitize people to environmental violence.
Desensitization to violence results in people being apathetic about the violence going on
around them. The remaining options are not true statements.
DIF: Cognitive Level: Application
REF: Page 528
18. Which symptom reported by an adult patient, who was sexually abused as a child,
reflects the diagnosis of posttraumatic stress disorder (PTSD)?
a. A history of substance abuse
b. Refusing to go to public places from which escape may be difficult
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c. Seeking advice and guidance prior to making any significant decision
d. Ruminating easily concerning the abuse with friends and acquaintances
ANS: A
Substance abuse to help manage the unpleasant symptoms is characteristic of PTSD.
Being uncomfortable in certain locations refers to agoraphobia. Seeking extensive
support characterizes a dependent person. Ease in talking about the experience is
uncharacteristic of PTSD.
DIF: Cognitive Level: Application
REF: Page 537
19. While planning care for a preschool child who has been physically and sexually
abused, the nurse includes play therapy because it assists the child to:
a. Learn adaptive behaviors through acting.
b. Express feelings that cannot easily be verbalized.
c. Act out aggression in a sociably acceptable manner.
d. Interact with other children in the appropriate age group.
ANS: B
Abused children, especially young children, are unable to put feelings into words as they
describe events. Play therapy affords the tools through which the child can access and
work through feelings. The other options are not purposes of play therapy.
DIF: Cognitive Level: Application
REF: Page 541
20. A new nurse asks the experienced nurse, “Why did you ask about culture when it was
obvious you needed to focus on the battering?” The experienced nurse should
respond:
a. “It’s just a habit I got into awhile ago.”
b. “It helps me focus on whether to do a complete physical assessment.”
c. “Culture is a determinant of how women interpret and respond to violence.”
d. “If I know more I can refer her to a shelter that caters to her cultural group.”
ANS: C
Understanding the woman’s culture not only helps understand how the woman will view
and respond to violence but also is essential to developing an effective treatment plan.
Some ethnic women are isolated and would not be able to seek assistance from police or
community agencies. The remaining options are made-up responses and have no basis
in theory or practice.
DIF: Cognitive Level: Application
REF: Page 531
21. The experienced nurse assessing a battered woman patient uses many open-ended
questions during the interview. The rationale for this is that:
a. The woman will feel more in charge of the interview.
b. Patients can’t refuse to answer when sensitive information is being probed.
c. The questions are direct and easily understood by the anxious individuals.
d. Such questions allow for simple “yes” or “no” answers when the patient is upset.
ANS: A
Open-ended questions reflecting what the woman is disclosing give the patient the sense
of being in control of the interview, and she is likely to reveal more than when direct
questions are used exclusively. Open-ended questions are not easily answered “yes” or
“no.” Open-ended questions are indirect. Patients can refuse to answer any question, so
this is not an acceptable rationale.
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DIF:
Cognitive Level: Application
REF:
Page 531
22. The nurse is interviewing a patient who presents with a dislocated shoulder and
demonstrates signs of anxiety although relying on her partner for answers. Although
the partner is out of the room, which question is most important to ask?
a. “Have you been with your partner long?”
b. “Are you being abused by your partner?”
c. “Shall I notify the police that you would like to press charges?”
d. “Have you ever been physically or emotionally hurt by someone?”
ANS: D
When the victim is alone, the nurse must seek information about abuse. Phrasing the
question to avoid use of such terms as “abuse” or “battered” is essential. These terms
are too emotionally charged, and patients often respond in the negative. The length of
the relationship is not a priority. Asking to call the police is premature.
DIF: Cognitive Level: Application
REF: Page 531
23. A woman whose husband physically abuses her mentions to the nurse, “Someday I’ll
have to leave him.” Which of the following would be the nurse’s best response?
a. “Yes, you should, before he harms you badly.”
b. “Could we talk about developing a safety plan?”
c. “Are you afraid of what your family will say?”
d. “I don’t know why you would stay with him.”
ANS: B
It is well known that the woman is at high risk for being killed or seriously injured when
she leaves the abuser. Having a safety plan lowers the risk and makes leaving a less
nebulous idea. The patient must make up her own mind. Asking about the family’s
response sidesteps the issue of safety. The patient needs empowerment, not criticism.
DIF: Cognitive Level: Application
REF: Page 532
24. The nurse is planning care for a battered woman who has mentioned, “Someday I’ll
have to leave him.” Which outcome should the nurse include in the plan of care for
this patient?
a. Patient will leave husband for a safe environment within 3 weeks.
b. Patient will verbalize awareness of the dangerousness of her situation.
c. Patient will state that she feels strong enough to return to the situation.
d. Patient will state that she feels more relaxed after consultation with nurse.
ANS: B
This is a realistic outcome for a patient who is beginning to consider leaving the abusive
situation. Setting a timeline is premature. Feeling relaxed is more related to a problem of
anxiety than to abuse. Returning is not an outcome that is in the patient’s best interest.
DIF: Cognitive Level: Application
REF: Page 532
25. A patient who has been battered by her partner sobs, “It was my own fault.” Which of
the following would be the priority response by the nurse?
a. “Why do you think he does it?”
b. “What did you do to deserve this?”
c. “No one has the right to abuse another.”
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d. “Tell me about when you were growing up.”
ANS: C
The patient must understand that as a human being she has the right not to be abused.
Victims of abuse should be given this information in a respectful way to counteract their
feelings of guilt and shame. Asking about behaviors suggests that the patient had a role
in provoking the battery. Asking why sidesteps the real issue. Enquiring about her
childhood continues to look at factors within the patient.
DIF: Cognitive Level: Application
REF: Page 530
26. The care plan for a battered woman will be most successful if the nurse:
a. Empowers the patient to make her own decisions
b. Develops the plan and presents it to the woman
c. Obtains photo evidence of the battery for use in court
d. Has a family conference and mediates among the parties
ANS: A
The nurse’s attitudes, values, and choices cannot be imposed upon the patient. The
nurse must empower the patient to make her own decisions. Empowerment will help the
patient develop strength to make growth-producing decisions independently. The
remaining options would be counterproductive or have no bearing on the success of the
care plan.
DIF: Cognitive Level: Application
REF: Page 532
27. A teenage boy has been periodically beaten by his father. The boy tells the nurse,
“He’ll pay for this one way or another.” The nurse treating his contusions should
assess for behaviors suggesting:
a. Aggression
b. Depression
c. Regression
d. Withdrawal
ANS: A
Research suggests that children who are abused are at high risk for antisocial behavior
and associated aggressive behaviors for a period of at least 2 years after the battering
incident. The boy’s remark is not consistent with any of the other options.
DIF: Cognitive Level: Application
REF: Page 538
28. A patient in her early teens who is being treated for irritable bowel syndrome has just
disclosed that she has been the victim of child abuse for 8 years. For what other
condition should the nurse assess this patient?
a. Schizophrenia
b. Agoraphobia
c. Posttraumatic stress disorder
d. Obsessive-compulsive disorder
ANS: C
The state of chronic hyperarousal caused by the abuse is the basis for three common
outcomes of childhood abuse: PTSD, depression, and irritable bowel syndrome. The
conditions mentioned in the other options are not related to child abuse.
DIF: Cognitive Level: Application
REF: Page 539
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29. Which statement regarding the various types of child offender is correct?
a. The physical offender lacks remorse, although the sexual offender usually shows
guilt and shame.
b. The physical offender has diverse characteristics, although the sexual offender
has lack of remorse.
c. The physical offender has a mature ego, although the sexual offender has a rigid,
overdeveloped superego.
d. The physical offender has poor self-esteem and unrealistic expectations of
children, although the sexual offender has diverse characteristics.
ANS: D
The child physical offender often is assessed as having poor self-esteem, poor impulse
control, unrealistic expectations of children, immaturity, and minimal external supports.
The child sexual offender has diverse characteristics, with no profile becoming apparent.
The child sexual offender often does not show remorse for the acts.
DIF: Cognitive Level: Application
REF: Pages 536-537
30. A toddler was brought to the hospital with a broken humerus and upper arm bruising.
The child’s father states that he shook the child while disciplining him to teach him to
be quiet. An appropriate family-related nursing diagnosis is:
a. Anxiety related to physical abuse
b. Powerlessness related to inability to keep child quiet
c. Impaired parenting related to unrealistic expectations for child
d. Risk for impaired parenting related to harsh disciplinary methods
ANS: C
This diagnosis is supported by data in the scenario. Violence has occurred, so a risk
diagnosis is not appropriate. The remaining diagnoses are not supported by data.
DIF: Cognitive Level: Application
REF: Page 540
31. An experienced nurse correctly notes that an important factor in assessing survivors
of childhood sexual abuse is to be aware that they often experience long-term
symptoms most closely resembling DSM-IV-TR criteria for:
a. Adjustment disorders
b. Schizophreniform reaction
c. Posttraumatic stress disorder
d. Obsessive-compulsive personality disorder
ANS: C
Although childhood sexual abuse produces a wide variety of long-term sequelae, the
most common psychosocial problems are PTSD, self-damaging behavior, mood
disturbances, interpersonal problems, and sexual difficulties. The other options are rarely
noted.
DIF: Cognitive Level: Application
REF: Page 541
32. An elderly patient who lives with her daughter, son-in-law, and their three children
reveals that her daughter sometimes slaps her when she does not move fast enough
or spills things. The daughter states, “I have so much to do that I become frustrated
when my mother can’t move fast enough or causes me extra work.” The nurse caring
for the mother could appropriately suggest:
a. Moving the mother to an adult ambulatory care facility
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b. Employing an aide to provide care and stimulation for the mother
c. Enrolling in a therapeutic group that addresses stress management
d. Reading the elder law of the state to learn the penalties for elder abuse
ANS: C
The daughter has many stressors and has few external supports. Enrolling in a stress
management group would provide support as well as teach new adaptive coping
strategies. Being required to read the law is threatening. The remaining options are
premature.
DIF: Cognitive Level: Application
REF: Page 546
33. After being raped, a woman was told by her aunt, “I’m not surprised that happened
to you. You always dress to show off your figure.” The victim states, “I can’t believe
that people can think that way.” The rape crisis nurse correctly hypothesizes that the
patient is:
a. Being revictimized by society
b. Overly sensitive to others’ views
c. Overreacting to not resisting more strongly
d. Unaware of the normalcy of male sexual aggression
ANS: A
Victim blaming is common following a rape. Instead of blaming the rapist, many
individuals lack knowledge and empathy and revictimize the woman. Rape education
programs can be helpful in changing attitudes. The other options are hypotheses that
continue to place blame on the victim.
DIF: Cognitive Level: Application
REF: Page 546
34. Which of the following would be an appropriate outcome for a patient diagnosed with
rape-trauma syndrome?
a. Patient will sleep 8 hours without medication by week 6 of therapy.
b. Patient will develop better self-esteem by week 8 of therapy.
c. Patient will accept nurse’s word that her reactions are normal.
d. Patient will verbalize that recovery may never happen totally.
ANS: D
Rape trauma victims require time to process what has happened to them and to
reorganize their lives, just as an individual who is grieving must do. The remaining
options are not realistic nor therapeutic.
DIF: Cognitive Level: Application
REF: Page 550
Chapter 24: Forensic Nursing
1. What is the primary expected outcome when a victim of a violent crime is initially
attended to by a forensic nurse?
a. Their physical injuries will be assessed and treated.
b. The evidence of the assault from their body will be preserved.
c. The legal system will be provided with evidence of the crime.
d. Their long-term emotional health will be of primary concern.
ANS: B
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Forensic nurses fill a gap where the health care system interacts with the legal system
by meeting the needs of victims and perpetrators of violent crimes through enhanced
quality of care and preventive services. Observation, documentation, preservation, and
notification are critical for determining the legal outcomes of cases that involve violence.
Although it is true that the legal system is supported, that is not the focus of care in
these cases. The remaining options are not responsibilities unique to the forensic nurse.
DIF: Cognitive Level: Application
REF: Page 558
2. Which therapeutic outcome has resulted from the introduction of the specialized
SANE nurse?
a. ED staff are no longer involved in the care of rape victims.
b. Retraumatizating of the rape victim has been decreased greatly.
c. The rights of both the rape victim and the rapist are preserved.
d. The rape victim is assured quality physical and mental healthcare.
ANS: B
The specialized attention of these nurses has addressed the long-standing issue of
retraumatizing victims. The ED staff may still be involved in the physical care of the
victim. The focus is not on the rights of the potential rapist. The physical and mental
health needs of the victim are not the sole responsibility of the SANE nurse.
DIF: Cognitive Level: Application
REF: Pages 555-556
3. When providing care to an assault victim, the forensic nurse will initially:
a. Notify the police that an assault has occurred.
b. Assess the individual for any resulting physical trauma.
c. Bag all clothing to preserve any relevant evidence.
d. Determine whether the victim as been sexually assaulted as well.
ANS: B
It is the role of the forensic nurse to immediately assess the assault victim for evidence
of acute physical injuries. The remaining options do not have the priority that the
individual’s physical health needs demand.
DIF: Cognitive Level: Application
REF: Page 556
4. Which intervention demonstrates the SANE nurse’s unique attention to the
assessment of a sexual assault?
a. Conducting the assessment in the most private exam room
b. Not directly questioning the patient about the attack or the attacker
c. Identifying that the patient is showing signs of anxiety by withdrawing
d. Meticulously assessing the patient for signs of any resulting physical trauma
ANS: C
Throughout the physical examination, the SANE nurse will be attuned to the victim’s
mental status and monitor him or her for signs and symptoms of anxiety, panic, and
grief. The event and the assailant are topics that must be discussed. The remaining
options identify interventions that are considered a nursing responsibility and not unique
to the role of the SANE nurse.
DIF: Cognitive Level: Application
REF: Page 556
5. To best address the assault victim’s psychosocial needs, the forensic nurse:
a. Warns the family that the patient will likely be suicidal
b. Suggests that the family provide continuous supervision of the patient for at least
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30 days
c. Encourages the patient to discuss medication therapy with the physician prior to
discharge from the ED
d. Provides education to both the patient and the family regarding the signs of
posttraumatic stress disorder (PTSD)
ANS: D
These patients are at extreme risk for PTSD, depression, and anxiety disorders, making
education on such topics vitally important to their mental health. Although the patient
may become depressed and have an increased risk for suicide, it is not true that the
patient is likely to attempt such an act nor is it necessary to provide constant
supervision. If such was needed, the patient would be hospitalized. The need for
medications will be determined by the physician.
DIF: Cognitive Level: Application
REF: Pages 556-557
6. Which nursing intervention demonstrates an understanding of the coping
mechanisms often used by individuals who are not receiving formal treatment for
their symptoms of postassault anxiety and stress?
a. Providing smoking cessation materials
b. Discussing the importance of safe sex
c. Assessing for the abuse of marijuana
d. Monitoring for weight gain since the assault
ANS: C
Rather than being engaged in formal treatment, 67% of a study’s participants reported
the use of illicit substances, mainly marijuana. The primary purpose for this substance
use is to aid in numbing the victim from the effects of intrusive thoughts and to allow
victims to self-medicate for the treatment of insomnia and irritability. Although some
individuals will use cigarette smoking, sexual promiscuity, and eating as coping
mechanisms, they do not appear to have the affects that marijuana has on managing
the symptoms of anxiety and stress.
DIF: Cognitive Level: Application
REF: Page 557
7. A patient, brought into the ED by family members who reported a fall, shares that the
injury was actually a result of physical abuse. The patient tells the nurse that this is
to be kept confidential because, “that is my right.” The nurse tells the patient that:
a. It is a patient right but it was intended to protect patients.
b. Nurses are required by law to report all incidents of abuse.
c. The report will not mention the patient’s admission that abuse has occurred.
d. The abuser needs to be stopped before they go on to really cause the patient
harm.
ANS: B
Releasing patient information in the context of a criminal act, such as physical abuse, is
exempt from confidentiality standards and laws, because the release of this information
is for the protection of the victim; it is used to investigate the crime and potentially to
apprehend the perpetrator. Although the remaining options are true, those statements
do not adequately address the patient’s remarks.
DIF: Cognitive Level: Analysis
REF: Page 558
8. Based on the importance of recognizing all the important elements for their role as
part of the assaulted patient’s context or environment of care, the nurse will:
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a. Keep the family well informed of the patient’s status and plan of care.
b. Document the patient’s statement for the purpose of future legal proceedings.
c. Provide the staff with a detailed shift change report including the patient’s state
of mind.
d. Notify the local police with updates concerning the patient’s health status and
verbal statements.
ANS: A
It is pertinent for nurses to adopt a family-centered approach that encompasses family
members in caring interventions so that they are recognized as part of the patient’s
context or environment. Providing effective shift change information is an expectation
regardless of the nature of the care. The remaining options would be considered
standard practice in cases involving violence as a crime and not related to the plan of
care.
DIF: Cognitive Level: Application
REF: Page 559
9. When preparing an educational session for urban adolescents concerning the
personal impact of violence in their communities, the nurse includes information on:
a. The need to report all incidences of violence to the local police
b. How depression and anxiety can result from living in a violent environment
c. The role of drug and alcohol abuse in the making of a violent neighborhood
d. The role that neighborhood police officers play in the management of violence
ANS: B
Witnessing a violent crime and having knowledge of a violent crime in the family or
community are considered precursors to posttraumatic illness. In addition to
demonstrating symptoms of PTSD, adolescents who live in poor urban neighborhoods
are more likely to be exposed to multiple incidents of violence during their adolescence,
which is strongly linked to major depression and anxiety disorders, particularly among
women. Although substance abuse does play a role in community violence, this option
lacks the personal connect of the correct option, at least in this scenario. The remaining
options do not relate to the personal but rather the communal impact of violence.
DIF: Cognitive Level: Application
REF: Page 559
10. The nurse demonstrates an understanding of the physical effects of posttraumatic
stress disorder (PTSD) when implementing which intervention for a patient who was
abducted and assaulted three months ago?
a. Regular evaluations for suicidal thoughts
b. Explaining the need for appropriate use of a rescue inhaler
c. Providing reinforcement for the patient’s new exercise program
d. Evaluating the patient’s understanding of the proper use of analgesic
medications
ANS: D
The presence of PTSD—particularly among those who have been exposed to violent
crimes—demonstrates a heightened risk for negative health outcomes that include
cardiac disease, intestinal problems, and chronic pain as common disorders found in
patients with PTSD. Although suicide and stress certainly have a physical impact, they
are considered psychiatric disorders. Respiratory issues are more related to anxiety
disorders.
DIF: Cognitive Level: Application
REF: Page 559
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11. Which intervention should be given highest priority when attempting to gain the trust
of the members of an urban family whose child has been violently assaulted and is in
critical condition?
a. Discussing the family needs with the child’s multidisciplinary care team
b. Constantly assuring them that their child is receiving quality nursing care
c. Encouraging and respecting their right to ask questions about their child and the
child’s care
d. Keeping them updated on the health and emotional status of their child during
each shift
ANS: C
Assuring the family that you are not hiding facts from them will best assist in
establishing a trusting relationship and can be facilitated by respecting and encouraging
them to ask questions that will be answered honestly by the staff. The remaining options
are appropriate but lack the interaction between nurse and family that the correct option
possesses.
DIF: Cognitive Level: Analysis
REF: Page 560
12. When encouraging healthy coping mechanisms for a group of parents attending a
workshop for families who have lost children to violent crimes, the nurse focuses on:
a. Discussing how the fathers are attempting to accept the death
b. Providing the fathers with information on the value of crying
c. Discussing the problems that occur when women suppress their feelings
d. Encouraging the mothers to adopt a rigorous exercise plan to help manage grief
ANS: A
A study of parental coping showed that mothers preferred to use emotion-focused
coping, whereas fathers preferred coping mechanisms that focused on restraint,
acceptance, and suppression.
DIF: Cognitive Level: Application
REF: Page 560
13. Which intervention is considered a responsibility of the forensic nurse working within
the correctional prison system?
a. Counseling inmate families
b. Identifying postdischarge community resources
c. Providing health care services to the prison staff
d. Protecting the legal rights of the inmates while incarcerated
ANS: B
The nurse may identify and provide community linkages for inmates after discharge. The
remaining options are not considered the responsibility of the forensic nurse when
working in the correctional prison setting.
DIF: Cognitive Level: Application
REF: Page 561
14. Which nursing intervention will best improve an inmate’s likelihood of not reoffending and thus not returning to the correctional system?
a. Frequently screening inmates for mental health disorders
b. Providing mandatory inmate focused anger management workshops
c. Providing as needed (prn) medications for inmates with a history of depression
d. Working with the families to prepare them for the inmates scheduled release
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ANS: A
More than 250,000 incarcerated offenders are believed to have been diagnosed with or
will develop a major mental illness while in the prison system. Without proper treatment
and intervention, these offenders are at higher risk for violence recidivism, which is the
criminal behavior of an offender after being released from incarceration. Frequent
screenings for mental health disorders and the resulting treatment will have the greatest
impact on this situation. PRN, as needed, treatment of mental disorders is not within the
nurse’s scope unless covered by standing orders. Attention to anger management is
appropriate but not as impactful as the correct option. Working with families is not a
typical responsibility of a nurse in the prison environment.
DIF: Cognitive Level: Application
REF: Page 561
15. Which intervention demonstrates that the nurse understands the risk factors for the
commission of violent crimes?
a. Reinforcement of anger management skills
b. Substance abuse rehabilitation counseling
c. Community focused depression screenings
d. Counseling for adult victims of child abuse
ANS: B
In addition to major mental illnesses, a common issue that is seen in prison and offender
populations is substance addiction. Substance abuse and addiction—particularly
involving alcohol—are strongly correlated with the commission of violent crime in the
United States. Although the remaining options have varying degrees of impact on violent
crime, none are as important as the correct option.
DIF: Cognitive Level: Analysis
REF: Page 561
Chapter 25: Psychopharmacology
1. The nurse manager on the psychiatric unit was explaining to the new staff the
differences between typical and atypical antipsychotics. The nurse correctly states
that atypical antipsychotics:
a. Remain in the system longer
b. Act more quickly to reduce delusions
c. Produce fewer extrapyramidal effects
d. Are risk free for neuroleptic malignant syndrome (NMS)
ANS: C
Atypical antipsychotics produce less D2 blockade; thus movement disorders are less of a
problem. No evidence suggests that the medication remains in the system longer nor
that it acts more quickly to reduce delusions. The atypicals are not risk free for NMS.
DIF: Cognitive Level: Application
REF: Page 567
2. The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on
haloperidol (Haldol) develops a:
a. 30 mm Hg decrease in blood pressure reading
b. Respiratory rate of 24 respirations per minute
c. Temperature reading of 104° F
d. Pulse rate of 70 beats per minute
ANS: C
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Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of
NMS. There are no significant findings to support the options related to respirations or
pulse rate.
DIF: Cognitive Level: Application
REF: Page 570
3. A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision.
What would the nurse assess as the likely cause of these symptoms?
a. Decreased dopamine at receptor sites
b. Blockade of histamine
c. Cholinergic blockade
d. Adrenergic blocking
ANS: C
Fluphenazine administration produces blockade of cholinergic receptors giving rise to
anticholinergic effects, such as dry mouth, blurred vision, and constipation.
DIF: Cognitive Level: Application
REF: Page 566
4. Which behavior displayed by a patient receiving a typical antipsychotic medication
would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)?
a. Grimacing and lip smacking
b. Falling asleep in the chair and refusing to eat lunch
c. Experiencing muscle rigidity and tremors
d. Having excessive salivation and drooling
ANS: A
TD manifests as abnormal movements of voluntary muscle groups after a prolonged
period of dopamine blockade. Movements may affect any muscle group, but muscles of
the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of
the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused
from imbalance between dopamine and acetylcholine.
DIF: Cognitive Level: Application
REF: Page 570
5. When the nurse realizes that a patient diagnosed with schizophrenia is not taking the
prescribed oral haloperidol (Haldol), which intervention would promote medication
compliance?
a. Instructing the patient to have friends monitor his medications
b. Beginning administration of haloperidol (Haldol) decanoate
c. Writing instructions in detail for the patient to follow
d. Changing haloperidol to an atypical antipsychotic
ANS: B
Haloperidol decanoate is a depot medication, given intramuscularly every 2 to 4 weeks.
It is unknown whether the patient has a support system. The patient probably received
education, including written instructions prior to discharge. Changing to another
classification of medication would not necessarily improve compliance.
DIF:
Cognitive Level: Application REF: Page 572
6. When asked how tricyclic antidepressants affect neurotransmitter activity, the nurse
should respond that they:
a. Decrease available dopamine.
b. Increase availability of norepinephrine and serotonin.
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c. Make available increased amounts of monoamine oxidase.
d. Increase the effects of the chemical gamma-aminobutyric acid.
ANS: B
Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of
norepinephrine and serotonin available. Decreasing dopamine is the action of typical
antipsychotic medication. Increasing monoamine oxidase is not the action of tricyclics.
Benzodiazepines, not tricyclics, increase the effects of GABA.
DIF: Cognitive Level: Application
REF: Page 578
7. A severely depressed patient has been prescribed clomipramine (Anafranil). For
which medication side effects should the patient be monitored?
a. Excess salivation and drooling
b. Muscle rigidity and restlessness
c. Polyuria and coarse hand tremors
d. Orthostatic hypotension and constipation
ANS: D
Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces
constipation. Mild tremors and urinary retention may occur. Drooling and excessive
salvation may occur with SSRIs. Muscle rigidity and restlessness may occur with
antipsychotics.
DIF: Cognitive Level: Application
REF: Page 578
8. Which of these statements made by a patient taking the MAOI phenelzine (Nardil)
would warrant further instruction?
a. “I often forget to wear sunscreen when I go outside.”
b. “I need to restrict the amount of sodium in my diet.”
c. “I should not use over-the-counter cold medications.”
d. “I usually order liver and onions when my wife and I eat out.”
ANS: D
MAOIs require patients to observe a tyramine-free diet to prevent hypertensive crisis.
Liver is a food that contains large amounts of tyramine. The remaining options have no
relevance for MAOI therapy.
DIF: Cognitive Level: Application
REF: Page 580
9. Which patient complaint should receive priority from a patient who is taking the MAOI
tranylcypromine (Parnate)?
a. “I haven’t had a bowel movement in 2 days.”
b. “Will you take my temperature? I feel too warm.”
c. “I get a headache when I drank several cups of coffee.”
d. “My legs get stiff when I sit in the chair for any length of time.”
ANS: C
Hypertensive crisis may occur if a patient taking a MAOI ingests certain food containing
tyramine or drugs that cause blood pressure (BP) elevation. Headache is a warning sign
of hypertensive crisis. The nurse should assess BP and inquire about other symptoms of
hypertensive crisis. Stiffness is not related to MAOI therapy. Elevated temperature is not
an initial sign of hypertensive crisis. Constipation is not a sign of hypertensive crisis.
DIF: Cognitive Level: Analysis
REF: Page 580
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10. Sertraline (Zoloft) has been prescribed for a patient with symptoms of a major
depression. Which factor was probably most important in the physician’s decision to
use an SSRI?
a. Good side-effect profile
b. Less expense for the patient
c. Increase in medication compliance
d. Rapid rate of absorption from the GI tract
ANS: A
Compared to other antidepressant medication groups, SSRIs have the best side-effect
profile. SSRIs are more costly. No studies have shown that SSRIs result in better
compliance. These drugs are absorbed slowly from the GI tract.
DIF: Cognitive Level: Application
REF: Page 578
11. Which statement made by a patient who will be maintained on lithium following
discharge will require further instruction by the nurse?
a. “I will have my blood work done regularly.”
b. “When I get home, I may go on a salt-free diet.”
c. “I have learned not to restrict my intake of water.”
d. “I understand some people gain weight on lithium.”
ANS: B
This statement shows that the patient does not understand the relationship between
lithium and sodium. The patient must be taught that changing dietary salt intake will
affect lithium levels. Adding salt can cause lower levels; reducing salt can result in
toxicity. The remaining options reflect correct information regarding lithium therapy.
DIF: Cognitive Level: Application
REF: Page 584
12. To educate a patient regarding what to expect following the administration of a
benzodiazepine, the nurse must understand that benzodiazepines:
a. Have a rapid onset of peak action
b. Reduce availability of GABA
c. Generally diminish the activity of GABA
d. Interact with serotonin to increase availability
ANS: A
Benzodiazepines do have a more rapid onset. There is no effect on the availability or
function of GABA. Benzodiazepines do not diminish GABA activity; they enhance it.
DIF: Cognitive Level: Application
REF: Page 587
13. A patient prescribed alprazolam (Xanax) for symptoms of anxiety shares with the
nurse that, “I’m concerned about getting off this medication.” Upon which fact will
the nurse base the response to the patient’s concern?
a. Long elimination half-life will result in a manageable withdrawal treatment plan.
b. Rapid absorption and distribution to brain cells make withdrawal more difficult to
manage.
c. Sensitivity of the mesencephalic reticular activating system makes addiction
unlikely.
d. The combination of medication with an antidepressant often positively impacts
withdrawal.
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ANS: B
In general, shorter-acting benzodiazepines are more difficult to taper and potentially
cause more problems with withdrawal. The remaining options are neither true nor
relevant.
DIF: Cognitive Level: Application
REF: Page 587
14. Which patient outcomes would be most applicable for the patient who has been
taking benzodiazepines? Patient will state:
a. That there are specific foods to avoid while on this medication
b. An understanding of how to increase medication dosage
c. That alcohol is a substance to avoid while on the medication
d. An understanding that he or she can return to work while on this medication
ANS: C
Combining a benzodiazepine with alcohol or other CNS depressant is potentially fatal. No
food restrictions exist. Dosage should not be changed without consultation with the
physician. Patients may return to work unless experiencing sedation. In this case, they
would be cautioned not to operate machinery.
DIF: Cognitive Level: Application
REF: Page 589
15. Which person with mania is the least likely candidate to receive lithium? The patient
who is:
a. Six weeks pregnant
b. Recovering from a hysterectomy
c. Taking hormone replacement therapy
d. Displaying symptoms of postpartum depression
ANS: A
Lithium is contraindicated during pregnancy because of teratogenic effects. The
remaining options would not be contraindicative to lithium therapy.
DIF: Cognitive Level: Application
REF: Page 583
16. An individual with poststroke depression is receiving an SSRI. What is the rationale
for giving the medication at breakfast and again at midday?
a. Prevent insomnia
b. Prevent toxic reactions
c. Decrease afternoon sleepiness
d. Give an opportunity to monitor behavior closely
ANS: A
CNS stimulants may cause insomnia if given late in the day. Toxicity is a result of
excessive medication in the system, not when it is administered. The drowsiness
resulting from SSRI use would not be minimized if taken as described. There is no
expectation that resulting behaviors will need to be so closely monitored.
DIF: Cognitive Level: Analysis
REF: Page 578
17. A patient who has received lithium for 3 weeks to control acute mania has the
following symptoms: coarse hand tremor, diarrhea, vomiting, lethargy, and mild
confusion. The priority nursing action should be to:
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a. Administer prn Cogentin to relieve the symptoms.
b. Provide reassurance that the symptoms are transient.
c. Obtain a stat lithium level; hold lithium pending results.
d. Assist the patient to decrease the sodium in their daily diet.
ANS: C
The symptoms the patient is experiencing are consistent with moderate lithium toxicity.
The nurse should hold lithium, obtain a stat lithium level, and notify the physician.
Cogentin is inappropriate; the symptoms are not EPS. The nurse may reassure the
patient but cannot suggest that the symptoms will resolve over time. Minimizing salt
would worsen lithium toxicity.
DIF: Cognitive Level: Application
REF: Pages 583-584
18. A patient with rapid cycling bipolar disorder is not responding well to lithium. The
patient tells the nurse, “It feels as though I’ll never get well. I get better, and then I
get worse.” The reply that is based on knowledge of current therapy would be:
a. “You’re feeling very discouraged aren’t you?”
b. “It’s not all bad, is it? Sometimes you like being high.”
c. “Another drug, valproic acid, is proving effective for rapid cycling.”
d. “If your kidneys hold out, the lithium will eventually control the symptoms.”
ANS: C
Valproic acid is a first-line agent for the treatment of bipolar disorder. It is particularly
effective with rapid cycling. The other options are not responsive to the question stem,
which asks for knowledge of current therapy.
DIF: Cognitive Level: Application
REF: Page 583
19. Which statement by a patient with generalized anxiety disorder for whom lorazepam
(Ativan) is prescribed as needed (prn) suggests the patient understands the purpose
of the medication?
a. “I can talk with my therapist more easily after my medication takes effect.”
b. “I wonder if I will have to take this medication for the rest of my entire life.”
c. “I’m embarrassed and don’t want anyone to know I’m on this kind of
medication.”
d. “I’m going to ask for my prn dose so I can sleep instead of worrying about my
kids.”
ANS: A
The patient recognizes the therapeutic effects of the medication in assisting her to work
effectively with the therapist. The remaining options show questions and inappropriate
use of the medication.
DIF: Cognitive Level: Application
REF: Page 587
20. A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks. He
drools, has hand tremors, and walks with a shuffling gait. The nurse would correctly
attribute these behaviors to:
a. Akinesia
b. Tardive dyskinesia
c. Pseudoparkinsonism
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d. Neuroleptic malignant syndrome
ANS: C
These are symptoms of pseudoparkinsonism associated with dopamine blockade. Tardive
dyskinesia occurs after long-term therapy. The remaining options are not associated with
the symptoms mentioned.
DIF: Cognitive Level: Application
REF: Page 569
21. What intervention will the nurse request for a patient reporting gastrointestinal side
effects related to valproate therapy?
a. Mild laxative
b. Low-fat diet
c. Oral antacid
d. Histamine-2 antagonist
ANS: D
Indigestion, heartburn, and nausea are common side effects of valproate therapy. The
administration of a histamine-2 antagonist such as famotidine (Pepcid) is sometimes
helpful. The other options would have no impact on the complaint.
DIF: Cognitive Level: Application
REF: Page 584
22. A patient’s serum lithium level is reported as 1.9 mEq/L. The nurse should
immediately:
a. Restrict sodium and fluid intake.
b. Assess for signs and symptoms of toxicity.
c. Seek to have the patient transferred to ICU.
d. Notify the patient’s physician immediately.
ANS: B
A serum lithium level this high suggests that the patient may be experiencing symptoms
of lithium toxicity. Clinical assessment is essential to determine what, if any, signs and
symptoms are present. After the clinical assessment has been made, the nurse can
provide the physician with a complete picture. Restricting sodium and fluids would raise
the serum level. Transferring may not be necessary and would require a physician’s
order.
DIF: Cognitive Level: Application
REF: Page 583
23. To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic
drug therapy, the nurse would look for improvement in:
a. Affective mobility
b. Positive symptoms
c. Self-care activities
d. Cognitive functioning
ANS: B
Typical antipsychotic medications produce improvement in the positive symptoms of
schizophrenia such as hallucinations and delusions. Negative symptoms and cognitive
functioning tend to show less improvement.
DIF: Cognitive Level: Application
REF: Pages 568-569
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24. During a psychiatric emergency, IM ziprasidone (Geodon) is administered to an
assaultive patient. During the next 2 hours, it is of primary importance that the nurse
assess for:
a. Tardive dyskinesia
b. Anticholinergic effects
c. Orthostatic hypotension
d. Pseudoparkinsonism
ANS: C
The side effect most likely to appear is orthostatic hypotension related to alpha 1 receptor
blockade preventing peripheral blood vessels from automatically responding to positional
change. Anticholinergic effects are of lesser concern. The remaining options are less
likely to occur at this point in therapy.
DIF: Cognitive Level: Application
REF: Page 575
25. A patient who began haloperidol (Haldol) therapy 24 hours ago tells the nurse that he
feels jittery and unable to sit or stand still. The nurse can hypothesize that this report
is related to:
a. Dystonia
b. Akathisia
c. Serotonin syndrome
d. Neuroleptic malignant syndrome
ANS: B
Akathisia, an extrapyramidal side effect, is characterized by restlessness, inability to sit
still, and the need to pace. It usually occurs early in the course of treatment with a
typical antipsychotic drug. The symptomology is not related or seen in the other options.
DIF: Cognitive Level: Analysis
REF: Page 570
26. When reviewing the medications being taken by an elderly patient diagnosed with
Alzheimer’s disease, the nurse should consult with the patient’s physician when
noting a prescription for:
a. Risperidone (Risperdal)
b. Fluphenazine (Prolixin)
c. Lorazepam (Ativan)
d. Sertraline (Zoloft)
ANS: A
Patients with dementia-related psychosis who were treated with atypical (secondgeneration) antipsychotics such as Risperdal were at an increased risk of death as
compared with patient taking a placebo. The other medications are not currently known
to have that risk.
DIF: Cognitive Level: Application
REF: Page 575
27. When a patient for whom haloperidol has been prescribed tells the nurse, “I’m
burning up and my muscles are stiff and sore,” the nurse suspects neuromuscular
malignant syndrome and recognizes the possibility that the physician may order:
a. Olanzapine (Zyprexa)
b. Benztropine (Cogentin)
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c. Venlafaxine (Effexor)
d. Dantrolene (Dantrium)
ANS: D
Dantrolene, a direct-acting skeletal muscle relaxant, is a drug often used to treat NMS.
The other drugs mentioned would have no therapeutic effect on NMS.
DIF: Cognitive Level: Application
REF: Page 571
28. A patient with schizophrenia is seen in the ED in an acutely agitated state resulting
from threatening auditory hallucinations. The patient’s medical record indicates he
has had severe dystonic reactions to parenteral administration of typical
antipsychotic medication. The nurse can anticipate that the physician will order:
a. Ziprasidone (Geodon)
b. Fluphenazine (Prolixin) decanoate
c. Clozapine (Clozaril)
d. Paroxetine (Paxil)
ANS: A
This atypical antipsychotic comes in an injectable form and is effective in controlling
agitated and assaultive behaviors. Fluphenazine (Prolixin) decanoate is a typical
antipsychotic. Clozapine (Clozaril) is used only for refractory schizophrenia. Paroxetine
(Paxil) is an SSRI.
DIF: Cognitive Level: Application
REF: Page 575
29. A patient whose schizophrenia has been refractory to treatment with other
medications has been placed on clozapine (Clozaril). The priority discharge teaching
should include:
a. Keep salt intake the same from day to day.
b. Maintain a strict tyramine-free daily diet.
c. Report for weekly blood tests for CBC level.
d. Use sunblocking agents when out of doors.
ANS: C
Clozaril has the potential to cause agranulocytosis; hence the need for weekly blood
draws for CBCs for the first 6 months of therapy and every other week after that point.
The other options are not relevant to Clozaril therapy. Salt intake refers to lithium
therapy, tyramine to MAOI therapy, and sunblocking to phenothiazine therapy.
DIF: Cognitive Level: Application
REF: Page 573
30. The nurse must notify the physician of the need to suspend treatment for a patient
receiving clozapine (Clozaril) when the weekly WBC monitoring shows:
a. WBCs below 2000/mm3 and absolute neutrophils below 1000/mm3
b. WBCs below 2500/mm3 and absolute neutrophils below 1500/mm3
c. WBCs below 3000/mm3 and absolute neutrophils below 2000/mm3
d. WBCs below 3500/mm3 and absolute neutrophils below 2500/mm3
ANS: A
Counts at this level indicate the presence of leukopenia. Agranulocytosis is a possible
side effect of Clozaril therapy for which the patient is closely monitored. The other levels
are high enough to be considered safe.
DIF: Cognitive Level: Application
REF: Page 573
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31. A patient receiving haloperidol urgently calls to the nurse and reports that his eyes
have rolled upward and he cannot redirect his gaze. The nurse contacts the physician
to seek an order for:
a. Fluphenazine (Prolixin)
b. Citalopram (Celexa)
c. Benztropine (Cogentin)
d. Risperidone (Risperdal)
ANS: C
The nurse should recognize the patient’s problem as dystonia and know the treatment is
IM administration of an antiparkinsonian drug, such as benztropine, or an antihistamine,
such as diphenhydramine (Benadryl), for which a physician’s order is necessary.
Fluphenazine (Prolixin) would worsen the condition. The remaining options would not be
useful.
DIF: Cognitive Level: Application
REF: Page 569
32. An appropriate outcome for trihexyphenidyl (Artane) therapy used in conjunction
with high potency typical antipsychotic medication therapy is that the patient will:
a. Demonstrate a brighter mood
b. Be less sedated and drowsy
c. Display fewer movement disorder symptoms
d. Display decreased anticholinergic symptoms
ANS: C
Trihexyphenidyl is used to treat extrapyramidal symptoms, such as pseudoparkinsonism.
The other options are not expected outcomes of administration of this medication.
DIF: Cognitive Level: Application
REF: Page 570
33. An atypical antipsychotic has been prescribed for an elderly patient. The nurse
developing the patient’s care plan includes:
a. Scheduling weekly WBC counts
b. Teaching about a tyramine-free diet
c. Requesting that a daily laxative be included
d. Teaching fall prevention strategies to both the patient and family
ANS: D
Orthostatic hypotension is a possible side effect due to alpha-adrenergic blockade. The
nurse should teach the patient about changing position slowly and using handrails when
walking to prevent falls. The remaining options are not related to antipsychotic
medications.
DIF: Cognitive Level: Application
REF: Page 571
34. The nurse notes that a patient who has been receiving paroxetine (Paxil) for
symptoms of major depression begins to behave in a confused and elated manner
with the presence of restlessness, muscle jerking, and diaphoresis. The nurse should
assess these symptoms as probable:
a. Neuroleptic malignant syndrome
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b. Anticholinergic blockade
c. Serotonin syndrome
d. Dystonia
ANS: C
These are symptoms of serotonin syndrome, a condition that requires medical
intervention. The other options are not associated with SSRI therapy.
DIF: Cognitive Level: Application
REF: Page 577
35. When following up on SSRI medication side effects, the nurse will need to make
specific inquiries about:
a. Anticholinergic symptoms
b. Alpha-adrenergic blockade
c. GI tract symptoms
d. Sexual dysfunction
ANS: D
SSRIs often cause sexual dysfunction, a symptom patients may be reluctant to bring up
voluntarily. Patients readily bring up the side effects mentioned in the other options.
DIF: Cognitive Level: Application
REF: Page 578
36. A patient taking SSRIs mentions to the nurse that his current medication causes
fewer side effects than the tricyclic antidepressant he took several years earlier. The
nurse understands that SSRIs advantage is due to:
a. Inhibiting both serotonin and norepinephrine uptake
b. Selectively inhibiting dopamine uptake
c. Blocking only serotonin reuptake
d. Making more GABA available
ANS: C
TCAs inhibit the reuptake of both norepinephrine and serotonin, producing more side
effects than SSRIs that selectively block only serotonin reuptake. SSRIs do not affect
dopamine or GABA availability.
DIF: Cognitive Level: Application
REF: Page 576
Chapter 26: Therapies: Theory and Clinical Practice
1. Which intervention best reflects the nursing role regarding effective implementation
of behavioral therapy goals?
a. Administering the prescribed medications accurately
b. Interacting effectively with members of the health care team
c. Being aware of all the patient related therapeutic modalities
d. Evaluating patient behaviors to reward economic tokens appropriately
ANS: D
The primary role of the nurse who is involved in behavioral therapy is to assess and
identify the patient’s problem behaviors in collaboration with the multidisciplinary team.
A token economy is a system of behavior reinforcements in which patients earn tokens
by performing predetermined desired behaviors. The remaining options are generalized
responsibilities that are relevant to any therapy format.
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DIF: Cognitive Level: Application
REF: Page 600
2. A new nurse asks the mentor, “How can I be sure I’m developing a therapeutic
environment for my unit?” The mentor uses as a basis for the response the fact that
a therapeutic milieu is characterized by:
a. Rigid adherence to timelines and unit routine
b. Relaxation of boundaries when doing so is accepted by all
c. The focus of the staff is directed to the most critically disturbed patients
d. Specific patient-centered goals are established mutually by patient and staff
ANS: D
Factors that determine the therapeutic effectiveness of the social environment includes
the presence of two-way communication between the patients and the members of the
multidisciplinary team for purposes of goal setting. In a therapeutic relationship,
boundaries are established early and maintained throughout and although adherence to
routine is important, there is room for adjustment when it benefits the therapeutic
nature of the milieu. Although short-term attention may require focus on the patient in
crisis, attention of the staff is equally shared.
DIF: Cognitive Level: Application
REF: Page 604
3. To plan care for a patient with a psychiatric disorder, the nurse keeps in mind that the
primary nursing role related to therapeutic activities is:
a. Assisting the patient in accomplishing the activity
b. Ensuring that the patient will comply with the rules of the activity
c. Ensuring that the patient can accomplish the activity in a timely manner
d. Providing a support system for the patient if they fail to complete the activity
ANS: A
The nurse’s role in therapeutic activities is that of a professional observer and participant
who works with the therapist to enhance the patient’s capabilities and functioning within
the parameters of the assigned activity. Assuring accomplishment, compliance, or
providing failure support are not nursing roles.
DIF: Cognitive Level: Application
REF: Page 620
4. Which statement would the nurse use to describe the primary purpose of
boundaries?
a. Boundaries define responsibilities and duties to one’s self in relation to others.
b. Boundaries determine objectives of the various working stage of the relationship.
c. Boundaries differentiate the assumed roles of both the nurse and of the patient.
d. Boundaries prevent undesired material from emerging during the interaction.
ANS: A
Boundaries are the social, physical, and emotional limits of the interaction. As such, they
serve to define the responsibilities and duties of the nurse in relation to the patient.
Objectives and roles are determined during the orientation stage. Emergence of
undesired material may be a significant issue for the patient.
DIF: Cognitive Level: Application
REF: Page 615
5. Which action will best facilitate the development of trust between a nurse and
patient?
a. Responding positively to the patient’s demands
b. Following through with whatever was promised
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c. Clarifying with the patient whenever there is doubt
d. Staying available to the patient for the entire shift
ANS: B
Being consistent in keeping one’s word implies that the nurse is trustworthy and does
what is agreed upon. Being responsive to demands may not be therapeutic. Instead, the
patient will need to learn new techniques for meeting needs. Clarification is important
but is not the best method for promoting trust. Trust is better served by shorter contacts
at agreed-upon intervals.
DIF: Cognitive Level: Application
REF: Page 603
6. Which statement best defines the nurse’s initial role as the patient’s source of help in
addressing interpersonal problems?
a. “I’ll work with your doctor to help you get better.”
b. “I’ll be working with you to help solve your marital troubles.”
c. “Your medications will help you feel better as soon as they take effect.”
d. “You will be expected to attend the group activities while you are here.”
ANS: B
This statement clearly specifies the nurse’s purpose as a helping professional, and
establishes the relationship as therapeutic, rather than social. The nurse has
independent functions and does not work exclusively with the doctor. Identifying only
medication overlooks the contributions of staff and the therapeutic milieu. Giving
information is appropriate, but this statement does not define the nurse’s role as
resource.
DIF: Cognitive Level: Application
REF: Page 604
7. The nurse is determining whether the patient’s needs could be best met in a task or
a process group. The decision is based on the understanding that a task group
focuses on:
a. Content issues
b. The “here and now”
c. Communication styles
d. Relations among the members
ANS: A
Content-oriented groups focus on goals and tasks of the group. Thus a task-oriented
group would focus on content issues. Process groups focus on interpersonal
relationships. Communication styles are not relevant to describing task-oriented groups.
“Here and now” refers to dealing with issues that are taking place at the present time.
DIF: Cognitive Level: Application
REF: Pages 608-609
8. The treatment team was engaged in planning how group therapy could be included
as a part of the structured daily activities of the unit. A new team member asked,
“Why is it so important to include group therapy for the patients?” The most accurate
response would be based on the assumption that:
a. Hidden agendas frequently surface in group sessions.
b. Some persons do not relate well on an individual basis.
c. Group therapy is far more cost-effective for the patients.
d. Psychopathology has its source in disordered relationships.
ANS: D
A key assumption of group therapy is that psychopathology has its source in disordered
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relationships. It follows that individuals will behave in the group as they do in other
settings, so group provides an opportunity to help individuals develop more functional
relationships. Ability to relate is not relevant to group work. It is dealt with in one-to-one
therapy. Hidden agenda is not a reason to offer group therapy. Cost-effectiveness is not
an assumption about the reason group therapy is effective.
DIF: Cognitive Level: Application
REF: Page 609
9. Which patient would the group co-leaders determine is demonstrating Yalom’s
therapeutic factor termed universality?
a. Patient A, who states he realizes he is not the only person who has a problem
with loneliness
b. Patient B, who displays dysfunctional interaction patterns learned in his family of
origin
c. Patient C, who states he finally feels a strong sense of belonging
d. Patient D, who openly expresses his anger about his work
ANS: A
Universality is the factor that refers to understanding that one is not unique, that others
share thoughts, reactions, and discomforts like your own. Dysfunctional interaction refers
to corrective recapitulation of the family group. A strong sense of belonging provides an
example of cohesiveness. Display of anger is an example of catharsis.
DIF: Cognitive Level: Application
REF: Page 610
10. A nurse, leading an inpatient group dealing with women’s issues, identifies a patient
who is assuming the role of aggressor. Which behavior characterizes this role?
a. Attempting to manipulate others
b. Mediating conflicts and disagreements
c. Criticizing the contributions of others
d. Seeking a position between contending sides
ANS: C
An aggressor acts in negative ways, displaying hostility, attacking the group, or
criticizing the members. Seeking a position between contending sides describes the
compromiser. Mediating conflicts and disagreements describes the harmonizer.
Attempting to manipulate others describes the dominator.
DIF: Cognitive Level: Application
REF: Page 612
11. Which statement by a 16-year-old is considered as positive evidence that the family’s
involvement in therapy is moving them towards effective functioning?
a. “My dad has finally stopped giving me advice on how to live my life.”
b. “I stopped playing football since practice required me to be away from home so
often.”
c. “Since my mother quit her job, she is more available to keep the home running
smoothly.”
d. “Eating dinner with my parents on Sunday nights has helped us be more aware of
each other’s needs.”
ANS: D
This statement shows the family has made an effort to improve communication and deal
with alienation without any one member bearing complete responsibility. Withdrawing
from the team suggests he felt solely responsible for the family problem. Quitting the job
suggests the mother saw herself as responsible; however, being home does not
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guarantee unification. A lack of advisement suggests withdrawal of the father from
participation in family matters.
DIF: Cognitive Level: Application
REF: Page 612
12. In response to the nurse’s statement, “Tell me about your family,” the patient
became silent and displayed nonverbally that he is uncomfortable. Which statement
by the nurse reflects sensitivity to the patient?
a. “I'm so sorry. I didn’t realize your family was a problem for you.”
b. “Learning to express negative feelings will assist you in getting well.”
c. “Perhaps you can talk about your feelings to the physician next time you meet.”
d. “That seems to be a difficult subject for you. We can discuss when you are
ready.”
ANS: D
This response acknowledges the situation, is respectful, and allows the patient to choose
when to refocus the therapeutic interaction. Referring to the family as a problem is not
sensitively worded. Offering false reassurance implies that feelings are negative.
Suggesting postponing the discussion represents avoidance of dealing with the patient’s
feelings.
DIF: Cognitive Level: Application
REF: Page 605
13. When sharing her feelings about separating from a therapy group, the patient stated,
“I feel a bit sad and empty that I won’t be seeing you folks again.” What is the most
accurate evaluation of the patient’s statement?
a. It indicates regression and her lack of readiness to terminate.
b. Unconsciously, she is hoping she will be permitted to continue the group.
c. She is demonstrating normal feelings associated with termination of therapy.
d. She needs further evaluation by her therapist to determine readiness to
terminate.
ANS: C
The patient is expressing feelings of sadness over the loss of the therapeutic group
relationships that have been helpful to her. Such feelings are considered normal, just as
they are considered normal when the nurse-patient relationship terminates. The feelings
expressed are normal, not regressive. No hidden meaning is present; the patient openly
expressed genuine feelings. Further evaluation is not needed.
DIF: Cognitive Level: Application
REF: Page 612
14. A patient asks the nurse manager to help resolve a situation between her and
another patient. Which action would best support the patient’s feelings of safety
when experimenting with new ways of being?
a. Encouraging the patient to report the incident to the other patient’s physician
b. Intervening on the patient’s behalf and sorting out the incident with the other
patient
c. Suggesting that the patient ignore the situation since the other patient was
probably not aware of her behavior
d. Offering to be present and help the patient discusses her feelings about the
incident with the other patient
ANS: D
Offering to be with the patient affords her a safe nonthreatening opportunity to assume
responsibility for meeting her own needs assertively by encouraging skills that affect
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positive communication. Intervening removes the responsibility from the patient.
Ignoring supports passive behavior. There is no need to bring in another person. The
patient is capable of addressing the problem herself.
DIF: Cognitive Level: Application
REF: Page 605
15. A patient tells the nurse, “I really like you. You’re the only true friend I have.” The
patient’s remarks call for the nurse to revisit the issue of:
a. Trust
b. Safety
c. Boundaries
d. Countertransference
ANS: C
The patient’s remarks call for the nurse to remind the patient of the parameters of the
nurse-patient relationship. The remark would also give the nurse the opening to go on to
discuss the matter of friendship. The patient’s remarks do not suggest the need to deal
with trust, safety, or countertransference.
DIF: Cognitive Level: Application
REF: Page 605
16. By the end of the orientation phase, which outcome can be identified for a newly
admitted patient? The patient will demonstrate:
a. Ability to problem solve one issue
b. Trust in at least one nurse on the unit
c. Positive transference with a staff member
d. Ability to ask for help in meeting needs
ANS: B
Establishing trust in the nurse is a fundamental task of the orientation phase of the
relationship; thus it is an appropriate outcome to identify. When trust is present, the
patient is free to focus on the work and tasks of therapy. The ability to problem solve is
an outcome appropriate for the working phase. Positive transference would not be an
identified outcome. The ability to ask for help would not be an identified outcome for the
orientation phase.
DIF: Cognitive Level: Application
REF: Page 611
17. The patient and the nurse have agreed on problems to be addressed during a short
course of outpatient therapy. At the beginning of the appointment, the patient states,
“I’d like to work on the issue of relationships today.” Which assessment can be
made?
a. Nurse-patient roles have not been clearly delineated.
b. The nurse should suggest several alternative behaviors.
c. The patient must be able to manage emotions before continuing.
d. The relationship is moving from orientation to working phase.
ANS: D
Once the patient and nurse have collaborated to define and prioritize problems, the
relationship moves from orientation to working phase. The remaining options have no
relevance to the scenario since there is no reference to roles, alternative behaviors, or
managing behaviors.
DIF: Cognitive Level: Application
REF: Page 612
18. A nurse and patient are entering the termination phase in the group experience. An
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important nursing intervention will be to:
a. Encourage the group to describe goals for change.
b. Inquire whether the group needs more time to accomplish goals.
c. Assist the group to explore alternative coping strategies for problems.
d. Discuss feelings about leaving the group and the support found with the group.
ANS: D
Healthy termination is facilitated when the group and nurse express reactions to
termination. The nurse serves as a role model by being open and genuine as the feelings
about the losses incurred with ending are discussed. On a positive note,
accomplishments and growth are acknowledged and the transfer of safety and trust to
the group members is accomplished. Describing goals is accomplished in the orientation
phase. Accomplishing goals is part of the working phase in a relationship that does not
have a strict time limit. Exploring alternative coping strategies would be part of the
working stage.
DIF: Cognitive Level: Application
REF: Page 612
19. A patient attending group therapy mentions, “In the beginning, I was so sick that
everyone had to help me. For the last few days, it’s felt good to be able to give
something back to the group.” This statement can be assessed as an example of
Yalom’s factor of:
a. Altruism
b. Harmonizing
c. Cohesiveness
d. Imitative behavior
ANS: A
Altruism refers to the experience of being helpful to others and is clearly what the
patient is displaying in the scenario. The other factors are not applicable.
DIF: Cognitive Level: Application
REF: Page 610
20. During the first family therapy session, the mother of a child being treated for
truancy and emotional outbursts asks the nurse, “Why are you bothering to ask the
rest of us questions? My son is the one with the problems.” The best response for the
nurse would be:
a. “We’ll get more accurate information if the entire family is involved.”
b. “It may seem strange to you, but we’ll get better results doing it this way.”
c. “When one family member is sick, the whole family system is sick as well.”
d. “Every family member’s perceptions are very important to the total picture.”
ANS: D
This response orients the family to the idea that each person’s opinion will be valued.
Having the family present for assessment prepares them for working together to identify
family issues, identify outcomes, and solve problems. It may or may not be true that this
will result in accurate information. Getting better results doesn’t convey the real reason.
Referring to the family as sick is pessimistic and conveys a threatening message.
DIF: Cognitive Level: Application
REF: Page 612
21. A novice mental health nurse shares that, “I’ll never get used to playing cards or
other games with patients. It seems like a poor use of scarce nursing time.” The best
response for the nurse’s mentor would be:
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a. “Perhaps you’ll want to rethink your transfer to this unit if you’re really
uncomfortable.”
b. “Your comments make a point about scarce resources. I’ll ask the treatment team
to review our position on activities.”
c. “Activity co-leadership puts us in a position to help patients develop social skills
and support them as they take small risks.”
d. “Managed care has cost us activities therapists. Activities are necessary to give
patients something to do, so we have to fill in.”
ANS: C
Nurses who engage in co-leadership of therapeutic activities recognize that each activity
contributes to outcome attainment. During activities, patients practice skills needed in
life situations, process emotions, and give and receive validation and feedback.
Suggesting a rethink is not supportive of the nurse. The remaining options do not
acknowledge the value of activities therapy.
DIF: Cognitive Level: Application
REF: Page 617
22. What is the primary reason for the nurse to have an understanding of the various
types of activity and adjunct therapies?
a. The nurse chooses the most cost-effective therapy group.
b. The nurse is expected to encourage patients’ involvement in the therapies.
c. The nurse is responsible for placing the patient in the appropriate group.
d. The nurse needs to be supportive of the treatment team members who direct
these therapies.
ANS: B
The nurse must interpret to patients and others that the purpose of activity therapies is
to increase patient awareness of feelings and behaviors and to minimize pathology and
promote mental health. Although they are important, supportiveness, encouragement,
and economics are not the primary reason.
DIF: Cognitive Level: Analysis
REF: Page 618
23. Which activity therapy should the nurse recommend to the treatment team to assist
the patient to relieve tension and achieve increased body awareness?
a. Psychodrama
b. Music therapy
c. Dance therapy
d. Recreation
ANS: C
The large movements involved in dance therapy would enable the patient to relieve
tension and move with greater body awareness and freedom. The other options will not
promote body awareness.
DIF: Cognitive Level: Application
REF: Page 619
24. To effectively plan care for a patient, the nurse will understand that activity and
adjunct therapies may be more useful in some situations than verbal therapies
because adjunct therapies:
a. Are readily available in the treatment setting
b. Do not require specific training or expertise to facilitate
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c. Provide the patient the opportunity to use ego-protective mechanisms
d. Allow the patient to express feelings on multiple levels at the same time
ANS: D
A patient is able to express feelings on the emotional, physical, and symbolic levels
during activity therapy, whereas verbal therapies are limited to one dimension. The
primary facilitator of the selected therapy is required to have formal education and
supervised experience. Adjunct therapy does not provide this opportunity, which would
be considered nontherapeutic. Treatment settings are not always readily available.
DIF: Cognitive Level: Application
REF: Page 617
25. A patient is scheduled to attend an occupational therapy group to work on the
identified goal of “recognizing and using more effective coping techniques.” What
measure can the nurse use to continue to support the patient’s attainment of this
goal after he returns to the unit?
a. Isolating him from more seriously ill patients
b. Praising him for positive behavioral changes
c. Avoiding setting limits that would increase his anxiety level
d. Permitting him to make mistakes prior to intervening on his behalf
ANS: B
Recognizing and pointing out positive changes provides encouragement to continue
pursuing change. The remaining option would not achieve the nurse’s goal of supporting
the patient’s use of effective coping techniques.
DIF: Cognitive Level: Application
REF: Page 617
26. How can the nurse encourage an extremely shy patient to participate therapeutically
in a dance activity group?
a. Offer to dance with the patient.
b. Ask the patient if this is the first dance he has attended.
c. Sit with the patient away from the group.
d. Encourage another patient to ask him to dance.
ANS: A
If trust has been established, the patient may feel safe enough to dance with the nurse.
If trust has not yet been established, the patient will see the nurse’s invitation as
demonstrating respect and reaching out to him. Either way, the action will encourage
participation. The nurse should not make another patient responsible for this patient’s
participation. The remaining options do not encourage participation.
DIF: Cognitive Level: Application
REF: Page 617
27. When leading a therapeutic group, the nurse demonstrates an understanding of the
need to act as the group’s executive when:
a. Restating rules when a new member joins
b. Being available to orient the new members
c. Helping a member defuse the anger they are experiencing
d. Working with a member to help improve their communication skills
ANS: A
Executive functioning refers to monitoring and attending to group rules and procedures.
Caring demonstrates expressions of kindness. Meaning attribution includes accepting of
feelings, although emotional stimulation would reflect working communication skills.
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DIF:
Cognitive Level: Application
REF:
Page 609
28. When another patient serves as “alter ego” during an outpatient group session, the
nurse documents that the group had been engaged in:
a. Role-playing
b. Psychodrama
c. Cognitive therapy
d. Consensus building
ANS: B
Psychodrama uses spontaneous dramas to act out emotional problems to promote
health through development of new perceptions, behaviors, and connections with others.
Others in the group take the role of significant others. Role-playing and cognitive therapy
do not use the technique of alter egos. Consensus building is not a form of therapy.
DIF: Cognitive Level: Application
REF: Page 619
29. The nurse is collecting the paintings from the patients after the art session is over.
After art therapy, a patient hands the nurse a paper that consists of several black
scribbles. Which statement demonstrates the nurse understands the goals and
objectives of the therapy?
a. “Do you want to complete your painting?”
b. “I see that you don’t take this very seriously.”
c. “Can you tell me what happened to prompt such work?”
d. “Thank you. I’ll put this away in a safe place for you.”
ANS: D
Art therapy is used to help resolve conflicts and promote self-awareness. The nurse
should not comment on the quality of the art or the patient’s talents, but rather treat the
project with respect and value. The work is simply each patient’s self-expression. The
other options make judgments about the work or the patient’s willingness to participate.
DIF: Cognitive Level: Application
REF: Page 619
30. When asked, “Why do you go to music therapy every morning at 10?” The nurse
explains that the nurse’s role in music therapy as:
a. Fostering and encouraging performance talent
b. Teaching patients about various styles of music
c. Noting patient verbal and nonverbal expression of feelings
d. Selecting and playing numbers that will reduce anxiety and stress
ANS: C
A goal of music therapy is to promote expression and social connection. The nurse
should observe and document expression of feelings as they occur. The observations
may be used later, as a basis for further consideration by the nurse and patient. The
other options do not reflect aspects of the nurse’s role in music therapy.
DIF: Cognitive Level: Application
REF: Page 619
31. When a novice nurse asks why the unit has a multidisciplinary approach to
therapeutic activities, the nurse should explain that multidisciplinary collaboration:
a. Produces a higher level of insurance reimbursement
b. Reduces the incidence of aggressive behavior by patients
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c. Produces quicker results and earlier discharge to the community
d. Produces better outcomes than when only one perspective is used
ANS: D
Broader input in problem identification and resolution enhances patient outcomes. The
remaining options are either untrue or irrelevant.
DIF: Cognitive Level: Application
REF: Page 617
32. When a patient asks the nurse, “How can jolting me with an electrical shock possibly
do me any good?” the answer most reflective of current biologic theory would be:
a. “ECT must sound like a very frightening treatment alternative to you.”
b. “ECT produces a change in brain chemistry that results in improved mood.”
c. “ECT interrupts brain impulses that are causing hallucinations and delusions.”
d. “ECT provides you with external punishment so you can stop punishing yourself.”
ANS: B
Current theory regarding use of ECT is that the electrical stimulus causes
electrochemical changes within the brain, resulting in increased availability of
neurotransmitters at the synapses and improvement of mood. To suggest that the
treatment is frightening does not answer the patient’s question. The treatment is not
appropriate for hallucinations or delusions. The remaining option is not appropriate or
founded in psychiatric therapy.
DIF: Cognitive Level: Application
REF: Page 618
33. Which statement made by a patient just prior to being transported for a scheduled
ECT treatment would result in cancellation of the treatment?
a. “I’ll be so glad when this treatment is over.”
b. “Will I remember having this treatment?”
c. “Did eating some crackers cause any problems?”
d. “I’m so tired of being depressed; I don’t think I can go on.”
ANS: C
Because the patient is to receive general anesthesia and has orders to remain without
food or liquids (NPO), the nurse should notify the physician immediately. The introduction
of food into the stomach could result in aspiration of stomach contents during treatment.
An expression of hopelessness related to depression would be reason to continue with
the treatment. The other options offer no contraindication to treatment.
DIF: Cognitive Level: Application
REF: Page 619
34. The physician has ordered atropine 0.5 mg intramuscularly (IM) for a patient to be
administered 30 minutes prior to ECT. The rationale for use of this medication is that
it reduces secretions and:
a. Protects against vagal bradycardia
b. Improves the scope of convulsive activity
c. Reduces the need for recovery room staff
d. Prevents incontinence of bladder and bowel
ANS: A
Atropine is used for its ability to prevent vagal bradycardia associated with the electrical
stimulus. The other options are neither relevant nor true.
DIF: Cognitive Level: Application
REF: Page 619
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35. Which statement by a patient who has given informed consent for ECT confirms that
the patient understands the side effects of this treatment?
a. “I won’t remember the pain.”
b. “It will take several weeks before I feel good again.”
c. “My short-term memory loss will be only temporary.”
d. “I will be at increased risk for developing epilepsy later.”
ANS: C
Temporary impairment of recent memory is an expected side effect that occurs to some
degree during the course of ECT. The other options suggest the patient’s understanding
of treatment and side effects is flawed.
DIF: Cognitive Level: Application
REF: Page 619
36. In the ECT treatment preparation period the morning of treatment, the nurse should:
a. Adequately hydrate the patient.
b. Assess the patient’s cognitive function.
c. Have the patient exercise for 10 minutes.
d. Ensure that the patient produces a urine sample.
ANS: B
Patient assessment is advisable to provide a baseline against which changes resulting
from ECT can be measured. Although taking vital signs and performing other preparatory
tasks, the nurse can assess orientation, immediate memory, thought processes, and
attention span. The other options are interventions the nurse should not undertake.
DIF: Cognitive Level: Application
REF: Page 620
37. Immediately after electroconvulsive therapy (ECT), nursing care of the patient is
most similar to care of a patient:
a. With severe dementia
b. With delirium tremens
c. Recovering from conscious sedation
d. Recovering from general anesthesia
ANS: D
The patient who has ECT receives a short-acting IV anesthetic and a skeletal muscle
relaxant. Thus care is most similar to the patient recovering from general anesthesia.
The nurse will assess vital signs, quality of respirations, presence or absence of the gag
reflex, level of consciousness, orientation, and motor abilities during the post-treatment
period.
DIF: Cognitive Level: Application
REF: Page 620
38. A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT)
asks her mentor, “What sort of memory impairment is present after several ECT
treatments?” The best response for the mentor would be:
a. “It’s hard to say. Treatment affects everyone differently.”
b. “Usually the patient has severe difficulty remembering remote events.”
c. “Patients have mild difficulty remembering recent events, like what was eaten for
breakfast.”
d. “Both recent and remote memory is affected, producing profound confused,
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cognitive states.”
ANS: C
Most patients experience transient recent memory impairment after electroconvulsive
therapy (ECT). The cognitive deficit becomes more pronounced as the number of
treatments increases. When the course of treatments is completed, cognitive deficit
generally improves to the pretreatment level. The other options are incorrect.
DIF: Cognitive Level: Application
REF: Page 620
39. About an hour after the patient has ECT, he complains of having a headache. The
nurse should:
a. Notify the physician stat.
b. Administer an as needed (prn) dose of acetaminophen.
c. Take the patient through a progressive relaxation sequence.
d. Advise going to activities to expend energy and relieve tension.
ANS: B
Post-ECT headache is common. Most physicians routinely write an as needed (prn) order
for a headache remedy. Notifying the physician is unnecessary, because this is an
expected side effect. Options c and d would not be as useful as medication in this
instance.
DIF: Cognitive Level: Application
REF: Page 620
40. For which patient is the nurse most likely to need to schedule a pre-ECT workup and
teaching?
a. Patient A, who is newly diagnosed with dysthymic disorder
b. Patient B, who has melancholic depression that responded well to ECT 2 years
ago
c. Patient C, who was unresponsive to a 6-week trial of SSRI antidepressant therapy
d. Patient D, who has depression associated with diagnosis of inoperable brain
tumor
ANS: B
Indications for ECT include patients with major mood disorders; patients who have
responded to ECT in the past; patients who are unresponsive to antidepressants or
unable to tolerate their side effects; and patients who are acutely suicidal or in danger of
fluid and electrolyte imbalance related to inability to eat due to depression, severe
mania, or severe catatonia. Patients with dysthymia are not candidates for ECT. The
patient has not run out of medication options when prescribed only an SSRI. Patients
with space-occupying lesions of the brain are not candidates for ECT.
DIF: Cognitive Level: Application
REF: Page 618
41. Which intervention will the nurse implement in the first half hour after the patient
has received ECT?
a. Continually stimulate patient to respond, using physical and verbal means.
b. Continue bagging patient to improve respiratory function until patient is
responsive for 10 minutes.
c. Reorient as necessary to time, place, and person as level of consciousness
improves.
d. Encourage walking and eating breakfast as quickly as possible.
ANS: C
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Patient memory is likely to be impaired in the immediate post-ECT period. Reorientation
will be necessary to help the individual return to a functional state. Continual stimulation
is not necessary. Bagging is unnecessary. The patient may be allowed to rest and recover
at his own pace.
DIF: Cognitive Level: Application
REF: Page 620
42. What milieu factor would need most attention from the nurse who is caring for a
patient who has received six ECT treatments and has two more scheduled?
a. Safety
b. Trust attainment
c. Therapeutic activities
d. Boundary maintenance
ANS: A
To feel safe, patients need to know what is expected of them in their role as patients.
The patient receiving ECT often has impaired recent memory and may become confused
about the milieu and expectations. The nurse will need to reorient and reteach the
patient with cognitive deficit. Options b, c, and d will require attention but not to the
same extent as safety.
DIF: Cognitive Level: Analysis
REF: Page 620
1. Which behaviors are reflective of legitimate phases of a group’s development? Select
all that apply.
a. Stating the goals of the group
b. Establishing who will assume the leadership role
c. Inviting family members to attend and provide their input
d. Feeling safe enough to discuss painful personal situations
e. Showing concern about assuming personal responsibility for life
ANS: A, B, E
All groups progress through the phases of development that are governed by group
dynamics and include orientation where goals are identified, conflict where leadership is
determined and tested, cohesion where a sense of safety is achieved, and termination
where discharge concerns are acted out and addressed. Family input may not
necessarily be introduced unless it was a defined goal of the group.
DIF: Cognitive Level: Application
REF: Pages 611-612
Chapter 27: Complementary and Alternative Therapies
1. A patient who experiences panic attacks when he is alone at home has been
instructed in the use of meditation techniques. The technique can be evaluated as
having proved most useful when the patient explains to a friend that meditation:
a. Is easy to learn
b. Provides me with a sense of control
c. Can be implemented at any time and place
d. Can be mastered by anyone, young or old
ANS: B
When implemented effectively, meditation has wide-ranging effects that include a sense
of control over one’s situation. All the remaining options are correct but they lack the
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connection to a patient’s sense of well-being and control.
DIF: Cognitive Level: Analysis
REF: Page 630
2. A patient reports little change in her blood pressure even though she has been doing
the biofeedback exercises stating that, “The machine has not been successful.” The
nurse will observe the next session being aware that:
a. There are several different components that need to be mastered in order to
achieve successful biofeedback results.
b. The machine is a critical component of biofeedback during all phases and it’s
response needs to be monitored by a professional.
c. A patient’s relaxation skills need to be excellent because muscle responses play
a large role in determining the success of biofeedback.
d. The patient’s mood and emotional stability affects one’s ability to alter
physiological results and thus affect positive results from biofeedback.
ANS: A
With biofeedback, a patient can learn to gain conscious control over bodily responses
thought to be beyond voluntary command. Listening to the monitoring device makes the
patient aware of whether or not the mental exercises, breathing, or other techniques
being used are effective. The machine is only needed early in therapy. Muscle relaxation
and emotions have a role to play but are not the only significant factors to be
considered.
DIF: Cognitive Level: Application
REF: Page 632
3. The nurse when entering the room to find a terminally ill child laughing at an old The
Three Stooges movie decides to postpone a scheduled treatment. This intervention is
based on the knowledge that humor:
a. Has been shown to have a positive effect on patients and staff alike
b. Can foster positive changes on several physiological systems and functions
c. Allows the patient to implement therapeutic denial to best manage the situation
d. May help the very young who are unaware of the seriousness of their situations
ANS: B
Research has shown humor may have positive effects on cognitive ability, heart and
respiratory rates, blood pressure, muscle tension, and pain. Humor does have the effects
reflected in the remaining options but none would be the basis for postponing a
treatment.
DIF: Cognitive Level: Analysis
REF: Page 631
4. The nurse describes in a balanced and neutral manner traditional medicine options
that are available to treat a patient’s health problems. The patient thanks the nurse
and shares that he prefers to continue treatment with acupuncture and Ayurvedic
medicine. The nurse encourages the patient to carefully consider his choices and
tells him that the staff is available if needed. The nurse’s response demonstrates:
a. Understanding of patient rights
b. Lack of concern for the patient’s well-being
c. Respect for the patient’s health care choices
d. Inability to confront the patient about his inappropriate health choices
ANS: C
After receiving all relevant, current information, patients have the right to make their
own decisions about health care. This response shows respect for the patient’s right to
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make such a choice and the nurse’s understanding of the philosophy of holistic nursing.
Although an understanding of patient rights is vital, it is not the best description of the
nurse’s response. The nurse must remain objective and empathetic but may not
interfere with the patient’s choices. There is no need for confrontation.
DIF: Cognitive Level: Application
REF: Page 629
5. Which nursing response best describes alternative therapies to a patient?
a. They are not widely used in hospitals or reimbursed by insurance.
b. They are often considered quackery and of little real value to those who use
them.
c. They are widely researched and can take their place with allopathic medicine.
d. They are more effective if used as preventive measures than if used for cure.
ANS: A
Alternative therapies are treatments and health care practices that are not widely taught
in Western medical schools, not generally used in Western hospitals, and not generally
reimbursed by health insurance. There are valuable forms of alternative therapies.
Alternative therapies have not been widely researched. No evidence supports the
statement regarding preventive measures.
DIF: Cognitive Level: Application
REF: Page 628
6. When a patient asks for an example of an alternative or complementary therapy, the
nurse would correctly identify:
a. ECT
b. Acupuncture
c. Response prevention
d. Classic conditioning
ANS: B
Acupuncture is considered an alternative or complementary therapy coming to Western
health care from traditional oriental medicine. Options a, c, and d are considered
allopathic therapies.
DIF: Cognitive Level: Knowledge
REF: Page 633
7. Which alternative treatment could the nurse suggest that would be appropriate for
the patient whose health-illness beliefs equate illness with bodily imbalance?
a. Naturopathy
b. Acupuncture
c. Foot reflexology
d. Chiropractic adjustment
ANS: B
The purpose of acupuncture is to activate qi and achieve balance when imbalance exists.
Naturopathy focuses on self-healing. Reflexology focuses on relief of tension.
Chiropractics provides manual adjustments of bones and joints to correct alignment
problems.
DIF: Cognitive Level: Comprehension REF: Page 633
8. A desired outcome for a patient who uses ginkgo biloba for improved cerebral
circulation would be that the patient will:
a. Experience elevated mood.
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b. Recall information accurately.
c. Remain relaxed under stress.
d. Eat smaller helpings at meals.
ANS: B
This herb is said to improve mental alertness, improve blood flow, and reduce the effects
of aging. Many use it to improve memory. This herb does not elevate mood, modify
appetite, or reduce stress.
DIF: Cognitive Level: Application
REF: Page 636
9. A patient experiencing symptoms of mild depression would prefer to take a “natural”
substance instead of a prescription antidepressant. The herbal preparation that could
be suggested for its antidepressant effects is:
a. Valerian
b. Echinacea
c. Saw palmetto
d. St. John’s wort
ANS: D
St. John’s wort is an herb often used to treat mild depressive symptoms. Valerian is
considered an anxiolytic. Saw palmetto is used to treat benign prostatic hyperplasia.
Echinacea is used to boost immunity.
DIF: Cognitive Level: Knowledge
REF: Page 636
10. The nurse is planning care for an anxious patient receiving antidepressant
medication. Which alternative therapy could the nurse incorporate in the care plan
without being concerned about untoward interactions?
a. St. John’s wort
b. Homeopathy
c. Ginseng
d. Yoga
ANS: D
Yoga and meditation are accepted alternative or complementary therapies for patients
with anxiety disorders. Patients report relaxation with use of yoga. There are no
untoward side effects of drug-herb interactions with the use of yoga. Untoward effects
are possible with ingestion of herbal medicines or homeopathic remedies.
DIF: Cognitive Level: Application
REF: Page 631
11. The nurse asked by a patient to contrast conventional Western medicine with
alternative therapy would correctly respond, “Conventional medicine focuses on
curing symptoms, whereas alternative therapy is concerned with:
a. culture-bound illnesses.”
b. building healer prestige.”
c. healing the total person.”
d. the importance of science.”
ANS: C
Healing the whole person is the focus of most alternative therapy. Unifying themes
among these therapies are the person’s inherent recuperative ability, the importance of
self-esteem, and the influence of spiritual and emotional beliefs on health. Culture-bound
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illnesses are not the whole focus of alternative therapies. Alternative therapy is patientcentered. Pure science is not the focus of alternative therapy; in fact, most alternative
methods have not been researched.
DIF: Cognitive Level: Comprehension REF: Page 625
12. Which statement made by a nurse discussing alternative and conventional therapies
supports the holistic philosophy that mind-body interrelationships influence wellness?
a. “The development of lung cancer is strongly influenced by environmental
factors.”
b. “Alternative therapy is often less expensive than conventional medical
treatment.”
c. “Widowed persons have higher death rates than married people of the same age
have.”
d. “Personal values and misconceptions are barriers to use of alternative therapy in
the Western world.”
ANS: C
The mind’s influence on the body is suggested by the statistics that married individuals
live longer. It is hypothesized that the sense of security and benefits of companionship
from marriage may be protective against disease. The other statements are true, but
have no bearing on mind-body relationships.
DIF: Cognitive Level: Analysis
REF: Page 626
13. During assessment, the patient tells the nurse that she eats a natural food/high
vitamin diet, exercises 30 minutes daily, uses meditation and yoga techniques for
stress reduction, and takes prescribed antihypertensive medication. The nurse would
assess that number of CAM therapies the patient uses as:
a. Four
b. Three
c. Two
d. One
ANS: A
CAM therapies include diet, exercise, yoga, and meditation. Only the prescribed
antihypertensive medication would be considered conventional medical treatment.
DIF: Cognitive Level: Knowledge
REF: Page 625
14. The fundamental belief of nurses that will foster use of a holistic nursing model to
promote wellness is which of the following?
a. Health care requires a partnership between patients and nurses.
b. Nurses must monitor environmental influences on patient health.
c. Wellness promotion centers on health teaching by professional nurses.
d. The public’s awareness of useful alternative therapies must be enhanced.
ANS: A
Holistic care requires patient participation as an equal partner in the process if healthy
outcomes are to be achieved. Environmental influences are important, but the central
belief concerns partnership. Health teaching is important in wellness promotion but is
not the central concept of holistic nursing. Public awareness is not a belief central to
holistic nursing.
DIF: Cognitive Level: Analysis
REF: Page 629
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15. An impact the popularity of alternative therapy has on the nursing application of
therapeutic interventions is that nurses:
a. Must be taught such intervention techniques
b. Need to possess understanding of herb-drug interactions
c. Will need in-depth courses to effectively use bio-electromagnetics
d. Will adopt the approach of regularly using more manual healing methods
ANS: B
Herbal preparations are presently in common use. Nurses must include assessment of
herbal use and be cognizant of herb-drug interactions in order to provide safe, effective
care. There is no support for any of the remaining options.
DIF: Cognitive Level: Application
REF: Page 629
16. The nurse planning care for an Asian-American patient who plans to use Oriental
medicinal dietary principles will need to understand that hot and cold substances are
an integral part of therapy. The substances used are:
a. Served iced or steaming hot
b. Determined by yin and yang characteristics
c. Selected by native shamans who divine patient needs
d. Often disrupt conventional Western medical therapy
ANS: B
Many Oriental patients believe illness is due to imbalance of yin and yang. Herbal
mixtures are prescribed according to their yin or yang characteristics (hot or cold) in
order to rebalance yin and yang. Hot and cold properties do not refer to thermal
properties in this case. Divining by shamans is not part of the Oriental medical tradition.
For the most part, the substances used are not disruptive of conventional therapy but
are complementary.
DIF: Cognitive Level: Application
REF: Page 633
17. When statement best answers a patient’s request for an explanation of how
homeopathy works?
a. “It cures by using tiny amounts of known poisons.”
b. “It purges foreign substances from the person’s body.”
c. “It controls illness symptoms by using medication.”
d. “It uses substances to stimulate the body to heal itself.”
ANS: D
Substances are given that produce reactions that correspond to existing symptoms. The
rationale is to follow the body’s lead to effect a cure. The substances used are not
necessarily poisonous or purgatives. Homeopathic medicines are not prescription
medications nor are they given for controlling symptoms.
DIF: Cognitive Level: Application
REF: Page 633
18. Which point should the nurse include when teaching about concurrent use of
alternative and prescription medicines?
a. Health care providers need to know when the patient is using both.
b. Health care provider cultural incompetence on this topic is relatively high.
c. Most nursing actions are consciously directed towards fulfilling holistic goals.
d. It is usually dangerous to combine these two types of patient-focused therapies.
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ANS: A
Only when the provider has accurate information about all therapies in use can safe,
effective care be provided. The provider cannot function with incomplete assessment
information. New standards for cultural competency exist and are generally observable.
It is not universally true that nurses focus on holistic goals because many actions are
designed to alleviate symptoms. Alternative and conventional therapies can be
effectively used together.
DIF: Cognitive Level: Application
REF: Page 624
19. What nursing activity is directed towards addressing a major goal identified by
Healthy People 2010?
a. Monitoring the urinary output of an older postsurgical patient
b. Educating a pregnant woman about the benefits of breastfeeding
c. Providing free depression screenings for single, teenage mothers
d. Providing a patient who has had several teeth extracted with a liquid diet
ANS: C
One of the major goals for Healthy People 2010 was to eliminate health disparities.
Providing depression screening for an identified underserved population would be an
example of such focus. Although appropriate, the remaining options do not address that
stated goal.
DIF: Cognitive Level: Analysis
REF: Page 629
1. Which health promotion activities address the statistical indicators of a healthy
population as stated by Healthy People 2010? Select all that apply.
a. Promoting a weight loss contest among hospital employees
b. Conducting a stress reduction seminar for college students
c. Discussing safe sex practices with older adults at a senior’s center
d. Providing information on cooking for children with allergies to wheat
e. Organizing a walking group that meets at the mall three times a week
ANS: A, B, C, E
Statistical indicators of a healthy population include evidence of physical activity, a
reduction in obesity, responsible sexual behavior, and improved mental health.
Management of allergies does not directly apply to any stated indicator.
DIF: Cognitive Level: Application
REF: Page 629
Chapter 28: Grief: In Loss and Death
1. Which physical disturbance is commonly assessed in patients experiencing acute
grief?
a. Hypersomnia
b. Increased appetite
c. Tightness in the chest
d. Cardiovascular problems
ANS: C
Chest discomfort is common with the bereaved person. Anorexia is more common. There
is no research to support the connection with cardiovascular involvement. Insomnia is
more frequent than sleepiness.
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DIF:
Cognitive Level: Application
REF:
Page 650
2. When differentiating between bereavement symptoms and depression, the nurse will
base the formulation on knowledge that in bereavement:
a. Suicide thoughts are common.
b. Symptoms remit and exacerbate.
c. Guilt feelings are overwhelming.
d. Psychomotor retardation is obvious.
ANS: B
Acute exacerbations are common especially around holidays and significant milestones.
The remaining options are more common with depression.
DIF: Cognitive Level: Application
REF: Page 649
3. A grief support group is held at the local community center to assist persons who are
dealing with issues of loss. Which remark by one of the members would the nurse
interpret as indicating unresolved feelings of guilt?
a. “I know that my husband had a good life.”
b. “It seems I miss my son more as time goes on.”
c. “I am still wishing I had gotten help to him sooner.”
d. “The Christmas season is always a sad time for me.”
ANS: C
Unresolved guilt reflects that the person should have done more. Expressing peace with
a situation indicates closure on the husband’s life. Missing indicates continued grieving
but not guilt. Reflection on difficult times is not guilt.
DIF: Cognitive Level: Application
REF: Page 654
4. A young woman had just learned of the accidental death of her husband. She begins
to cry and states, “It’s not fair! How could he do this to me?” This remark is assessed
as:
a. A plea for help
b. An explosive episode
c. An expression of anger
d. Fear of making decisions alone
ANS: C
The remark indicates anger that her husband died on purpose. She is not asking for help
nor is there data to support an explosive response. She is not stating fear.
DIF: Cognitive Level: Application
REF: Page 646
5. Family and friends rush to offer support to a friend who has lost her teenage son.
Which of these persons, through an intended act of kindness, may contribute to
prolonging the woman’s grief?
a. The physician who prescribed antianxiety agents
b. The nurse who offered to spend the night at her home
c. The next-door teenager who provided care for the son’s pet
d. The accountant who assisted with stabilizing their financial affairs
ANS: A
Frequent use of anxiolytic medications can mask grief. The other options are usual offers
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of assistance.
DIF: Cognitive Level: Analysis
REF:
Page 654
6. When a hospitalized patient dies, his wife stares blankly at the nurse and states, “It
can’t be.” The nurse assesses this as indicating:
a. Despair and protest
b. Shock and disbelief
c. Anger and hostility
d. Disorganization and confusion
ANS: B
Shock and disbelief are often the first responses to a death, followed by protest and
despair. The wife’s statement does not indicate confusion or anger.
DIF: Cognitive Level: Application
REF: Page 646
7. When asked, the nurse explains that “grief work” refers to:
a. Establishing new methods of coping with stress
b. Evaluating progress made toward accepting the loss
c. The means by which one moves through the grief process
d. Actively seeking assistance to cope with the loss experiences
ANS: C
Grief work is moving through the stages of grief. The remaining options can be
components of grief work.
DIF: Cognitive Level: Application
REF: Page 644
8. A teen is grieving the loss of her pet dog. She states to her mother, “I miss my dog
so much, but I know that if I start crying, I will never stop.” The teen is expressing a
fear of:
a. Losing control over her emotions
b. Appearing emotionally immature
c. Embarrassing herself by crying in public
d. Losing the support of her friends and family
ANS: A
The teen’s statement that she will never stop indicates a “control” concern. The
statement does not indicate embarrassment, immaturity concerns, or lack of support.
DIF: Cognitive Level: Application
REF: Page 654
9. During a grief-processing group, an elderly patient stated, “For the first time since my
husband died, I’m having more good days than bad.” This statement suggests that
the patient has:
a. Replaced old memories with new ones
b. Reached the phase of reestablishment
c. Completed her “grief work” successfully
d. Determined she is ready to terminate the support group
ANS: B
Reestablishment is the gradual decrease in symptoms. There are not enough data to
support the remaining options.
DIF: Cognitive Level: Application
REF: Pages 644-645
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10. A patient returned from attending the service memorializing his wife, who died after
a sudden illness. Although those around him were visibly saddened, he smiled and
remained in control. He refused support from friends, stating, “I can handle anything
that comes my way.” The patient’s behavior is an example of _____ grief.
a. Normal
b. Inhibited
c. Distorted
d. Conflicted
ANS: B
The statement indicates inhibited grief that is characterized by minimal emotional
expression of grief. There is not enough data to support conflicted grief, which involves
ambivalence in the relationship with the departed. Distorted grief is not one of the
standard types, and normal grief is not characterized by this behavior.
DIF: Cognitive Level: Application
REF: Page 647
11. Which person would the nurse assess as experiencing chronic sorrow?
a. The mother of a child diagnosed with asthma
b. The father of an adult son who is a schizophrenic
c. The daughter whose father experienced a hip replacement
d. The wife whose husband has recently requested a trial separation
ANS: B
The only situation that presents as a long-term, chronic loss is having a child with a
chronic disorder like schizophrenia. The other situations are resolving or at least hopeful
for recovery.
DIF: Cognitive Level: Application
REF: Page 648
12. A patient is being seen for symptoms of insomnia and significant weight loss that has
occurred during the 2 months since her husband’s death. What is the purpose of the
query, “Describe how it has been for you since your husband died?”
a. To display an attitude of concern and sympathy to the patient
b. To learn whether the patient has a significant support system
c. To rule out factors that may interfere with diagnosing her illness
d. To determine the risk for pathologic grief and the need for grief therapy
ANS: D
The question is a common assessment question to determine the grief work that has
been done. The query does not ask about support systems or specific factors, and the
query is more than a display of concern.
DIF: Cognitive Level: Application
REF: Page 650
13. A nurse plans care based upon the fact that anticipatory grief:
a. Is associated with a high risk for depression
b. Is associated with fewer expressions of guilt
c. Prevents development of symptoms of depression
d. Requires a longer period of time to effect resolution
ANS: A
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Pre-mourning or anticipatory grief is associated with a high risk for depression or family
withdrawal from the patient. It is normative and does not necessarily require a longer
period of resolution or indicate fewer guilt expressions. It does not prevent depression.
DIF: Cognitive Level: Application
REF: Page 646
14. A woman whose abusive husband was killed in an automobile accident 3 years
earlier continues to idealize him and repeatedly talks about their “wonderful
relationship.” Which outcome is most appropriate for the patient? Patient will:
a. Enlist the emotional support of both family and friends.
b. Keep a daily journal recording memories of time spent with her husband.
c. Read information on the affects of physical abuse and the support groups
available to her.
d. Express both positive and negative feelings about her husband and their life
together.
ANS: D
Chronic grief involves unresolved issues in a relationship with the person who died. In
this case, a more realistic expression of their life together is needed. The remaining
options are appropriate but do not address the primary need to establish realistic
memories of the relationship.
DIF: Cognitive Level: Analysis
REF: Page 648
15. During a bereavement group, one of the members states, “I should have been the
one to die. My husband had so much to offer.” The member was expressing:
a. An intention to commit suicide
b. Ambivalence and low self-esteem
c. Unresolved anger toward her husband
d. A need for attention from group members
ANS: B
The statement suggests low self-esteem. There is no mention of suicidal ideation. This is
not simply an attention-getting statement. The statement does not imply anger.
DIF: Cognitive Level: Application
REF: Page 653
16. The community health nurse is visiting a patient diagnosed with dysfunctional
grieving since the death of his wife and child over a year ago. Which actions should
the nurse implement first?
a. Promote interaction with others.
b. Assess risk of self-directed violence.
c. Facilitate expression of feelings related to the loss.
d. Determine the degree of ambivalence toward the loss.
ANS: B
Safety issues would be the priority in cases of depression and dysfunctional grief. The
remaining options are appropriate actions after risk is assessed.
DIF: Cognitive Level: Analysis
REF: Page 647
17. An adult patient shares that, “When my mother died when we were children, I never
saw my father show any emotion. What do you think will happen with those
unexpressed feelings?” Which response is most appropriate?
a. “Pent-up emotions may lead to depression or other disorders.”
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b. “Your father probably has worked through his grief by this time.”
c. “Maybe you can teach him how to best express his own feelings.”
d. “If feelings are not effectively expressed, the person can become suicidal.”
ANS: A
Inhibited expression of grief can lead to depression. It cannot be assumed that the
grieving process has been completed. The adult child should not be made to feel
responsible for counseling the father. Unexpressed feelings do not necessarily lead to
suicidality.
DIF: Cognitive Level: Application
REF: Page 647
18. An elderly couple who lived in the same home for the past 50 years have moved into
an adult retirement center in a nearby town. Changes in lifestyle such as this couple
is experiencing should alert the nurse to the possibility of:
a. Acute grief
b. Traumatic grief
c. Chronic sorrow
d. Adventitious crisis
ANS: A
Adjustment to life cycle transitions may initiate acute grief. This could be a situational
crisis but not an adventitious crisis. There are no indications that this will become chronic
and lacks the magnitude needed to result in traumatic grief.
DIF: Cognitive Level: Application
REF: Page 642 | Page 646
19. A teenage boy has lost his best friend as a result of a hunting accident. His parents
report that he is eating and sleeping very little and expresses little interest in school.
They are concerned that he talks about the accident repeatedly. These behaviors are
generally seen as:
a. Expressing responsibility for his friend’s death
b. Attempts to avoid dealing with his pain
c. Expressions of a normal grief reaction
d. Indications of a risk for self-harm
ANS: C
The teen is displaying normal grief responses. He is not avoiding his pain but rather
expressing it various ways. There are no data to support that he feels responsible. He
has not expressed suicidal ideation.
DIF: Cognitive Level: Application
REF: Page 643
20. An outcome for a patient experiencing anticipatory grieving for a spouse diagnosed
with terminal cancer would be that the patient will:
a. Continue to be emotionally involved with the dying spouse
b. Develop protective mental mechanisms to allay the pain of spousal loss
c. Not voice threats of physical violence that is either self or others directed
d. Agree to stay at home and care for the spouse with appropriate assistance
ANS: A
Some families who are experiencing anticipatory grieving withdraw prematurely from the
ill member, so this is an important outcome. There are no protective mechanisms to
prevent loss experiences. Anticipatory grieving does not imply violence. A contract to
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stay home and care for the spouse even with assistance is not helpful.
DIF: Cognitive Level: Application
REF: Page 646
21. Which patient would the nurse determine to be at highest risk for dysfunctional grief?
The patient:
a. Whose 16-year-old daughter was raped and killed while going on an errand for
the patient
b. Whose 86-year-old mother, with whom she has shared her home, died after a
long illness.
c. Who attended a support group and had been assisted by hospice to care for her
terminally ill husband
d. Who attended a bereavement group, where she learned to express feelings after
the deaths of her twin daughters
ANS: A
The traumatic nature of the death makes this patient at highest risk. The death of the
mother was of an elderly person and expected. The remaining options involve patients
involved with hospice or support groups that lessen the likelihood for dysfunctional grief.
DIF: Cognitive Level: Application
REF: Page 648
22. Which intervention will the nurse planning care for a patient with acute grief
implement?
a. Providing information about the grief process
b. Encouraging dependence on the nurse for support
c. Suggesting utilization of community resources in a few weeks
d. Advising the patient to minimize contact with nonfamily members
ANS: A
Patient education is always helpful. Limiting contact with support is not helpful.
Postponing use of resources and encouraging dependence on the nurse are unhelpful
and therefore incorrect.
DIF: Cognitive Level: Application
REF: Page 653
23. The nurse determines that the most effective point of intervention for bereavement
is:
a. Promotion of mental and spiritual health across the life span
b. At the time a newly discovered loss is impending
c. Immediately after the loss has occurred
d. When requested by the patient
ANS: A
Effective health promotion before stress and loss regardless of age is most helpful. The
remaining options provide help around the time of loss, which is helpful but not as
effective as long-term help throughout a person’s life.
DIF: Cognitive Level: Analysis
REF: Pages 648-649
24. The nurse counseling a patient with acute grief would assess the patient for:
a. Severe depressive symptoms
b. Conflicted and unresolved issues
c. Increased arousal and hypervigilance
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d. Preoccupation with the image of the deceased
ANS: D
Acute grief can involve images of the deceased. Acute grief does not include severe
depression or conflicted issues. Hypervigilance is a PTSD symptom.
DIF: Cognitive Level: Application
REF: Pages 646-647
25. Which person has the greatest potential for developing dysfunctional grief?
a. A teen who has always been one of the ‘popular kids’
b. A widow who regularly states, “I really loved my deceased wife”
c. A woman whose husband died as a result of a sudden, traumatic injury
d. An adult who has dealt with the loss of several family members over the years
ANS: C
A sudden separation could increase risk for dysfunctional grieving. An extensive social
support network and a “loving” relationship do not predispose to dysfunctional grief.
Appropriate grief work in the past would not increase the risk for dysfunction.
DIF: Cognitive Level: Application
REF: Page 648
26. The common element seen in every type of bereavement is:
a. Bereavement is a predictable process that is a result of loss.
b. The individual has experienced the loss of something of importance.
c. Acute depression is generally experienced by all who grieve for a loss.
d. The course of the grieving will be determined by the seriousness of the loss.
ANS: B
Each type of loss means that something meaningful has been taken away, whether it is
physical, psychological, social, or symbolic. The remaining options are not true
statements regarding bereavement.
DIF: Cognitive Level: Application
REF: Page 641
27. Which statement best explains how a mother of several children should prepare to
help them cope with the loss of a dear aunt?
a. Children are resilient and simply need love as they grieve.
b. People regardless of age or gender experience stages of grief.
c. Each child will grieve in a unique way and on their own timetable.
d. Extreme reactions are more commonly observed in the young griever.
ANS: C
No two people regardless of age will grieve the same way, even in the same family. Each
person’s grief has unique characteristics and a timetable all its own. It is not necessarily
true that young grievers experience severe reactions to loss and require only love during
this experience. Although most individuals do experience the various stages of grief, that
information is not the most instructive for the mother.
DIF: Cognitive Level: Application
REF: Page 648
1. The patient’s daughter was murdered while they were customers in a local bank.
Which statements would support the patient’s diagnosis of posttraumatic stress
disorder (PTSD)? Select all that apply:
a. “I feel numb, like a robot going through the motions of existing.”
b. “I’m so nervous and jump at the slightest noise.”
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c. “I have not slept very well at all since I lost her.”
d. “I can’t stop reliving the last time I saw her alive.”
e. “I’d love nothing better than to kill that murderer.”
ANS: A, B, C, D
The traumatic nature of the murder and the patient’s symptoms of hypervigilance,
intrusive thoughts, and numbness indicate PTSD. Homicidal thoughts are not generally
associated with PTSD.
DIF: Cognitive Level: Analysis
REF: Page 647
Chapter 29: Mental and Emotional Responses to Medical Illness
1. A teenaged patient hospitalized with the diagnosis of HIV places a “No Visitors” sign
on the door, refuses phone calls, and states to the nurse, “I know you don’t want to
be around me.” Which of these nursing diagnoses is applicable to this situation?
a. Fear of dying related to medical diagnosis
b. Social isolation related to fear of rejection
c. Deficient knowledge related to cognitive limitations
d. Anger related to having to face death at such a young age
ANS: B
The patient has placed barriers between self and others. His statement referring to the
nurse not wanting to be around him suggests use of projection as a means of defending
against anxiety. Data given in the scenario do not support the diagnosis of fear. Neither
lack of knowledge nor cognitive limitation is suggested in the scenario. Anger is not a
NANDA-accepted diagnosis.
DIF: Cognitive Level: Application
REF: Page 670
TOP: Nursing Process:
Diagnosis
2. Which factor should be the primary consideration when assessing the advisability of
prescribing psychotropic medications for a patient with AIDS?
a. Nutritional status of the patient
b. Tolerance for oral medications
c. Characteristics of emotional distress
d. Length of time since the diagnosis was made
ANS: C
The severity of symptoms present will determine the type and dosage of medication that
should be prescribed (e.g., antidepressants would be used for symptoms of depression,
anxiolytics for acute anxiety, and psychotropics for symptoms of acute psychosis such as
delusions or hallucinations). The other factors are not as relevant to the prescription of
medications.
DIF: Cognitive Level: Application
REF: Page 673
3. A patient diagnosed with AIDS is observed attempting to hide an article on the
subject of lethal injections. Which response by the nurse would be most appropriate?
a. “Please let me have the journal. An article like that will only upset you.”
b. “I noticed what you are reading. Why are you trying to hide it?”
c. “Tell me what you think of the article you were reading.”
d. “Isn’t that a pretty grim article?”
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ANS: C
Suicide thoughts are common in the patient with AIDS. The correct option accepts this
fact and indicates the nurse’s willingness to listen to the patient’s thoughts about the
article and his situation. This intervention can address feelings of hopelessness and
powerlessness. The remaining options imply the patient was doing something wrong or
is passing judgment on the article.
DIF: Cognitive Level: Application
REF: Page 672
4. Which statement made by a patient with AIDS indicates that the patient is exhibiting
symptoms associated with acute psychotic-type dementia?
a. “I move more slowly than I used to.”
b. “I don’t enjoy being with other people anymore.”
c. “I’d like to stop the voices I hear in my head.”
d. “I can’t always remember where I put things.”
ANS: C
Hallucinations, dementia, psychomotor agitation, and other psychotic behaviors are part
of acute psychotic presentation of dementia associated with AIDS. The other options are
more consistent with dementia chiefly characterized by mild depression.
DIF: Cognitive Level: Analysis
REF: Page 667
5. A patient with HIV infection asks the nurse, “What do they mean by opportunistic
infections?” The nurse’s best response would be, “They are:
a. Infections transmitted by sexual contact.”
b. Rare illnesses that occur only in homosexual men.”
c. Infectious diseases from tropical or subtropical countries.”
d. Infections that develop when the immune system is suppressed.”
ANS: D
Opportunistic infections occur when the immune system is suppressed. Under ordinary
circumstances with an active immune system, these infectious organisms would not
cause illness. Opportunistic infections are not sexually transmitted diseases. Both
homosexual and heterosexual men, as well as women who are HIV-positive, may develop
opportunistic infections. Opportunistic infections are not limited to tropical diseases.
DIF: Cognitive Level: Application
REF: Page 665
6. The plan of care for a patient who is HIV-positive calls for the nurse to observe the
patient for symptoms of AIDS dementia. Which symptoms support that diagnosis?
a. Fever, night sweats, and nausea
b. Elevated pulse, respirations, and blood pressure
c. Inability to concentrate, forgetfulness, and apathy
d. Increased appetite and specific food and drink cravings
ANS: C
Behavioral and cognitive symptoms of AIDS dementia are poor concentration, inability to
problem solve, apathy, social withdrawal, forgetfulness, slowness of thinking, and motor
deficits. None of the other options would suggest the presence of AIDS dementia
because they are not related to cognitive function.
DIF: Cognitive Level: Application
REF: Page 667
7. A teen is concerned that she may have been exposed to the HIV virus by her sexual
partner but has resisted being tested. The nurse can hypothesize that the primary
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reason she has not been tested is because she:
a. Distrusts the confidentiality of the health care system
b. Is concerned about possibly losing her current partner
c. Is waiting to see whether symptoms would develop
d. Fears she might test seropositive
ANS: D
Fear of testing seropositive is a strong deterrent to being tested. As long as one has no
concrete evidence, denial can be protective. Distrust may be a factor for some patients,
but this is probably secondary to the fear of learning that one is HIV-positive. The
remaining options are rarely seen as primary reasons.
DIF: Cognitive Level: Application
REF: Page 668
8. A patient with AIDS is feeling threatened by his inability to work and take care of the
yard and garden he loves. Which patient outcome is appropriate at this time? The
patient will:
a. Explain his declining state of health to the family.
b. Realign goals to achieve a positive emotional state.
c. Enlist others to help him carry out his former tasks.
d. Accept the fact he will not be able to assume previous roles.
ANS: B
Goal realignment is necessary because it is not possible for the patient to carry out
former roles. Acceptance is not stated in behavioral terms. Asking for help does not
address the patient’s need to maintain self-worth and self-esteem. The family is not the
focus of the question.
DIF: Cognitive Level: Application
REF: Page 670
9. A patient has been hospitalized with problems related to AIDS and is experiencing
profound dementia. Which intervention will be most helpful in assisting the family to
adjust and plan for the patient’s future?
a. Provide information on available support groups.
b. Encourage placement of the patient in an adult care home.
c. Explain the importance of engaging in social activities with friends.
d. Advise the family to focus on present rather than possible future problems.
ANS: A
Associating with others who are experiencing similar problems is most helpful. The
family will receive needed information and support. An adult care home would not be a
suitable placement. Social involvement with others is not as high a priority as receiving
support and information. This is not appropriate, because a plan for care that considers
future deterioration must evolve.
DIF: Cognitive Level: Application
REF: Page 671
10. While being bathed, a patient with AIDS asks the nurse, “Aren’t you afraid of getting
this disease from me?” Which response would be most therapeutic?
a. “You sound surprised that I want to spend time with you.”
b. “No; I always use universal precautions to manage the risk.”
c. “Statistics show that few nurses get AIDS from their patients.”
d. “I have always firmly believed that whatever will be, will be.”
ANS: A
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This response reflects the patient’s feelings and encourages communication. The other
options do not respond to the patient’s feelings.
DIF: Cognitive Level: Application
REF: Page 672
11. The nurse manager is interviewing staff to work on the AIDS unit and asks the
applicants this question: “How do you feel about working with patients who have
AIDS?” The best candidate for the position would be the applicant who responds:
a. “I firmly believe there will soon be a cure for AIDS.”
b. “I believe that everyone is worthy of the best care I can provide.”
c. “I have done extensive research on AIDS and understand the disease.”
d. “I know I will have to be more careful, especially with injections and IVs.”
ANS: B
This response shows a belief in the worth and dignity of each patient. It suggests that
the nurse will be able to be accepting and nonjudgmental. One option shows a lack of
understanding of universal precautions. The other options do not answer the question or
sidesteps the issue.
DIF: Cognitive Level: Application
REF: Page 672
12. At an educational session for patients with HIV infection and their support persons,
the nurse is asked, “If the incidence of AIDS has declined, why is it that its prevalence
has increased?” The nurse can explain this by responding:
a. “This is a statistical aberration; don’t let it confuse you.”
b. “More people are living longer with both HIV infection and AIDS.”
c. “Delays in diagnosis and treatment contribute to the increased death rate.”
d. “Transmission to vulnerable populations has affected AIDS surveillance data.”
ANS: B
The incidence of AIDS began to decline only recently; however, HAART has prolonged the
interval between HIV infection and development of AIDS and has reduced deaths from
AIDS. Consequently, the number of people living with AIDS has increased. This situation
is not an aberration. Discussing diagnosis delays has no bearing on the issue. The
comment about surveillance data is unsupported by evidence.
DIF: Cognitive Level: Application
REF: Page 665
13. When planning care for a patient newly diagnosed with AIDS, the nurse takes into
consideration that the patient should be closely monitored for covert symptoms
associated with:
a. Fluid and electrolyte imbalance
b. Imbalanced nutrition
c. Adjustment disorder
d. Schizophrenia
ANS: C
Adjustment disorder commonly occurs related to overwhelming feelings associated with
having a fatal disease or being overwhelmed by feelings engendered by living with HIV.
Untreated negative feelings severely affect both the physical and psychologic well-being
of the patient. AIDS patients are not at high risk for schizophrenia. The remaining options
would be evidenced by overt symptoms.
DIF: Cognitive Level: Application
REF: Page 669
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14. A patient with AIDS persistently uses denial with respect to the seriousness of the
condition. The nurse will need to be alert for the presence of defining characteristics
for the nursing diagnosis of:
a. Anxiety
b. Hopelessness
c. Noncompliance
d. Powerlessness
ANS: C
Denial of his illness may lead to noncompliance with the medical regimen. The nurse
needs to intervene quickly if noncompliance occurs, since the patient’s condition will
deteriorate without the benefit of HAART. The remaining options are not likely to be seen
as long as the patient uses denial.
DIF: Cognitive Level: Application
REF: Page 670
15. A patient who is HIV-seropositive continues to use heroin on a daily basis but has
agreed that his behavior endangers others and promises not to share needles. What
can the nurse give as a realistic estimate for success in attaining this outcome?
a. Low potential for achievement
b. High potential for achievement
c. Moderate potential for achievement
d. Ultra-high potential for achievement
ANS: A
Despite the patient’s good intentions not to share needles, he may not care who uses his
needle when the heroin takes effect. The other options are unrealistically optimistic.
High-risk behaviors are difficult to change. They are hard to discuss and harder still to
achieve when they are drug-related, because substance use alters judgment.
DIF: Cognitive Level: Application
REF: Page 669
16. A patient with AIDS tells the nurse, “My recent life has been a series of losses. I’ve
lost my job and my income, as well as my identity as a prominent business leader.
What’s next?” What can the nurse offer that will facilitate adaptive coping?
a. “I can see that you’re feeling discouraged and hopeless.”
b. “I will help you plan to live as normally as possible in the months ahead.”
c. “Perhaps it would be wise to restrict your contacts to those who know of your
illness.”
d. “If you wish, I can help you investigate to see if you have been the victim of
discrimination.”
ANS: B
Nurses who engage in problem solving with patients help minimize the patient’s burden
of adapting to the disease. With this remark, the nurse is assisting the patient to make
plans to maintain the highest level of functioning possible. Achieving the goal of living as
normally as possible will enhance self-esteem. Focusing on negative feelings does not
help the patient move ahead. To suggest severing relationships at a time when social
networking is important is inappropriate. Discussing discrimination does not move the
patient into the future.
DIF: Cognitive Level: Application
REF: Page 671
17. Which remark by a patient would suggest that the treatment plan for a patient with
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AIDS has been successful in promoting decisional control?
a. “I recognize that what I’ve lost, I will never be able to regain.”
b. “I’ve learned enough about my disease to be able to make informed decisions.”
c. “I’ll be happy when my suffering comes to an end and I can join my partner.”
d. “I see no advantage in antiviral therapy. The side effects are worse than the
symptoms of AIDS.”
ANS: B
This response reflects the patient’s satisfaction with his knowledge of the disease and his
ability to make informed decisions. Suggesting limitations has a sense of powerlessness.
Discussing what happens after death shows resignation to impending death. Discussing
side effects reflects a poor quality of life.
DIF: Cognitive Level: Application
REF: Page 672
18. The nurse is preparing to teach a patient who is newly diagnosed with diabetes about
medications and blood testing. As the teaching occurs, the nurse knows that
effective coping will depend to a great degree on the patient’s:
a. Perceived self-efficacy
b. External locus of control
c. Religious belief systems
d. Number of significant others
ANS: A
Research has shown that, especially with chronic diseases, perceived self-efficacy
(internal locus of control) increases the likelihood of managing difficult situations.
External locus of control is associated with uncontrollable factors. A particular religion
has not been associated with effective coping and the number of significant others have
not been influential.
DIF: Cognitive Level: Application
REF: Page 663
19. A patient newly diagnosed with diabetes has also been diagnosed with depression.
The nurse knows to be alert for:
a. Increased low blood glucose results
b. Increased high blood glucose results
c. Failure to follow treatment plans consistently
d. Anger and potential of violence against significant others
ANS: C
Depression is frequently associated with fatigue and hopelessness, leading to erratic
treatment compliance. Research has not shown depression to have a direct impact on
blood sugar. There are not enough data to support the outcomes related to anger and
violence.
DIF: Cognitive Level: Application
REF: Page 664
20. A patient diagnosed with HIV has moved back to her small hometown to be close to
family. The major impact on the health management of this patient will include:
a. Emotional toll on families
b. The lack of supportive services
c. Financial burden of care on families
d. Distance from emergency acute care facilities
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ANS: B
This migration has raised concern about the adequacy of health care and supportive
services in regions where many do not understand HIV/AIDS and where specialists are
typically not available. Although the other options are impactful, they do not have the
same impact on the basic lack of needed services.
DIF: Cognitive Level: Application
REF: Page 666
21. Which intervention addresses a strategy identified by the federal government to
achieve an HIV-free generation?
a. Nutritional programs that deliver meals
b. Free medications for the uninsured patient
c. Screening programs directed towards women
d. Home health personnel available to deliver care
ANS: C
The Presidential Advisory Council on HIV/AIDS in February 2010 recommended several
strategies to assist with the achievement of an HIV-free generation. Strategies and
policies include early screenings addressing at-risk women. Although useful, the
remaining options do not directly address the stated strategies.
DIF: Cognitive Level: Application
REF: Page 666
1. A patient who received a diagnosis of HIV infection a week ago, reports to the clinic
nurse symptoms that are seen in acute anxiety. Which behaviors are supportive of
that diagnosis? Select all that apply.
a. Incapable of staying physically relaxed
b. Difficulty with focusing thoughts
c. Muscular tension
d. Bradycardia
e. Insomnia
ANS: A, B, C, E
The symptoms described are consistent with anxiety with the exception of bradycardia;
typically tachycardia is seen in such patients.
DIF: Cognitive Level: Application
REF: Page 665
2. A patient recently diagnosed with HIV infection reports symptoms that support a
diagnosis of adjustment disorder. These symptoms include telling the nurse, “I feel so
sad every time I think of my diagnosis. I cry a lot, and I don’t go out as much as I did
before. It just doesn’t seem right to laugh. I don’t have a good appetite, but I force
myself to eat something at every meal, so I haven’t lost weight.” From this
description, the nurse would determine that the patient’s symptoms most closely
correspond to those of (select all that apply):
a. Sadness
b. Anorexia
c. Aggression
d. Frequent crying
e. Delusional beliefs
ANS: A, B, D
The selected symptoms most closely resemble those of adjustment disorder with
depressive features. Aggression is more impulsive in nature and delusions are related to
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psychotic conditions.
DIF: Cognitive Level: Application
REF:
Page 669
Chapter 30: Community Mental Health Nursing for Patients with Severe and
Persistent Mental Illness
1. In addition to excellent assessment skills and keen insight into human behavior, what
additional ability is most critical to effective community mental health nursing?
a. Attention to economical nursing practice
b. Willingness to advocate for the patient
c. Familiarity with local patient-focused resources
d. Working relationship with community medical professionals
ANS: C
The role of the community mental health nurse is to help the patient to maintain his or
her highest level of functioning and independence within the community. It is critical for
the nurse to be familiar with the available community resources and community
networks, so they can work with the multidisciplinary treatment team to help patients
and their families adjust to the community. The remaining options are appropriate but
are not unique to community mental health nursing and its role in facilitating the
patient’s ability to live and function as a member of a community.
DIF: Cognitive Level: Analysis
REF: Page 678
2. What factor had the greatest impact on the limited success of the
deinstitutionalization of the mentally ill population?
a. The initiative was never funded by the federal government.
b. The mentally ill population found it too difficult to function autonomously.
c. Community support systems were unprepared to provide the required services.
d. The communities were biased against having the mentally ill living among them.
ANS: A
During deinstitutionalization, federal dollars were designated for community mental
health facilities; however, the enacted legislation was never funded. The effects of the
other options would have been directly related to the lack of sufficient funding.
DIF: Cognitive Level: Analysis
REF: Page 678
3. What is the primary event that results in many “eccentric” individuals being initially
diagnosed with a psychiatric disorder?
a. They commit a crime and are incarcerated.
b. They become both homeless and destitute.
c. They are unable to meet their own physical needs.
d. There is proof that they are a danger to themselves or others.
ANS: D
The family may describe the person’s behavior as “odd” or “eccentric” without realizing
or being willing to admit that the family member has a psychiatric illness that needs
professional help. The family generally seeks treatment for the ill member when the
behavior becomes irrational, threatening, assaultive, or self-destructive. Although the
remaining options are characteristic of mental illness, they are generally not sufficient to
warrant a mental illness diagnosis.
DIF: Cognitive Level: Analysis
REF: Page 679
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4. To best respect the mentally ill patient’s rights, no restricting intervention can be
implemented without:
a. First securing the patient’s informed consent
b. Proof that the patient is a danger to self or others
c. Initially attempting to secure the patient’s cooperation
d. Securing an order from the patient’s psychiatric care provider
ANS: B
Mentally ill persons who are disturbed or actively psychotic are not required to obtain
psychiatric treatment unless they are a threat to themselves or others. In cases where
safety is a concern, informed consent is not required and actions can be approved by the
care provider postintervention.
DIF: Cognitive Level: Application
REF: Page 679
5. Which nursing intervention by a community mental health nurse demonstrates an
understanding of the potential health risks that psychotropic medications present?
a. Discussing the risk of food interactions when taking buspirone (BuSpar)
b. Monitoring the blood glucose levels of a patient prescribed risperidone (Risperdal)
c. Stressing the importance of using alprazolam (Xanax) only as a short-term
therapy
d. Evaluating a patient’s understanding of the possible weight gain resulting from
escitalopram oxalate (Lexapro) therapy
ANS: B
The onset of type 2 diabetes is one of the less known side effects of commonly used
antipsychotic medications. Diabetes associated with psychotropic medications has been
demonstrated to be more frequent with risperidone (Risperdal).
Weight gain is a possible side effect of the antidepressant escitalopram oxalate
(Lexapro). Drugs used to treat anxiety, including buspirone (BuSpar), have known food
interactions such as grapefruit. Benzodiazepines, like alprazolam (Xanax), are prescribed
for depression and anxiety but should not be used on a long-term basis.
DIF: Cognitive Level: Analysis
REF: Page 679
6. Which behavior engaged in by a patient diagnosed with both schizophrenia and
hepatitis C presents the community mental health nurse with the greatest need to
share information ordinarily protected by the patient’s right to confidentiality?
a. Engaging in unprotected sex
b. Wearing the uniform of a police officer
c. Expressing a “real hatred for the government”
d. Stealing clothing and food from stores in the neighborhood
ANS: A
Legal and ethical issues continually challenge community mental health nurses. Nurses
need to be aware of state laws that mandate patient confidentiality while sharing
necessary information about a patient. For example, a nurse who learns this patient is
engaging in high-risk sexual behavior needs to report such findings to the appropriate
professionals in order to protect the public. The other options, although problematic, do
not have this level of seriousness regarding the good of the general public.
DIF: Cognitive Level: Analysis
REF: Page 680
7. Regarding freedom-of-choice care systems, what information must the patient
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receive regarding the criteria for terminating treatment of a patient with mental
health disorders?
a. Patient’s inability to pay for the services
b. Aggressive behavior on the part of the patient
c. Facility finds it uneconomical to provide the treatment
d. Patient’s noncompliance with an appropriate treatment plan
ANS: D
Freedom-of-choice systems have experienced some common problems with patient care
resulting in many agencies choosing not to develop treatment options for severe mental
disorders because they disagree with the premise of freedom of choice. Both the
provider and the patient have the freedom to make decisions; however, treatment
providers in these systems have the right to refuse to treat anyone whose symptoms
make that person resistant to accept treatment. The remaining options are not
considered as criteria for treatment termination regarding freedom of choice.
DIF: Cognitive Level: Application
REF: Page 681
8. Which interview question demonstrates cultural competency when conducting an
admission interview for a Jewish patient being admitted for severe depression?
a. “Is there a history of depression in your family?”
b. “Do you find comfort in your religious beliefs?”
c. “Has been being Jewish contributed to your depression?”
d. “How has your family responded to you since you have been depressed?”
ANS: D
Every cultural group has traditions and beliefs about the acceptance of mental illness
and the ability and willingness to trust health care providers. Members of the Jewish
community generally view severe mental illness as a stigma. The other options do not
directly address this culturally stigma.
DIF: Cognitive Level: Application
REF: Page 681
9. Which intervention demonstrates cultural competency regarding the care provided
an African American who is experiencing depression after the death of a child?
a. Providing information regarding local grief support groups
b. Assessing the patient’s ability to understand the grief process
c. Encouraging family members to be present when discharge planning is discussed
d. Consulting with the patient before discussing treatment plans with her adult
children
ANS: A
African Americans are more likely to rely on family and religious groups for support. The
remaining options are appropriate for all patients regardless of cultural considerations.
DIF: Cognitive Level: Application
REF: Page 681
10. What understanding is the most critical to the delivery of effective culturallycongruent nursing care to the mentally ill patient?
a. Willingness to learn about the cultural beliefs of the affected population
b. Consciousness of the role cultural beliefs play regarding the acceptance of
mental health nursing interventions
c. Attentiveness to the individual’s expression of cultural beliefs and reliance on the
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culture for various support
d. Awareness of the biases the culturally diverse population experiences when
experiencing mental illness
ANS: B
Understanding the cultural beliefs about mental illness and being sensitive to diverse
ethnic and cultural groups is a critical goal for community mental health nurses since
this has an immense impact on the planning and acceptance of nursing interventions.
The other options, although impactful, lack the direct relationship to the patient’s
willingness to accept and comply with mental health treatment
DIF: Cognitive Level: Analysis
REF: Page 681
11. Which activity best reflects the role of the mental health nurse case manager?
a. Advocating for the patient in all aspects of care
b. Attending to the patient’s physical and emotional needs
c. Acting as the leader of a patient’s multidisciplinary care team
d. Assuming responsibility for maintaining the patient’s mental health records
ANS: C
Case management facilitates and promotes the coordination of patient care, thereby
minimizing the fragmentation of treatment which is a major factor in the relapsing of the
patient’s symptomology. The other options are roles of the case manager but they lack
the attention to the basic concept of integrated, focused, and supervised care of the
patient.
DIF: Cognitive Level: Analysis
REF: Page 684
12. Which statement supports the fact that a patient diagnosed with chronic
schizophrenia who is being prepared for placement in an adult family home
understands the unique expectations of such an arrangement?
a. “I’ll have a safe, clean place to live.”
b. “I’m excited about having a bedroom of my own.”
c. “I will help wash dishes and sweep floors but I like doing that.”
d. “I can’t wait to live my life like I want to and make my own decisions.”
ANS: C
Adult family homes (supportive housing programs) provide a quieter and more personal
living arrangement for patients who need supervision. The patient becomes a part of the
family structure and is expected to fit into the normal routines of the household
performing routine tasks of daily living when appropriate. The patient may not have a
private bedroom and will have only the independence they are capable of managing
effectively and safely. Any placement is intended to ensure a clean, safe place to live.
DIF: Cognitive Level: Application
REF: Page 686
13. Which intervention demonstrates the community mental health nurse’s
understanding of the potential risks that home visits present?
a. Calling ahead to make an appointment to visit
b. Being sure to have access to a telephone during the actual visit
c. Asking family members to describe the patient’s recent behavior
d. Taking a small gift to give to the patient’s family during the visit
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ANS: C
It is crucial that the nurse who is planning a home visit evaluate the potential risks of
that visit before beginning the actual interventions. Risk evaluation always includes the
patient’s history, especially current emotional and behavioral status. Calling ahead to
make an appointment is standard procedure and is more directed towards respect than
safety. Having access to a telephone is good practice but has little impact on minimizing
risk. It is not recommended to set the expectation that the family will receive a gift with
each visit.
DIF: Cognitive Level: Application
REF: Page 686
14. Which action provides the nurse with evidence that a Hispanic patient diagnosed
with schizophrenia 10 years ago is likely to continue to benefit from social support
after being discharged for a psychotic break?
a. The patient’s brother and sister-in-law offer suggestions concerning the support
they can provide after discharge
b. The patient’s mother expresses an understanding of the need for compliance
with the treatment plan
c. The family’s religious leader visits the patient regularly and suggests part-time
employment at the church
d. Friends of the patient offer to provide transportation to and from therapy sessions
that the patient is scheduled to attend
ANS: A
Racial and ethnic differences play a significant role in the family’s response to mentally
ill members. Some cultural groups are protective of the ill individual, whereas others
soon become exhausted and emotionally drained with the care, dependency needs, and
symptoms of the ill person. The family’s continued involvement in the patient’s care is
the most positive example of continued support. The other options are positive but lack
the element of long-term active involvement with the patient.
DIF: Cognitive Level: Analysis
REF: Page 682
1. Which intervention is considered an essential element of a community nurse’s
mental health home visit? Select all that apply.
a. Documenting the patient’s current level of function
b. Evaluating the patient’s compliance with the plan of care
c. Ensuring that the patient’s family is supportive of the patient
d. Assessing the patient’s ability to understand their condition
e. Determining whether the patient has access to prescribed medication
ANS: A, B, D, E
The psychiatric nurse’s visit needs to include psychiatric evaluation, medication
compliance, health teaching, crisis intervention, and documentation. It would not be
possible for the nurse to ensure the family’s support regardless of its impact on the
patient’s prognosis.
DIF: Cognitive Level: Application
REF: Page 678
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