Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based
Practice 10th Edition Townsend Test Bank
Chapter 1. The Concept of Stress Adaptation
MULTIPLE CHOICE
1.
A client has experienced the death of a close family member and at the
same time becomes unemployed. The client’s 6-month score on the Recent Life Changes
Questionnaire is 110. The nurse:
A.
Understands the client is at risk for significant
stress-related illness.
B.
Determines the client is not at risk for
significant stress-related illness.
C.
Needs further assessment of the client’s
coping skills to determine susceptibility to
stress-related illness.
D.
Recognizes the client may view the losses as
challenges and perceive them as
opportunities.
ANS: C
C
Chapter learning objective: Explain the relationship between stress and diseases of
adaptation.
Page: 5–6
Heading: Stress as an Environmental Event
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. Assessment is the first step
of the nursing process. The nurse should
assess the client’s coping skills and available
support before determining susceptibility to
stress-related physical and psychological
illness. The Recent Life Changes
Questionnaire is an expanded version of the
Schedule of Recent Experiences and the RaheHolmes Social Readjustment Rating Scale. A
6-month score of 300 or more, or a year-score
total of 500 or more, indicates high stress in a
client’s life and susceptibility to stress-related
illnesses.
Feedback
This is incorrect. Assessment is the first step
of the nursing process. The nurse should
assess the client’s coping skills and available
support before determining susceptibility to
stress-related physical and psychological
illness. The Recent Life Changes
Questionnaire is an expanded version of the
Schedule of Recent Experiences and the RaheHolmes Social Readjustment Rating Scale. A
6-month score of 300 or more, or a year-score
total of 500 or more, indicates high stress in a
client’s life and susceptibility to stress-related
illnesses.
This is incorrect. Assessment is the first step
in the nursing process. The nurse should
assess the client’s coping skills and available
support before determining the client’s
perception of the current stresses. A 6-month
score of 300 or a year-score of 500 or more
on the Recent Life Changes Questionnaire
indicates high stress in a client’s life and
susceptibility to stress-related physical and
psychological illness.
This is correct. Assessment is the first step in
the nursing process. The nurse should assess
the client’s coping skills and available support
before determining susceptibility to stressrelated physical and psychological illness. A
6-month score of 300 or a year-score of 500
or more indicates high stress in a client’s life
and risk for significant stress-related physical
and psychological illness.
This is incorrect. Assessment is the first step
in the nursing process. The nurse should
assess the client’s coping skills and available
support before determining susceptibility to
stress-related illness. A 6-month score of 300
or a year-score of 500 or more on the Recent
Life Changes Questionnaire indicates high
stress in a client’s life is susceptible to
significant stress-related physical and
psychological illness.
A
B
C
D
PTS: 1
CON: Stress
2.
A physically and emotionally healthy client has just been fired. During a
routine office visit, he tells the nurse, “Perhaps this was the best thing to happen. Maybe
I’ll consider pursuing an art degree.” The nurse determines the client perceives the
stressor of his job loss as:
A.
Irrelevant.
B.
Harm/loss.
C.
A threat.
D.
A challenge.
ANS: D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 7
Heading: Individual’s Perception of the Event > Primary Appraisal
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. The client’s statement
indicates he perceives the loss of his job as a
challenge and an opportunity for growth.
B
This is incorrect. The client’s statement
indicates he perceives the loss of his job as a
challenge and an opportunity for growth.
C
This is incorrect. The client’s statement
indicates he perceives the loss of his job as a
challenge and an opportunity for growth.
D
This is correct. The client’s statement
indicates he perceives the loss of his job as a
challenge and an opportunity for growth.
PTS: 1
CON: Stress
3.
Which client statement alerts the nurse that the client may be responding
maladaptively to stress?
A.
“Avoiding contact with others helps me
cope.”
B.
“I really enjoy journaling; it’s my private
time.”
C.
“I signed up for a yoga class this week.”
D.
“I made an appointment to meet with a
therapist.”
A.
“Avoiding contact with others helps me
cope.”
“I really enjoy journaling; it’s my private
time.”
“I signed up for a yoga class this week.”
“I made an appointment to meet with a
therapist.”
B.
C.
D.
ANS: A
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 8–9
Heading: Stress Management
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
A
This is correct. Reliance on social isolation as
a coping mechanism is a maladaptive method
to relieve stress. It can prevent learning
appropriate coping skills and can prevent
access to needed support systems.
B
This is incorrect. Journaling is not considered
a maladaptive coping method.
C
This is incorrect. Group exercise is not
considered a maladaptive coping method.
D
This is incorrect. Seeing a therapist is not
considered a maladaptive coping method.
PTS: 1
CON: Stress
4.
A nursing student comes down with a sinus infection toward the end of
every semester. Which stage of stress is the student most likely experiencing when this
occurs?
A.
Alarm reaction
B.
Resistance
C.
Exhaustion
D.
Fight or flight
ANS: C
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the relationship between stress and diseases of
adaptation.
Page: 9
Heading: Stress as a Biological Response > Stage of Exhaustion
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. At the alarm reaction stage,
physiological responses of the fight-or-flight
syndrome are initiated.
B
This is incorrect. At the stage of resistance,
the individual uses the physiological
responses of the first stage as a defense in the
attempt to adapt to the stressor. Physiological
symptoms may disappear.
C
This is correct. At the stage of exhaustion, the
student’s exposure to stress has been
prolonged and adaptive energy has been
depleted. Diseases of adaptation occur more
frequently in this stage.
D
This is incorrect. The fight-or-flight syndrome
occurs during the alarm reaction stage.
PTS: 1
CON: Stress
5.
A school nurse is assessing a female high-school student who is overly
concerned about her appearance. The client’s mother states, “That’s not something to be
stressed about!” Which response by the nurse is best?
A.
“Teenagers! They don’t know a thing about
real stress.”
B.
“Psychological or physical stress occur only
when there is a loss.”
C.
“Poor physical condition can interfere with
psychological well-being.”
D.
“A threat to self-esteem can result in
psychological stress.”
ANS: D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Describe the core concept of stress as an environmental
event.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. This response is judgmental
and nontherapeutic.
B
This is incorrect. Physical and psychological
stress can be precipitated by events other than
loss.
C
This is incorrect. Stress can be physical or
psychological in nature. A perceived threat to
self-esteem can be as stressful as a
physiological change.
D
This is correct. Determination of an event as
stressful depends on the individual’s cognitive
appraisal of the situation, which is an
individual’s evaluation of the personal
significance of the event or occurrence. Stress
can be physical or psychological in nature. A
perceived threat to self-esteem can be as
stressful as a physiological change.
PTS: 1
CON: Stress
6.
A student confides in the school nurse that he is “stressed out” about
deciding whether to go to college or work to provide income the family needs. Which
coping strategy is the nurse’s best recommendation?
A.
Meditation
B.
Problem-solving training
C.
Relaxation
D.
Journaling
ANS: B
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 8
Heading: Stress Management
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. The student must assess his
or her situation and determine which coping
strategy is best for him.
B
This is correct. The student must assess his or
her situation and determine which coping
strategy is best for him. Problem-solving
training, by providing structure and
objectivity, can assist in decision-making.
C
This is incorrect. The student must assess his
or her situation and determine which coping
strategy is best for him.
D
This is incorrect. The student must assess his
or her situation and determine which coping
strategy is best for him.
PTS: 1
CON: Stress
7.
An unemployed college graduate confides in the clinic nurse that she is
experiencing severe anxiety over not finding a teaching position and that she is having
difficulty with independent problem-solving. Which nursing intervention is best?
A.
Encourage her to use other coping
mechanisms.
B.
Complete the problem-solving process for
her.
C.
Assist her with the problem-solving process.
D.
Encourage her to keep a daily journal of
feelings.
ANS: C
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 9
Heading: Stress Management
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. The nurse should assist the
client to problem-solve to determine the best
coping strategy for her.
B
This is incorrect. Completing the client’s
problem-solving does not provide the
opportunity for her to utilize this coping
strategy.
C
This is correct. Assist the client with problemsolving. During times of high anxiety and
stress, clients will need more assistance in
problem-solving and decision-making.
D
This is incorrect. The nurse should assist the
client to problem solve to determine the best
coping strategy for her.
PTS: 1
CON: Stress
8.
The school nurse is assessing a female high school student who is
distraught because her parents can’t afford horseback riding lessons. The nurse
recognizes the student’s perception is that the problem is:
A.
Endangering her well-being.
B.
Personally relevant.
C.
Based on immaturity.
D.
Exceeds her capacity to cope.
ANS: B
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the concept of stress as a transaction between the
individual and the environment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
This is incorrect. An event becomes relevant
to an individual when the outcome holds
personal significance.
This is correct. Determination of an event as
stressful depends on the individual’s cognitive
appraisal of the situation. An event becomes
relevant to an individual when the outcome
holds personal significance.
This is incorrect. An event becomes relevant
to an individual when the outcome holds
personal significance.
This is incorrect. An event becomes relevant
to an individual when the outcome holds
personal significance.
A
B
C
D
PTS: 1
CON: Stress
9.
Meditation has been shown to be an effective stress management
technique. Which nursing assessment indicates meditation has been effective?
A.
An achieved state of relaxation
B.
An achieved insight into one’s feelings
C.
A demonstration of appropriate role behaviors
D.
An enhanced ability to problem-solve
ANS: A
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 8
Heading: Stress Management > Adaptive Coping Strategies
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
A
This is correct. Meditation produces
relaxation by creating a special state of
consciousness through focused concentration.
B
This is incorrect. Meditation does not
necessarily produce an achieved insight into
one’s feelings.
C
This is incorrect. Meditation does not help to
demonstrate appropriate role behaviors.
D
This is incorrect. Meditation does not
Feedback
This is correct. Meditation produces
relaxation by creating a special state of
consciousness through focused concentration.
This is incorrect. Meditation does not
necessarily produce an achieved insight into
one’s feelings.
This is incorrect. Meditation does not help to
demonstrate appropriate role behaviors.
This is incorrect. Meditation does not
necessarily enhance one’s ability to solve
problems.
A
B
C
D
PTS: 1
CON: Stress
10.
A first-time mother is crying and asks the nurse, “How can I go to work if
I can’t afford child care?” Which is the nurse’s initial action to assist the client with
problem-solving?
A.
Determine the risks and benefits for each
alternative
B.
Formulate goals for resolution of the problem
C.
Evaluate the outcome of the implemented
alternative
D.
Assess the facts of the situation
ANS: D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 9
Heading: Stress Management >Adaptive Coping Strategies
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
A
B
C
D
Feedback
This is incorrect. Assessment is the first step
of the nursing process. Before any other steps
can be taken, accurate information about the
situation must be gathered.
This is incorrect. Assessment is the first step
of the nursing process. Before any other steps
can be taken, accurate information about the
situation must be gathered.
This is incorrect. Assessment is the first step
of the nursing process. Before any other steps
can be taken, accurate information about the
situation must be gathered.
This is correct. Assessment is the first step of
situation must be gathered.
This is incorrect. Assessment is the first step
of the nursing process. Before any other steps
can be taken, accurate information about the
situation must be gathered.
This is incorrect. Assessment is the first step
of the nursing process. Before any other steps
can be taken, accurate information about the
situation must be gathered.
This is correct. Assessment is the first step of
the nursing process. Before any other steps
can be taken, accurate information about the
situation must be gathered.
B
C
D
PTS: 1
CON: Stress
11.
A nursing instructor asks students when diseases of adaptation are likely to
occur. Which student response indicates that teaching is effective?
A.
“When an individual has limited experience
dealing with stress.”
B.
“When an individual inherits maladaptive
genes.”
C.
“When an individual experiences existing
conditions that exacerbate stress.”
D.
“When an individual’s physiological and
psychological resources are depleted.”
ANS: D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the relationship between stress and diseases of
adaptation.
Page: 4
Heading: Stress as a Biological Response
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. Diseases of adaptation occur
when the individual loses the capacity to
adapt effectively because physiological and
psychological resources have become
depleted. This is referred to as the stage of
exhaustion.
B
This is incorrect. Diseases of adaptation occur
when the individual loses the capacity to
adapt effectively because physiological and
psychological resources have become
depleted. This is referred to as the stage of
exhaustion.
C
This is incorrect. Diseases of adaptation occur
when the individual loses the capacity to
adapt effectively because physiological and
psychological resources have become
depleted. This is referred to as the stage of
exhaustion.
This is incorrect. Diseases of adaptation occur
when the individual loses the capacity to
adapt effectively because physiological and
psychological resources have become
depleted. This is referred to as the stage of
exhaustion.
This is incorrect. Diseases of adaptation occur
when the individual loses the capacity to
adapt effectively because physiological and
psychological resources have become
depleted. This is referred to as the stage of
exhaustion.
This is correct. Diseases of adaptation occur
when the individual loses the capacity to
adapt effectively because physiological and
psychological resources have become
depleted. This is referred to as the stage of
exhaustion.
B
C
D
PTS: 1
CON: Stress
12.
When an individual’s stress response is sustained over a long period, the
nurse anticipates which physiological effect?
A.
Decreased resistance to disease
B.
Increased libido
C.
Decreased blood pressure
D.
Increased inflammatory response
ANS: A
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Identify physiological responses to stress.
Page: 4
Heading: Stress as a Biological Response
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is correct. Selye’s general adaptation
syndrome identified prolonged exposure to
stress leads to a decreased immune response
and resistance to disease. During the stage of
exhaustion, the body’s compensatory
mechanisms no longer function effectively
and diseases of adaptation occur.
B
This is incorrect. Selye’s general adaptation
Feedback
This is correct. Selye’s general adaptation
syndrome identified prolonged exposure to
stress leads to a decreased immune response
and resistance to disease. During the stage of
exhaustion, the body’s compensatory
mechanisms no longer function effectively
and diseases of adaptation occur.
This is incorrect. Selye’s general adaptation
syndrome identified prolonged exposure to
stress leads to a decreased immune response
and resistance to disease. During the stage of
exhaustion, the body’s compensatory
mechanisms no longer function effectively
and diseases of adaptation occur.
This is incorrect. Selye’s general adaptation
syndrome identified prolonged exposure to
stress leads to a decreased immune response
and resistance to disease. During the stage of
exhaustion, the body’s compensatory
mechanisms no longer function effectively
and diseases of adaptation occur.
This is incorrect. Selye’s general adaptation
syndrome identified prolonged exposure to
stress leads to a decreased immune response
and resistance to disease. During the stage of
exhaustion, the body’s compensatory
mechanisms no longer function effectively
and diseases of adaptation occur.
A
B
C
D
PTS: 1
13.
response?
A.
B.
C.
D.
CON: Stress
The nurse identifies which symptom as typical of the fight-or-flight
Decreased heart rate
Increased peristalsis
Increased salivation
Pupil constriction
ANS: B
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Identify physiological responses to stress.
Page: 4
Heading: Stress as a Biological Response
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. During the fight-or-flight
response, the heart rate increases in response
to the release of epinephrine. Pupils dilate to
enhance vision. Salivation and peristalsis
decrease as the body slows unessential
functions.
B
This is correct. During the fight-or-flight
response, the heart rate increases in response
to the release of epinephrine. Pupils dilate to
enhance vision. Salivation and peristalsis
decrease as the body slows unessential
functions.
C
This is incorrect. During the fight-or-flight
response, the heart rate increases in response
to the release of epinephrine. Pupils dilate to
enhance vision. Salivation and peristalsis
decrease as the body slows unessential
functions.
D
This is incorrect. During the fight-or-flight
response, the heart rate increases in response
to the release of epinephrine. Pupils dilate to
enhance vision. Salivation and peristalsis
decrease as the body slows unessential
functions.
PTS: 1
CON: Stress
14.
A nurse is assessing a client’s response to stress. The nurse concludes that
the client is performing a secondary appraisal of a stressful event when the client
determines:
A.
The event is benign.
B.
The event is irrelevant.
C.
Resources are available.
D.
The event is pleasurable.
ANS: C
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the concept of stress as a transaction between the
individual and the environment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment >
Individual’s Perception of the Event
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. When the individual judges
the resources and skills needed to deal with
the event, the individual is conducting a
secondary appraisal. There are three types of
primary appraisals: irrelevant, benignpositive, and stressful.
B
This is incorrect. When the individual judges
the resources and skills needed to deal with
the event, the individual is conducting a
secondary appraisal. There are three types of
primary appraisals: irrelevant, benignpositive, and stressful.
C
This is correct. When the individual judges
the resources and skills needed to deal with
the event, the individual is conducting a
secondary appraisal. There are three types of
primary appraisals: irrelevant, benignpositive, and stressful.
D
This is incorrect. When the individual judges
the resources and skills needed to deal with
the event, the individual is conducting a
secondary appraisal. There are three types of
primary appraisals: irrelevant, benignpositive, and stressful.
PTS: 1
CON: Stress
15.
Miller and Rahe (1997) identified a correlation between the effects of life
change and illness. This research led to the development of the Recent Life Changes
Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool?
A.
Specific physical and psychological illnesses
are not identified.
Numerical values associated with specific life
events are randomly assigned.
Stress is viewed as a solely physiological
response.
An individual’s personal perception of the
event is excluded.
B.
C.
D.
ANS: D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the relationship between stress and diseases of
adaptation.
Page: 5–6
Heading: Stress as an Environmental Event
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback
This is incorrect. Individuals differ in
response to life events. The RLCQ uses a
scale that does not take these differences into
consideration.
This is incorrect. Individuals differ in
response to life events. The RLCQ uses a
scale that does not take these differences into
consideration.
This is incorrect. Individuals differ in
response to life events. The RLCQ uses a
scale that does not take these differences into
consideration.
This is correct. Individuals differ in response
to life events. The RLCQ uses a scale that
does not take these differences into
consideration.
A
B
C
D
PTS: 1
16.
CON: Stress
A client tells the nurse, “I experience stress on a regular basis. Why do I
feel this way?” Which is the nurse’s most appropriate response?
A.
“Genetics has nothing to do with your
temperament or feelings.”
B.
“Your reactions to past experiences influence
your current feelings.”
C.
“Your stress level is lower when you are in
good physical health.”
D.
“You’ll experience less stress if you use
appropriate coping skills.”
ANS: B
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the concept of stress as a transaction between the
individual and the environment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment >
Predisposing Factors
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. Past experiences are
occurrences that result in learned patterns that
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
general, learned coping responses, and degree
of adaptation to previous stressors.
B
This is correct. Past experiences are
occurrences that result in learned patterns that
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
general, learned coping responses, and degree
of adaptation to previous stressors.
C
This is incorrect. Past experiences are
occurrences that result in learned patterns that
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
general, learned coping responses, and degree
of adaptation to previous stressors.
D
This is incorrect. Past experiences are
occurrences that result in learned patterns that
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
general, learned coping responses, and degree
of adaptation to previous stressors.
This is incorrect. Past experiences are
occurrences that result in learned patterns that
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
general, learned coping responses, and degree
of adaptation to previous stressors.
This is incorrect. Past experiences are
occurrences that result in learned patterns that
can influence an individual’s current
adaptation response. They include previous
exposure to the stressor or other stressors in
general, learned coping responses, and degree
of adaptation to previous stressors.
C
D
PTS: 1
CON: Stress
17.
A nurse is providing education on anxiety and stress management. Which
of the following should be identified as the most important initial step in learning how to
manage anxiety?
A.
Diagnostic blood tests
B.
Awareness of factors creating stress
C.
Relaxation exercises
D.
Identification of support systems
ANS: B
Chapter: Chapter 0, The Core concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 8
Heading: Stress Management > Adaptive Coping Strategies
Integrated Processes: Teaching/Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. The initial step is awareness
that stress is being experienced and awareness
of factors that create stress. Diagnostic blood
tests, identification of support systems, and
relaxation exercises can be implemented after
the client becomes aware of factors that create
stress.
B
This is correct. The initial step is awareness
that stress is being experienced and awareness
of factors that create stress. Diagnostic blood
tests, identification of support systems, and
Feedback
This is incorrect. The initial step is awareness
that stress is being experienced and awareness
of factors that create stress. Diagnostic blood
tests, identification of support systems, and
relaxation exercises can be implemented after
the client becomes aware of factors that create
stress.
This is correct. The initial step is awareness
that stress is being experienced and awareness
of factors that create stress. Diagnostic blood
tests, identification of support systems, and
relaxation exercises can be implemented after
the client becomes aware of factors that create
stress.
This is incorrect. The initial step is awareness
that stress is being experienced and awareness
of factors that create stress. Diagnostic blood
tests, identification of support systems, and
relaxation exercises can be implemented after
the client becomes aware of factors that create
stress.
This is incorrect. The initial step is awareness
that stress is being experienced and awareness
of factors that create stress. Diagnostic blood
tests, identification of support systems, and
relaxation exercises can be implemented after
the client becomes aware of factors that create
stress.
A
B
C
D
PTS: 1
CON: Stress
18.
A 32-year-old woman is speaking to the office nurse at an initial visit. The
nurse asked, “What brings you in today?” The woman replied, “I have been having
headaches three to four times a week for the past month or so. I’m not sleeping well and
feel tired most of the time. I work 60 hours per week and am going through a divorce.”
The nurse determines the client’s symptoms represent which of the following?
A.
Adaptive coping
B.
Maladaptive coping
C.
Problem-solving
D.
Self-awareness
ANS: B
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Define adaptation and maladaptation.
Page: 8
Heading: Core Concepts
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
A
This is incorrect. When behavior disrupts the
integrity of the individual, it is perceived as
maladaptive. Maladaptive responses are
considered negative or unhealthy. An adaptive
response to stress is a behavior that maintains
the integrity of the individual.
B
This is correct. When behavior disrupts the
integrity of the individual, it is perceived as
maladaptive. Maladaptive responses are
considered negative or unhealthy.
C
This is incorrect. The client demonstrates a
maladaptive response to stress. When
behavior disrupts the integrity of the
individual, it is perceived as maladaptive.
Maladaptive responses are considered to be
negative or unhealthy
D
This is incorrect. When behavior disrupts the
integrity of the individual, it is perceived as
maladaptive. Maladaptive responses are
considered negative or unhealthy. An adaptive
response to stress is a behavior that maintains
the integrity of the individual.
PTS: 1
CON: Stress
19.
The emergency department nurse is providing discharge instructions to a
23-year-old man who was injured in a motor vehicle crash. The client stated, “My heart
was racing when I saw the car coming through the red light was going to hit me. I didn’t
know my heart could go that fast!” Which is the nurse’s best response?
A.
“Don’t worry, your heart is strong because
you are young and in good health.”
B.
“Everyone gets scared when they realize
another car is going to hit them.”
C.
“You had a panic attack when you saw the car
that hit you was not going to stop.”
D.
“Your body responded to the stress of
knowing the car was going to hit you.”
A.
“Don’t worry, your heart is strong because
you are young and in good health.”
“Everyone gets scared when they realize
another car is going to hit them.”
“You had a panic attack when you saw the car
that hit you was not going to stop.”
“Your body responded to the stress of
knowing the car was going to hit you.”
B.
C.
D.
ANS: D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Identify physiological responses to stress.
Page: 3–4
Heading: Stress as a Biological Response
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. The nurse’s response in this
example is nontherapeutic.
B
This is incorrect. The nurse’s response does
not explain the reason for the client’s rapid
heart rate.
C
This is incorrect. The client experienced a
physical reaction to the stressor of the
impending car crash. A stressor is a
biological, psychological, social, or chemical
factor that causes physical or emotional
tension. The client’s increased heart rate was
a physical response during the alarm reaction
stage of the fight-or-flight syndrome.
D
This is correct. The client experienced a
physical reaction to the stressor of the
impending car crash. A stressor is a
biological, psychological, social, or chemical
factor that causes physical or emotional
tension. The client’s increased heart rate was
a physical response during the alarm reaction
stage of the fight-or-flight syndrome.
PTS: 1
CON: Stress
20.
The nurse in the intensive care unit (ICU) is giving report to the nurse on
the cardiac step-down unit. The nurse states, “The patient is a 48-year-old woman
admitted 3 days ago for chest pain and a stent placement. Vital signs are stable, but I am
worried about her stress level. She said she just moved here due to a job transfer and her
husband stayed behind to sell the house. She told me they have a high insurance
deductible and she is worried about the hospital bill.” Which factor has the most
significant influence on the client’s health?
A.
Coping skills
B.
Existing conditions
C.
Individual vulnerability
D.
Perceived threat
ANS: B
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Identify physiological responses to stress.
Page: 7
Heading: Stress as a Transaction between the Individual and the Environment >
Predisposing Factors
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
Feedback
A
This is incorrect. Predisposing factors
influence how an individual responds to a
stressful event. Existing conditions
incorporate vulnerabilities that influence the
adequacy of an individual’s resources to deal
with adaptive demands. Existing stressors are
the recent move, loss of the support system,
and financial concerns.
B
This is correct. Predisposing factors influence
how an individual responds to a stressful
event. Existing conditions incorporate
vulnerabilities that influence the adequacy of
an individual’s resources to deal with adaptive
demands. Existing stressors are the recent
move, loss of the support system, and
financial concerns.
C
This is incorrect. Predisposing factors
influence how an individual responds to a
stressful event. Existing conditions
incorporate vulnerabilities that influence the
adequacy of an individual’s resources to deal
with adaptive demands. Existing stressors are
the recent move, loss of the support system,
and financial concerns.
D
This is incorrect. Predisposing factors
influence how an individual responds to a
stressful event. Existing conditions
vulnerabilities that influence the adequacy of
an individual’s resources to deal with adaptive
demands. Existing stressors are the recent
move, loss of the support system, and
financial concerns.
This is incorrect. Predisposing factors
influence how an individual responds to a
stressful event. Existing conditions
incorporate vulnerabilities that influence the
adequacy of an individual’s resources to deal
with adaptive demands. Existing stressors are
the recent move, loss of the support system,
and financial concerns.
This is incorrect. Predisposing factors
influence how an individual responds to a
stressful event. Existing conditions
incorporate vulnerabilities that influence the
adequacy of an individual’s resources to deal
with adaptive demands. Existing stressors are
the recent move, loss of the support system,
and financial concerns.
C
D
PTS: 1
CON: Stress
MULTIPLE RESPONSE
21.
A nurse is interviewing a distressed client who reports being fired after 15
years of loyal employment. Which of the following questions best assists the nurse to
determine the client’s appraisal of the situation? Select all that apply.
A.
“What resources have you used previously in
stressful situations?”
B.
“Have you ever experienced a similar
stressful situation?”
C.
“Who do you think is to blame for this
situation?”
D.
“Why do you think you were fired from your
job?”
E.
“What skills do you possess that might lead to
gainful employment?”
ANS: A, B, E
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the concept of stress as a transaction between the
individual and the environment.
Page: 7–8
Heading: Stress as a Transaction Between the Individual and the Environment >
Individual’s Perception of the Event
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
This is correct. This question specifically
addresses the client’s coping resources.
This is correct. This question encourages the
client to apply learning from past experiences.
This is incorrect. Asking who is to blame does
not assess coping abilities, but rather,
encourages maladaptive behavior.
This is incorrect. This question does not
assess coping abilities. Requesting an
explanation is a nontherapeutic block to
communication.
This is correct. This question focuses on
coping strategies and alternative methods for
dealing with stress.
1.
2.
3.
4.
5.
PTS: 1
CON: Stress
22.
A nurse is working with a client who has recently been under a great deal
of stress. Which nursing recommendations would be most helpful to assist the client to
cope with stress? Select all that apply.
A.
“Enjoy a pet.”
B.
“Spend time with a loved one.”
C.
“Listen to music.”
D.
“Focus on the stressors.”
E.
“Journal your feelings.”
ANS: A, B, C, D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 8–9
Heading: Stress Management > Adaptive Coping Strategies
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
Feedback
This is correct. Pets have been shown to
decrease stress.
This is correct. Healthy relationships have
been shown to decrease stress.
This is correct. Music has been shown to
decrease stress.
This is incorrect. Focusing on the stressors is
more likely to increase stress.
This is correct. Journaling feelings has been
shown to decrease stress.
1.
2.
3.
4.
5.
PTS: 1
CON: Stress
23.
A patient presents in the emergency department immediately following a
shooting incident in a school where she has been teaching. There is no evidence of
physical injury, but she appears very hyperactive and talkative. Which are common initial
biological responses to stress? Select all that apply.
A.
Constricted pupils
B.
Watery eyes
C.
Unusual food cravings
D.
Increased heart rate
E.
Increased respirations
ANS: B, D, E
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Identify physiological responses to stress.
Page: 3–4
Heading: Stress as a Biological Response
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
1.
2.
3.
Feedback
This is incorrect. Dilated pupils, rather than
constricted pupils, are related to the fight-orflight syndrome.
This is correct. Increased lacrimal secretions,
increased heart rate, and increased
respirations are identified as initial biological
responses to stress.
This is incorrect. Unusual food cravings have
Feedback
This is incorrect. Dilated pupils, rather than
constricted pupils, are related to the fight-orflight syndrome.
This is correct. Increased lacrimal secretions,
increased heart rate, and increased
respirations are identified as initial biological
responses to stress.
This is incorrect. Unusual food cravings have
not been identified as a typical biological
response to stress.
This is correct. Increased lacrimal secretions,
increased heart rate, and increased
respirations are identified as initial biological
responses to stress.
This is correct. Increased lacrimal secretions,
increased heart rate, and increased
respirations are identified as initial biological
responses to stress.
1.
2.
3.
4.
5.
PTS: 1
CON: Stress
24.
Which concepts are included in Hobfoll’s Conservation of Resources
theory? Select all that apply.
A.
Availability of resources
B.
Disequilibrium
C.
Genetics
D.
Past experiences
E.
Resilience
ANS: A, C, D
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Explain the concept of stress as a transaction between the
individual and the environment.
Page: 7–8
Heading: Stress as a Transaction Between the Individual and the Environment
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
1.
Feedback
This is correct. Hobfoll’s Conservation of
Resources theory asserts a variety of elements
influence an individual’s perception and
response to a stressful event. Predisposing
factors strongly influence whether the
response is adaptive or maladaptive. These
include genetic influences, past experiences,
and existing conditions. Available resources
1.
2.
3.
4.
5.
Feedback
This is correct. Hobfoll’s Conservation of
Resources theory asserts a variety of elements
influence an individual’s perception and
response to a stressful event. Predisposing
factors strongly influence whether the
response is adaptive or maladaptive. These
include genetic influences, past experiences,
and existing conditions. Available resources
also affect an individual’s perception of
adaptive capabilities. An individual who
experiences stress in the present becomes
more vulnerable to future stress when there is
a loss or lack of resources.
This is incorrect. Disequilibrium is not
included as part of Hobfoll’s theory.
This is correct. Hobfoll’s Conservation of
Resources theory asserts a variety of elements
influence an individual’s perception and
response to a stressful event. Predisposing
factors strongly influence whether the
response is adaptive or maladaptive. These
include genetic influences, past experiences,
and existing conditions. Available resources
also affect an individual’s perception of
adaptive capabilities. An individual who
experiences stress in the present becomes
more vulnerable to future stress when there is
a loss or lack of resources.
This is correct. Hobfoll’s Conservation of
Resources theory asserts a variety of elements
influence an individual’s perception and
response to a stressful event. Predisposing
factors strongly influence whether the
response is adaptive or maladaptive. These
include genetic influences, past experiences,
and existing conditions. Available resources
also affect an individual’s perception of
adaptive capabilities. An individual who
experiences stress in the present becomes
more vulnerable to future stress when there is
a loss or lack of resources.
This is incorrect. Resilience is not included as
part of Hobfoll’s theory.
PTS: 1
CON: Stress
ORDERED RESPONSE
25.
Place the selected steps of the problem-solving process in the correct
order.
1. Determine risks and benefits of each option.
2. Formulate goals to resolve the stressful situation.
3. Implement a second alternative.
4. Study the alternatives for dealing with the situation.
ANS:
The correct order is 2, 4, 1, 3
Chapter: Chapter 0, The Concept of Stress Adaptation
Chapter learning objective: Discuss adaptive coping strategies in the management of
stress.
Page: 9
Heading: Stress Management > Adaptive Coping Strategies
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
Feedback: Problem-solving is an adaptive coping strategy in which an individual views
the situation objectively and applies a decision-making model. The steps of the problemsolving process are: (1) Assessing the facts of the situation; (2) formulating goals for
resolution of the stressful situation; (3) studying the alternatives for dealing with the
situation; (4) determining the risks and benefits of each alternative; (5) selecting an
alternative; (6) implementing the selected alternative; (7) evaluating the outcome of the
alternative implemented; and (8) if the first choice is ineffective, selecting and
implementing a second option.
PTS: 1
CON: Stress
Chapter 2. Mental Health and Mental Illness: Historical and Theoretical Concepts
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A nurse is assessing a client who is experiencing occasional feelings of sadness
because of the recent death of a beloved pet. The client’s appetite, sleep patterns, and daily
routine have not changed. How should the nurse interpret the client’s behaviors?
1.
2.
3.
4.
The client’s behaviors demonstrate mental illness in the form of depression.
The client’s behaviors are extensive, which indicates the presence of mental illness.
The client’s behaviors are not congruent with cultural norms.
The client’s behaviors demonstrate no functional impairment, indicating no mental
illness.
____ 2.
At what point should the nurse determine that a client is at risk for developing a
mental illness?
1.
When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria.
2.
When maladaptive responses to stress are coupled with interference in daily
functioning.
3.
When a client communicates significant distress.
4.
When a client uses defense mechanisms as ego protection.
____ 3.
A nurse is assessing a set of 15-year-old identical twins who respond very
differently to stress. One twin becomes anxious and irritable, and the other withdraws and cries.
How should the nurse explain these different stress responses to the parents?
1.
Reactions to stress are relative rather than absolute; individual responses to stress
vary.
2.
It is abnormal for identical twins to react differently to similar stressors.
3.
Identical twins should share the same temperament and respond similarly to stress.
4.
Environmental influences to stress weigh more heavily than genetic influences.
____ 4.
Which client should the nurse anticipate to be most receptive to psychiatric
treatment?
1.
A Jewish, female social worker.
2.
A Baptist, homeless male.
3.
A Catholic, black male.
4.
A Protestant, Swedish business executive.
____ 5.
A psychiatric nurse intern states, “This client’s use of defense mechanisms should
be eliminated.” Which is a correct evaluation of this nurse’s statement?
1.
Defense mechanisms can be appropriate responses to stress and need not be
eliminated.
2.
Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and
should always be eliminated.
3.
Defense mechanisms, used by individuals with weak ego integrity, should be
discouraged and not eliminated.
4.
Defense mechanisms cause disintegration of the ego and should be fostered and
encouraged.
2.
3.
4.
eliminated.
Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and
should always be eliminated.
Defense mechanisms, used by individuals with weak ego integrity, should be
discouraged and not eliminated.
Defense mechanisms cause disintegration of the ego and should be fostered and
encouraged.
____ 6.
During an intake assessment, a nurse asks both physiological and psychosocial
questions. The client angrily responds, “I’m here for my heart, not my head problems.” Which is
the nurse’s best response?
1.
“It is just a routine part of our assessment. All clients are asked these same
questions.”
2.
“Why are you concerned about these types of questions?”
3.
“Psychological factors, like excessive stress, have been found to affect medical
conditions.”
4.
“We can skip these questions, if you like. It isn’t imperative that we complete this
section.”
____ 7.
An employee uses the defense mechanism of displacement when the boss openly
disagrees with suggestions. What behavior would be expected from this employee?
1.
The employee assertively confronts the boss.
2.
The employee leaves the staff meeting to work out in the gym.
3.
The employee criticizes a coworker.
4.
The employee takes the boss out to lunch.
____ 8.
A fourth-grade boy teases and makes jokes about a cute girl in his class. This
behavior should be identified by a nurse as indicative of which defense mechanism?
1.
Displacement
2.
Projection
3.
Reaction formation
4.
Sublimation
____
1.
2.
3.
4.
____
1.
2.
3.
4.
9.
Which nursing statement about the concept of neurosis is most accurate?
An individual experiencing neurosis is unaware that he or she is experiencing
distress.
An individual experiencing neurosis feels helpless to change his or her situation.
An individual experiencing neurosis is aware of the psychological causes of his or
her behavior.
An individual experiencing neurosis has a loss of contact with reality.
10.
Which nursing statement regarding the concept of psychosis is most accurate?
Individuals experiencing psychoses are aware that their behaviors are maladaptive.
Individuals experiencing psychoses experience little distress.
Individuals experiencing psychoses are aware of experiencing psychological
problems.
Individuals experiencing psychoses are based in reality.
1.
2.
3.
4.
Individuals experiencing psychoses are aware that their behaviors are maladaptive.
Individuals experiencing psychoses experience little distress.
Individuals experiencing psychoses are aware of experiencing psychological
problems.
Individuals experiencing psychoses are based in reality.
____ 11.
When under stress, a client routinely uses alcohol to excess. Finding her drunk,
her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to
the client’s use of the defense mechanism of denial?
1.
The client hides liquor bottles in a closet.
2.
The client yells at her son for slouching in his chair.
3.
The client burns dinner on purpose.
4.
The client says to the spouse, “I don’t drink too much!”
____ 12.
Devastated by a divorce from an abusive husband, a wife completes grief
counseling. Which statement by the wife should indicate to a nurse that the client is in the
acceptance stage of grief?
1.
“If only we could have tried again, things might have worked out.”
2.
“I am so mad that the children and I had to put up with him as long as we did.”
3.
“Yes, it was a difficult relationship, but I think I have learned from the experience.”
4.
“I still don’t have any appetite and continue to lose weight.”
____ 13.
A nurse is performing a mental health assessment on an adult client. According to
Maslow’s hierarchy of needs, which client action would demonstrate the highest achievement in
terms of mental health?
1.
Maintaining a long-term, faithful, intimate relationship
2.
Achieving a sense of self-confidence
3.
Possessing a feeling of self-fulfillment and realizing full potential
4.
Developing a sense of purpose and the ability to direct activities
____ 14.
According to Maslow’s hierarchy of needs, which situation on an inpatient
psychiatric unit would require priority intervention by a nurse?
1.
A client rudely complaining about limited visiting hours
2.
A client exhibiting aggressive behavior toward another client
3.
A client stating that no one cares
4.
A client verbalizing feelings of failure
____ 15.
How would a nurse best complete the new DSM-5 definition of a mental disorder?
“A health condition characterized by significant dysfunction in an individual’s cognitions, or
behaviors that reflect a disturbance in …” which of the following?
1.
Psychosocial, biological, or developmental process underlying mental functioning
2.
Psychological, cognitive, or developmental process underlying mental functioning
3.
Psychological, biological, or developmental process underlying mental functioning
4.
Psychological, biological, or psychosocial process underlying mental functioning
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 16.
A nurse is assessing a client who appears to be experiencing some anxiety during
questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select
all that apply.)
1.
Fidgeting
2.
Laughing inappropriately
3.
Palpitations
4.
Nail biting
5.
Limited attention span
Completion
Complete each statement.
17.
_______________________ is a diffuse apprehension that is vague in nature and
is associated with feelings of uncertainty and helplessness.
18.
_______________________ is a subjective state of emotional, physical, and
social responses to the loss of a valued entity.
Chapter 0: Mental Health and Mental Illness
Answer Section
MULTIPLE CHOICE
1.
ANS: 4
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Discuss cultural elements that influence attitudes toward mental health and mental
illness.
Page: 9
Heading: Grief
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The client’s behaviors are to be expected in a time of grief.
The client’s behaviors are not presented as being extensive.
The client’s behaviors are to be expected after a loss.
The nurse should assess that the client’s daily functioning is not impaired. The
client who experiences feelings of sadness after the loss of a pet is responding
within normal expectations.
CON: Grief and Loss
2.
ANS: 2
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Define mental health and mental illness.
Page: 3
Heading: Mental Illness
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The client with a mental illness would have symptoms that reflect the DSM-5.
The nurse should determine that the client is at risk for mental illness when
responses to stress are maladaptive and interfere with daily functioning. The
DSM-5 indicates that in order to be diagnosed with a mental illness, daily
functioning must be significantly impaired.
The client’s ability to communicate distress would be considered a positive
attribute.
The use of defense mechanisms does not indicate that the client is at risk for
mental illness.
CON: Stress
3.
ANS: 1
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 7
Heading: Physical and Psychological Responses to Stress > Mild Anxiety
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Growth and Development
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The nurse should explain to the parents that, although the twins have identical
DNA, there are several other factors that affect reactions to stress.
It is considered normal for twins to react differently to stress.
Identical twins do not necessarily respond similarly to stress, due to differences in
temperament and personality.
Environmental influences and temperament can affect stress reactions.
CON: Growth and Development
4.
ANS: 1
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Discuss cultural elements that influence attitudes toward mental health and mental
illness.
Page: 4
Heading: Box 1-1 Cultural Aspects of Mental Illness
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
Feedback
1
The nurse should anticipate that the client of Jewish culture would place a high
importance on preventative health care and would consider mental health as
equally important to physical health.
2
The homeless client may have difficulty accessing health care and may not place a
high emphasis on mental health treatment.
3
Women are more likely to seek treatment for mental health problems than men.
4
This client is not typically as receptive to psychiatric treatment as the client of
Jewish culture.
PTS: 1
CON: Culture
5.
ANS: 1
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 7
Heading: Physical and Psychological Responses to Stress > Mild Anxiety
Cognitive Level: Application [Applying]
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Concept: Stress
Difficulty: Moderate
Feedback
1
The nurse should determine that defense mechanisms can be appropriate during
times of stress.
2
Defense mechanisms are not maladaptive attempts of the ego to manage anxiety.
3
Defense mechanisms are a normal part of coping with stress. They are not used by
individuals with weak ego integrity. They should not be discouraged and
eliminated.
4
Defense mechanisms are normal and are used by all individuals in some way
during times of stress; they do not cause disintegration of the ego.
PTS: 1
CON: Stress
6.
ANS: 3
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 9
Heading: Physical and Psychological Responses to Stress > Severe Anxiety
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
1
This statement is not therapeutic to the client.
2
This statement is not therapeutic and may anger the client further.
3
The nurse should attempt to educate the client on the negative effects of excessive
stress on medical conditions.
4
It is not appropriate to skip physiological and psychosocial questions, as this
would lead to an inaccurate assessment.
PTS: 1
CON: Stress
7.
ANS: 3
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 7
Heading: Table 1-1 Ego Defense Mechanisms > Displacement
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Easy
Feedback
1
Confronting others is not a behavior consistent with displacement.
2
Leaving the staff meeting is not a behavior consistent with displacement.
3
The nurse should expect that the client using the defense mechanism displacement
would criticize a coworker after being confronted by the boss.
4
Taking the boss out to lunch is not a behavior consistent with displacement.
PTS: 1
CON: Stress
8.
ANS: 3
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 7
Heading: Table 1-1 Ego Defense Mechanisms > Reaction Formation
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
1
Displacement refers to transferring feelings from one target to another.
2
Projection refers to the attribution of unacceptable feelings or behaviors to another
person.
3
The nurse should identify that the boy is using reaction formation as a defense
mechanism. Reaction formation is the attempt to prevent undesirable thoughts
from being expressed by expressing opposite thoughts or behaviors.
4
Sublimation refers to channeling unacceptable drives or impulses into more
constructive, acceptable activities.
PTS: 1
CON: Stress
9.
ANS: 2
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 9
Heading: Physical and Psychological Responses to Stress > Severe Anxiety
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback
1
The client is aware that he or she is experiencing distress.
2
The client feels helpless to change his or her situation.
3
The client is unaware of the psychological causes of the distress.
4
The client experiences no loss of contact with reality.
PTS: 1
CON: Stress
10.
ANS: 2
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 6
Heading: Physical and Physiological Responses to Stress > Anxiety
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The client with psychosis is unaware that his or her behavior is maladaptive.
The nurse should understand that the client with psychosis experiences little
distress owing to his or her lack of awareness of reality.
The client with psychosis is unaware he or she has a psychological problem.
The client experiencing psychosis has a lack of awareness of reality.
CON: Stress
11.
ANS: 4
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Identify physiological responses to stress.
Page: 7
Heading: Table 1-1 Ego Defense Mechanisms > Denial
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Easy
Feedback
1
This behavior does not indicate denial.
2
Yelling at family members does not indicate denial.
3
Burning dinner on purpose is not an action that indicates denial.
4
The client’s statement “I don’t drink too much!” alerts the nurse to the use of the
defense mechanism of denial. The client is refusing to acknowledge the existence
1
2
3
4
PTS: 1
Feedback
This behavior does not indicate denial.
Yelling at family members does not indicate denial.
Burning dinner on purpose is not an action that indicates denial.
The client’s statement “I don’t drink too much!” alerts the nurse to the use of the
defense mechanism of denial. The client is refusing to acknowledge the existence
of a real situation and the feelings associated with it.
CON: Addiction and Behaviors
12.
ANS: 3
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Discuss the concepts of anxiety and grief as psychological responses to stress.
Page: 10
Heading: Stages of Grief
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Easy
Feedback
1
This statement indicates denial.
2
This statement indicates anger.
3
The nurse should evaluate that the client is in the acceptance stage of grief because
during this stage of the grief process, the client would be able to focus on the
reality of the loss and its meaning in relation to life.
4
This statement indicates prolonged grieving.
PTS: 1
CON: Grief and Loss
13.
ANS: 3
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Define mental health and mental illness.
Page: 3
Heading: Mental Health
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Self
Difficulty: Easy
1
2
3
Feedback
This option is not the highest level on Maslow’s hierarchy of needs.
While this option is important, it is not the highest level on Maslow’s hierarchy of
needs.
The nurse should identify that the client who possesses a feeling of self-fulfillment
and realizes his or her full potential has achieved self-actualization, the highest
level on Maslow’s hierarchy of needs.
1
2
3
4
PTS: 1
Feedback
This option is not the highest level on Maslow’s hierarchy of needs.
While this option is important, it is not the highest level on Maslow’s hierarchy of
needs.
The nurse should identify that the client who possesses a feeling of self-fulfillment
and realizes his or her full potential has achieved self-actualization, the highest
level on Maslow’s hierarchy of needs.
This option is important for the development of the client, but is not the most
important on Maslow’s hierarchy of needs.
CON: Self
14.
ANS: 2
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Define mental health and mental illness.
Page: 3
Heading: Mental Health
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Clients who complain are struggling with higher-level needs, such as the need for
love and belonging or the need for self-esteem.
The nurse should immediately intervene when a client exhibits aggressive
behavior toward another client. Safety and security are considered lower-level
needs according to Maslow’s hierarchy of needs and must be fulfilled before other
higher-level needs can be met.
Clients who state that no one cares are struggling with higher-level needs such as
the need for love and belonging or the need for self-esteem.
Clients who have feelings of failure are struggling with higher-level needs, such as
the need for love and belonging or the need for self-esteem.
CON: Stress
15.
ANS: 3
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Define mental health and mental illness.
Page: 4
Heading: Mental Illness
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
Feedback
1
This option in not part of the DSM-5 definition of a mental disorder.
2
This option does not define the DSM-5’s mental disorder definition.
3
The new DSM-5 definition of a mental disorder is “A health condition
characterized by significant dysfunction in an individual’s cognitions, or behaviors
that reflect a disturbance in the psychological, biological, or developmental
process underlying mental functioning.”
4
This option is incorrect, because it does not meet the definition set by the DSM-5
for mental health disorders.
PTS: 1
CON: Patient-Centered Care
MULTIPLE RESPONSE
16.
ANS: 1, 2, 4
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Discuss the concepts of anxiety and grief as psychological responses to stress.
Page: 7
Heading: Physical and Physiological Responses to Stress > Mild Anxiety
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This symptom is a sign of anxiety.
This is a symptom that the nurse would expect in a client experiencing anxiety.
The nurse would not expect the client to have palpitations.
This option indicates anxiety.
Limited attention span does not indicate anxiety.
PTS: 1
CON: Stress
COMPLETION
17.
ANS:
Anxiety
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Discuss the concepts of anxiety and grief as psychological responses to stress.
Page: 6
Heading: Core Concept > Anxiety
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
Feedback: The definition of anxiety is a diffuse apprehension that is vague in nature and is
associated with feelings of uncertainty and helplessness. Townsend considers this a core concept.
PTS: 1
18.
CON: Stress
ANS:
Grief
Chapter: Chapter 0, Mental Health and Mental Illness
Objective: Discuss the concepts of anxiety and grief as psychological responses to stress.
Page: 9
Heading: Physical and Psychological Responses to Stress > Psychological Responses
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Easy
Feedback: The definition of grief is a subjective state of emotional, physical, and social
responses to the loss of a valued entity. Townsend considers this a core concept.
PTS: 1
CON: Grief and Loss
Chapter 3. Concepts of Psychobiology
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A depressed client states, “I have a chemical imbalance in my brain. I have no
control over my behavior. Medications are my only hope to feel normal again.” Which nursing
response is appropriate?
1.
“Medications only address biological factors. Environmental and interpersonal
factors must also be considered.”
2.
“Because biological factors are the sole cause of depression, medications will
improve your mood.”
3.
“Environmental factors have been shown to exert the most influence in the
development of depression.”
4.
“Researchers have been unable to demonstrate a link between nature (biology and
genetics) and nurture (environment).”
1.
2.
3.
4.
“Medications only address biological factors. Environmental and interpersonal
factors must also be considered.”
“Because biological factors are the sole cause of depression, medications will
improve your mood.”
“Environmental factors have been shown to exert the most influence in the
development of depression.”
“Researchers have been unable to demonstrate a link between nature (biology and
genetics) and nurture (environment).”
____ 2.
A client diagnosed with major depressive disorder asks, “What part of my brain
controls my emotions?” Which nursing response is appropriate?
1.
“The occipital lobe governs perceptions, judging them as positive or negative.”
2.
“The parietal lobe has been linked to depression.”
3.
“The medulla regulates key biological and psychological activities.”
4.
“The limbic system is largely responsible for one’s emotional state.”
____ 3.
Which part of the nervous system should a nurse identify as playing a major role
during stressful situations?
1.
Peripheral nervous system
2.
Somatic nervous system
3.
Sympathetic nervous system
4.
Parasympathetic nervous system
____ 4.
Which client statement reflects an understanding of circadian rhythms in
psychopathology?
1.
“When I dream about my mother’s horrible train accident, I become hysterical.”
2.
“I get really irritable during my menstrual cycle.”
3.
“I’m a morning person. I get my best work done before noon.”
4.
“Every February, I tend to experience periods of sadness.”
____ 5.
Which types of adoption studies should a nurse recognize as providing useful
information for the psychiatric community?
1.
Studies in which children with mentally ill biological parents are raised by adoptive
parents who were mentally healthy
2.
Studies in which children with mentally healthy biological parents are raised by
adoptive parents who were mentally ill
3.
Studies in which monozygotic twins from mentally ill parents were raised
separately by different adoptive parents
4.
Studies in which monozygotic twins were raised together by mentally ill biological
parents
5.
All of the above
____ 6.
Six months after her husband and children were killed in a car accident, a client is
diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which
study perspective?
1.
Neuroendocrinology
2.
Psychoneuroimmunology
3.
Diagnostic technology
4.
Neurophysiology
____ 7.
A withdrawn client, diagnosed with schizophrenia, expresses little emotion and
refuses to attend group therapy. What altered component of the nervous system should a nurse
recognize as being responsible for this behavior?
1.
Dendrites
2.
Axons
3.
Neurotransmitters
4.
Synapses
____ 8.
An instructor is teaching nursing students about neurotransmitters. Which best
explains the process of how neurotransmitters released into the synaptic cleft may return to the
presynaptic neuron?
1.
Regeneration
2.
Reuptake
3.
Recycling
4.
Retransmission
____ 9.
A nurse concludes that a restless, agitated client is manifesting a fight-or-flight
response. The nurse should associate this response with which neurotransmitter?
1.
Acetylcholine
2.
Dopamine
3.
Serotonin
4.
Norepinephrine
____ 10.
A client is admitted to a psychiatric unit with the diagnosis of catatonic
schizophrenia. Which of the client’s neurotransmitters should a nurse expect to be elevated?
1.
Serotonin
2.
Dopamine
3.
Gamma-aminobutyric acid (GABA)
4.
Histamine
____ 11.
A client’s wife of 34 years dies unexpectedly. The client cries often and becomes
socially isolated. The client’s therapist encourages open discussion of feelings, proper nutrition,
and exercise. What is the best rationale for the therapist’s recommendations?
1.
The therapist is using an interpersonal approach.
2.
The client has an alteration in neurotransmitters.
3.
It is routine practice to remind clients about nutrition, exercise, and rest.
4.
The client is susceptible to illness because of effects of stress on the immune
system.
____ 12.
Which mental illness should a nurse identify as being associated with an increase
in prolactin hormone level?
1.
Major depressive episode
2.
Schizophrenia
3.
Anorexia nervosa
4.
Alzheimer’s disease
____ 13.
Which cerebral structure should a nursing instructor describe to students as the
“emotional brain”?
1.
The cerebellum
2.
The limbic system
3.
The cortex
4.
The left temporal lobe
____ 14.
A nurse understands that the abnormal secretion of growth hormone may play a
role in which illness?
1.
Acute mania
2.
Schizophrenia
3.
Anorexia nervosa
4.
Alzheimer’s disease
____ 15.
A client is admitted to an emergency department experiencing memory deficits
and decreased motor function. What alteration in brain chemistry should a nurse correlate with
the production of these symptoms?
1.
Abnormal levels of serotonin
2.
Decreased levels of dopamine
3.
Increased levels of norepinephrine
4.
Decreased levels of acetylcholine
____ 16.
A nurse should recognize that a decrease in norepinephrine levels would play a
significant role in which mental illness?
1.
Bipolar disorder: mania
2.
Schizophrenia spectrum disorder
3.
Generalized anxiety disorder
4.
Major depressive episode
____ 17.
A nurse should expect that an increase in dopamine activity might play a
significant role in the development of which mental illness?
1.
Schizophrenia spectrum disorder
2.
Major depressive disorder
3.
Body dysmorphic disorder
4.
Parkinson’s disease
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 18.
Which of the following information should a nurse include when explaining
causes of anorexia nervosa to a client? (Select all that apply.)
1.
There is a possible correlation between abnormal secretion of growth hormone and
anorexia nervosa.
2.
There is a possible correlation between antidiuretic hormone levels and anorexia
nervosa.
3.
There is a possible correlation between low levels of gonadotropin and anorexia
nervosa.
4.
There is a possible correlation between increased levels of prolactin and anorexia
nervosa.
5.
There is a possible correlation between altered levels of oxytocin and anorexia
nervosa.
____ 19.
Which of the following symptoms should a nurse associate with the development
of decreased levels of thyroid-stimulating hormone (TSH) in a newly admitted client? (Select all
that apply.)
1.
Depression
2.
Fatigue
3.
Increased libido
4.
Mania
5.
Hyperexcitability
Completion
Complete each statement.
20.
____________________________ is the study of the biological foundations of
cognitive, emotional, and behavioral processes.
Chapter 0: Biological Implications
Answer Section
MULTIPLE CHOICE
1.
ANS: 1
Chapter: Chapter 0, Biological Implications
Objective: Recognize various theorized influences in the development of psychiatric disorders
including brain physiology, genetics, endocrine function, immune system, and psychosocial, and
environmental factors.
Page: 15–19
Headings: The Parietal Lobes, The Occipital Lobes, Limbic System, Medulla
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Mood
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The nurse should advise the client that medications address biological factors, but
there are other factors that affect mood. The nurse should educate the client on
environmental and interpersonal factors that can lead to depression.
The statement is false because biological factors are not the sole cause of
depression.
It is false that environmental factors have been shown to exert the most influence
in the development of depression.
Researchers have demonstrated a link between nature and nurture.
CON: Mood
2.
ANS: 4
Chapter: Chapter 0, Biological Implications
Objective: Identify gross anatomical structures of the brain and describe their functions.
Page: 16
Headings: The Nervous System: An Anatomical Review > The Brain
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The occipital lobes are the area of visual reception and interpretation.
Somatosensory input (touch, taste, temperature, etc.) occurs in the parietal lobes.
The medulla contains vital centers that regulate heart rate and reflexes.
The nurse should explain to the client that the limbic system is largely responsible
for one’s emotional state. This system is often called the “emotional brain” and is
associated with feelings, sexuality, and social behavior.
CON: Mood
3.
ANS: 3
Chapter: Chapter 0, Biological Implications
Objective: Discuss the physiology of neurotransmission in the central nervous system.
Page: 21
Heading: Autonomic Nervous System
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The peripheral nervous system does not play a major role during stressful
situations.
The somatic nervous system is part of the peripheral nervous system.
The nurse should identify that the sympathetic nervous system plays a major role
during stressful situations. The sympathetic nervous system prepares the body for
the fight-or-flight response.
The parasympathetic nervous system is dominant when an individual is in a
nonstressful state.
CON: Mood
4.
ANS: 3
Chapter: Chapter 0, Biological Implications
Objective: Discuss the physiology of neurotransmission in the central nervous system.
Page: 29–30
Heading: Circadian Rhythms
Integrated Processes: Teaching and Learning
Client Need: Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Sleep and Rest
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement does not indicate understanding of circadian rhythms.
The menstrual cycle is not affected by the circadian rhythm.
By stating, “I am a morning person,” the client demonstrates an understanding that
circadian rhythms may influence a variety of regulatory functions, including the
sleep-wake cycle, regulation of body temperature, and patterns of activity. Most
humans follow a 24-hour cycle that is largely affected by lightness and darkness.
Experiencing periods of sadness is not indicative of the circadian rhythm.
CON: Sleep and Rest
5.
ANS: 5
Chapter: Chapter 0, Biological Implications
Objective: Discuss the implications of psychobiological concepts to the practice of psychiatric/
mental health nursing.
Page: 31
Heading: Genetics > Adoptions Studies
Client Need: Physiological Integrity: Physiological Adaptation
Concept: Evidence-based Practice
Cognitive Level: Analysis [Analyzing]
Integrated Processes: Teaching and Learning
Difficulty: Moderate
1
2
3
4
5
Feedback
This type of adoption study can provide information on children with mentally ill
biological parents who are raised by adoptive parents who are mentally healthy
parents.
This type of adoption study can provide information on children with mentally
healthy biological parents who are raised by adoptive parents who are mentally ill.
This type of adoption study provides important information on monozygotic twins
from mentally ill parents who were raised separately by different adoptive parents.
This type of adoption study provides important information on monozygotic twins
who were raised together by mentally ill biological parents.
The nurse should determine that all of the studies could possibly benefit the
psychiatric community. The studies may reveal research findings relating genetic
links to mental illness. Adoption studies allow comparisons to be made of the
influences of the environment versus genetics.
3
4
5
PTS: 1
healthy biological parents who are raised by adoptive parents who are mentally ill.
This type of adoption study provides important information on monozygotic twins
from mentally ill parents who were raised separately by different adoptive parents.
This type of adoption study provides important information on monozygotic twins
who were raised together by mentally ill biological parents.
The nurse should determine that all of the studies could possibly benefit the
psychiatric community. The studies may reveal research findings relating genetic
links to mental illness. Adoption studies allow comparisons to be made of the
influences of the environment versus genetics.
CON: Evidence-based Practice
6.
ANS: 2
Chapter: Chapter 0, Biological Implications
Objective: Discuss the influence of psychological factors on the immune system.
Page: 31
Heading: Psychoneuroimmunology > Implications of the Immune System in Psychiatric Illness
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Neuroendocrinology is the study of the interaction between the nervous system
and the endocrine system.
Psychoneuroimmunology is the branch of medicine that studies the effects of
social and psychological factors on the functioning of the immune system. Studies
of the biological response to stress hypothesize that individuals become more
susceptible to physical illness following exposure to stressful stimuli.
Diagnostic testing assists in diagnosing.
Neurophysiology is the physiology of the nervous system.
CON: Stress
7.
ANS: 3
Chapter: Chapter 0, Biological Implications
Objective: Describe the role of neurotransmitters in the central nervous system.
Page: 21
Heading: The Nervous System: An Anatomical Review > Neurotransmitters
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Moderate
1
2
3
Feedback
Dendrites are processes that transmit impulses toward the cell body.
Axons transmit impulses away from the cell body. A junction between two neurons
is a synapse.
The nurse should recognize that neurotransmitters play an essential function in the
role of human emotion and behavior. Neurotransmitters are targeted and affected
1
2
3
4
PTS: 1
Feedback
Dendrites are processes that transmit impulses toward the cell body.
Axons transmit impulses away from the cell body. A junction between two neurons
is a synapse.
The nurse should recognize that neurotransmitters play an essential function in the
role of human emotion and behavior. Neurotransmitters are targeted and affected
by many psychotropic medications.
A junction between two neurons is a synapse.
CON: Mood
8.
ANS: 2
Chapter: Chapter 0, Biological Implications
Objective: Describe the role of neurotransmitters in the central nervous system.
Page: 21
Heading: The Nervous System: An Anatomical Review > Neurotransmitters
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Regeneration is incorrect wording to describe this process.
The nursing instructor should explain that the process by which neurotransmitters
are released into the synaptic cleft and returned to the presynaptic neuron is termed
reuptake. Reuptake is the process by which neurotransmitters are stored for reuse.
Recycling is incorrect wording to describe this process.
Retransmission is incorrect wording to describe this process.
CON: Mood
9.
ANS: 4
Chapter: Chapter 0, Biological Implications
Objective: Describe the role of neurotransmitters in the central nervous system.
Page: 21
Heading: Monoamines > Norepinephrine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Acetylcholine functions include pain, arousal, and pain perception.
Dopamine functions include regulation of movement and coordination.
Serotonin plays a role in sleep, libido, and appetite.
The nurse should associate the neurotransmitter norepinephrine with the fight-orflight response. Norepinephrine produces activity in the sympathetic postsynaptic
nerve terminal and is associated with the regulation of mood, cognition,
perception, locomotion, and sleep and arousal.
CON: Mood
10.
ANS: 2
Chapter: Chapter 0: Biological Implications
Objective: Describe the role of neurotransmitters in the central nervous system.
Page: 21
Heading: Monoamines > Norepinephrine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Serotonin plays a role in sleep, libido, and appetite.
The nurse should expect that elevated dopamine levels might be an attributing
factor to the client’s current level of functioning. Dopamine functions include
regulation of movements and coordination, emotions, and voluntary decisionmaking ability.
GABA prevents postsynaptic excitation.
Histamine mediates allergic and inflammatory reactions.
CON: Mood
11.
ANS: 4
Chapter: Chapter 0: Biological Implications
Objective: Discuss the influence of psychological factors on the immune system.
Page: 31
Heading: Psychoneuroimmunology > Implications of the Immune System in Psychiatric Illness
Integrated Processes: Planning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This approach is not proven by evidence-based research.
This rationale is not proven by evidence-based research.
Reminding clients about nutrition, exercise and rest is routine but is not proven by
evidence-based research.
The therapist’s recommendations should be based on the knowledge that the client
has been exposed to stressful stimuli and is at an increased risk to develop illness
because of the effects of stress on the immune system. The study of this branch of
medicine is called psychoneuroimmunology.
CON: Stress
12.
ANS: 2
Chapter: Chapter 0, Biological Implications
Objective: Recognize various theorized influences in the development of psychiatric disorders
including brain physiology, genetics, endocrine function, immune system, and psychosocial, and
environmental factors.
Page: 29
Heading: Psychoneuroimmunology > Prolactin
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
There is no known correlation between increased levels of prolactin and major
depressive disorder.
Although the exact mechanism is unknown, there may be some correlation
between increased levels of the hormone prolactin and schizophrenia.
There is no known correlation between increased levels of prolactin and anorexia
nervosa.
There is no known correlation between increased levels of prolactin and
Alzheimer’s disease.
CON: Stress
13.
ANS: 2
Chapter: Chapter 0, Biological Implications
Objective: Identify gross anatomical structures of the brain and describe their functions.
Page: 19
Heading: The Nervous System: An Anatomical Review > Limbic System
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The cerebellum is concerned with involuntary movement, posture, and
equilibrium.
The limbic system is often referred to as the “emotional brain.” The limbic system
is largely responsible for one’s emotional state and is associated with feelings,
sexuality, and social behavior.
The cortex is identified by numerous folds called gyri and sulci.
The left temporal lobe is concerned with auditory functions.
CON: Mood
14.
ANS: 3
Chapter: Chapter 0, Biological Implications
Objective: Discuss the association of endocrine functioning to the development of psychiatric
disorders.
Page: 31
Heading: Psychoneuroimmunology > Growth Hormone
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Moderate
1
2
3
4
Feedback
There is no correlation between abnormal levels of growth hormone and acute
mania.
There is no correlation between abnormal levels of growth hormone and
schizophrenia.
The nurse should understand that research has found a correlation between
abnormal levels of growth hormone and anorexia nervosa. The growth hormone is
responsible for growth in children, as well as continued protein synthesis
throughout life.
There is no correlation between abnormal levels of growth hormone and
Alzheimer’s Disease.
PTS: 1
CON: Mood
15.
ANS: 4
Chapter: Chapter 0, Biological Implications
Objective: Describe the role of neurotransmitters in human behavior.
Page: 31
Heading: Psychoneuroimmunology > Acetylcholine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Abnormal levels of serotonin do not cause memory deficits and decreased motor
functions.
Abnormal levels of dopamine do not cause memory deficits and decreased motor
functions.
Abnormal levels of norepinephrine do not cause memory deficits and decreased
motor functions.
The nurse should correlate memory deficits and decreased motor function with
decreased levels of acetylcholine. Acetylcholine is a major chemical effector of the
autonomic nervous system. Functions of acetylcholine include sleep regulation,
pain perception, the modulation and coordination of movement, and memory.
CON: Mood
16.
ANS: 4
Chapter: Chapter 0, Biological Implications
Objective: Discuss the physiology of neurotransmitters in human behavior.
Page: 21
Heading: Monoamines > Norepinephrine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
Feedback
A decrease in norepinephrine would not lead to mania.
A decrease in norepinephrine would not lead to schizophrenia.
A decrease in norepinephrine would not lead to generalized anxiety disorder.
The nurse should recognize that a decrease in norepinephrine level would play a
significant role in the development of major depressive disorder. The functions of
norepinephrine include the regulation of mood, cognition, perception, locomotion,
cardiovascular functioning, and sleep and arousal.
1
2
3
4
PTS: 1
Feedback
A decrease in norepinephrine would not lead to mania.
A decrease in norepinephrine would not lead to schizophrenia.
A decrease in norepinephrine would not lead to generalized anxiety disorder.
The nurse should recognize that a decrease in norepinephrine level would play a
significant role in the development of major depressive disorder. The functions of
norepinephrine include the regulation of mood, cognition, perception, locomotion,
cardiovascular functioning, and sleep and arousal.
CON: Mood
17.
ANS: 1
Chapter: Chapter 0, Biological Implications
Objective: Discuss the physiology of neurotransmitters in human behavior.
Page: 21, 24
Heading: Psychoneuroimmunology > Dopamine
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should expect that an increase in dopamine activity might play a
significant role in the development of schizophrenia spectrum disorder. Functions
of dopamine include regulation of emotions, coordination, and voluntary decisionmaking ability. Increased dopamine activity is also associated with mania.
Increased dopamine activity is not associated with major depressive disorder.
Increased dopamine activity is not associated with body dysmorphic disorder.
Increased dopamine activity is not associated with Parkinson’s disease.
CON: Mood
MULTIPLE RESPONSE
18.
ANS: 1, 3
Chapter: Chapter 0, Biological Implications
Objective: Discuss the association of endocrine functioning to the development of psychiatric
disorders.
Page: 29
Headings: Growth Hormone > Gonadotropic Hormones
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The nurse should explain to the client that there is a possible correlation between
anorexia nervosa and decreased levels of growth hormones.
There is no correlation between anorexia nervosa and antidiuretic hormone levels.
Research shows that there is possible correlation between low levels of
gonadotropin and anorexia nervosa.
There is no correlation between anorexia nervosa and increased prolactin levels.
There is no correlation between anorexia nervosa and altered levels of oxytocin.
PTS: 1
CON: Mood
19.
ANS: 1, 2
Chapter: Chapter 0, Biological Implications
Objective: Discuss the association of endocrine functioning to the development of psychiatric
disorders.
Page: 28
Heading: Neuroendocrinology > The Anterior Pituitary (Adenohypophysis)
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The nurse should associate depression with decreased levels of TSH.
The nurse should associate fatigue with decreased levels of TSH.
Decreased libido is associated with decreased levels of TSH.
Mania is not associated with decreased levels of TSH.
Hyperexcitability is not associated with decreased levels of TSH.
PTS: 1
CON: Mood
COMPLETION
20.
ANS:
Psychobiology
Chapter: Chapter 0 Biological Implications
Objective: Discuss the implications of psychobiological concepts to the practice of psychiatric/
mental health nursing.
Page: 15
Heading: Introduction
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
Feedback: Psychobiology is the study of the biological foundations of cognitive, emotional, and
behavioral processes. In recent years, a greater emphasis has been placed on the study of the
organic basis for psychiatric illness.
PTS: 1
CON: Mood
Chapter 4. Psychopharmacology
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
When used in combination with anxiolytic medication, alcohol leads to
_____________ effects, and caffeine leads to _______________ effects.
1.
increased; increased
2.
increased; decreased
3.
decreased; decreased
4.
decreased; increased
____ 2.
A client was recently admitted to the inpatient unit after a suicide attempt. He has
been placed on a tricyclic antidepressant. In terms of medication, what steps should be taken to
maintain the client’s safety when he is discharged?
1.
Provide a 6-month supply to ensure long-term compliance.
2.
Provide a 1-week supply of medication, with refills authorized only after he visits
his provider.
3.
Encourage him to increase fluid intake to counteract the common side effect of
diarrhea.
4.
Educate him not to eat foods that contain tyramine.
____ 3.
A client was recently admitted to the inpatient unit after a suicide attempt and is
prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse teaches the client about
serotonin syndrome. Which of the following is a symptom of serotonin syndrome?
1.
Change in mental status
2.
Myoclonus
3.
Blood pressure lability
4.
Priapism
____ 4.
A client was recently admitted to the inpatient unit after a suicide attempt and has
not responded to SSRIs or tricyclic antidepressants. The client asks the nurse, “I heard about
monoamine oxidase inhibitors (MAOIs). Why can’t they be added to what I am on now?
Wouldn’t adding one help?” Which is the appropriate nursing response?
1.
“Electroconvulsive therapy is your best option at this point.”
2.
“Combined use can lead to a life-threatening condition called hypertensive crisis.”
3.
“There is no reason why an MAOI couldn’t be added to your therapy.”
4.
“They can’t be used together because their mechanisms of action are very
different.”
____ 5.
A client began taking lithium for the treatment of bipolar disorder approximately
1 month ago and asks why he has gained 12 lbs. since then. Which is the appropriate nursing
response?
1.
“I’m surprised you have gained; weight loss is the typical pattern when taking
lithium.”
2.
“Your weight gain is more likely related to food intake than medication.”
3.
“Weight gain is a common, but troubling side effect. Let’s talk about some
strategies for safely improving your nutrition and exercise habits.”
4.
“There’s not much you can do about the weight gain. It’s better than being
emotionally unstable, though.”
____ 6.
The nurse is assessing a client who has a diagnosis of schizophrenia and takes an
antipsychotic agent daily. Which finding requires further nursing assessment?
1.
Respirations of 22 beats/minute
2.
Weight gain of 8 lbs. in 2 months
3.
Temperature of 101oF
4.
Excess salivation
____ 7.
An aging client with chronic schizophrenia takes a beta-adrenergic blocking agent
(propranolol) for hypertension and an antipsychotic. Given the combined side effects of these
drugs, what teaching should the nurse provide?
1.
“Make sure you concentrate on taking slow, deep, cleansing breaths.”
2.
“Watch your diet and try to engage in some regular physical activity.”
3.
“Rise slowly when you change position from lying to sitting or sitting to standing.”
4.
“Wear sunscreen and try to avoid midday sun exposure.”
____
8.
A client with depression and substance abuse has an interrupted sleep pattern. She
demands that her psychiatrist prescribe her a sedative. What teaching would the nurse provide
about the rationale for the use of nonpharmacological interventions instead?
1.
“Sedative-hypnotics are potentially addictive and gradually lose their effectiveness
as one builds up tolerance to them.”
2.
“Sedative-hypnotics work best in combination with other techniques.”
3.
“Sedative-hypnotics are not permitted for use in patients with substance abuse
disorders.”
4.
“Sedative-hypnotics are not as effective as the antidepressant medications for
treating sleep disturbances.”
____ 9.
Which statement about the tricyclic group of antidepressant medications is
accurate?
1.
Strong or aged cheese should not be eaten while taking them.
2.
Their full therapeutic potential may not be reached until 4 weeks.
3.
They may cause hypomania or recent memory impairment.
4.
They should not be given with antianxiety agents.
____ 10.
A client was admitted with major depression that was a single episode and
moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg orally every day. The
nurse’s discharge teaching should include all of the following except:
1.
Continue taking Prozac as prescribed. You will continue to see improvement over
the next few weeks.
2.
Make sure that you follow up with outpatient psychotherapy as you and the social
worker have arranged.
3.
You may be able to discontinue the medication within 6 months to 1 year, but only
under a doctor’s supervision. However, there is a chance of recurring episodes.
4.
You should avoid foods with tyramine, including beer, beans, processed meats, and
red wine.
____ 11.
In the treatment of anxiety disorders, benzodiazepines (such as Ativan and Xanax)
are indicated for_________ use and have__________ abuse potential.
1.
short-term; high
2.
long-term; high
3.
short-term; low
4.
long-term; low
____
1.
2.
3.
4.
12.
Which medication does not require periodic blood-level monitoring?
Eskalith (lithium carbonate)
Depakote (valproic acid)
Clozaril (clozapine)
Paxil (paroxetine)
1.
2.
3.
4.
Eskalith (lithium carbonate)
Depakote (valproic acid)
Clozaril (clozapine)
Paxil (paroxetine)
____ 13.
As part of discharge teaching, which guideline regarding lithium therapy will the
nurse plan to include?
1.
Avoid excessive use of beverages containing caffeine.
2.
Maintain a consistent sodium intake.
3.
Consume at least 2,500 to 3,000 mL of fluid per day.
4.
All of the above
____ 14.
A client with schizophrenia has recently begun a new medication, clozapine
(Clozaril). Which potentially fatal side effect will the nurse teach the client about?
1.
Agranulocytosis
2.
Akathisia
3.
Dystonia
4.
Akinesia
____ 15.
A client with schizophrenia has recently begun a new medication, clozapine
(Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the
client about?
1.
Blurring vision and muscular weakness
2.
Sore throat, fever, and malaise
3.
Tremor, shuffling gait, and rigidity
4.
Fine tremor, tinnitus, and nausea
____ 16.
A client with schizophrenia has recently begun a new medication, clozapine
(Clozaril). Which blood cell counts would reveal a potentially fatal side effect of this
medication?
1.
WBCs, >3,000/mm3; granulocytes, >2,000/mm3
2.
3.
4.
WBCs, <3,000/mm3; granulocytes, >2,000/mm3
WBCs, >3,000/mm3; granulocytes, <2,000/mm3
WBCs, <3,000/mm3; granulocytes, <2,000/mm3
____ 17.
A psychiatrist prescribes a MAOI for a client. When teaching the client about the
effects of tyramine, which foods will the nurse caution the client to avoid?
1.
Pepperoni pizza and red wine
2.
Bagels with cream cheese and tea
3.
Apple pie and coffee
4.
Potato chips and Diet Coke
1.
2.
3.
4.
Pepperoni pizza and red wine
Bagels with cream cheese and tea
Apple pie and coffee
Potato chips and Diet Coke
____ 18.
A client has been diagnosed with major depression and is prescribed imipramine
(Tofranil). What information specifically related to this class of antidepressants will the nurse
plan to include in client and family education?
1.
The medication may cause dry mouth.
2.
The medication may cause nausea.
3.
The medication should not be discontinued abruptly.
4.
The medication may cause photosensitivity.
____ 19.
Which information suggests that caution is necessary in prescribing a
benzodiazepine to an anxious client?
1.
The client has a history of alcohol dependence.
2.
The client has a history of diabetes mellitus.
3.
The client has a history of schizophrenia.
4.
The client has a history of hypertension.
____ 20.
Which medication is most likely to be prescribed for the extrapyramidal side
effects of antipsychotic medications?
1.
Diazepam (Valium)
2.
Amitriptyline (Elavil)
3.
Benztropine (Cogentin)
4.
Methylphenidate (Ritalin)
____ 21.
A client takes a maintenance dosage of lithium carbonate for a bipolar disorder.
She has come to the community health clinic, stating that she “has had the flu for over a week.”
She describes her symptoms as coughing, runny nose, chest congestion, fever, and
gastrointestinal upset. Her temperature is 100.9°F. What situation does the nurse anticipate?
1.
She has consumed some foods high in tyramine.
2.
She has stopped taking her lithium carbonate.
3.
She has probably developed a tolerance to the lithium carbonate.
4.
The lithium carbonate may be producing symptoms of toxicity.
____ 22.
Joey, age 8 years, takes methylphenidate (Ritalin) for attention deficit/
hyperactivity disorder. His mother complains to the nurse that Joey has a very poor appetite, and
she struggles to help him gain weight. What teaching will the nurse provide?
1.
Administer Joey’s medication immediately after meals.
2.
Administer Joey’s medication at bedtime.
3.
Skip a dose of the medication when Joey does not eat anything.
4.
Assure Joey’s mother that Joey will eat when he is hungry.
1.
2.
3.
4.
Administer Joey’s medication immediately after meals.
Administer Joey’s medication at bedtime.
Skip a dose of the medication when Joey does not eat anything.
Assure Joey’s mother that Joey will eat when he is hungry.
____ 23.
A client is experiencing a psychotic episode. He is in good physical health but has
allergies to penicillin, prochlorperazine (Compazine), and bee stings. Which antipsychotic
medication would be contraindicated for the client?
1.
Haloperidol, because it is used only in elderly patients
2.
Clozapine, because it is incompatible with desipramine
3.
Risperidone, because it exacerbates symptoms of depression
4.
Thioridazine, because of cross-sensitivity among phenothiazines
____ 24.
A physician prescribes an additional medication for a client taking an
antipsychotic agent. The medication is to be administered “prn for EPS.” When will the nurse
plan to give this medication?
1.
When the client’s white blood cell count falls below 3,000/mm3
2.
3.
4.
When the client exhibits tremors and a shuffling gait
When the client complains of dry mouth
When the client experiences a seizure
____ 25.
A client is diagnosed with anxiety disorder. Which medication is prescribed for
anxiety?
1.
Chlorpromazine (Thorazine)
2.
Clozapine (Clozaril)
3.
Diazepam (Valium)
4.
Methylphenidate (Ritalin)
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26.
The nurse is preparing to assess a client before the physician prescribes a regimen
of psychopharmacological therapy. Which components will the nurse assess? (Select all that
apply.)
1.
Medical history
2.
Physical examination findings
3.
Ethnocultural characteristics
4.
Current medication
Chapter 0: Psychopharmacology
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antianxiety agents.
Page: 67
Heading: Interactions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Alcohol leads to increased effects and caffeine leads to decreased effects.
Anxiolytic medications work through depression of certain central nervous system
(CNS) functions. Alcohol, which is a CNS depressant, would increase/potentiate
their effects. Caffeine, which is a CNS stimulant, would decrease/inhibit their
effects.
Alcohol leads to increased effects and caffeine leads to decreased effects
Alcohol leads to increased effects and caffeine leads to decreased effects.
CON: Addiction and Behaviors
2.
ANS: 2
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 69
Heading: Clinical Pearl
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Easy
1
2
3
4
Feedback
A limited supply should be given to reduce the risk for suicide.
To prevent suicide through overdose on antidepressant medication, a limited
supply should be given at discharge. Clients with a history of depression who have
a lifting of mood may have an increased risk for suicide. Giving the client a larger
supply of antidepressant medication increases the chances of overdose.
Although increasing fluid intake is generally a way to promote health, it will not
decrease the client’s risk for suicide.
Avoiding foods with tyramine will not decrease the chances of suicide.
1
2
3
4
PTS: 1
Feedback
A limited supply should be given to reduce the risk for suicide.
To prevent suicide through overdose on antidepressant medication, a limited
supply should be given at discharge. Clients with a history of depression who have
a lifting of mood may have an increased risk for suicide. Giving the client a larger
supply of antidepressant medication increases the chances of overdose.
Although increasing fluid intake is generally a way to promote health, it will not
decrease the client’s risk for suicide.
Avoiding foods with tyramine will not decrease the chances of suicide.
CON: Stress
3.
ANS: 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 69
Heading: Clinical Pearl
Integrated Processes: Nursing Process: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Violence
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Change in mental status is not a symptom of serotonin syndrome.
Myoclonus is not a symptom of serotonin syndrome.
Blood pressure lability is not a symptom of serotonin syndrome.
Impotence may be a side effect of an SSRI antidepressant.
CON: Violence
4.
ANS: 2
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 70
Heading: Table 4-4 Drug Interactions with SSRIs
Integrated Processes: Nursing Processes: Teaching/Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Violence
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This statement does not provide accurate information to the client.
If MAOIs are taken with other antidepressants, a hypertensive crisis could result.
The statement is false; use of an MAOI with an SSRI could cause harm to the
client.
This statement is not therapeutic or accurate.
CON: Violence
5.
ANS: 3
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: mood-stabilizing agents.
Page: 74
Heading: Lithium Maintenance
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Weight gain is typical with lithium treatment.
While a healthy diet is helpful at reducing weight gain, this side effect is common
with lithium treatment.
Weight gain is a common side effect of lithium therapy. To ensure compliance the
nurse should help the client develop strategies to prevent excessive weight gain.
This statement is not therapeutic to the client.
CON: Mood
6.
ANS: 3
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 80–81
Heading: Table 4-12 Safety Issues in Planning and Implementing Care for Clients Taking,
Antipsychotic Medication
Integrated Processes: Nursing Processes: Caring
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This finding is considered normal.
Slow weight gain is not concerning.
A fever could be one of the first signs of an infection caused by reduced immunity
from agranulocytosis secondary to antipsychotic medication.
This symptom is not life-threatening.
CON: Mood
7.
ANS: 3
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 80–81
Heading: Table 4-12 Safety Issues in Planning and Implementing Care for Clients Taking,
Antipsychotic Medication
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This will not prevent the client from having a syncopal episode.
While watching diet is important, it will not prevent the client from suffering from
propranolol side effects.
The antipsychotic medication can cause orthostatic hypotension that could be
magnified by the propranolol.
Wearing sunscreen will not prevent syncopal episodes.
CON: Health Promotion
8.
ANS: 1
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: sedative-hypnotics.
Page: 85
Heading: Contraindications/Precautions
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Sedative-hypnotics are potentially addictive and should be used with caution by
clients with a history of substance abuse. Tolerance can easily develop.
This statement is not accurate regarding sedative-hypnotics.
Sedative-hypnotics can become habit forming.
This statement is misleading to the client.
CON: Health Promotion
9.
ANS: 2
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 67
Heading: Applying the Nursing Process in Psychopharmacological Therapy > Antianxiety
Agents
Integrated Processes: Nursing Processes: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This statement is misleading to the client.
It may take several weeks for tricyclic medications to reach their full therapeutic
effect.
These medications do not cause hypomania or recent memory impairment.
These medications can be administered with antianxiety agents.
CON: Health Promotion
10.
ANS: 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 71
Heading: Table 4-7. Diet Restrictions for Clients on MAOI Therapy.
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The client should see improvement over the next few weeks.
The client should follow up as scheduled.
The client should only discontinue the medication under a doctor’s supervision.
This is true regarding MAOIs, not an SSRI antidepressant, such as fluoxetine.
CON: Health Promotion
11.
ANS: 1
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 71
Heading: Table 4-7.
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Because tolerance to these medications occurs, there is high risk for abuse.
Therefore, they should be used as a short-term intervention for anxiety.
Benzodiazepines should not be used for long-term treatment of anxiety.
Benzodiazepines have high abuse potential.
Benzodiazepines should not be used for long-term treatment of anxiety, as they
have high abuse potential.
CON: Health Promotion
12.
ANS: 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 77
Heading: Lithium Maintenance, Clozaril and the risk for agranulocytosis, Table 4-10 Safety
Issues and Nursing Interventions for Clients Taking Mood Stabilizers.
Integrated Processes: Nursing Processes: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Blood level monitoring is required for Eskalith (lithium carbonate)
Blood level monitoring is required for Depakote (valproic acid)
Blood level monitoring is required for Clozaril (clozapine).
Blood level monitoring is usually not done for Paxil (paroxetine).
CON: Health Promotion
13.
ANS: 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: mood stabilizers.
Page: 77
Headings: Interactions, Table 4-10 Safety Issues and Nursing Interventions for Clients Taking
Mood Stabilizers.
Integrated Processes: Nursing Processes: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The client should avoid excessive use of beverages containing caffeine.
The client should maintain a consistent sodium intake.
The client should consume at least 2,500 to 3,000 mL of fluid per day.
Caffeine, a stimulant, should be limited in clients with mania. Adequate sodium
and fluid intake is necessary to prevent lithium toxicity.
CON: Health Promotion
14.
ANS: 1
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 81
Heading: Clozaril and risk for agranulocytosis
Integrated Processes: Nursing Processes: Teaching/Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Agranulocytosis is a potentially fatal disorder in which the client’s white blood
cell count drops to extremely low levels, placing the client at great risk for
infections.
The client is not at risk for akathisia.
The client is not at risk for dystonia.
The client is not at risk for akinesia.
CON: Health Promotion
15.
ANS: 2
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 81
Heading: Table 4-12 Safety Issues in Planning and Implementing Care for Clients Taking
Antipsychotic Medications.
Integrated Processes: Nursing Process: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Blurred vision and muscular weakness are not side effects of clozapine (Clozaril).
These are symptoms of agranulocytosis, which is a potentially fatal disorder in
which the client’s white blood cell count drops to extremely low levels. This
places the client at great risk for infections.
Tremor, shuffling gait, and rigidity are not side effects of clozapine (Clozaril).
Fine tremor, tinnitus, and nausea are not side effects of clozapine (Clozaril).
CON: Health Promotion
16.
ANS: 4
Chapter: Chapter 0 Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 81
Heading: Clozaril and risk for agranulocytosis.
Integrated Processes: Nursing Processes: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
Feedback
1
The following results do not indicate agranulocytosis: WBCs, >3,000/mm3;
granulocytes, >2,000/mm3.
2
The following results do not indicate agranulocytosis: WBCs, <3,000/mm3;
granulocytes, >2,000/mm3.
3
The following results do not indicate agranulocytosis: WBCs, >3,000/mm3;
granulocytes, <2,000/mm3.
4
These blood test results are indicative of agranulocytosis, a potentially fatal
disorder in which the client’s white blood cell count drops to extremely low levels.
PTS: 1
CON: Health Promotion
17.
ANS: 1
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 71
Heading: Table 4-7. Diet Restrictions for Clients on MAOI Therapy.
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Both these foods are high in tyramine.
Bagels with cream cheese and tea are not high in tyramine.
Apple pie and coffee are not high in tyramine.
Potato chips and Diet Coke are not high in tyramine.
CON: Health Promotion
18.
ANS: 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antidepressants.
Page: 71
Heading: Others (Heterocyclics and SNRIs.)
Integrated Processes: Nursing Processes: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This medication does not cause dry mouth.
This medication does not cause nausea.
This medication can be discontinued under a doctor’s supervision.
Tricyclic antidepressants cause photosensitivity.
CON: Health Promotion
19.
ANS: 1
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 81
Heading: Issues in Antipsychotic Maintenance Therapy.
Integrated Processes: Nursing Processes: Caring
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Tolerance and psychological dependence are common problems with the longterm use of benzodiazepines. They should be used cautiously with clients who
have a history of substance abuse.
Clients with a history of diabetes mellitus can still take benzodiazepines.
Clients with a history of schizophrenia can still take benzodiazepines.
Clients with a history of hypertension can still take benzodiazepines.
CON: Addiction and Behaviors
20.
ANS: 3
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: Antipsychotics.
Page: 83
Heading: Applying the Nursing Process in Psychopharmacological Therapy > Antianxiety
Agents
Integrated Processes: Nursing Processes: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Diazepam (Valium) would not be prescribed for the extrapyramidal side effects of
antipsychotic medications.
Amitriptyline (Elavil) would not be prescribed for the extrapyramidal side effects
of antipsychotic medications.
Benztropine (Cogentin) is one of the most commonly used medications for
extrapyramidal side effects.
Methylphenidate (Ritalin) would not be prescribed for the extrapyramidal side
effects of antipsychotic medications.
CON: Health Promotion
21.
ANS: 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 77
Headings: Lithium Maintenance, Clozaril and the risk for agranulocytosis, Table 4-10 Safety
Issues and Nursing Interventions for Clients Taking Antipsychotics
Integrated Processes: Nursing Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
Feedback
The nurse would not anticipate the cause to be foods high in tyramine.
Discontinuation of lithium carbonate is not likely.
The development of tolerance to lithium carbonate is not likely.
Blurred vision, gastrointestinal upset, and tinnitus are symptoms of lithium
toxicity.
1
2
3
4
PTS: 1
Feedback
The nurse would not anticipate the cause to be foods high in tyramine.
Discontinuation of lithium carbonate is not likely.
The development of tolerance to lithium carbonate is not likely.
Blurred vision, gastrointestinal upset, and tinnitus are symptoms of lithium
toxicity.
CON: Health Promotion
22.
ANS: 1
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 89
Heading: Applying the Nursing Process in Psychopharmacological Therapy > Agents for
Attention Deficit/Hyperactivity Disorder (ADHD)
Integrated Processes: Nursing Process: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application[Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
To reduce the anorexia associated with methylphenidate (Ritalin), the medication
should be given after meals.
Administering Joey’s medication at bedtime could keep him awake at night.
Joey will likely have a decrease in appetite. The medication should be given after
breakfast.
Assuring Joey’s mother that he will eat when hungry does not help improve Joey’s
appetite.
CON: Health Promotion
23.
ANS: 4
There may be cross-sensitivity among phenothiazines. Both prochlorperazine (Compazine) and
thioridazine (Mellaril) are phenothiazines. Since the client has a known allergy to one
phenothiazine, he should not be given another phenothiazine. The other options would not be
contraindicated because of cross sensitivities.
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 78
Heading: Applying the Nursing Process in Psychopharmacological Therapy > Antipsychotic
Agents
Integrated Processes: Nursing Process: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Haloperidol would not be contraindicated because of cross sensitivities.
Clozapine would not be contraindicated because of cross sensitivities.
Risperidone would not be contraindicated because of cross sensitivities.
There may be cross-sensitivity among phenothiazines. Both prochlorperazine
(Compazine) and thioridazine (Mellaril) are phenothiazines. Since the client has a
known allergy to one phenothiazine, he should not be given another phenothiazine.
CON: Health Promotion
24.
ANS: 2
Tremors and a shuffling gait are examples of extrapyramidal side effects (EPS). The other
options are not examples of extrapyramidal side effects.
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 81
Heading: Issues in Antipsychotic Maintenance Therapy
Integrated Processes: Nursing Process: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
White blood cell count is not an example of an EPS.
Tremors and a shuffling gait are examples of EPS.
Dry mouth is not an extrapyramidal side effect.
Seizure is not an extrapyramidal side effect.
CON: Health Promotion
25.
ANS: 3
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antianxiety agents.
Page: 85
Heading: Action
Integrated Processes: Nursing Process: Communication and Documentation
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Chlorpromazine (Thorazine) is not an antianxiety agent.
Clozapine (Clozaril) is not an antianxiety agent.
Diazepam (Valium) is an antianxiety agent.
Methylphenidate (Ritalin) is not an antianxiety agent.
CON: Health Promotion
MULTIPLE RESPONSE
26.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Psychopharmacology Core Concepts
Objective: Describe indications, actions, contraindications, precautions, side effects, and nursing
implications for the following classes of drugs: antipsychotics.
Page: 64–67
Heading: Apply the steps of the nursing process to the administration of psychotropic
medications.
Integrated Processes: Nursing Process: Caring
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
1.
2.
3.
4.
PTS: 1
Feedback
The nurse should assess medical history.
The nurse should assess physical examination findings.
The nurse should assess ethnocultural characteristics.
The nurse should assess current medications.
CON: Health Promotion
Chapter 5. Ethical and Legal Issues
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
In response to a student’s question regarding choosing a psychiatric specialty, a
charge nurse states, “Mentally ill clients need special care. If I were in that position, I’d want a
caring nurse also.” From which ethical framework is the charge nurse operating?
1.
Kantianism
2.
Christian ethics
3.
Ethical egoism
4.
Utilitarianism
____ 2.
During a hiring interview, which response by a nursing applicant should indicate
that the applicant operates from an ethical egoism framework?
1.
“I would want to be treated in a caring manner if I were mentally ill.”
2.
“This job will pay the bills, and the workload is light enough for me.”
3.
“I will be happy caring for the mentally ill. Working in med/surg kills my back.”
4.
“It is my duty in life to be a psychiatric nurse. It is the right thing to do.”
____ 3.
Without authorization, a nurse administers an extra dose of narcotic tranquilizer to
an agitated client. The nurse’s coworker observes this action but does nothing for fear of
retaliation. What is the ethical interpretation of the coworker’s lack of involvement?
1.
Taking no action is still considered an unethical action by the coworker.
2.
Taking no action releases the coworker from ethical responsibility.
3.
Taking no action is advised when potential adverse consequences are foreseen.
4.
Taking no action is acceptable, because the coworker is only a bystander.
____ 4.
Group therapy is strongly encouraged, but not mandatory, in an inpatient
psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not
to attend group therapy. Which ethical principle does the unit manager’s policy preserve?
1.
Justice
2.
Autonomy
3.
Veracity
4.
Beneficence
____
1.
2.
3.
4.
5.
Which is an example of an intentional tort?
A nurse fails to assess a client’s obvious symptoms of neuroleptic malignant
syndrome.
A nurse physically places an irritating client in four-point restraints.
A nurse makes a medication error and does not report the incident.
A nurse gives patient information to an unauthorized person.
____ 6.
An involuntarily committed client is verbally abusive to the staff, repeatedly
threatening to sue. The client records the full names and phone numbers of the staff. Which
nursing action is most appropriate to decrease the possibility of a lawsuit?
1.
Verbally redirect the client, and then refuse one-on-one interaction.
2.
Involve the hospital’s security division as soon as possible.
3.
Notify the client that documenting personal staff information is against hospital
policy.
4.
Continue professional attempts to establish a positive working relationship with the
client.
____ 7.
Which statement should a nurse identify as correct regarding a client’s right to
refuse treatment?
1.
Clients can refuse pharmacological but not psychological treatment.
2.
Clients can refuse any treatment at any time.
3.
Clients can refuse only electroconvulsive therapy (ECT).
4.
Professionals can override treatment refusal by an actively suicidal or homicidal
client.
____ 8.
Which potential client should a nurse identify as a candidate for involuntarily
commitment?
1.
The client living under a bridge in a cardboard box
2.
The client threatening to commit suicide
3.
The client who never bathes and wears a wool hat in the summer
4.
The client who eats waste out of a garbage can
____ 9.
A client diagnosed with schizophrenia refuses to take medication, citing the right
of autonomy. Under which circumstance would a nurse have the right to medicate the client
against the client’s wishes?
1.
A client makes inappropriate sexual innuendos to a staff member.
2.
A client constantly demands attention from the nurse by begging, “Help me get
better.”
3.
A client physically attacks another client after being confronted in group therapy.
4.
A client refuses to bathe or perform hygienic activities.
____ 10.
A psychiatric nurse working on an inpatient unit receives a call asking if an
individual has been a client in the facility. Which nursing response reflects appropriate legal and
ethical obligations?
1.
The nurse refuses to give any information to the caller, citing rules of
confidentiality.
2.
The nurse hangs up on the caller.
3.
The nurse confirms that the person has been at the facility but adds no additional
information.
4.
The nurse suggests that the caller speak to the client’s therapist.
1.
2.
3.
4.
The nurse refuses to give any information to the caller, citing rules of
confidentiality.
The nurse hangs up on the caller.
The nurse confirms that the person has been at the facility but adds no additional
information.
The nurse suggests that the caller speak to the client’s therapist.
____ 11.
A client requests information on several medications in order to make an informed
choice about management of depression. A nurse should provide this information to facilitate
which ethical principle?
1.
Autonomy
2.
Beneficence
3.
Nonmaleficence
4.
Justice
____ 12.
An inpatient psychiatric physician refuses to treat clients without insurance and
prematurely discharges those whose insurance benefits have expired. Which ethical principle
should a nurse determine has been violated based on these actions?
1.
Autonomy
2.
Beneficence
3.
Nonmaleficence
4.
Justice
____
1.
2.
3.
4.
13.
Which situation reflects violation of the ethical principle of veracity?
A nurse discusses with a client another client’s impending discharge.
A nurse refuses to give information to a physician who is not responsible for the
client’s care.
A nurse tricks a client into seclusion by asking the client to carry linen to the
seclusion room.
A nurse does not treat all of the clients equally, regardless of illness severity.
____ 14.
A client who will be receiving ECT must provide informed consent. Which
situation should cause a nurse to question the validity of the informed consent?
1.
The client is paranoid.
2.
The client is 87 years old.
3.
The client incorrectly reports his or her spouse’s name, date, and time of day.
4.
The client relies on his or her spouse to interpret the information.
____ 15.
A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin
Decanoate) from a home-health nurse. The client refuses medication at one regularly scheduled
home visit. Which nursing intervention is ethically appropriate?
1.
Allow the client to decline the medication and document the decision.
2.
Tell the client that if the medication is refused, hospitalization will occur.
3.
Arrange with a relative to add the medication to the client’s morning orange juice.
4.
Call for help to hold the client down while the injection is administered.
____
1.
2.
3.
4.
16.
Which situation exemplifies both assault and battery?
The nurse becomes angry, calls the client offensive names, and withholds treatment.
The nurse threatens to “tie down” the client and then does so, against the client’s
wishes.
The nurse hides the client’s clothes and medicates the client to prevent elopement.
The nurse restrains the client without just cause and communicates this to family.
____ 17.
A geriatric client is confused and wandering in and out of every door. Which
scenario reflects the least restrictive alternative for this client?
1.
The client is placed in seclusion.
2.
The client is placed in a geriatric chair with tray.
3.
The client is placed in soft Posey restraints.
4.
The client is monitored by an ankle bracelet.
____ 18.
A brother calls to speak to his sister, who has been admitted to a psychiatric unit.
The nurse connects him to the community phone, and the sister is summoned. Later the nurse
realizes that the brother was not on the client’s approved call list. What law has the nurse
broken?
1.
The National Alliance for the Mentally Ill Act
2.
The Tarasoff Ruling
3.
The Health Insurance Portability and Accountability Act
4.
The Good Samaritan Law
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 19.
After disturbing the peace, an aggressive, disoriented, unkempt, homeless
individual is escorted to an emergency department. The client threatens suicide. Which of the
following criteria would enable a physician to consider involuntary commitment? (Select all that
apply.)
1.
Being dangerous to others
2.
Being homeless
3.
Being disruptive to the community
4.
Being gravely disabled and unable to meet basic needs
5.
Being suicidal
1.
2.
3.
4.
5.
Being dangerous to others
Being homeless
Being disruptive to the community
Being gravely disabled and unable to meet basic needs
Being suicidal
Completion
Complete each statement.
20.
A valid, legally recognized claim or entitlement, encompassing both freedom
from government interference or discriminatory treatment and an entitlement to a benefit or a
service is defined as a _______________________.
21.
A branch of philosophy that addresses methods for determining the rightness or
wrongness of one’s actions is defined as _______________________.
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss ethical theories including utilitarianism, Kantianism, Christian ethics, natural
law, theories, and ethical egoism.
Page: 42
Heading: Ethical Considerations > Theoretical Perspectives
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Self
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Kantianism states that decisions should be made based on moral law and that
actions are bound by a sense of moral duty.
The charge nurse is operating from a Christian ethics framework. The imperative
demand of Christian ethics is that all decisions about right and wrong should be
centered in love for God and in treating others with the same respect and dignity
with which we would expect to be treated.
Ethical egoism promotes the idea that what is right is good for the individual.
Utilitarianism holds that decisions should be made focusing on the end result
being happiness.
CON: Self
2.
ANS: 2
Objective: Discuss ethical theories including utilitarianism, Kantianism, Christian ethics, natural
law, theories, and ethical egoism.
Page: 42
Heading: Ethical Considerations > Theoretical Perspectives
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Self
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This statement reflects Christian ethics.
The applicant’s comment reflects the ethical egoism framework. This framework
promotes the idea that decisions are made based on what is good for the individual
and may not take the needs of others into account.
This statement does not accurately reflect the ethical egoism framework.
This statement reflects Kantianism.
CON: Self
3.
ANS: 1
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Define ethical dilemma.
Page: 42
Heading: Ethical Dilemmas
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Analysis [Analyzing]
Concept: Ethics
Difficulty: Easy
1
2
3
4
Feedback
The coworker’s lack of involvement can be interpreted as an unethical action. The
coworker is experiencing an ethical dilemma in which a decision needs to be made
between two unfavorable alternatives. The coworker has a responsibility to report
any observed unethical actions.
The coworker is not released from responsibilities by taking no action.
Taking no action is never advised when harm could come to the client.
The coworker has a responsibility to report any observed unethical actions.
PTS: 1
CON: Ethics
4.
ANS: 2
Chapter: Chapter 0, Ethical and Legal Issues
Objective: 4. Discuss the ethical principles of autonomy, beneficence, nonmaleficence, justice,
and veracity.
Page: 42
Heading: Ethical Principles
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Ethics
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The principle of justice requires individuals to be treated fairly.
The unit manager’s policy regarding voluntary client participation in group
therapy preserves the ethical principle of autonomy. The principle of autonomy
presumes that individuals are capable of making independent decisions for
themselves and that health-care workers must respect these decisions.
Veracity refers to one’s duty to always be truthful.
Beneficence refers to the duty to promote the good of others.
CON: Ethics
5.
ANS: 2
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Differentiate between civil and criminal law.
Page: 47
Heading: Classifications Within Statutory and Common Law > Civil Law
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Legal
Difficulty: Easy
1
2
3
4
Feedback
Failing to assess a client is an example of an unintentional tort.
A tort, which can be intentional or unintentional, is a violation of civil law in
which an individual has been wronged. A nurse who intentionally physically
places an irritating client in restraints has touched the client without consent and
has committed an intentional tort.
Failing to report a medical error is an example of an unintentional tort.
Giving patient information to an unauthorized person is a violation of the Health
Insurance Portability and Accountability Act (HIPAA).
2
3
4
PTS: 1
A tort, which can be intentional or unintentional, is a violation of civil law in
which an individual has been wronged. A nurse who intentionally physically
places an irritating client in restraints has touched the client without consent and
has committed an intentional tort.
Failing to report a medical error is an example of an unintentional tort.
Giving patient information to an unauthorized person is a violation of the Health
Insurance Portability and Accountability Act (HIPAA).
CON: Legal
6.
ANS: 4
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 55
Heading: Nursing Liability > Avoiding Liability
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Ethics
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The involuntarily committed client should be respected and has the right to assert
grievances if rights are infringed.
This option is likely important, but it is not the most appropriate action for
decreasing the possibility of a lawsuit.
This option is not therapeutic for the client.
The most appropriate nursing action is to continue professional attempts to
establish a positive working relationship with the client.
CON: Ethics
7.
ANS: 4
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 50
Heading: Informed Consent
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
1
2
3
4
Feedback
Clients can refuse both pharmacological and psychological treatment.
Clients may not be able to refuse emergency treatment.
Clients can refuse pharmacological and psychological treatment in a nonemergent
situation.
The nurse should understand that health-care professionals can override treatment
refusal when a client is actively suicidal or homicidal. A suicidal or homicidal
client who refuses treatment may be in danger or a danger to others. This situation
should be treated as an emergency, and treatment may be performed without
1
2
3
4
PTS: 1
Feedback
Clients can refuse both pharmacological and psychological treatment.
Clients may not be able to refuse emergency treatment.
Clients can refuse pharmacological and psychological treatment in a nonemergent
situation.
The nurse should understand that health-care professionals can override treatment
refusal when a client is actively suicidal or homicidal. A suicidal or homicidal
client who refuses treatment may be in danger or a danger to others. This situation
should be treated as an emergency, and treatment may be performed without
informed consent.
CON: Ethics
8.
ANS: 2
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 52
Heading: Involuntary Commitment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Safety
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This client’s personal safety is not in jeopardy.
The nurse should identify the client threatening to commit suicide as eligible for
involuntary commitment. The suicidal client who refuses treatments is in danger
and needs emergency treatment.
This client seems capable of making decisions regarding personal safety.
This client does not meet the requirements for involuntary commitment.
CON: Safety
9.
ANS: 3
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 44
Heading: The Right to Refuse Treatment Including Medications
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Safety
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Making inappropriate sexual innuendos does not give the nurse reason to medicate
the client against wishes.
Demanding attention does not give the nurse reason to medicate the client against
wishes.
The nurse would have the right to medicate a client against his or her wishes if the
client physically attacks another client. This client poses a significant risk to safety
and is incapable of making informed choices. The client’s refusal to accept
treatment can be challenged, because the client is endangering the safety of others.
Refusing to bathe does not give the nurse reason to medicate the client against
wishes.
CON: Safety
10.
ANS: 1
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 48
Heading: HIPAA
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Legal
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The most appropriate action by the nurse is to refuse to give any information to the
caller.
This would be an inappropriate and unprofessional action by the nurse.
Admission to the facility would be considered protected health information and
should not be disclosed by the nurse without prior client consent.
Giving this information would violate the client’s right to privacy.
CON: Legal
11.
ANS: 1
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence, nonmaleficence, justice, and
veracity.
Page: 50
Heading: Informed Consent
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The nurse should provide the information to support the client’s autonomy. A
client who is capable of making independent choices should be permitted to do so.
In instances when clients are incapable of making informed decisions, a legal
guardian or representative would be asked to give consent.
The principle of beneficence refers to one’s duty to promote the good of others.
Nonmaleficence means to do no harm.
Justice refers to the right of individuals to be treated fairly.
CON: Ethics
12.
ANS: 4
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence, nonmaleficence, justice, and
veracity.
Page: 43
Heading: Ethical Principles > Justice
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Ethics
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Autonomy refers to an individual’s right to make informed decisions.
Beneficence refers to one’s duty to promote the good of others.
Nonmaleficence means to do no harm.
The nurse should determine that the ethical principle of justice has been violated
by the physician’s actions. The principle of justice requires that individuals should
be treated equally, regardless of race, sex, marital status, medical diagnosis, social
standing, economic level, or religious belief.
CON: Ethics
13.
ANS: 3
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence, nonmaleficence, justice, and
veracity.
Page: 43
Heading: Ethical > Veracity
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Discussing a client’s personal information with another client is a HIPAA
violation.
Discussing another client’s personal information with uninvolved health-care
providers is a HIPAA violation.
The nurse who tricks a client into seclusion has violated the ethical principle of
veracity. The principle of veracity refers to one’s duty to always be truthful and not
intentionally deceive or mislead clients.
Not treating all clients equally violates the principle of justice.
CON: Ethics
14.
ANS: 3
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 50
Heading: Informed Consent
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level:Application [Applying]
Concept: Legal
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This would not lead the nurse to believe that the client is incompetent to make
informed choices.
If the client is oriented, then informed consent can be obtained.
The nurse should question the validity of informed consent when the client
incorrectly reports the spouse’s name, date, and time of day. This indicates that this
client is disoriented and may not be competent to make informed choices.
The use of an interpreter does not make the informed consent invalid.
CON: Legal
15.
ANS: 1
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 44
Heading: The Right to Refuse Treatment (Including Medications)
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Ethics
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
It is ethically appropriate for the nurse to allow the client to decline the medication
and provide accurate documentation. The client’s right to refuse treatment should
be upheld, unless the refusal puts the client or others in harm’s way.
It would be unethical for the nurse to force hospitalization.
It would be unethical for the nurse to trick the client into taking the medication.
It would be unethical for the nurse to force the client to take the medication.
CON: Ethics
16.
ANS: 2
Chapter: Chapter 0, Ethical and Legal Issues
Objective: 9. Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 55
Heading: Types of Lawsuits that Occur in Psychiatric Nursing
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Legal
Difficulty: Easy
1
2
3
4
Feedback
This action is unethical.
The nurse in this situation has committed both the acts of assault and battery.
Assault refers to an action that results in fear and apprehension that the person will
be touched without consent. Battery is the touching of another person without
consent.
This action is unethical by the nurse, but is not considered assault and battery.
This action would be considered battery because the nurse touched the client, but
it is not considered assault.
PTS: 1
CON: Legal
17.
ANS: 4
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 44–46
Heading: The Right to the Least-restrictive Treatment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The client does not pose a direct dangerous threat to self or others, so seclusion
would not be justified.
This is not the least restrictive option.
The client does not pose a direct dangerous threat to self or others, so physical
restraints would not be justified.
The least-restrictive alternative for this client would be monitoring by an ankle
bracelet.
CON: Legal
18.
ANS: 3
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 48
Heading: Legal Issues in Psychiatric/Mental Health Nursing > HIPAA
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Easy
1
2
3
4
Feedback
This act does not require consent to discuss private medical information.
This is incorrect wording for the protection of private health information.
The nurse has violated HIPAA by revealing that the client had been admitted to the
psychiatric unit. The nurse should not have provided any information without
proper consent from the client.
This law protects individuals who help others in a time of need.
PTS: 1
CON: Legal
MULTIPLE RESPONSE
19.
ANS: 1, 4, 5
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 44–45
Heading: The Right to the Least-Restrictive Treatment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Easy
Feedback
The physician could consider involuntary commitment when a client is dangerous
to others.
Being homeless is not enough for involuntary commitment.
Being disruptive to the community is not enough for involuntary commitment.
The physician could consider involuntary commitment when a client is gravely
disabled.
The physician could consider involuntary commitment when a client is suicidal.
1.
2.
3.
4.
5.
PTS: 1
CON: Legal
COMPLETION
20.
ANS:
right
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric/mental health nursing.
Page: 41
Heading: Core Concepts
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Easy
Feedback: A right is a valid, legally recognized claim or entitlement, encompassing both freedom
from government interference or discriminatory treatment and an entitlement to a benefit or a
service. A right is absolute when there is no restriction whatsoever on the individual’s
entitlement.
PTS: 1
CON: Ethics
21.
ANS:
ethics
Chapter: Chapter 0, Ethical and Legal Issues
Objective: Differentiate among ethics, morals, values, and rights.
Page: 41
Heading: Core Concepts
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Easy
Feedback: Ethics is a branch of philosophy that deals with systematic approaches to
distinguishing right from wrong behavior. Bioethics is the term applied to these principles when
they refer to concepts within the scope of medicine, nursing, and allied health.
PTS: 1
CON: Ethics
Chapter 6. Relationship Development
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
What is the most essential task for a nurse to accomplish prior to forming a
therapeutic relationship with a client?
1.
Clarify personal attitudes, values, and beliefs.
2.
Obtain thorough assessment data.
3.
Determine the client’s length of stay.
4.
Establish personal goals for the interaction.
____ 2.
If a client demonstrates transference toward a nurse, how should the nurse
respond?
1.
Promote safety and immediately terminate the relationship with the client.
2.
Encourage the client to ignore these thoughts and feelings.
3.
Immediately reassign the client to another staff member.
4.
Help the client to clarify the meaning of the relationship, based on the present
situation.
1.
2.
3.
4.
Promote safety and immediately terminate the relationship with the client.
Encourage the client to ignore these thoughts and feelings.
Immediately reassign the client to another staff member.
Help the client to clarify the meaning of the relationship, based on the present
situation.
____ 3.
What should be the priority nursing action during the orientation (introductory)
phase of the nurse-client relationship?
1.
Acknowledge the client’s actions, and generate alternative behaviors.
2.
Establish rapport and develop treatment goals.
3.
Attempt to find alternative placement.
4.
Explore how thoughts and feelings about this client may adversely impact nursing
care.
____ 4.
Which client action should a nurse expect during the working phase of the nurseclient relationship?
1.
The client gains insight and incorporates alternative behaviors.
2.
The client establishes rapport with the nurse and mutually develops treatment goals.
3.
The client explores feelings related to reentering the community.
4.
The client explores personal strengths and weaknesses that impact behavioral
choices.
____ 5.
Which client statement should a nurse identify as a typical response to stress most
often experienced in the working phase of the nurse-client relationship?
1.
“I can’t bear the thought of leaving here and failing.”
2.
“I might have a hard time working with you, because you remind me of my
mother.”
3.
“I really don’t want to talk any more about my childhood abuse.”
4.
“I’m not sure that I can count on you to protect my confidentiality.”
____ 6.
A mother who is notified that her child was killed in a tragic car accident states, “I
can’t bear to go on with my life.” Which nursing statement conveys empathy?
1.
“This situation is very sad, but time is a great healer.”
2.
“You are sad, but you must be strong for your other children.”
3.
“Once you cry it all out, things will seem so much better.”
4.
“It must be horrible to lose a child, and I’ll stay with you until your husband
arrives.”
____ 7.
When an individual is “two-faced,” which characteristic—essential to the
development of a therapeutic relationship—should a nurse identify as missing?
1.
Respect
2.
Genuineness
3.
Sympathy
4.
Rapport
1.
2.
3.
4.
Respect
Genuineness
Sympathy
Rapport
____ 8.
On which task should a nurse place priority during the working phase of
relationship development?
1.
Establishing a contract for intervention
2.
Examining feelings about working with a particular client
3.
Establishing a plan for continuing aftercare
4.
Promoting the client’s insight and perception of reality
____ 9.
Which therapeutic communication technique is being used in the following nurseclient interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”
1.
Restatement
2.
Offering general leads
3.
Focusing
4.
Accepting
____ 10.
Which therapeutic communication technique is being used in the following nurseclient interaction?
Client: “When I am anxious, the only thing that calms me down is alcohol.”
Nurse: “Other than drinking, what alternatives have you explored to decrease anxiety?”
1.
Reflecting
2.
Making observations
3.
Formulating a plan of action
4.
Giving recognition
____ 11.
The nurse is interviewing a newly admitted psychiatric client. Which of the
following nursing statements is an example of offering a “general lead”?
1.
“Do you know why you are here?”
2.
“Are you feeling depressed or anxious?”
3.
“Yes, I see. Go on.”
4.
“Can you order the specific events that led to your admission?”
____ 12.
A nurse says to a client, “Things will look better tomorrow after a good night’s
sleep.” This is an example of which communication technique?
1.
2.
3.
4.
The therapeutic technique of giving advice
The therapeutic technique of defending
The nontherapeutic technique of presenting reality
The nontherapeutic technique of giving reassurance
____ 13.
A client diagnosed with posttraumatic stress disorder related to a rape is admitted
to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic
communication technique might a nurse use that is an example of “broad openings”?
1.
“What occurred prior to the rape, and when did you go to the emergency
department?”
2.
“What would you like to talk about?”
3.
“I notice you seem uncomfortable discussing this.”
4.
“How can we help you feel safe during your stay here?”
____ 14.
A nurse maintains an uncrossed arm and leg posture when communicating with a
client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active
listening?
1.
S
2.
O
3.
L
4.
E
5.
R
____ 15.
An instructor is correcting a nursing student’s clinical worksheet. Which
instructor statement is the best example of effective feedback?
1.
“Why did you use the client’s name on your clinical worksheet?”
2.
“You were very careless to refer to your client by name on your clinical worksheet.”
3.
“Surely you didn’t do this deliberately, but you breeched confidentiality by using
names.”
4.
“It is disappointing that after being told you’re still using client names on your
worksheet.”
____
1.
2.
3.
4.
16.
What is a nurse’s purpose for providing appropriate feedback?
To give the client good advice
To advise the client on appropriate behaviors
To evaluate the client’s behavior
To give the client critical information
____ 17.
A client exhibiting dependent behaviors says, “Do you think I should move from
my parent’s house and get a job?” Which nursing response is most appropriate?
1.
“It would be best to do that in order to increase independence.”
2.
“Why would you want to leave a secure home?”
3.
“Let’s discuss and explore all of your options.”
4.
“I’m afraid you would feel very guilty leaving your parents.”
____ 18.
A mother rescues two of her four children from a house fire. In an emergency
department, she cries, “I should have gone back in to get them. I should have died, not them.”
What is the nurse’s best response?
1.
“The smoke was too thick. You couldn’t have gone back in.”
2.
“You’re experiencing feelings of guilt, because you weren’t able to save your
children.”
3.
“Focus on the fact that you could have lost all four of your children.”
4.
“It’s best if you try not to think about what happened. Try to move on.”
____ 19.
A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD),
washes his hands continually. This behavior prevents unit activity attendance. Which nursing
statement best addresses this situation?
1.
“Everyone diagnosed with OCD needs to control their ritualistic behaviors.”
2.
“It is important for you to discontinue these ritualistic behaviors.”
3.
“Why are you asking for help, if you won’t participate in unit therapy?”
4.
“Let’s figure out a way for you to attend unit activities and still wash your hands.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 20.
Which of the following characteristics should be included in a therapeutic nurseclient relationship? (Select all that apply.)
1.
Meeting the psychological needs of the nurse and the client
2.
Ensuring therapeutic termination
3.
Promoting client insight into problematic behavior
4.
Collaborating to set appropriate goals
5.
Meeting both the physical and psychological needs of the client
____ 21.
Which of the following individuals are communicating a message? (Select all that
apply.)
1.
A mother spanking her son for playing with matches
2.
A teenage boy isolating himself and playing loud music
3.
A biker sporting an eagle tattoo on his biceps
4.
A teenage girl writing, “No one understands me”
5.
A father checking for new email on a regular basis
1.
2.
3.
4.
5.
A mother spanking her son for playing with matches
A teenage boy isolating himself and playing loud music
A biker sporting an eagle tattoo on his biceps
A teenage girl writing, “No one understands me”
A father checking for new email on a regular basis
Completion
Complete each statement.
22.
The term ________________________ implies special feelings on the part of
both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a
sense of trust, and a nonjudgmental attitude.
23.
___________________ refers to a nurse’s behavioral and emotional response to a
client. These responses may be related to unresolved feelings toward significant others from the
nurse’s past.
Relationship development
Answer Section
MULTIPLE CHOICE
1.
ANS: 1
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Identify and discuss essential conditions for a therapeutic relationship to occur.
Page: 126
Heading: The Therapeutic Use of Self > Therapeutic Use of Self
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The most essential task for a nurse to accomplish prior to forming a therapeutic
relationship with a client is to clarify personal attitudes, values, and beliefs.
Understanding one’s own attitudes, values, and beliefs is called self-awareness.
Obtaining thorough assessment data is not the most important task.
Determining the client’s length of stay is not the most important task.
Establishing personal goals for the interaction is not the most important task.
CON: Patient-Centered Care
2.
ANS: 4
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe the phases of relationship development and the tasks associated with each
phase.
Page: 129
Heading: Phases of a Therapeutic Nurse-Client Relationship > Transference and
Countertransference
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This action would not be therapeutic to the client.
The nurse should assist the client in separating the past from the present.
This option would not be therapeutic to the client, who may continue to displace
feelings onto others.
The nurse should respond to a client’s transference by clarifying the meaning of
the nurse-client relationship based on the present situation. Transference occurs
when the client unconsciously displaces feelings about a person from the past
toward the nurse.
CON: Patient-Centered Care
3.
ANS: 2
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe the phases of relationship development and the tasks associated with each
phase.
Page: 129
Heading: Phases of Therapeutic Nurse-Client Relationship > The Orientation (Introductory)
Phase
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
Acknowledging the client’s actions and generating alternative behaviors can occur
after rapport has been established.
The priority nursing action during the orientation phase of the nurse-client
relationship should be to establish rapport and develop treatment goals. Rapport
implies feelings on the part of both the nurse and the client, based on respect,
acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential
foundation of the nurse-client relationship.
Attempting to find alternative placement can occur after rapport has been
established.
Exploring how thoughts and feelings about this client may adversely impact
nursing care can occur after rapport has been established.
1
2
3
4
PTS: 1
Feedback
Acknowledging the client’s actions and generating alternative behaviors can occur
after rapport has been established.
The priority nursing action during the orientation phase of the nurse-client
relationship should be to establish rapport and develop treatment goals. Rapport
implies feelings on the part of both the nurse and the client, based on respect,
acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential
foundation of the nurse-client relationship.
Attempting to find alternative placement can occur after rapport has been
established.
Exploring how thoughts and feelings about this client may adversely impact
nursing care can occur after rapport has been established.
CON: Communication
4.
ANS: 1
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe the phases of relationship development and the tasks associated with each
phase.
Page: 129
Heading: Phases of Therapeutic Nurse-Client Relationship > The Working Phase
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The nurse should expect that the client will gain insight and incorporate alternative
behaviors during the working phase of the nurse-client relationship.
Establishing rapport with the nurse and mutually developing treatment goals
occurs before the working phase.
Exploring feelings related to reentering the community does not occur during the
working phase.
Exploring personal strengths and weaknesses that impact behavioral choices does
not occur during the working phase.
CON: Communication
5.
ANS: 3
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe the phases of relationship development and the tasks associated with each
phase.
Page: 129
Heading: The Working Phase
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Analysis [Analyzing]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Stating, “I can’t bear the thought of leaving here and failing,” does not indicate
resistance to the therapeutic relationship between the nurse and client.
Stating, “I might have a hard time working with you, because you remind me of
my mother,” does not indicate resistance to the therapeutic relationship between
the nurse and client.
The nurse should identify that the client statement, “I really don’t want to talk any
more about my childhood abuse,” reflects that the client is in the working phase of
the nurse-client relationship. The working phase includes overcoming resistance
behaviors on the part of the client as the level of anxiety rises in response to
discussion of painful issues.
Stating, “I’m not sure that I can count on you to protect my confidentiality,” does
not indicate resistance to the therapeutic relationship between the nurse and client.
CON: Communication
6.
ANS: 4
Chapter: Chapter Relationship Development and Therapeutic Communication
Objective: Identify and discuss essential conditions for a therapeutic relationship to occur.
Page: 127–128
Heading: Empathy
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
Stating, “This situation is very sad, but time is a great healer,” does not convey
empathy and would not be therapeutic to the mother.
Stating, “You are sad, but you must be strong for your other children,” does not
convey empathy and would not be therapeutic to the mother.
Stating, “Once you cry it all out, things will seem so much better,” does not
convey empathy and would not be therapeutic to the mother.
The nurse’s response, “It must be horrible to lose a child, and I’ll stay with you
until your husband arrives,” conveys empathy to the client. Empathy is the ability
to see the situation from the client’s point of view. Empathy is considered to be
one of the most important characteristics of the therapeutic relationship.
2
3
4
PTS: 1
empathy and would not be therapeutic to the mother.
Stating, “You are sad, but you must be strong for your other children,” does not
convey empathy and would not be therapeutic to the mother.
Stating, “Once you cry it all out, things will seem so much better,” does not
convey empathy and would not be therapeutic to the mother.
The nurse’s response, “It must be horrible to lose a child, and I’ll stay with you
until your husband arrives,” conveys empathy to the client. Empathy is the ability
to see the situation from the client’s point of view. Empathy is considered to be
one of the most important characteristics of the therapeutic relationship.
CON: Communication
7.
ANS: 2
Chapter: Chapter 0, Relationship Development and Therapeutic Communication Objective:
Identify and discuss essential conditions for a therapeutic relationship to occur. Page: 127
Heading: Conditions Essential to Development of a Therapeutic Relationship > Genuineness
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Respect is not the characteristic missing when an individual is “two-faced.”
When an individual is “two-faced,” which means double-dealing or deceitful, the
nurse should identify that genuineness is missing in the relationship. Genuineness
refers to the nurse’s ability to be open and honest and maintain congruence
between what is felt and what is communicated. When a nurse fails to bring
genuineness to the relationship, trust cannot be established.
Sympathy is not the characteristic missing when an individual is “two-faced.”
Rapport is not the characteristic missing when an individual is “two-faced.”
CON: Communication
8.
ANS: 4
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Identify and discuss essential conditions for a therapeutic relationship to occur.
Page: 129
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Working Phase
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
Establishing a contract for intervention would occur in the orientation phase.
Examining feelings about working with a client should occur in the preinteraction
phase.
Establishing a plan for aftercare would occur in the termination phase.
The nurse should place priority on promoting the client’s insight and perception of
1
2
3
4
PTS: 1
Feedback
Establishing a contract for intervention would occur in the orientation phase.
Examining feelings about working with a client should occur in the preinteraction
phase.
Establishing a plan for aftercare would occur in the termination phase.
The nurse should place priority on promoting the client’s insight and perception of
reality during the working phase of relationship development.
CON: Communication
9.
ANS: 1
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 137–138
Heading: Table 6-3 Therapeutic Communication Techniques
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The nurse is using the therapeutic communication technique of restatement.
Restatement involves repeating the main idea of what the client has said. It allows
the client to know whether the statement has been understood and provides an
opportunity to continue.
Offering general leads does not involve summarizing the client’s statement.
Offering focusing does not involve summarizing the client’s statement.
Offering accepting does not involve summarizing the client’s statement.
CON: Communication
10.
ANS: 3
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 137–138
Heading: Table 6-3 Therapeutic Communication Techniques
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Reflecting does not explore behavior alternatives.
Making observations does not explore behavior alternatives.
The nurse is using the therapeutic communication technique of formulating a plan
of action to help the client explore alternatives to drinking. The use of this
technique may serve to prevent anger or anxiety from escalating.
Giving recognition does not explore behavior alternatives.
CON: Communication
11.
ANS: 3
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 137
Heading: Table 6-3 Therapeutic Communication Techniques; Giving broad openings
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This is a specific question, not a general lead.
This is a closed ended question; it does not encourage the client to elaborate.
The nurse’s statement, “Yes, I see. Go on,” is an example of a general lead.
Offering general leads encourages the client to continue sharing information.
This question does not encourage the client to give more information.
CON: Communication
12.
ANS: 4
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 139
Heading: Table 6-4 Nontherapeutic Communication Techniques; Giving false reassurance
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
The nurse’s statement does not give advice to the client.
This is not an example of the therapeutic technique of defending.
This statement does not present reality to the client.
The nurse’s statement, “Things will look better tomorrow after a good night’s
sleep,” is an example of the nontherapeutic communication technique of giving
1
2
3
4
PTS: 1
Feedback
The nurse’s statement does not give advice to the client.
This is not an example of the therapeutic technique of defending.
This statement does not present reality to the client.
The nurse’s statement, “Things will look better tomorrow after a good night’s
sleep,” is an example of the nontherapeutic communication technique of giving
reassurance. Giving reassurance indicates to the client that there is no cause for
anxiety, thereby devaluing the client’s feelings.
CON: Communication
13.
ANS: 2
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 137
Heading: Table 6-3 Therapeutic Communication Techniques; Giving broad openings
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This question asks specific information about the rape.
The nurse’s statement, “What would you like to talk about?” is an example of the
therapeutic communication technique of a broad opening. Using broad openings
allows the client to take the initiative in introducing the topic and emphasizes the
importance of the client’s role in the interaction.
This question is not an example of a broad opening.
While this question is important, it is not an example of a broad opening.
CON: Communication
14.
ANS: 2
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe active listening.
Page: 136
Heading: Interpersonal Communication > Active Listening
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
5
PTS: 1
Feedback
The acronym SOLER includes: sitting squarely facing the client (S).
The nurse should identify that maintaining an uncrossed arm and leg posture is
nonverbal behavior that reflects the O in the active-listening acronym SOLER.
The acronym SOLER includes: leaning forward toward the client (L).
The acronym SOLER includes: establishing eye contact (E).
The acronym SOLER includes: relaxing (R).
CON: Communication
15.
ANS: 3
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Discuss therapeutic feedback.
Page: 138
Heading: Interpersonal Communication > Feedback
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Asking questions does not give feedback to the student.
Feedback should impart information to the student.
The instructor’s statement, “Surely you didn’t do this deliberately, but you
breeched confidentiality by using names,” is an example of effective feedback.
Feedback is method of communication for helping others consider a modification
of behavior.
Feedback should be descriptive, specific, and directed toward a behavior that the
person has the capacity to modify and should impart information rather than offer
advice.
CON: Communication
16.
ANS: 4
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Discuss therapeutic feedback.
Page: 138
Heading: Interpersonal Communication > Feedback
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Feedback should not be used to give advice.
Feedback should not be used to give advice on behaviors.
Feedback should not be used to evaluate behaviors.
The purpose of providing appropriate feedback is to give the client critical
information.
CON: Communication
17.
ANS: 3
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 139–140
Heading: Table 6-4 Nontherapeutic Communication Techniques
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Stating, “It would be best to do that in order to increase independence,” does not
encourage the client to think independently.
Stating, “Why would you want to leave a secure home?” does not encourage the
client to think independently.
The most appropriate response by the nurse is, “Let’s discuss and explore all of
your options.” In this example, the nurse is encouraging the client to formulate
ideas and decide independently the appropriate course of action.
Stating, “I’m afraid you would feel very guilty leaving your parents,” does not
encourage the client to think independently.
CON: Communication
18.
ANS: 2
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 137–138
Heading: Table 6-3 Therapeutic Communication Techniques
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Stating, “The smoke was too thick. You couldn’t have gone back in,” is not
therapeutic and would not benefit the mother.
The best response by the nurse is, “You’re experiencing feelings of guilt, because
you weren’t able to save your children.” This response uses the therapeutic
communication technique of restating what the client has said. This lets the client
know whether an expressed statement has been understood or if clarification is
necessary.
Stating, “Focus on the fact that you could have lost all four of your children,” is
not therapeutic and would not benefit the mother.
Stating, “It’s best if you try not to think about what happened. Try to move on,” is
not therapeutic and would not benefit the mother.
CON: Communication
19.
ANS: 4
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 137–138
Heading: Table 6-3 Therapeutic Communication Techniques
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
Stating, “Everyone diagnosed with OCD needs to control their ritualistic
behaviors,” is not therapeutic to the client and may damage rapport.
Stating, “It is important for you to discontinue these ritualistic behaviors,” is not
therapeutic to the client and may damage rapport.
Stating, “Why are you asking for help, if you won’t participate in unit therapy?” is
not therapeutic to the client and may damage rapport.
The most appropriate statement by the nurse is, “Let’s figure out a way for you to
attend unit activities and still wash your hands.” This statement reflects the
therapeutic communication technique of formulating a plan of action. The nurse
attempts to work with the client to develop a plan without damaging the
therapeutic relationship.
2
3
4
PTS: 1
behaviors,” is not therapeutic to the client and may damage rapport.
Stating, “It is important for you to discontinue these ritualistic behaviors,” is not
therapeutic to the client and may damage rapport.
Stating, “Why are you asking for help, if you won’t participate in unit therapy?” is
not therapeutic to the client and may damage rapport.
The most appropriate statement by the nurse is, “Let’s figure out a way for you to
attend unit activities and still wash your hands.” This statement reflects the
therapeutic communication technique of formulating a plan of action. The nurse
attempts to work with the client to develop a plan without damaging the
therapeutic relationship.
CON: Communication
MULTIPLE RESPONSE
20.
ANS: 2, 3, 4, 5
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Identify and discuss essential conditions for a therapeutic relationship to occur.
Page: 125
Heading: The Therapeutic Nurse-Client Relationship
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
Meeting the nurse’s psychological needs should never be addressed within the
nurse-client relationship.
The nurse-client therapeutic relationship should include ensuring therapeutic
termination.
The nurse-client therapeutic relationship should include promoting client insight
into problematic behavior.
The nurse-client therapeutic relationship should include collaborating to set
appropriate goals.
The nurse-client therapeutic relationship should include meeting both the physical
and psychological needs of the client.
CON: Communication
21.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Identify components of nonverbal expression.
Page: 134
Heading: Nonverbal Communication
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
The nurse should determine that a mother spanking her son for playing with
matches is a way in which people communicate messages to others.
The nurse should determine that a teenage boy isolating himself and playing loud
music is a way in which people communicate messages to others.
The nurse should determine that a biker sporting an eagle tattoo on his biceps is a
way in which people communicate messages to others.
The nurse should determine that writing is a way in which people communicate
messages to others.
Checking for new emails is not an example of communicating a message.
PTS: 1
CON: Communication
COMPLETION
22.
ANS:
rapport
Feedback: Rapport implies special feelings on the part of both the client and the nurse, based on
acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental
attitude. Establishing rapport may be accomplished by discussing non-health-related topics.
Chapter: Chapter 0, Relationship Development and Therapeutic Communication
Objective: Identify and discuss essential conditions for a therapeutic relationship to occur.
Page: 126
Heading: The Therapeutic Nurse-Client Relationship > Rapport
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
PTS: 1
CON: Communication
23.
ANS:
Countertransference
Chapter:
Objective: Identify and discuss essential conditions for a therapeutic relationship to occur.
Page: 130
Heading: The Therapeutic Nurse-Client Relationship > Countertransference
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
Feedback: Countertransference refers to a nurse’s behavioral and emotional response to a client.
These responses may be related to unresolved feelings toward significant others from the nurse’s
past or they may be generated in response to transference feelings on the part of the client.
PTS: 1
CON: Communication
Chapter 7. Therapeutic Communication
When assessing a patient's mental health status, which of the following describe
the purpose of the psychosocial assessment? Select all that apply.
•
To assess the client's current emotional state
•
To assess the client's mental capacity
•
To assess the client's behavioral function
•
To assess the client's plan of care
•
To assess the client's physical
health status Ans: A, B, C
Feedback:
The purpose of the psychosocial assessment is to construct a picture of the client's
current emotional state, mental capacity, and behavioral function. This assessment
serves as the basis for developing a plan of care to meet the client's needs. The
client's physical health status would need to be completed as another assessment
or an extended assessment.
•
Which of the following factors influencing assessment is under the nurse's control?
•
Client participation and feedback
•
Client's health status
•
Nurse's attitude and approach
•
Client's ability to
understand Ans: C
Feedback:
The factors that influence assessment include client participation and feedback,
client's health status, client's ability to understand, client's previous experiences,
and misconceptions about health care. The only one of these that is under the
control of the nurse is the nurse's attitude and approach.
•
Which of the following are components of the assessment of thought
process and content? Select all that apply.
•
What the client is thinking
•
•
•
•
Abstract thinking abilities
How the client is thinking
Clarity of ideas
Self-harm or
suicide urges
Ans: A, C, D, E
Feedback:
The components of the assessment of thought process and content include content
(what the client is thinking), process (how the client is thinking), clarity of ideas,
self-harm, or suicide urges. Abstract thinking abilities are an element of the
abnormal sensory experiences or misperception assessment.
•
A client is being evaluated for dementia. The nurse knows that a client who
is able to complete very few tasks is most likely to have
•
a greater cognitive deficit.
•
A less precise mental status exam.
•
more potential for agitation.
•
no bearing on
mental status.
Ans: A
Feedback:
The fewer tasks the client competes accurately, the greater the cognitive
deficit. The other choices are not true.
•
During the assessment, the nurse asks the client to describe his problems. The
purpose of this question is to obtain information about the client's
•
admitting diagnosis.
•
communication skills.
•
perception of the problem.
•
perso
nal
needs
.
Ans: C
Feedback:
The question will elicit information about the client's view or perspective
of the problem.
•
A delusion represents a problem in which of the following areas?
•
Memory
•
Motivation
•
Orientation
•
T
h
i
n
k
i
n
g
A
n
s
:
D
F
e
e
d
b
a
c
k
:
A delusion is a fixed false idea or thought. Memory relates to the client's
knowledge of past events. Motivation relates to the client's interest in doing
things. Orientation relates to the client's perception of reality.
•
The nurse asks a patient to list the days of the week in reverse order. The
nurse is assessing which of the following?
•
Concentration
•
Memory
•
Orientation
•
Abstrac
t
thinkin
g Ans:
A
Feedback:
The nurse assesses the client's ability to concentrate by asking the client to
perform certain tasks such as repeating the days of the week backward. The nurse
directly assesses memory, both recent and remote, by asking questions with
verifiable answers. Orientation refers to the client's recognition of person, place,
and time. Abstract thinking is to making associations or interpretations about a
situation or comment.
•
When the nurse asks the client to restate the following in his or her own
words, which sensorium and intellectual process is the nurse attempting to
identify? The nurse states, ìA stitch in time saves nine.î
•
The client's orientation
•
The client's memory
•
The client's ability to concentrate
•
The client's ability to use
abstract thinking Ans: D
Feedback:
When the nurse states, ìA stitch in time saves nine,î and asks the client to restate it
in his or her own words, the nurse is assessing the client's ability to use abstract
thinking. The client's orientation is recognizing person, place, and time. The
client's memory, both recent and remote, can be assessed by asking the client
questions that have verifiable answers. The client's ability to concentrate can be
assessed by asking the client to perform certain tasks including spelling the word
ìworldî backward.
•
The nurse is assessing suicide potential in a patient who has expressed
hopelessness. In what order does the nurse question the patient about suicidal
thoughts?
•
ìHow would you carry out this plan?î
•
ìDo you have a plan to kill yourself?î
•
ìAre you thinking of killing yourself?î
•
ìHow do you plan to kill
yourself?î Ans: C, B, D, A
Feedback:
Suicide assessment should be performed through direct questioning. First, the
nurse would need to know if the patient has ideations: ìAre you thinking about
killing yourself?î; then if the patient has a plan, ìDo you have a plan to kill
yourself?î If the patient has a plan, then the nurse would ask about method: ìHow
do you plan to kill yourself?î If the patient has ideations, a plan, a method, then
does the patient have access to that method the nurse asks, ìHow would you carry
out this plan? Do you have access to the means to carry out the plan?î
•
The nurse best assesses a patient's memory by asking which of the following questions?
•
ìDo you have any problems with memory?î
•
ìWhat did you have for lunch yesterday?î
•
ìDo you know where you are?î
•
ìWho is the current
president?î Ans: D
Feedback:
The nurse directly assesses memory, both recent and remote, by asking questions
with verifiable answers such as ìWhat is the name of the current president?î The
nurse may not be able to verify the accuracy of the client's responses to
questions such as ìDo you have any memory problems?î or ìWhat did you do
yesterday?î Orientation refers to the client's recognition of person, place, and
time.
•
A patient shows no facial expression when engaging in a game with peers
during an outing at a park. The nurse uses which of the following terms
when documenting the patient's affect?
•
Blunt affect
•
Restricted affect
•
Broad affect
•
F
l
a
t
a
f
f
e
c
t
A
n
s
:
D
F
e
e
d
b
a
c
k
:
Common terms used in assessing affect include blunted affect: showing little or a
slow- to-respond facial expression; broad affect: displaying a full range of
emotional expressions; flat affect: showing no facial expression; inappropriate
affect: displaying a facial expression that is incongruent with mood or situation,
often silly or giddy regardless of circumstances; restricted affect: displaying one
type of expression, usually serious or somber.
•
The patient states that he is 14 trillion years old and created the world. The
nurse documents this statement as an example of which type of thinking
displayed by the patient?
•
Delusional thinking
•
Ideas of reference
•
Word salad
•
Hal
luci
nati
on
Ans
:A
Feedback:
A delusion is a fixed false belief not based in reality. Ideas of reference are client's
inaccurate interpretation that general events are personally directed to him or her,
such as hearing a speech on the news and believing the message had personal
meaning. Word salad is flow of unconnected words that convey no meaning to the
listener.
Hallucinations are false sensory perceptions or perceptual experiences that do not
really exist.
•
A patient is known to express tangential thinking. The nurse would assess for
which of the following when interacting with the patient?
•
Stopping abruptly in the middle of expressing himself
•
Jumping from one idea to another
•
Wandering off the topic and never answering the question
•
Excessive and fast talking about an
array of ideas Ans: C
Feedback:
Tangential thinking is wandering off the topic and never providing the
information requested. Thought blocking is stopping abruptly in the middle of a
sentence or train of thoughts, sometimes unable to continue the idea. Loose
associations are disorganized thinking that jumps from one idea to another with
little or no evident relation between the thoughts. Flight of ideas is excessive
amount and rate of speech composed of fragmented or unrelated ideas.
•
A nurse can best assess a patient's ability to use abstract thinking by asking
the patient which of the following questions?
•
ìWhat would you do if you found a wallet containing $100 on the sidewalk?î
•
ìWhat do I mean when I say, 'Don't sweat the small stuff?'î
•
ìWhat are you going to do next time you hear voices?î
•
ìCan you begin with the number 100 and subtract 7, and then subtract
7 again?î Ans: B
Feedback:
The nurse assesses the client's ability to use abstract thinking, which is to make
associations or interpretations about a situation or comment. The nurse usually can
do so by asking the client to interpret a common proverb. If the client can explain
the proverb correctly, his or her abstract thinking abilities are intact. Judgment
refers to the ability to interpret one's environment and situation correctly and to
adapt one's behavior and decisions accordingly. Insight is the ability to understand
the true nature of one's situation and accept some personal responsibility for that
situation. The nurse assesses the client's ability to concentrate by asking the client
to perform certain tasks such as ìserial sevens.î
•
A patient reported to the nurse that on his way to the clinic, a policeman in a
patrol car turned on his lights and pulled him over. When asked what he did
next, the patient stated, ìI pulled over, of course.î Which of the following was
the nurse trying to assess?
•
The client's judgment
•
The client's insight
•
The client's concentration
•
The client's
self-concept
Ans: A
Feedback:
Judgment refers to the ability to interpret one's environment and situation correctly
and to adapt one's behavior and decisions accordingly. Insight is the ability to
understand the true nature of one's situation and accept some personal
responsibility. Self-concept is the way one views oneself in terms of personal
worth and dignity. The nurse assesses the client's ability to concentrate by asking
the client to perform certain cognitive tasks. To assess a client's self-concept, the
nurse can ask the client to describe himself or herself and what characteristics he
or she likes and what he or she would change.
•
The client spoke of a current event in the national news and described it as it
relates to the client. Then the client spoke of a historical event and described it
as it relates to the client. Which of the following questions might the nurse ask
to determine if the client is experiencing ideas of reference?
•
ìWhere were you when this happened?î
•
ìWhy do you think that?î
•
ìAre you sure?î
•
ìThat is
unbelievable
!î Ans: A
Feedback:
Ideas of reference are the client's inaccurate interpretation that general evens are
personally directed to him or her, such as hearing a speech on the news and
believing the message had personal meaning. ìWhere were you when this
happened,î would relate to the place and might give the nurse more information to
validate the client's previous comments. ìWhy do you think that,î may be
interpreted as the nurse challenging the client. ìAre you sure,î is a closed-ended
question and does not encourage the client to elaborate. ìThat is unbelievable,î is
a statement rather than a question and could be interpreted as the nurse's opinion
of the information provided by the client.
•
Which of the following questions is best to ask when assessing the client's judgment?
•
ìCan you describe your usual daily activities for me?î
•
ìIf you found yourself downtown without money or a car, how
would you get home?î
•
ìOn a scale of 1 to 10, how stressed would you rate yourself?î
•
ìWhat problem would you like to work on while you're
hospitalized?î Ans: B
Feedback:
Judgment refers to the ability to interpret one's environment and situation
correctly and to adapt one's own behavior and decisions accordingly. This
question will elicit information about the client's problem-solving and decisionmaking abilities. The other choices do not assess the concept of judgment.
•
The nurse asks the client, ìWhat is similar about a cow and a horse?î and ìWhat
do a bus and an airplane have in common?î These questions would best assess
which of the following areas?
•
Intellectual function
•
Insight
•
Judgment
•
M
e
m
o
r
y
A
n
s
:
A
F
e
e
d
b
a
c
k
:
These questions would elicit information about the client's intellectual function.
Insight is the ability to understand the true nature of one's situation and accept
some personal responsibility for that situation. Judgment refers to the ability to
interpret one's environment and situation correctly and to adapt one's behavior
and decisions accordingly. Questions about memory would require that the client
identify knowledge of past events.
•
Which of the following would best assess a client's judgment?
•
Counting by serial sevens
•
Discussing hypothetical situations
•
Interpreting proverbs
•
Spelling words
backward Ans:
B
Feedback:
The client's judgment can be elicited by asking the client to discuss hypothetical
situations, which would indicate one's ability to interpret one's environment and
situation correctly and to adapt one's behavior and decisions accordingly.
Counting by serial sevens and spelling words backward would assess the
client's ability to concentrate. Interpreting proverbs would assess the client's
abstract thinking.
•
The nurse plans to assess a patient's self-concept in the admission assessment
knowing that self-concept influences which of the following? Select all that
apply.
•
Body image
•
Cognitive processing
•
Frequently experienced emotions
•
Coping strategies
•
Responsiveness to
medications Ans: A,
C, D
Feedback:
Self-concept is the way one views oneself in terms of personal worth and dignity.
The client's description of self in terms of physical characteristics gives the nurse
information about the client's body image. Also included in an assessment of selfconcept are the emotions that the client frequently experiences and whether or not
the client is comfortable with those emotions. The nurse also must assess the
client's coping strategies. Cognitive processing and response to medications are
biologically based.
•
Which of the following are the types of roles that are usually included when
assessing roles and relationships? Select all that apply.
•
Family
•
Hobbies
•
Occupation
•
Activities
•
Race
•
E
t
h
n
i
c
i
t
y
A
n
s
:
A
,
B
,
C
,
D
F
e
e
d
b
a
c
k
:
The number and type of roles may vary, but they usually include family,
occupation, and hobbies or activities.
•
Knowing that relationships with others are significant to mental health, the
nurse effectively assesses a patient's family relationships through which of
the following?
•
ìDo you feel your family helps you?î
•
ìHow many people are in your family?î
•
ìWhom are you closest to in your family?î
•
ìDescribe your relationships with
your family.î Ans: D
Feedback:
The nurse must assess the relationships in the client's life, the client's
satisfaction with those relationships, or any loss of relationships. Open-ended
questions and statements elicit more descriptive responses from the patient than
direct questions.
•
A nurse assesses that a depressed patient is lethargic during the day and does
not actively participate in unit activities. The notes from the night shift
document that the patient did not sleep well. The most probable
interpretation of these data is
•
the patient's medications are ineffective.
•
the patient is being kept awake at night due to noise on the unit.
•
the patient's depressed mood is impairing restful sleep patterns.
•
the patient is resisting treatment recommendations to participate in unit
activities Ans: C
Feedback:
Emotional problems often affect some areas of physiologic function.
Emotional problems can greatly affect eating and sleeping patterns. Therefore,
the nurse must assess the client's usual patterns of eating and sleeping and then
determine how those patterns have changed.
•
A nurse suspects that a patient is abusing alcohol while taking prescribed
medications. The nurse plans to educate the patient on the dangers of mixing
medicine with alcohol. Which of the following would be the most effective
way for the nurse to approach this subject with the patient?
•
Firmly inform the patient of the dangers of mixing medications with alcohol.
•
Recommend a higher level of care, so the patient can be more closely supervised.
•
Emphasize the importance of truthful information using a
nonjudgmental approach
•
Recognize the patient's right to self-determination and avoid
addressing the subject.
Ans: C
Feedback:
Noncompliance with prescribed medications is an important area. If the client
has stopped taking medication or is taking medication other than as prescribed,
the nurse must help the client feel comfortable enough to reveal this information.
The nurse also explores the client's use of alcohol and over-the-counter or illicit
drugs. Such questions require nonjudgmental phrasing; the nurse must reassure
the client that truthful information is crucial in determining the client's plan of
care.
•
The nurse has completed the psychosocial assessment. Which of the following
is the best approach toward analysis of the data to identify nursing diagnoses
and develop an appropriate plan of care?
•
Focus on each piece of information obtained from the patient.
•
Look for patterns reflected in the overall assessment.
•
Consider only the abnormal findings in the assessment.
•
Present all data obtained in the treatment
team meeting. Ans: B
Feedback:
After completing the psychosocial assessment, the nurse analyzes all the data that
he or she has collected. Data analysis involves thinking about the overall
assessment rather than focusing on isolated bits of information. The nurse looks
for patterns or themes in the data that lead to conclusions about the client's
strengths and needs and to a particular nursing diagnosis. No one statement or
behavior is adequate to reach such a conclusion.
•
The nurse reviews results of the Minnesota Multiphasic Personality Inventory
(MMPI) recorded in a patient record. While considering the usefulness of these
data, the nurse is mindful that the MMPI has which limitation?
•
The patient must be able to read to complete the MMPI.
•
The results of the MMPI could be culturally biased.
•
The MMPI assesses a narrow scope of functioning.
•
The MMPI does not have
established validity. Ans: B
Feedback:
Both intelligence tests and personality tests are frequently criticized as being
culturally biased. It is important to consider the client's culture and environment
when evaluating the importance of scores or projections from any of these tests.
Objective personality tests compare the client's answers with standard answers or
criteria and obtain a score or scores. The MMPI provides scores on 10 clinical
scales such as hypochondriasis, depression, hysteria, and paranoia; four special
scales such as anxiety and alcoholism; three validity scales to evaluate the truth
and accuracy of responses.
•
The client tells the nurse, ìThat new TV anchor is telling the world about me.î
This is an example of
•
ideas of reference.
•
persecutory delusions.
•
•
thought broadcasting.
thought
insertio
n. Ans:
A
Feedback:
The client's inaccurate interpretation that general events are personally directed
to him or her is an example of ideas of reference. Persecutory delusions involve
the client's belief that ìothersî are planning to harm the client. Thought
broadcasting is a delusional belief that others can hear or know what the client is
thinking. Thought insertion is a delusional belief that others are putting ideas or
thoughts into the client's head.
•
During the admission assessment, the nurse asks the client, ìHow are you
feeling?î The client responds, ìI was able to purchase gas for 7 cents a gallon
less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon
gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have
saved so much money.î The nurse recognizes this response as which of the
following?
•
Circumstantial thinking
•
Echolalia
•
Flight of ideas
•
N
eo
lo
gi
s
m
s
A
ns
:
A
F
ee
d
b
ac
k:
With circumstantial thinking, the client eventually answers a question but only
after giving excessive unnecessary detail. Echolalia is repetition or imitation of
what someone else says. Flight of ideas is excessive amount and rate of speech
composed of fragmented or unrelated ideas. Neologisms are invented words that
have meaning only for the client.
•
A client is admitted to the psychiatric unit and states, ìI am president of the
largest corporation in the world. Everyone comes to me for advice.î The
client is exhibiting which of the following?
•
Flight of ideas
•
Thought broadcasting
•
Delusion
•
Loose
associati
ons Ans:
C
Feedback:
The client has a delusion (a fixed false belief not based in reality) about his
superiority over others. Flight of ideas is excessive amount and rate of speech
composed of fragmented or unrelated ideas. Thought broadcasting is a
delusional belief that others can hear or know what the client is thinking. Loose
associations are disorganized thinking that jumps from one idea to another with
little or no evident relation between the thoughts.
•
In the space of 5 minutes, the client has been laughing and euphoric, then
angry, and then crying for no reason that is apparent to the nurse. This
behavior would be best described as
•
flight of ideas.
•
lack of insight.
•
labile mood.
•
tangential
thinking.
Ans: C
Feedback:
Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight
of ideas is manifested by excessive amount and rate of speech composed of
fragmented or unrelated ideas. Lack of insight would be manifested by the lack
of the ability to understand the true nature of one's situation and accept some
personal responsibility for that situation. Tangential thinking would be
manifested by wandering off the topic and never providing the information
requested.
•
Throughout the assessment, the client displays disorganized thinking, jumping
from one idea to another with no clear relationship between the thoughts. The
nurse would assess the client as having which of the following?
•
Tangential thinking
•
Ideas of reference
•
•
Loose associations
W
o
r
d
s
al
a
d
A
n
s:
C
F
e
e
d
b
a
c
k
:
The client displayed ideas that were loosely associated to one another. Tangential
thinking is manifested by wandering off the topic and never providing the
information requested. Ideas of reference are the client's inaccurate interpretation
that general events are personally directed to him or her. Word salad is a flow of
unconnected words that convey no meaning to the listener.
•
Sexuality and self-harm behaviors are often difficult areas for nurses to
assess. An effective way for nurses to deal with this discomfort includes
•
recognizing that these areas may also be uncomfortable for the patient to discuss.
•
share feelings of discomfort with the patient.
•
defer assessing these areas to a more experienced nurse.
•
develop a standard question to ask of all patients during this area of
assessment Ans: A
Feedback:
Two areas that may be uncomfortable or difficult for the nurse to assess are
sexuality and self-harm behaviors. The beginning nurse may feel uncomfortable,
as if prying into personal matters, when asking questions about a client's intimate
relationships and behavior and any self-harm behaviors or thoughts of suicide.
Asking such questions, however, is essential to obtaining a thorough and
complete assessment. The nurse needs to remember that it may be uncomfortable
for the client to discuss these topics as well.
•
Which of the following is the most compelling reason for the nurse to discuss
matters of sexuality and suicide?
•
It is required by the law by the federal government and in most states in the union.
•
It is the nurse's professional responsibility to keep safety needs first and foremost.
•
This is commonly required documentation for every encounter with every client.
•
It allows the nurse to gain valuable experience in these kind
of difficult discussions.
Ans: B
Feedback:
It is the nurse's professional responsibility to keep the client's safety needs first
and foremost, and this includes overcoming any personal discomfort in talking
about suicide. This is not required by any laws nor is it commonly required
documentation for every encounter with every client. The nurse needs to gain
experience in these kind of difficult discussions, but that is not a compelling
reason for the nurse to discuss it if not warranted.
Chapter 8. The Nursing Process in Psychiatric-Mental Health Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
Which statement is most accurate regarding the assessment of clients diagnosed
with psychiatric problems?
1.
Medical history is of little significance and can be eliminated from the nursing
assessment.
2.
Assessment provides a holistic view of the client, including biopsychosocial
aspects.
3.
Comprehensive assessments can be performed only by advanced practice nurses.
4.
Psychosocial evaluations are gained by subjective reports rather than objective
observations.
____ 2.
Which statement regarding nursing interventions should a nurse identify as
accurate?
1.
Nursing interventions are independent from the treatment team’s goals.
2.
Nursing interventions are solely directed by written physician orders.
3.
Nursing interventions occur independently but in concert with overall treatment
team goals.
4.
Nursing interventions are standardized by policies and procedures.
____ 3.
Within the nurse’s scope of practice, which function is exclusive to the advanced
practice psychiatric nurse?
1.
2.
3.
4.
Teaching about the side effects of neuroleptic medications
Using psychotherapy to improve mental health status
Using milieu therapy to structure a therapeutic environment
Providing case management to coordinate continuity of health services
____ 4.
The nurse should recognize which acronym as representing problem-oriented
charting?
1.
SOAPIE
2.
APIE
3.
DAR
4.
PQRST
____ 5.
Which tool would be appropriate for a nurse to use when assessing mental acuity
prior to and immediately following electroconvulsive therapy (ECT)?
1.
CIWA scale
2.
GGT
3.
MMSE
4.
CAPS scale
____ 6.
What is being assessed when a nurse asks a client to identify name, date,
residential address, and situation?
1.
Mood
2.
Perception
3.
Orientation
4.
Affect
____
1.
2.
3.
4.
7.
What is the purpose of a nurse gathering client information?
It enables the nurse to modify behaviors related to personality disorders.
It enables the nurse to make sound clinical judgments and plan appropriate care.
It enables the nurse to prescribe the appropriate medications.
It enables the nurse to assign the appropriate Axis I diagnosis.
____ 8.
A nurse on an inpatient psychiatric unit implements care by scheduling client
activities, interacting with clients, and maintaining a safe therapeutic environment. These actions
reflect which role of the nurse?
1.
Health teacher
2.
Case manager
3.
Milieu manager
4.
Psychotherapist
1.
2.
3.
4.
Health teacher
Case manager
Milieu manager
Psychotherapist
____ 9.
The following outcome was developed for a client: “Client will list five personal
strengths by the end of day one.” Which correctly written nursing diagnostic statement most
likely generated the development of this outcome?
1.
Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
2.
Self-care deficit R/T altered thought process
3.
Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
4.
Risk for disturbed self-concept R/T hopelessness AEB suicide attempt
____
1.
2.
3.
4.
10.
How should a nurse prioritize nursing diagnoses?
By the established goal of care
By the life-threatening potential
By the physician’s priority of care
By the client’s preference
____ 11.
A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB MNA,
DFA, and daytime napping. Which is a correctly written and appropriate outcome for this client?
1.
The client will avoid daytime napping and attend all groups.
2.
The client will exercise, as needed, before bedtime.
3.
The client will sleep seven uninterrupted hours by day four of hospitalization.
4.
The client’s sleep habits will improve during hospitalization.
____ 12.
The following NANDA-I nursing diagnostic stem was developed for a client on
an inpatient unit: Risk for injury. What assessment data most likely led to the development of this
problem statement?
1.
The client is receiving ECT and is diagnosed with Parkinsonism.
2.
The client has a history of four suicide attempts in adolescence.
3.
The client expresses hopelessness and helplessness and isolates self.
4.
The client has disorganized thought processes and delusional thinking.
____ 13.
A student nurse asks an instructor how best to develop nursing outcomes for
clients. Which response by the instructor most accurately answers the student’s question?
1.
“You can use NIC, a standardized reference for nursing outcomes.”
2.
“Look at your client’s problems and set a realistic, achievable goal.”
3.
“With client collaboration, outcomes should be based on client problems.”
4.
“Copy your standard outcomes from a nursing care plan textbook.”
____ 14.
A client diagnosed with schizophrenia is exhibiting nonverbal behaviors
indicating that the client is hearing things that others do not. Which nursing diagnosis, which was
recently removed from the NANDA-I list, still accurately reflects this client’s problem?
1.
Disturbed thought processes
2.
Disturbed sensory perception
3.
Anxiety
4.
Chronic confusion
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 15.
Which of the following characteristics of accurately developed client outcomes
should a nurse identify? (Select all that apply.)
1.
Client outcomes are specifically formulated by nurses.
2.
Client outcomes are not restricted by time frames.
3.
Client outcomes are specific and measurable.
4.
Client outcomes are realistically based on client capability.
5.
Client outcomes are formally approved by the psychiatrist.
Other
16.
Number the following nursing interventions as they would proceed through the
steps of the nursing process.
________ Determine if an antianxiety medication is decreasing a client’s stress.
________ Measure a client’s vital signs and review past history.
________ Encourage deep breathing and teach relaxation techniques.
________ Aim, with client collaboration, for a seven-hour night’s sleep.
________ Recognize and document the client’s problem.
Completion
Complete each statement.
17.
A _________________ __________________ provides the basis for selection of
nursing interventions to achieve outcomes for which the nurse has accountability.
Chapter 0: The Nursing Process in Psychiatric/Mental Health Nursing
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 148
Heading: The Nursing Process > Assessment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Medical history is significant and should not be eliminated from the nursing
assessment.
The assessment of clients diagnosed with psychiatric problems should provide a
holistic view of the client.
Assessments can be completed by a variety of health-care providers.
The nurse should gather subject and objective information.
CON: Patient-Centered Care
2.
ANS: 3
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 156
Heading: Standards of Practice > Nursing Interventions Classification (NIC)
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Nursing interventions should be developed and implemented in collaboration with
other health-care professionals involved in the client’s care.
Nursing interventions are not solely directed by written physician orders.
The nurse should understand that nursing interventions occur independently but in
concert with overall treatment goals.
Nursing interventions are created in conjunction with standardized by policies and
procedures.
CON: Patient-Centered Care
3.
ANS: 2
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 156
Heading: The Nursing Process > Standard 5D. Prescriptive Authority and Treatment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Teaching about the side effects of neuroleptic medications can be completed by
Registered Nurses.
The advanced practice psychiatric nurse is authorized to use psychotherapy to
improve mental health. This includes individual, couples, group, and family
psychotherapy.
Using milieu therapy to structure a therapeutic environment can be completed by
Registered Nurses.
Providing case management to coordinate continuity of health services can be
completed by Registered Nurses.
CON: Patient-Centered Care
4.
ANS: 1
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Document client care that validates use of the nursing process.
Page: 162
Heading: Documentation of the Nursing Process > Problem-oriented Recording
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension (Understanding)
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
The acronym SOAPIE represents problem-oriented charting, which reflects the
subjective, objective, assessment, plan, implementation, and evaluation format.
APIE does not represent problem-oriented charting.
DAR does not represent problem-oriented charting.
PQRST does not represent problem-oriented charting.
PTS: 1
CON: Patient-Centered Care
5.
ANS: 3
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 147
Heading: The Nursing Process > Assessment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The CIWA scale, or clinical institute withdrawal assessment scale, would be used
to assess withdrawal from substances such as alcohol.
The GGT test is a blood test used to assess gamma-glutamyl transferase levels,
which may be an indication of alcoholism.
The MMSE, or mini mental status exam, would be the appropriate tool to use to
assess the mental acuity of a client prior to and immediately following ECT.
The CAPS refers to the clinician-administered PTSD scale and would be used to
assess signs and symptoms of PTSD.
CON: Patient-Centered Care
6.
ANS: 3
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric
setting.
Page: 155
Heading: Table 7-1 Brief Mental Status Evaluation
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
These questions do not assess mood.
These questions do not assess perception.
The nurse should ask the client to identify name, date, residential address, and
situation to assess the client’s orientation. Assessment of the client’s orientation to
reality is part of a mental status evaluation.
These questions do not assess affect.
1
2
3
4
PTS: 1
Feedback
These questions do not assess mood.
These questions do not assess perception.
The nurse should ask the client to identify name, date, residential address, and
situation to assess the client’s orientation. Assessment of the client’s orientation to
reality is part of a mental status evaluation.
These questions do not assess affect.
CON: Patient-Centered Care
7.
ANS: 2
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 156
Heading: The Nursing Process > Planning
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Modifying behaviors can occur after the nurse completes a thorough assessment.
The purpose of gathering client information is to enable the nurse to make sound
clinical judgments and plan appropriate care. The nurse should complete a
thorough assessment of the client, including information collected from the client,
significant others, and health-care providers.
After completing a thorough assessment, the nurse can prescribe the appropriate
medications.
After completing a thorough assessment, the nurse can assign the appropriate Axis
I diagnosis.
CON: Patient-Centered Care
8.
ANS: 3
Chapter: Chapter 0 The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric
setting.
Page: 156
Heading: The Nursing Process > Standard 5F. Milieu Therapy
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Health teaching involves promoting health in a safe environment.
Case management is used to organize client care so that outcomes are achieved.
The milieu manager implements care by scheduling client activities, interacting
with clients, and maintaining a safe therapeutic environment.
Psychotherapy involves conducting individual, couples, group, and family
counseling.
CON: Patient-Centered Care
9.
ANS: 1
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric
setting.
Page: 159
Heading: Applying the Nursing Process in the Psychiatric Setting
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should determine that altered self-esteem and self-deprecating
statements would generate the outcome to list personal strengths by the end of day
one.
The self-care deficit nursing diagnoses is incorrectly written.
Disturbed body image would generate specific outcomes in accordance with
specific needs and goals.
The risk for disturbed self-concept nursing diagnoses is incorrectly written.
CON: Patient-Centered Care
10.
ANS: 2
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric
setting.
Page: 159
Heading: Applying the Nursing Process in the Psychiatric Setting
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Client care goals can be met after safety has been established.
The nurse should prioritize nursing diagnoses related to their life-threatening
potential. Safety is always the nurse’s first priority.
The physician’s priority of care can be met after safety has been established.
The client can choose a goal as a priority after safety has been established.
CON: Patient-Centered Care
11.
ANS: 3
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Apply the six steps of the nursing process in the care of a client within the psychiatric
setting.
Page: 159
Heading: Applying the Nursing Process in the Psychiatric Setting
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Avoiding naps and attending all groups may not be realistic for this client.
Exercising before bedtime will not help the client overcome insomnia.
The outcome “The client will sleep seven uninterrupted hours by day four of
hospitalization” is accurately written and an appropriate outcome for a client
diagnosed with insomnia.
This diagnosis is not specific towards the client’s needs.
CON: Patient-Centered Care
12.
ANS: 1
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical
use and testing.
Page: 155
Heading: The Nursing Process > Standard 2. Diagnosis
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should identify that a client receiving ECT and who is diagnosed with
Parkinsonism is at risk for injury.
History of suicide, hopelessness, and disorganized thoughts would not lead the
nurse to formulate a nursing diagnostic stem of risk for injury.
History of hopelessness and helplessness would not lead the nurse to formulate a
nursing diagnostic stem of risk for injury.
History of disorganized thoughts and delusional thinking would not lead the nurse
to formulate a nursing diagnostic stem of risk for injury.
CON: Patient-Centered Care
13.
ANS: 3
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical
use and testing.
Page: 155
Heading: The Nursing Process > Standard 2. Diagnosis
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Using NIC does not help develop outcomes specific for the client.
This option is helpful, but the most attainable goals are set with collaboration.
Client outcomes are most realistic and achievable when there is collaboration
among the interdisciplinary team members, the client, and significant others.
Goals should be personalized for each client.
CON: Patient-Centered Care
14.
ANS: 2
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Discuss the list of nursing diagnoses approved by NANDA International for clinical
use and testing.
Page: 161
Heading: Applying the Nursing Process in the Psychiatric Setting
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nursing diagnosis, disturbed thought processes, does not accurately reflect the
client’s problem.
The nursing diagnosis disturbed sensory perception accurately reflects the client’s
symptoms of hearing things that others do not. The nursing diagnosis describes the
client’s condition and facilitates the prescription of interventions.
The nursing diagnosis, anxiety, does not accurately reflect the client’s problem.
The nursing diagnosis, chronic confusion, does not accurately reflect the client’s
problem.
CON: Patient-Centered Care
MULTIPLE RESPONSE
15.
ANS: 3, 4
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 155
Heading: Standard 3. Outcomes Identification
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
4. 5.
Feedback
Outcomes are most effective when formulated cooperatively by the
interdisciplinary team members, the client, and significant others.
Outcomes should be given a time frame.
The nurse should identify that client outcomes should be specific and measurable.
The nurse should identify that client outcomes should be based on client
capability.
Outcomes do not need to be approved by a psychiatrist.
PTS: 1
CON: Patient-Centered Care
ORDERED RESPONSE
16.
ANS:
2, 5, 4, 3, 1.
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 147
Heading: The Nursing Process
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: Measuring a client’s vital signs and reviewing past history is a nursing intervention
that occurs in the assessment step of the nursing process. Recognizing and documenting the
client’s problem occurs in the nursing diagnosis step. Setting a goal with client collaboration, for
a seven-hour night’s sleep occurs in the planning step. Encouraging deep breathing and teaching
relaxation techniques occurs in the implementation step. Determining if an antianxiety
medication is decreasing a client’s stress occurs in the evaluation step.
PTS: 1
CON: Patient-Centered Care
COMPLETION
17.
nursing diagnosis
ANS:
Chapter: Chapter 0, The Nursing Process in Psychiatric/Mental Health Nursing
Objective: Identify six steps of the nursing process and describe nursing actions associated with
each.
Page: 154
Heading: Core Concept
Integrated Processes: Nursing Process
Cognitive Level: Application [Applying]
Client Need: Psychosocial Integrity
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: Nursing diagnoses are clinical judgments about individual, family, or community
experiences/responses to actual or potential health problems/life processes. A nursing diagnosis
provides the basis for selection of nursing interventions to achieve outcomes for which the nurse
has accountability.
PTS: 1
CON: Patient-Centered Care
Chapter 9. Therapeutic Groups
1. An angry client on an inpatient unit approaches a nurse stating, Someone took my
lunch! People need to respect others, and you need to do something about this now!
The nurses response should be guided by which basic assumption of milieu therapy?
•
Conflict should be avoided at all costs on inpatient psychiatric units.
•
Conflict should be resolved by the nursing staff.
•
On inpatient units, every interaction is an opportunity for therapeutic intervention.
•
Conflict resolution should only be addressed during group therapy.
ANS: 3
Rationale: The nurses response should be guided by the basic assumption that every
interaction is an opportunity for therapeutic intervention. The nurse can use milieu
therapy to effect behavioral change and improve psychological health and functioning.
Cognitive Level:
Application Integrated
Process: Implementation
2. A client on an inpatient unit angrily says to a nurse, Peter is not cleaning up after
himself in the community bathroom. You need to address this problem. Which is the
appropriate nursing response?
•
Ill talk to Peter and present your concerns.
•
Why are you overreacting to this issue?
•
You should bring this to the attention of your treatment team.
•
I can see that you are angry. Lets discuss ways to approach Peter with your concerns.
ANS: 4
Rationale: The most appropriate nursing response involves restating the clients feeling and
developing a plan with the client to solve the problem. According to Skinner, every interaction is
an opportunity for therapeutic intervention to improve communication and relationshipdevelopment skills.
Cognitive Level:
Application Integrated
Process: Implementation
3. A newly admitted client asks, Why do we need a unit schedule? Im not going to these
groups. Im here to get some rest. Which is the most appropriate nursing response?
•
The purpose of group therapy is to learn and practice new coping skills.
•
Group therapy is mandatory. All clients must attend.
•
Group therapy is optional. You can go if you find the topic helpful and interesting.
•
Group therapy is an economical way of providing therapy to many clients concurrently.
ANS: 1
Rationale: The nurse should explain to the client that the purpose of group therapy is to learn and
practice new coping skills. The client owns his or her environment and can make
decisions to attend group or not.
Cognitive Level:
Application Integrated
Process: Implementation
4. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and
interactive during hospitalization but then decompensates after discharge. What does the
milieu provide that may be missing in the home environment?
•
Peer pressure
•
Structured programming
•
Visitor restrictions
•
Mandated activities
ANS: 2
Rationale: The milieu, or therapeutic community, provides the client with structured
programming that may be missing in the home environment. The therapeutic community
provides a structured schedule of activities in which interpersonal interaction and
communication with others are emphasized. Time is also devoted to personal problems
and focus groups.
Cognitive Level:
Application
Integrated Process:
Evaluation
•
•
•
•
•
To promote self-reliance, how should a psychiatric nurse best
conduct medication administration?
Encourage clients to request their medications at the appropriate times.
Refuse to administer medications unless clients request them at the appropriate times.
Allow the clients to determine appropriate medication times.
Take medications to the clients bedside at the appropriate times.
ANS: 1
Rationale: The psychiatric nurse promoting self-reliance would encourage clients to
request their medications at the appropriate times. Nurses are responsible for the
management of medication administration on inpatient psychiatric units, but nurses must
work with clients to encourage self- reliance and responsibility, which may result in
independent decision-making, leading to medication adherence.
Cognitive Level:
Application Integrated
Process: Implementation
6. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute
education group. What should the nurse identify as an appropriate group topic?
•
Dream analysis
•
Creative cooking
•
Paint by number
•
Stress management
ANS: 4
Rationale: The nurse should identify that teaching clients about stress management is
an appropriate education group topic. Nurses should be able to perform the role of
client teacher in
the psychiatric area. Nurses need to be able to assess a clients learning readiness. Other topics for
education groups include medical diagnoses, side effects of medications, and the importance of
medication adherence.
Cognitive Level:
Application
Integrated Process:
Planning
7. What is the best rationale for including family in the clients therapy within the
inpatient milieu?
•
To structure a program of social and work-related activities
•
To facilitate discharge from hospitalization
•
To provide a concrete demonstration of caring
•
To encourage the family to model positive behaviors
ANS: 2
Rationale: The nurse should include the clients family in therapy within the inpatient
milieu to facilitate discharge from the hospital. Family members are invited to
participate in some therapy groups and to share meals with the client in the communal
dining room. Family involvement may also serve to prevent the client from becoming
too dependent on the therapeutic environment.
Cognitive Level:
Application
Integrated Process:
Planning
8. How does a democratic form of self-government in the milieu contribute to client therapy?
•
By setting punishments for clients who violate the community rules
•
By dealing with inappropriate behaviors as they occur
•
By setting expectations wherein all clients are treated on an equal basis
•
By interacting with professional staff members to learn about therapeutic interventions
ANS: 3
Rationale: A democratic form of self-government in the milieu contributes to client
therapy by setting the expectation that all clients should be treated on an equal basis.
Clients participate in the decision-making and problem-solving aspects that affect
treatment setting. The norms, rules, and behavioral limits are established by the staff and
clients. All individuals have input.
Cognitive Level:
Application
Integrated Process:
Evaluation
9. A client is to undergo psychological testing. Which member of the interdisciplinary
team should a nurse consult for this purpose?
•
The psychiatrist
•
The psychiatric social worker
•
The clinical psychologist
•
The clinical nurse specialist
ANS: 3
Rationale: The nurse should consult with the clinical psychologist to obtain
psychological testing for the client. Clinical psychologists can administer, interpret, and
evaluate psychological tests to assist in the diagnostic process.
Cognitive Level:
Application
Integrated Process:
Planning
10. In the role of milieu manager, which activity should the nurse prioritize?
•
Setting the schedule for the daily unit activities
•
Evaluating clients for medication effectiveness
•
Conducting therapeutic group sessions
•
Searching newly admitted clients for hazardous objects
ANS: 4
Rationale: The milieu manager should search newly admitted clients for hazardous
objects. Safety of the client and others always takes priority. Nurses are responsible for
ensuring that the clients safety and physiological needs are met.
Cognitive Level:
Analysis Integrated
Process: Evaluation
Multiple Response
11. A nurse attends an interdisciplinary team meeting regarding a newly admitted
client. Which of the following individuals are typically included as members of the
interdisciplinary treatment team in psychiatry? (Select all that apply.)
•
Respiratory therapist and psychiatrist
•
Occupational therapist and psychologist
•
Recreational therapist and art therapist.
•
Social worker and hospital volunteer
•
Mental health technician and chaplain
ANS: 2, 3, 5
Rationale: The interdisciplinary treatment team in psychiatry consists of a psychologist,
occupational therapist, recreational therapist, art therapist, mental health technician, and
chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music
therapist, psychodramatist, and dietitian also participate in the interdisciplinary
treatment team.
Respiratory therapists and hospital volunteers are not included in the interdisciplinary
treatment team in psychiatry.
Cognitive Level:
Application Integrated
Process: Assessment
12. Which of the following conditions promote a therapeutic community? (Select all that apply.)
•
The unit schedule includes unlimited free time for personal reflection.
•
Unit responsibilities are assigned according to client capabilities.
•
A flexible schedule is determined by client needs.
•
The individual is the sole focus of therapy.
•
A democratic form of government exists.
ANS: 2, 5
Rationale: A therapeutic community is promoted when unit responsibilities are assigned
according to client capability and a democratic form of government exists. Therapeutic
communities are structured and provide therapeutic interventions that focus on
communication and relationship-development skills.
Cognitive Level:
Application Integrated
Process: Implementation
Fill-in-the-Blank
13. A scientific structuring of the environment in order to effect behavioral changes and
to improve the psychological health and functioning of the individual is defined as
therapy.
ANS: milieu
Rationale: Milieu therapy is defined as a scientific structuring of the environment in
order to effect behavioral changes and to improve the psychological health and
functioning of the individual. The goal of milieu therapy is to manipulate the
environment so that all aspects of the clients hospital experience are considered
therapeutic.
Chapter 10. Intervention with Families
1. During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style?
•
The nurse mandates that all group members reveal an embarrassing personal situation.
•
The nurse asks for a show of hands to determine group topic preference.
•
The nurse sits silently as the group members stray from the assigned topic.
•
The nurse shuffles through papers to determine the facility policy on length of group.
ANS: 3
Rationale: The nurse leader who sits silently and allows group members to stray from
the assigned topic is demonstrating a laissez-faire leadership style. This style allows
group members to do as they please with no direction from the leader. Group members
often become frustrated and confused in reaction to a laissez-faire leadership style.
Cognitive Level:
Application Integrated
Process: Implementation
2. During a community meeting, a nurse encourages clients to present unit problems and
discuss possible solutions. Which type of leadership style is the nurse demonstrating?
•
Democratic
•
Autocratic
•
Laissez-faire
•
Bureaucratic
ANS: 1
Rationale: The nurse who encourages clients to present problems and discuss solutions
is demonstrating a democratic leadership style. Democratic leaders share information
with group
members and promote decision-making by the members of the group. The leader
provides guidance and expertise as needed.
Cognitive Level:
Application Integrated
Process: Implementation
3. Which situation should a nurse identify as an example of an autocratic leadership style?
•
The president of Sigma Theta Tau assigns members to committees to research problems.
•
Without faculty input, the dean mandates that all course content be delivered via the
Internet.
•
During a community meeting, a nurse listens as clients generate solutions.
•
The student nurses association advertises for candidates for president.
ANS: 2
Rationale: The nurse should identify that mandating decisions without consulting the
group is considered an autocratic leadership style. Autocratic leadership increases
productivity but often reduces morale and motivation owing to lack of member input
and creativity.
Cognitive Level:
Application Integrated
Process: Implementation
4. A single, pregnant teenager in a parenting class discloses her ambivalence toward the
pregnancy and the subsequent guilt that these thoughts generate. A mother of three
admits to having felt that way herself. Which of Yaloms curative group factors does this
illustrate?
•
Imparting of information
•
Instillation of hope
•
Altruism
•
Universality
ANS: 4
Rationale: The scenario is an example of the curative group factor of universality.
Universality occurs when individuals realize that they are not alone in the problems,
thoughts, and feelings they are experiencing. This realization reduces anxiety by the
support and understanding of others.
Cognitive Level:
Analysis Integrated
Process: Evaluation
•
•
•
•
•
A client diagnosed with alcohol use disorder experiences a first relapse.
During an AA meeting, another group member states, I relapsed three times,
but now have been sober for 15 years. Which of Yaloms curative group
factors does this illustrate?
Imparting of information
Instillation of hope
Catharsis
Universality
ANS: 2
Rationale: This scenario is an example of the curative group factor instillation of
hope. This occurs when members observe the progress of others in the group with
similar problems and begin to believe that personal problems can also be resolved.
Cognitive Level:
Analysis Integrated
Process: Evaluation
6. During a group discussion, members freely interact with each other. Which member
statement is an example of Yaloms curative group factor of imparting information?
•
I found a Web site explaining the different types of brain tumors and their treatment.
•
My brother also had a brain tumor and now is completely cured.
•
I understand your fear and will be by your side during this time.
•
My mother was also diagnosed with cancer of the brain.
ANS: 1
Rationale: Yaloms curative group factor of imparting information involves group
members sharing knowledge gained through formal instruction as well as advice and
suggestions.
Cognitive Level:
Application Integrated
Process: Assessment
7. Prayer group members at a local Baptist church are meeting with a poor, homeless
family whom they are supporting. Which member statement is an example of Yaloms
curative group factor of altruism?
•
Ill give you the name of a friend that rents inexpensive rooms.
•
The last time we helped a family, they got back on their feet and prospered.
•
I can give you all of my baby clothes for your little one.
•
I can appreciate your situation. I had to declare bankruptcy last year.
ANS: 3
Rationale: Yaloms curative group factor of altruism occurs when group members
provide assistance and support to each other that creates a positive self-image and
promotes self-growth. Individuals gain self-esteem through mutual caring and concern.
Cognitive Level:
Application Integrated
Process: Assessment
8. During an inpatient educational group, a client shouts out, This information is
worthless. Nothing you have said can help me. These statements indicate to a nurse
leader that the client is assuming which group role?
•
The group role of aggressor
•
The group role of initiator
•
The group role of gatekeeper
•
The group role of blocker
ANS: 1
Rationale: The nurse should identify that the client is assuming the group role of the
aggressor. The aggressor expresses negativism and hostility toward others in the group
or to the group leader and may use sarcasm in an effort to degrade the status of others.
Cognitive Level:
Application Integrated
Process: Assessment
9. During a group session, which client statement demonstrates that the group has
progressed to the middle, or working, phase of group development?
•
Its hard for me to tell my story when Im not sure about the reactions of others.
•
I think Joes Antabuse suggestion is a good one and might work for me.
•
My situation is very complex, and I need professional, not peer, advice.
•
I am really upset that you expect me to solve my own problems.
ANS: 2
Rationale: The nurse should recognize that group members have progressed to the
working phase of group development when members begin to look to each other instead
of to the leader for guidance. Group members in the working phase begin to accept
criticism from each other and use it constructively to create change.
Cognitive Level:
Application
Integrated Process:
Evaluation
10. Which group leader activity should a nurse identify as being most effective in the
final, or termination, phase of group development?
•
The group leader establishes the rules that will govern the group after discharge.
•
The group leader encourages members to rely on each other for problem solving.
•
The group leader presents and discusses the concept of group termination.
•
The group leader helps the members to process feelings of loss.
ANS: 4
Rationale: The most effective intervention in the final, or termination, phase of group
development would be for the group leader to help the members to process feelings of
loss. The leader should encourage the members to review the goals and discuss
outcomes, reminisce about what has occurred, and encourage members to provide
feedback to each other about progress.
Cognitive Level:
Application Integrated
Process: Assessment
11. A nursing instructor is teaching students about self-help groups like Alcoholics
Anonymous (AA). Which student statement indicates that learning has occurred?
•
There is little research to support AAs effectiveness.
•
Self-help groups used to be the treatment of choice, but their popularity is waning.
•
These groups have no external regulation, so clients need to be cautious.
•
Members themselves run the group, with leadership usually rotating among the members.
ANS: 4
Rationale: The student indicates an understanding of self-help groups when stating,
Members themselves run the group, with leadership usually rotating among the
members. Nurses may or may not be involved in self-help groups. These groups allow
members to talk about feelings and reduce feelings of isolation, while receiving support
from others undergoing similar experiences.
Cognitive Level:
Application
Integrated Process:
Evaluation
12. When planning group therapy, a nurse should identify which configuration as most
optimal for a therapeutic group?
•
•
•
•
Open-ended membership; circle of chairs; group size of 5 to 10 members
Open-ended membership; chairs around a table; group size of 10 to 15 members
Closed membership; circle of chairs; group size of 5 to 10 members
Closed membership; chairs around a table; group size of 10 to 15 members
ANS: 3
Rationale: The nurse should identify that the most optimal conditions for a therapeutic
group is one in which the membership is closed and in which the group size is
between 5 and 10 members, who are arranged in a circle of chairs. The focus of
therapeutic groups is directed to relations within the group and the interactions among
group members.
Cognitive Level:
Application
Integrated Process:
Planning
13. During the sixth week of a 10-week parenting skills group, a nurse observes as
several members get into a heated dispute about spanking. As a group, they decide to
create a pros-and- cons poster on the use of physical discipline. At this time, what is
the role of the group leader?
•
The leader should referee the debate.
•
The leader should adamantly oppose physical disciplining measures.
•
The leader should redirect the group to a less-controversial topic.
•
The leader should encourage the group to solve the problem collectively.
ANS: 4
Rationale: The role of the group leader is to encourage the group to solve the problem
collectively. A democratic leadership style supports members in their participation and
problem- solving. Members are encouraged to solve issues that relate to the group
cooperatively.
Cognitive Level:
Application Integrated
Process: Implementation
14. A 10-week, prenuptial counseling group composed of five couples is terminating. At
the last group meeting, a nurse notices that the two most faithful and participative
couples are absent. When considering concepts of group development, what might
explain this behavior?
•
They are experiencing problems with termination, leading to feelings of abandonment.
•
They did not think any new material would be covered at the last session.
•
They were angry with the leader for not extending the length of the group.
•
They were bored with the material covered in the group.
ANS: 1
Rationale: The nurse should determine that the clients absence from the final group
meeting may indicate that they are experiencing problems with termination. The
termination phase of group development may elicit feelings of abandonment and anger.
Successful termination may help members develop skills to cope with future unrelated
losses.
Cognitive Level:
Application
Integrated Process:
Evaluation
15. An experienced psychiatric registered nurse has taken a new position leading groups
in a day treatment program. Which group is this nurse most qualified to lead?
•
A psychodrama group
•
•
•
A psychotherapy group
A parenting group
A family therapy group
ANS: 3
Rationale: A psychiatric registered nurse is qualified to lead a parenting group. A
parenting group can be classified as either a teaching group or therapeutic group.
Psychodrama, psychotherapy, and family therapy are forms of group therapy and must
be lead by qualified leaders who generally have advanced degrees in psychology, social
work, nursing, or medicine.
Cognitive Level:
Application Integrated
Process: Implementation
16. A nursing instructor is teaching about psychodrama, a specialized type of therapeutic
group. Which student statement indicates that further teaching is necessary?
•
Psychodrama provides a safe setting in which to discuss painful issues.
•
In psychodrama, the client is the protagonist.
•
In psychodrama, the client observes actor interactions from the audience.
•
Psychodrama facilitates resolution of interpersonal conflicts.
ANS: 2
Rationale: The nurse should educate the student that in psychodrama the client plays the
role of him or herself in a life-situation scenario and is called the protagonist. During
psychodrama, the client does not observe interactions from the audience. Other group
members perform the role of the audience and discuss the situation they have observed,
offer feedback, and express their feelings. Leaders of psychodrama must have
specialized training to become a psychodramatist.
Cognitive Level:
Application
Integrated Process:
Evaluation
Multiple Response
17. Which of the following behavioral skills should a nurse implement when leading a group that
is functioning in the orientation phase of group development? (Select all that apply.)
•
Encourage members to provide feedback to each other about individual progress.
•
Ensure that group rules do not interfere with goal fulfillment.
•
Work with group members to establish rules that will govern the group.
•
Emphasize the need for and importance of confidentiality within the group.
•
Help the leader to resolve conflicts and foster cohesiveness within the group.
ANS: 2, 3, 4
Rationale: During the orientation phase of group development, the nurse leader should
work together with members to establish rules that will govern the group. The leader
should ensure that group rules do not interfere with goal fulfillment and establish the
need for and importance of confidentiality within the group. Members need to establish
trust and cohesion in order to move into the working phase.
Cognitive Level:
Application Integrated
Process: Implementation
Ordered Response
18. Order the following leadership expectations that occur in the three phases of
the group development process.
The leader encourages members to provide feedback to each other about
individual progress and to review goals and discuss outcomes.
The leader promotes an environment of trust and ensures that rules
established by the group do not interfere with fulfillment of the goals.
The leader helps to resolve conflict and fosters cohesiveness, while ensuring that
members do not deviate from the intended task.
ANS: The correct order
is 3, 1, 2 Rationale:
•
•
•
In the Initial, or Orientation, phase, the leader is expected to orient members to
specific group processes, encourage members to participate without disclosing
too much too soon, promote an environment of trust, and ensure that rules
established by the group do not interfere with fulfillment of the goals.
In the Middle, or Working, phase, the role of leader diminishes and becomes
more one of facilitator. Some leadership functions are shared by certain
members of the group as they progress toward resolution. The leader helps to
resolve conflicts and continues to foster cohesiveness among the members,
while ensuring that they do not deviate from the intended task or purpose for
which the group was organized.
In the Final, or Termination, phase, the leader encourages the group members to
reminisce about what has occurred within the group, to review the goals and
discuss the actual outcomes, and to encourage members to provide feedback to
each other about individual progress within the group. The leader encourages
members to discuss feelings of loss associated with termination of the group.
Cognitive Level: Analysis
Integrated Process:
Implementation
Fill-in-the-Blank
19. A is a collection of individuals whose association is founded on
shared commonalities of interest, values, norms, or purpose.
ANS: group
Rationale: A group is a collection of individuals whose association is founded on
shared commonalities of interest, values, norms, or purpose. Membership in a group is
generally by chance (born into the group), by choice (voluntary affiliation), or by
circumstance (the result of life-cycle events over which an individual may or may not
have control).
Chapter 11. Milieu Therapy—The Therapeutic Community
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
An angry client on an inpatient unit approaches a nurse stating, “Someone took
my lunch! People need to respect others, and you need to do something about this now!” The
nurse’s response should be guided by which basic assumption of milieu therapy?
1.
Conflict should be avoided at all costs on inpatient psychiatric units.
2.
Conflict should be resolved by the nursing staff.
3.
On inpatient units, every interaction is an opportunity for therapeutic intervention.
4.
Conflict resolution should only be addressed during group therapy.
____ 2.
A client on an inpatient unit angrily says to a nurse, “Peter is not cleaning up after
himself in the community bathroom. You need to address this problem.” Which is the appropriate
nursing response?
1.
“I’ll talk to Peter and present your concerns.”
2.
“Why are you overreacting to this issue?”
3.
“You should bring this to the attention of your treatment team.”
4.
“I can see that you are angry. Let’s discuss ways to approach Peter with your
concerns.”
____ 3.
A newly admitted client asks, “Why do we need a unit schedule? I’m not going to
these groups. I’m here to get some rest.” Which is the most appropriate nursing response?
1.
“The purpose of group therapy is to learn and practice new coping skills.”
2.
“Group therapy is mandatory. All clients must attend.”
3.
“Group therapy is optional. You can go if you find the topic helpful and
interesting.”
4.
“Group therapy is an economical way of providing therapy to many clients
concurrently.”
____ 4.
A client diagnosed with schizophrenia functions well and is bright, spontaneous,
and interactive during hospitalization but then decompensates after discharge. What does the
milieu provide that may be missing in the home environment?
1.
Peer pressure
2.
Structured programming
3.
Visitor restrictions
4.
Mandated activities
____ 5.
To promote self-reliance, how should a psychiatric nurse best conduct medication
administration?
1.
Encourage clients to request their medications at the appropriate times.
2.
Refuse to administer medications unless clients request them at the appropriate
times.
3.
Allow the clients to determine appropriate medication times.
4.
Take medications to the clients’ bedside at the appropriate times.
____ 6.
A nurse working on an inpatient psychiatric unit is assigned to conduct a 45minute education group. What should the nurse identify as an appropriate group topic?
1.
Dream analysis
2.
Creative cooking
3.
Paint by number
4.
Stress management
1.
2.
3.
4.
Dream analysis
Creative cooking
Paint by number
Stress management
____ 7.
What is the best rationale for including family in the client’s therapy within the
inpatient milieu?
1.
To structure a program of social and work-related activities
2.
To facilitate discharge from hospitalization
3.
To provide a concrete demonstration of caring
4.
To encourage the family to model positive behaviors
____ 8.
How does a democratic form of self-government in the milieu contribute to client
therapy?
1.
By setting punishments for clients who violate the community rules
2.
By dealing with inappropriate behaviors as they occur
3.
By setting expectations wherein all clients are treated on an equal basis
4.
By interacting with professional staff members to learn about therapeutic
interventions
____ 9.
A client is to undergo psychological testing. Which member of the
interdisciplinary team should a nurse consult for this purpose?
1.
The psychiatrist
2.
The psychiatric social worker
3.
The clinical psychologist
4.
The clinical nurse specialist
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 10.
A nurse attends an interdisciplinary team meeting regarding a newly admitted
client. Which of the following individuals are typically included as members of the
interdisciplinary treatment team in psychiatry? (Select all that apply.)
1.
Respiratory therapist and psychiatrist
2.
Occupational therapist and psychologist
3.
Recreational therapist and art therapist
4.
Social worker and hospital volunteer
5.
Mental health technician and chaplain
____ 11.
Which of the following conditions promote a therapeutic community? (Select all
that apply.)
1.
The unit schedule includes unlimited free time for personal reflection.
2.
Unit responsibilities are assigned according to client capabilities.
3.
A flexible schedule is determined by client needs.
4.
The individual is the sole focus of therapy.
5.
A democratic form of government exists.
Completion
Complete each statement.
12.
A scientific structuring of the environment in order to af fect behavioral changes
and to improve the psychological health and functioning of the individual is defined as
________________________ therapy.
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Identify seven basic assumptions of a therapeutic community.
Page: 172
Heading: Basic Assumptions
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
Feedback
Conflict is often hard to avoid, and at times is resolved between clients or other
staff members.
Conflict should be resolved between clients or other staff members.
The nurse’s response should be guided by the basic assumption that every
interaction is an opportunity for therapeutic intervention.
Conflict resolution should be addressed as soon as it is therapeutic to the
individuals involved.
1
2
3
4
PTS: 1
2.
CON: Communication
ANS: 4
Chapter: Chapter 0 Milieu Therapy—The Therapeutic Community
Objective: Identify seven basic assumptions of a therapeutic community.
Page: 173
Heading: Basic Assumptions
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
It would be inappropriate for the nurse to solve the problem for the client.
It would be inappropriate for the nurse to ignore the conflict.
The nurse should not pass the conflict off to other members of the treatment team,
but should assist the client in handling it immediately.
The most appropriate nursing response involves restating the client’s feeling and
developing a plan with the client to solve the problem. According to Skinner,
every interaction is an opportunity for therapeutic intervention to improve
communication and relationship-development skills.
CON: Communication
3.
ANS: 1
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Identify seven basic assumptions of a therapeutic community.
Page: 172
Heading: Basic Assumptions
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1
2
3
4
Feedback
The nurse should explain to the client that the purpose of group therapy is to learn
and practice new coping skills.
The client owns his or her environment and can make decisions to attend group or
not.
Group therapy is encouraged so that the client can learn new coping skills.
Group therapy is important because it teaches clients how to interact with others
and problem solve.
PTS: 1
CON: Communication
4.
ANS: 2
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Discuss conditions that characterize a therapeutic community.
Page: 173
Heading: Conditions That Promote a Therapeutic Community Integrated
Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The milieu does not provide peer pressure.
The milieu, or therapeutic community, provides the client with structured
programming that may be missing in the home environment. The therapeutic
community provides a structured schedule of activities in which interpersonal
interaction and communication with others are emphasized. Time is also devoted
to personal problems and focus groups.
The milieu does not provide visitor restrictions.
The milieu does not provide mandated activities.
CON: Patient-Centered Care
5.
ANS: 1
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 175
Heading: The Role of the Nurse in Milieu Therapy
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application (Application)
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
Feedback
The psychiatric nurse promoting self-reliance would encourage clients to request
their medications at the appropriate times. Nurses are responsible for the
management of medication administration on inpatient psychiatric units, but
nurses must work with clients to encourage self-reliance and responsibility, which
may result in independent decision-making, leading to medication adherence.
Refusing to administer medication does not promote self-reliance.
Allowing clients to choose medication times does not promote self-reliance.
Taking medications to the bedside does not promote self-reliance.
2
3
4
PTS: 1
their medications at the appropriate times. Nurses are responsible for the
management of medication administration on inpatient psychiatric units, but
nurses must work with clients to encourage self-reliance and responsibility, which
may result in independent decision-making, leading to medication adherence.
Refusing to administer medication does not promote self-reliance.
Allowing clients to choose medication times does not promote self-reliance.
Taking medications to the bedside does not promote self-reliance.
CON: Patient-Centered Care
6.
ANS: 4
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 175
Heading: The Role of the Nurse in Milieu Therapy
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Teaching dream analysis does not teach clients the life skills that they need to
become self-reliant.
Teaching creative cooking does not teach clients the life skills that they need to
become self-reliant.
Teaching paint by number does not teach clients the life skills that they need to
become self-reliant.
The nurse should identify that teaching clients about stress management is an
appropriate education group topic. Nurses should be able to perform the role of
client teacher in the psychiatric area. Nurses need to be able to assess a client’s
learning readiness. Other topics for education groups include medical diagnoses,
side effects of medications, and the importance of medication adherence.
CON: Patient-Centered Care
7.
ANS: 2
Chapter: Chapter 0: Milieu Therapy—The Therapeutic Community
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 179
Heading: Summary and Key Points
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The family is not expected to structure a program of social and work-related
activities
The nurse should include the client’s family in therapy within the inpatient milieu
to facilitate discharge from the hospital. Family members are invited to participate
in some therapy groups and to share meals with the client in the communal dining
room. Family involvement may also serve to prevent the client from becoming too
dependent on the therapeutic environment.
The family is not included to provide a concrete demonstration of caring.
The family is not included to model positive behaviors.
CON: Patient-Centered Care
8.
ANS: 3
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Discuss conditions that characterize a therapeutic community.
Page: 173
Heading: Conditions That Promote a Therapeutic Community Integrated
Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Setting punishments does not represent a democratic self-government.
Dealing with inappropriate behaviors as they occur does not represent a
democratic self-government.
A democratic form of self-government in the milieu contributes to client therapy
by setting the expectation that all clients should be treated on an equal basis.
Clients participate in the decision-making and problem-solving aspects that affect
treatment setting. The norms, rules, and behavioral limits are established by the
staff and clients.
Interacting with staff members does not does not represent a democratic selfgovernment.
CON: Patient-Centered Care
9.
ANS: 3
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Identify the various therapies that may be included within the program of the
therapeutic community and the health-care workers that make up the interdisciplinary treatment
team.
Page: 176–177
Heading: Table 8-1 The Interdisciplinary Treatment Team in Psychiatry
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Consulting the psychiatrist would be inappropriate in this scenario.
Consulting the psychiatric social worker would be inappropriate in this scenario.
The nurse should consult with the clinical psychologist to obtain psychological
testing for the client. Clinical psychologists can administer, interpret, and evaluate
psychological tests to assist in the diagnostic process.
Consulting the clinical nurse specialist would be inappropriate in this scenario.
CON: Patient-Centered Care
MULTIPLE RESPONSE
10.
ANS: 2, 3, 5
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Identify the various therapies that may be included within the program of the
therapeutic community and the health-care workers that make up the interdisciplinary treatment
team.
Page: 176–177
Heading: Table 8-1 The Interdisciplinary Treatment Team in Psychiatry
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-centered Care
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
The respiratory therapist and psychiatrist are not typical members of the
interdisciplinary treatment team in psychiatry.
The occupational therapist and psychologist participate in the interdisciplinary
treatment team.
The recreational therapist and art therapist participate in the interdisciplinary
treatment team.
The social worker and hospital volunteer do not participate in the interdisciplinary
treatment team.
Mental health technician and chaplain participate in the interdisciplinary treatment
team.
interdisciplinary treatment team in psychiatry.
The occupational therapist and psychologist participate in the interdisciplinary
treatment team.
The recreational therapist and art therapist participate in the interdisciplinary
treatment team.
The social worker and hospital volunteer do not participate in the interdisciplinary
treatment team.
Mental health technician and chaplain participate in the interdisciplinary treatment
team.
2.
3.
4.
5.
PTS: 1
CON: Patient-Centered Care
11.
ANS: 2, 5
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Discuss conditions that characterize a therapeutic community.
Page: 179
Heading: Summary and Key Points
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
Feedback
Unlimited free time does not promote a therapeutic community.
A therapeutic community is promoted when unit responsibilities are assigned
according to client capability.
Flexible schedules do not promote a therapeutic community.
Sole focus of one individual during therapy does not promote a therapeutic
community.
A therapeutic community is promoted when a democratic form of government
exists.
1.
2.
3.
4.
5.
PTS: 1
CON: Patient-Centered Care
COMPLETION
12.
ANS:
milieu
Chapter: Chapter 0, Milieu Therapy—The Therapeutic Community
Objective: Define Milieu therapy
Page: 172
Heading: Milieu, Defined
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
Feedback: Milieu therapy is defined as a scientific structuring of the environment in order to
effect behavioral changes and to improve the psychological health and functioning of the
individual. The goal of milieu therapy is to manipulate the environment so that all aspects of the
client’s hospital experience are considered therapeutic.
PTS: 1
CON: Patient-Centered Care
Chapter 12. Crisis Intervention
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A new mother is concerned about her ability to perform her parental role. She is
quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a
nurse should be familiar with what information about this type of crisis?
1.
This type of crisis is precipitated by unexpected external stressors.
2.
This type of crisis is precipitated by preexisting psychopathology.
3.
This type of crisis is precipitated by an acute response to an external situational
stressor.
4.
This type of crisis is precipitated by normal life-cycle transitions that overwhelm
the client.
____ 2.
A wife brings her husband to an emergency department after an attempt to hang
himself. He is a full-time student and works 8 hours at night to support his family. He states, “I
can’t function any longer under all this stress.” Which type of crisis is the client experiencing?
1.
Maturational/developmental crisis
2.
Psychiatric emergency crisis
3.
Anticipated life transition crisis
4.
Traumatic stress crisis
____ 3.
A client comes to a psychiatric clinic experiencing sudden extreme fatigue and
decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a
numeric scale. What long-term outcome is realistic in addressing this client’s crisis?
1.
The client will change his type-A personality traits to more adaptive ones by one
week.
2.
The client will list five positive self-attributes.
3.
The client will examine how childhood events led to his overachieving orientation.
4.
The client will return to previous adaptive levels of functioning by week six.
____ 4.
A high school student has learned that she cannot graduate. Her boyfriend will be
attending a college out of state that she planned to attend. She is admitted to a psychiatric unit
after overdosing on Tylenol. Which is the priority nursing diagnosis for this client?
1.
Ineffective coping R/T situational crisis AEB powerlessness
2.
Anxiety R/T fear of failure
3.
Risk for self-directed violence R/T hopelessness
4.
Risk for low self-esteem R/T loss events AEB suicidal ideations
____ 5.
After threatening to jump off of a bridge, a client is brought to an emergency
department by police. To assess for suicide potential, which question should a nurse ask first?
1.
“Are you currently thinking about harming yourself?”
2.
“Why do you want to harm yourself?”
3.
“Have you thought about the consequences of your actions?”
4.
“Who is your emergency contact person?”
____ 6.
An involuntarily committed client, when offered a dinner tray, pushes it off the
bedside table onto the floor. Which nursing intervention should a nurse implement to address this
behavior?
1.
Initiate forced medication protocol.
2.
Help the client to explore the source of anger.
3.
Ignore the act to avoid reinforcing the behavior.
4.
With staff support and a show of solidarity, set firm limits on the behavior.
____ 7.
A college student, who was nearly raped while jogging, completes a series of
appointments with a rape crisis nurse. At the final session, which client statement most clearly
suggests that the goals of crisis intervention have been met?
1.
“You’ve really been helpful. Can I count on you for continued support?”
2.
“I work out in the college gym rather than jogging outdoors.”
3.
“I’m really glad I didn’t go home. It would have been hard to come back.”
4.
“I carry mace when I jog. It makes me feel safe and secure.”
____ 8.
A despondent client who has recently lost her husband of 30 years tearfully states,
“I’ll feel a lot better if I sell my house and move away.” Which nursing response is most
appropriate?
1.
“I’m confident you know what’s best for you.”
2.
“This may not be the best time for you to make such an important decision.”
3.
“Your children will be terribly disappointed.”
4.
“Tell me why you want to make this change.”
____ 9.
An inpatient client with a known history of violence suddenly begins to pace.
Which additional client behavior should alert a nurse to escalating anger and aggression?
1.
The client requests prn medications.
2.
The client has a tense facial expression and body language.
3.
The client refuses to eat lunch.
4.
The client sits in group with back to peers.
____ 10.
What is the best nursing rationale for holding a debriefing session with clients and
staff after a take-down intervention has taken place in an inpatient unit?
1.
Reinforce unit rules with the client population.
2.
Create protocols for the future release of tensions associated with anger.
3.
Process client feelings and alleviate fears of undeserved seclusion and restraint.
4.
Discuss the situation that led to inappropriate expressions of anger.
____ 11.
A nursing instructor is teaching about the Roberts’ Seven-stage Crisis Intervention
Model. Which nursing action should be identified with Stage IV?
1.
Collaboratively implement an action plan.
2.
Help the client identify the major problems or crisis precipitants.
3.
Help the client deal with feelings and emotions.
4.
Collaboratively generate and explore alternatives.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 12.
Which of the following nursing statements or questions represent appropriate
communication to assess an individual in crisis? (Select all that apply.)
1.
“Tell me what happened.”
2.
“What coping methods have you used, and did they work?”
3.
“Describe to me what your life was like before this happened.”
4.
“Let’s focus on the current problem.”
5.
“I’ll assist you in selecting functional coping strategies.”
____ 13.
Which of the following interventions should a nurse use when caring for an
inpatient client who expresses anger inappropriately? (Select all that apply.)
1.
Maintain a calm demeanor.
2.
Clearly delineate the consequences of the behavior.
3.
Use therapeutic touch to convey empathy.
4.
Set limits on the behavior.
5.
Teach the client to avoid “I” statements related to expression of feelings.
1.
2.
3.
4.
5.
Maintain a calm demeanor.
Clearly delineate the consequences of the behavior.
Use therapeutic touch to convey empathy.
Set limits on the behavior.
Teach the client to avoid “I” statements related to expression of feelings.
____ 14.
Which of the following are behavior assessment categories in the Broset Violence
Checklist? (Select all that apply.)
1.
Confusion
2.
Paranoia
3.
Boisterousness
4.
Panic
5.
Irritability
Other
15.
Order the following stages of Roberts’ Seven-stage Crisis Intervention Model.
________ Deal with feelings and emotions.
________ Generate and explore alternatives.
________ Rapidly establish rapport.
________ Psychosocial and lethality assessment.
________ Identify the major problems or crisis precipitants.
________ Follow up.
________ Implement an action plan.
Completion
Complete each statement.
16.
A sudden event in one’s life that disturbs homeostasis, during which usual coping
mechanisms cannot resolve the problem, can be defined as a ______________________.
Answer Section
MULTIPLE CHOICE
1.
ANS: 4
Chapter: Chapter 0, Crisis Intervention
Objective: Identify types of crisis that occur in people’s lives.
Page: 196
Heading: Types of Crises > Class 2: Crises of Anticipated Life Transitions
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This type of stress is not caused by unexpected external stressors.
This type of stress is not caused by preexisting psychopathology.
This type of stress is not caused by an acute response to an external situational
stressor.
The nurse should understand that this type of crisis is precipitated by normal lifecycle transitions that overwhelm the client. Reassurance and guidance should be
provided as needed, and the client should be referred to services that can provide
assistance.
CON: Health Promotion
2.
ANS: 2
Chapter: Chapter 0, Crisis Intervention
Objective: Identify types of crisis that occur in people’s lives.
Page: 197
Heading: Types of Crises > Class 6: Psychiatric Emergencies
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client is not experiencing a maturational/developmental crisis.
The nurse should determine that the client is experiencing a psychiatric emergency
crisis. Psychiatric emergencies occur when crisis situations result in severe
impairment, incompetence, or an inability to assume personal responsibility.
The client is not experiencing an anticipated life transition crisis.
The client is not experiencing a traumatic stress crisis.
CON: Health Promotion
3.
ANS: 4
Chapter: Chapter 0, Crisis Intervention
Objective: Describe the steps in crisis intervention.
Page: 197
Heading: Types of Crises > Class 5: Crisis Reflecting Psychopathology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Changing his type-A personality traits to more adaptive ones by one week may be
unrealistic for this client.
Listing five positive self-attributes may not be realistic for this client.
Examining childhood events may not be realistic for this client.
The nurse should identify that a realistic long-term outcome for this client is to
return to previous adaptive levels of functioning. The nurse should work with the
client to develop attainable outcomes that reflect immediacy of the situation.
CON: Health Promotion
4.
ANS: 3
Chapter: Chapter 0, Crisis Intervention
Objective: Describe the steps in crisis intervention.
Page: 201–202
Heading: Table 10-1. Nursing Diagnosis: Risk for Self-directed or Other Directed Violence
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Ineffective coping R/T situational crisis AEB powerlessness is inappropriate
because safety is a priority.
Anxiety R/T fear of failure is inappropriate because safety is a priority.
The priority nursing diagnosis for this client is risk for self-directed violence R/T
hopelessness. Nurses should prioritize diagnoses and outcomes based on potential
safety risk to the client or others.
Risk for low self-esteem R/T loss events AEB suicidal ideations is inappropriate
because safety is a priority.
CON: Health Promotion
5.
ANS: 1
Chapter: Chapter 0, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 203
Heading: Phases of Crises Intervention: The Role of the Nurse > Phase 1: Assessment
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should first assess the client for current harmful or suicidal thoughts to
minimize risk of harm to the client and provide appropriate interventions. A
suicidal client is experiencing a psychiatric emergency. The crisis team’s priority is
to assess client safety.
This question is important after the immediate risk of harm has been ruled out.
This question should be addressed after the client is safe.
The client’s safety should be assessed prior to asking this question.
CON: Health Promotion
6.
ANS: 4
Chapter: Chapter 0, Crises Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 205
Heading: Phases of Crises Intervention: The Role of the Nurse > Phase 3: Intervention
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Pushing food onto the floor should not warrant forced medication. This
intervention may be too restrictive, considering the behavior.
Exploring the source of anger may be more appropriate once the client has
resolved the current emotion or in a therapeutic group setting.
Ignoring the act may further upset the client and is not a method of teaching
appropriate behavior.
The most appropriate nursing intervention is to set firm limits on the behavior.
CON: Health Promotion
7.
ANS: 4
Chapter: Chapter 0, Crisis Intervention
Objective: Identify the role of the nurse in crises intervention.
Page: 205
Heading: Phases of Crises Intervention: The Role of the Nurse > Phase 4: Evaluation of Crisis
Resolution and Anticipatory Resolution
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Asking for continued support does not indicate the development of adaptive
coping strategies.
This statement may indicate fear.
This statement indicates that the client has not developed coping strategies.
The nurse should evaluate that the client who has developed adaptive coping
strategies has achieved the goals of crisis intervention. The final phase of crisis
intervention involves evaluating the outcome of the crisis intervention and
anticipatory planning.
CON: Health Promotion
8.
ANS: 2
Chapter: Chapter 0, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 205
Heading: Phases of Crises Intervention: The Role of the Nurse > Phase 3: Intervention
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
This statement does not help the client in solving the problem.
During crisis intervention, the nurse should guide the client through a problemsolving process. The nurse should help the individual confront the source of the
problem, encourage the individual to discuss changes he or she would like to
make, and encourage exploration of feelings about aspects of the crisis that cannot
be changed.
This statement is not therapeutic to the client.
The nurse should also assist the client in determining whether any changes are
realistic.
PTS: 1
CON: Health Promotion
9.
ANS: 2
Chapter:
, Crisis Intervention
Objective: Identify the role of the nurse in crises intervention.
Page: 198
Heading: Crisis on the Inpatient Unit: Anger and Aggression Management
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
Feedback
1
Requesting prn medications is not an indication that anger is escalating.
2
The nurse should assess that tense facial expressions and body language may
indicate that a client’s anger is escalating.
3
Refusing lunch does not indicate that anger is escalating.
4
Sitting with peers does not indicate that anger is escalating.
PTS: 1
CON: Health Promotion
10.
ANS: 4
Chapter: Chapter 0, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 199
Heading: Crisis on the Inpatient Unit: Anger and Aggression Management
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
Reinforcing unit rules is important but does not help process feelings about the
situation.
Creating protocols does not help process feelings about the situation.
Processing feelings related to seclusion and restraint does not help clients through
the take-down intervention.
The nurse should determine that the purpose for holding a debriefing session with
clients and staff after a take-down intervention is to discuss the situation that led to
inappropriate behavior. It is important to determine the factors leading to the
inappropriate behavior in order to develop future intervention strategies. It is also
important to help clients and staff process feelings about the situation.
1
2
3
4
PTS: 1
Reinforcing unit rules is important but does not help process feelings about the
situation.
Creating protocols does not help process feelings about the situation.
Processing feelings related to seclusion and restraint does not help clients through
the take-down intervention.
The nurse should determine that the purpose for holding a debriefing session with
clients and staff after a take-down intervention is to discuss the situation that led to
inappropriate behavior. It is important to determine the factors leading to the
inappropriate behavior in order to develop future intervention strategies. It is also
important to help clients and staff process feelings about the situation.
CON: Health Promotion
11.
ANS: 3
Chapter: Chapter 0, Crisis Intervention
Objective: Describe the steps in crisis intervention.
Page: 203
Heading: Phases of Crisis Intervention > The Role of the Nurse
Integrated Process: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Stage VI: Implement an Action Plan
Stage III: Identify the Major Problems or Crisis Precipitants
Stage IV: Deal with Feelings and Emotions
Stage V: Generate and Explore Alternatives
CON: Health Promotion
MULTIPLE RESPONSE
12.
ANS: 1, 2, 3
Chapter: Chapter 0, Crisis Intervention
Objective: Describe the steps in crisis intervention.
Page: 203
Heading: Phases of Crises Intervention: The Role of the Nurse > Phase 1: Assessment
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is an appropriate statement to encourage the client to communicate.
This statement enables the client to evaluate current coping strategies for
effectiveness.
This is an appropriate statement to encourage the client to communicate.
Focusing on the current problem would not occur until after a complete
assessment.
1.
2.
3.
4.
5.
PTS: 1
Feedback
This is an appropriate statement to encourage the client to communicate.
This statement enables the client to evaluate current coping strategies for
effectiveness.
This is an appropriate statement to encourage the client to communicate.
Focusing on the current problem would not occur until after a complete
assessment.
Selecting functional coping strategies would not occur until after a complete
assessment.
CON: Health Promotion
13.
ANS: 1, 2, 4
Chapter: Chapter 0, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 200–202
Heading: Crisis on the Inpatient Unit: Anger and Aggression Management
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should determine that, when working with an inpatient client with
difficulty expressing anger appropriately, it is important to maintain a calm
demeanor.
The nurse should determine that, when working with an inpatient client with
difficulty expressing anger appropriately, it is important to clearly define the
consequences.
The use of therapeutic touch may not be appropriate and could increase the client’s
anger.
The nurse should determine that, when working with an inpatient client with
difficulty expressing anger appropriately, it is important to set limits on the
behavior.
Teaching would not be appropriate when a client is agitated.
CON: Health Promotion
14.
ANS: 1, 3, 5
Chapter: Chapter 0, Crisis Intervention
Objective: Describe the steps in crisis intervention.
Page: 199
Heading: Crisis on the Inpatient Unit: Anger and Aggression Management
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The Broset Violence Checklist is a quick, simple, and reliable tool that can be used
to assess the risk of potential violence. One of the behavior assessment categories
is confusion.
The behavior assessment category does not include paranoia.
The Broset Violence Checklist is a quick, simple, and reliable tool that can be used
to assess the risk of potential violence. One of the behavior assessment categories
is boisterousness.
The behavior assessment category does not include panic.
The Broset Violence Checklist is a quick, simple, and reliable tool that can be used
to assess the risk of potential violence. One of the behavior assessment categories
is irritability.
PTS: 1
CON: Health Promotion
ORDERED RESPONSE
15.
ANS:
The correct order is 4, 5, 2, 1, 3, 7, 6
Chapter: Chapter 0, Crisis Intervention
Objective: Describe the steps in crisis intervention.
Page: 204
Heading: Crisis on the Inpatient Unit: Anger and Aggression Management
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
Feedback: The stages of Roberts’ Seven-stage Crisis Intervention Model include: 1. Psychosocial
and lethality assessment; 2. Rapidly establish rapport; 3. Identify the major problems or crisis
precipitants; 4. Deal with feelings and emotions; 5. Generate and explore alternatives; 6.
Implement an action plan; 7. Follow up.
PTS: 1
COMPLETION
CON: Health Promotion
16.
ANS:
crisis
Chapter: Chapter 0, Crises Intervention
Objective: Define crisis.
Page: 194
Heading: Characteristics of a Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
Feedback: A crisis is a sudden event in one’s life that disturbs homeostasis, during which usual
coping mechanisms cannot resolve the problem. Crises result in a disequilibrium, from which
many individuals require assistance to recover.
PTS: 1
CON: Health Promotion
[Chapter 13-Chapter 15. Assertiveness Training Chapter 14. Promoting Self Esteem
Chapter 15Anger and Aggression Management
Page 1
1. A nurse is working with a client who has frequent angry outbursts. Which of the
following statements is most helpful when working with this client?
A) ìAnger is a normal feeling, and you can use it to solve problems.î
B) ìYou need to learn to suppress your angry feelings.î
C) ìYou can reduce your anger by hitting a punching bag.î
D) ìYou need to learn how to be less assertive in your communications.î
Ans: A
Feedback:
Anger can be a normal and healthy reaction when situations or circumstances are unfair
or unjust, personal rights are not respected, or realistic expectations are not met. If the
person can express his or her anger assertively, problem solving or conflict resolution is
possible. Anger becomes negative when the person denies it, suppresses it, or expresses
it inappropriately. A person may deny or suppress (i.e., hold in) angry feelings if he or
she is uncomfortable expressing anger. Catharsis can increase rather than alleviate angry
feelings. Effective methods of anger expression, such as using assertive communication,
to express anger should replace angry aggressive outbursts.
2. Which of the following statements about anger, hostility and aggression are accurate?
Select all that apply.
A) Anger is an emotional response to a real or perceived provocation.
B) Hostility stimulates the sympathetic nervous system.
C) Physical aggression involves harming other persons or property.
D) Anger, hostility, and physical aggression are normal human emotions.
E) Hostility is also referred to as verbal aggression.
F) Physical aggression often progresses to hostility.
Ans: A, C, E
Feedback:
Anger is an emotional response to a real or perceived provocation. Anger energizes the
body physically for self-defense, when needed, by activating the ìfight-or-flightî
response mechanism of the sympathetic nervous system. Hostility is different than
anger. Physical aggression is behavior in which a person attacks or injures another
person or that involves destruction of property. Hostility is also referred to as verbal
aggression. Anger is a normal human emotion. Hostility is an emotion that is expressed
through negative behavior. Physical aggression is behavior. Hostility may lead to
physical aggression.
Page 2
3. A married man expresses to the nurse that his wife's frequent nagging angers him. The
nurse role-plays assertive communication techniques with the husband. Which of the
following indicates the husband understands how to use assertive techniques
effectively?
A) ìI really wish you would stop nagging me.î
B) ìYou are not perfect either.î
C) ìI feel unappreciated when you criticize me.î
D) ìAre you telling me you want me to change?î
Ans: C
Feedback:
The nurse can help clients express anger appropriately by serving as a model and by
role-playing assertive communication techniques. Assertive communication uses ìIî
statements that express feelings and are specific to the situation; for example, ìI feel
angry when you interrupt me,î or ìI am angry that you changed the work schedule
without talking to me.î Statements such as these allow appropriate expression of anger
and can lead to productive problem-solving discussions and reduced anger.
4. Which one of the following statements about anger is most accurate?
A) Anger is an abnormal human emotion that is always negative.
B) It is best to express anger by whatever means possible to minimize its
consequences.
C) Most men are socialized to suppress anger.
D) Anger awareness and expression are necessary for women's growth and
development.
Ans: D
Feedback:
Women must recognize that anger awareness and expression are necessary for their
growth and development. Anger is a normal human emotion and is often perceived as a
negative feeling. However, anger becomes negative when denied, suppressed, or
expressed inappropriately. Anger that is expressed inappropriately can lead to hostility
and aggression. Catharsis can increase rather than alleviate angry feelings. Men are
often socialized to believe that it is acceptable to express anger, while women are often
socialized to maintain and enhance relationships with others and avoid expression of
emotions such as anger.
Page 3
5. At which point in the stages of aggressive incidents is intervention least likely to be
effective in preventing physically aggressive behavior?
A) Triggering
B) Escalation
C) Crisis
D) Postcrisis
Ans: C
Feedback:
Interventions during the triggering and escalation phases are key to prevent physically
aggressive behavior. During the crisis phase, behavior escalation may lead to physical
aggression. During the postcrisis phase, the physically aggressive behavior has stopped
and the client returns to the level of functioning before the aggressive incident.
6. Anger management is likely to be included in the care of clients with which of the
following psychiatric diagnoses? Select all that apply.
A) Alzheimer's dementia
B) Schizophrenia
C) Anorexia nervosa
D) Acute alcohol intoxication
E) Generalized anxiety disorder
Ans: A, B, D
Feedback:
Although most clients with psychiatric disorders are not aggressive, clients with a
variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior.
Clients with paranoid delusions may believe others are out to get them; believing they
are protecting themselves, they retaliate with hostility or aggression. Some clients have
auditory hallucinations that command them to hurt others. Aggressive behavior also is
seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other
drugs, and antisocial and borderline personality disorders.
7. Which is most likely to be the subject of an aggressive attack from a client with mental
illness?
A) Other people
B) The client
C) Animals
D) Objects
Ans: B
Feedback:
Clients with psychiatric disorders are more likely to hurt themselves than other people.
Page 4
8. Which psychiatric disorder makes a person most susceptible to anger attacks that do not
result in physical aggression?
A) Delusions
B) Depression
C) Dementia
D) Delirium
Ans: B
Feedback:
Some clients with depression have anger attacks that are sudden intense spells of anger
that typically occur in situation where the depressed person feels emotionally trapped.
Anger attacks involve verbal expressions of anger or rage but no physical aggression.
Persons with delusions, dementia, and delirium are most likely to become physically
aggressive.
9. A client is observed pacing the hall with clenched fists and swearing at others. The
nurse intervenes immediately to prevent the client from moving to which phase of the
aggressing cycle?
A) Triggering
B) Escalation
C) Crisis
D) Recovery
Ans: B
Feedback:
During escalation, the client's responses represent escalating behaviors that indicate
movement toward a loss of control, including pale or flushed face, yelling, swearing,
agitated, threatening, demanding, clenched fists, threatening gestures, hostility, loss of
ability to solve the problem or think clearly. This phase is followed by the crisis phase.
During a period of emotional and physical crisis, the client loses control. Behaviors may
include loss of emotional and physical control, throwing objects, kicking, hitting,
spitting, biting, scratching, shrieking, screaming, and inability to communicate clearly.
10. The client's son is yelling and is hitting his hand with a rolled up newspaper. Which
stage of aggression does the nurse identify that the client's son is exhibiting?
A) Triggering
B) Escalation
C) Crisis
D) Recovery
Ans: B
Feedback:
During the escalation phase of aggression, a person may exhibit yelling and threatening,
clenched fist, threatening gestures. During the triggering phase of aggression, a person
may exhibit signs and symptoms and behaviors including restlessness, anxiety,
irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger.
Page 5
11. The nurse is teaching a client to recognize early signs of anger and aggression. The
nurse explores ways that the client can recognize which of the following?
A) Decreased problem-solving ability
B) Restlessness and irritability
C) Remorse
D) Severe muscle tension
Ans: B
Feedback:
Earliest signs of anger include restlessness, anxiety, irritability, pacing, muscle tension,
rapid breathing, perspiration, loud voice, and anger. Escalated signs include pale or
flushed face, yelling, swearing, agitation, threatening, demanding, increased muscle
tension such as clenched fists, threatening gestures, hostility, and loss of ability to solve
the problem or think clearly. Remorse is seen after the anger crisis when attempts are
made at reconciliation.
12. A client suddenly jumps up from the chair and begins yelling and cursing at the nurse.
Which would be the best response by the nurse?
A) ìI can see that you need attention; you should calmly ask for what you want.î
B) ìI don't want to hear that kind of language; don't ever do that again.î
C) ìI will limit your smoking privileges if you can't control yourself.î
D) ìYou seem angry. Tell me more about how you're feeling.î
Ans: D
Feedback:
The nurse recognizes and validates the client's feelings and offers to focus on those
feelings and what the client needs. In this situation, the client is not at a point where he
can be calm. Taking away privileges will not help the current situation. ìI don't want to
hear that kind of language; don't ever do that againî is demeaning to the client.
13. A client approaches the nurse and loudly states, ìI'm not putting up with this anymore!î
The most appropriate response by the nurse would be which of the following?
A) ìI can see you are angry. Tell me what's going on.î
B) ìYou are not allowed to make threats. Please keep your voice down.î
C) ìWhy do you say that?î
D) ìYou are here voluntarily. You can leave if you want.î
Ans: A
Feedback:
In the triggering phase, the nurse should approach the client in a nonthreatening, calm
manner in order to deescalate the client's emotion and behavior. Conveying empathy for
the client's anger or frustration is important. The nurse can encourage the client to
express his or her angry feelings verbally, suggesting that the client is still in control and
can maintain that control. Use of clear, simple, short statements is helpful.
Page 6
14. A client is clenching his fists and yelling at another client on the unit. He appears to be
close to losing control of his anger. Which of the following actions by the nurse is
appropriate at this time?
A) Clear others out of the immediate area.
B) Prepare a PRN sedative.
C) Tell the client to stop and take a time-out.
D) Alert the security department of an impending aggressive outburst.
Ans: C
Feedback:
If the client progresses to the escalation phase (period when client builds toward loss of
control), the nurse must take control of the situation. The nurse should provide
directions to the client in a calm, firm voice. The client should be directed to take a
time-out for cooling off in a quiet area or his or her room. Clearing others from the area
or alerting security does not help the client regain control. Administering a sedative is
not the least restrictive intervention at this time.
15. In the psychiatric setting, what is the most effective intervention in preventing the
hostile client's behavior from escalating to physical aggression?
A) Getting as far away from him or her as possible
B) Engaging the hostile person in dialogue
C) Yelling at the client to settle down now
D) Ensuring that the client gets his or her way
Ans: B
Feedback:
In a psychiatric setting, engaging the hostile person is most effective to prevent the
behavior from escalating to physical aggression. In the psychiatric setting, it is not
possible to get as far away from them as possible. Yelling at the client will likely
escalate the hostility. Ensuring that the client gets his or her way may eliminate
frustration that may lead to acting out, but is unrealistic and not ultimately helpful to the
client.
Page 7
16. An angry client has just thrown a chair across the room and is racing to pick up another
chair to throw. The most appropriate action by the nurse would be which of the
following?
A) Call for an emergency response from trained personnel.
B) Approach the client and firmly say, ìStop, put it down.î
C) Calmly call the client by name and encourage verbal expression of anger.
D) Assist the client to use problem-solving techniques instead of aggression.
Ans: A
Feedback:
When the client becomes physically aggressive (crisis phase), the staff must take charge
of the situation for the safety of the client, staff, and other clients. Psychiatric facilities
offer training and practice in safe techniques for managing behavioral emergencies, and
only staff with such training should participate in the restraint of a physically aggressive
client. Verbal expression and problem solving are ineffective once a client has reached
the crisis phase. The priority is to maintain safety and regain control.
17. A client who has been physically aggressive arrives at the emergency room for a
psychiatric assessment. Which would be the best approach for the nurse to use?
A) Have a sense of humor to show a lack of fear.
B) Provide close contact to increase the client's sense of safety.
C) Use brief statements and questions to obtain information.
D) Use open-ended questions, so the client can elaborate.
Ans: C
Feedback:
Following an aggressive episode, clients may have difficulty expressing themselves;
short, concise statements and questions will get needed information. Humor or openended
questions may be frustrating or annoying for the client. It is not safe for the nurse
to provide close contact under these circumstances.
18. The nurse is interviewing a client with a history of physical aggression. Which of the
following should the nurse avoid?
A) Anticipating that a loss of control is possible and planning accordingly
B) Explaining the consequences the client will face if control is lost
C) Interviewing the client with another staff member present
D) Responding to verbal threats by terminating the interview and obtaining assistance
Ans: B
Feedback:
Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the
other measures are all appropriate for a client with a history of aggression.
Page 8
19. When interacting with a client in the day room, the nurse determines that a violent
outburst is imminent. Which of the following should the nurse do first?
A) Call for assistance.
B) Give the client choices.
C) Remove the other clients.
D) Talk to the client calmly.
Ans: A
Feedback:
Safety is the priority; the nurse needs assistance to remove other clients and to deal with
the violent outburst. The other interventions may be implemented after calling for
assistance.
20. The client with a history of explosive outbursts becomes angry and states, ìI am really
getting angry.î The nurse sees this as
A) controlling.
B) manipulation.
C) progress.
D) regression.
Ans: C
Feedback:
When the client is able to verbalize angry feelings, this is progress from having an
outburst. The client is not trying to control the situation. Manipulation occurs when a
person tries to persuade another to act in a desired way. Regression occurs when one
retreats to an earlier level of functioning and development.
21. The client identifies anger management as a problem. What is the next step in planning
therapeutic interactions?
A) Give the client a variety of choices on how to express anger.
B) Give the client permission to be angry.
C) Point out the senselessness of anger.
D) Tell the client not to be angry all the time.
Ans: B
Feedback:
Many people view anger as a negative and abnormal feeling in addition to feeling guilty
about being angry; the nurse can help the client see anger as a normal, acceptable
emotion. Giving choices on how to express anger would not be the next step in the
planning stage. Pointing out the senselessness of anger and telling the client not to be
angry all the time are not appropriate responses in this situation.
Page 9
22. The nurse decides to place an aggressive and violent client in mechanical restraints. The
nurse bases this decision on which of the following?
A) Client's mood
B) Client's safety
C) Court order
D) Physician's order
Ans: B
Feedback:
The use of restraints is warranted only when the client's safety is in jeopardy and other,
less restrictive measures have not been effective. The nurse does not base her decision
on the client's mood or court order. Just because there is a physician's order for use of
restraints, this does not mean that they are appropriate in every situation; this is based on
nursing judgment.
23. The nurse observes two clients in the day room arguing. One client runs into the corner
and huddles while the other follows and continues with verbal abuse. Which is the best
action by the nurse?
A) Take an authoritatively step between the two clients.
B) Comfort the client huddled in the corner.
C) Directly address both clients and ask what is going on.
D) Engage the attention of the client who is still yelling and ask what is happening.
Ans: D
Feedback:
Engaging the attention of the dominant person will diffuse the situation and stop the
argument from continuing. The other choices would not be appropriate actions in this
situation. The nurse placing herself in between two arguing clients is a safety concern.
24. Which of the following interventions would assist the client with the appropriate
expression of anger?
A) Encourage catharsis
B) Encourage verbalization
C) Improve self-esteem
D) Isolate the client from others
Ans: B
Feedback:
Verbally expressing angry feelings is a safe and appropriate way to deal with anger.
Isolation and catharsis can increase angry and hostile feelings. The other choices are not
appropriate responses in this situation.
Page 10
25. A client lost control of his behavior, broke a window, and made verbal threats to staff
and other clients. The client was placed in mechanical restraints. Which statement
should the nurse make to explain the use of restraints to the client?
A) ìThe length of time you'll be in restraints is undetermined.î
B) ìThe staff will monitor your behavior closely.î
C) ìThis is what happens when you lose control.î
D) ìThis is a means of keeping you and others safe.î
Ans: D
Feedback:
Use of restraints is a temporary, short-term way of ensuring the safety of everyone until
the client regains behavioral control; it is not a punishment. The other choices are not
appropriate explanations of the use of restraints.
26. Which of the following interventions are most effective in managing the environment to
reduce or eliminate aggressive behavior? Select all that apply.
A) Planning group activities such as playing games
B) Scheduling one-to-one interactions with the client
C) Providing structure and consistency in the unit
D) Avoiding discussions among clients on the unit
E) Discouraging clients from negotiating solutions
Ans: A, B, C
Feedback:
Group and planned activities such as playing card games, watching and discussing
movies, or participating in informal discussions give the clients the opportunity to talk
about events or issues when they are calm. Scheduling one-to-one interactions with
clients indicates the nurse's genuine interest in the client and a willingness to listen to
the client's concerns, thoughts, and feelings. Knowing what to expect enhances the
client's feelings of security. Avoiding discussions does not give clients the opportunity
to talk about events or issues when they are calm. If clients have a conflict or dispute
with one another, the nurse can offer the opportunity for problem solving or conflict
resolution. Expressing angry feelings appropriately, using assertive communication
statements, and negotiating a solution are important skills clients can practice. These
skills will be useful for the client when he or she returns to the community.
Page 11
27. Which of the following statements about the crisis phase of aggression when the client
becomes physically aggressive is true?
A) All staff should act to take charge of the situation.
B) The client must be restrained or sedated at once.
C) Staff should avoid communicating with the client.
D) Four to six trained staff members are needed to restrain.
Ans: D
Feedback:
Four to six trained staff members are needed to restrain, with four staff members each
handling a limb and one protecting the client's head and one helps control the client's
torso, if needed. When a client becomes physically aggressive, the staff must take
charge of the situation for the safety of the client, staff, and other clients. Only staff with
training in safe techniques for managing behavioral emergencies should participate. All
staff may not have had this training, and if the team is not working in a cooperative and
coordinated fashion, it is less safe to restrain the client. The nurse should follow the
facility's protocols and standards for restraint and seclusion. Staff should inform the
client that his or her behavior is out of control and that the staff is taking control to
provide safety and prevent injury.
28. After an angry outburst, a client quickly appears more calm and rational. The nurse
approaches the client. Which of the following is the most helpful response to the client
at this time?
A) ìWe will have to talk about this later.î
B) ìYou really scared me. I'm glad you are okay.î
C) ìWhat happened that got you so upset?î
D) ìWhat can you do differently next time you get angry?î
Ans: C
Feedback:
As the client regains control (recovery phase), he or she is encouraged to talk about the
situation or triggers that led to the aggressive behavior. The nurse should help the client
relax, perhaps sleep, and return to a calmer state. Talking about the event at a later time
does let the client rest, but it does less to address the client's feelings associated with the
angry outburst. It is too early postcrisis to discuss behavior change for the future as the
client needs to recover from intense emotions first.
Page 12
29. After an angry outburst, the client is tearful and remorseful. Which statement by the
nurse would be most supportive?
A) ìYou still need to work on your problem-solving skills.î
B) ìI will not allow you to get that angry again.'
C) ìYou should not have let your anger buildup like you did.î
D) ìWhat could you have done when you first started to feel angry?î
Ans: D
Feedback:
In the postcrisis phase, the nurse should not lecture or chastise the client for the
aggressive behavior but should discuss the behavior in a calm, rational manner. The
client can be given feedback for regaining control, with the expectation that he or she
will be able to handle feelings or events in a nonaggressive manner in the future.
30. One of the first steps that a nurse should take to deal effectively with aggressive clients
is which of the following?
A) Reflect on abilities to handle own feelings of anger
B) Learn professional skills of anger management
C) Become proficient using reflective communication techniques
D) Understand how to activate crisis response teams
Ans: A
Feedback:
The nurse must be aware of how he or she deals with anger before helping clients do so.
The nurse who is afraid of angry feelings may avoid a client's anger, which allows the
client's behavior to escalate. If the nurse's response is angry, the situation can escalate
into a power struggle, and the nurse loses the opportunity to ìtalk downî the client's
anger. Identifying how you handle angry feelings is an initial task. Once the nurse
understands his or her own experiences with anger, the clients can be helped through
learning the use of assertive communication and conflict resolution. Increasing your
skills in dealing with your angry feelings will help you to work more effectively with
clients. Activating a crisis response is a late option in dealing with anger.
Page 13
31. Which of the following is most important to maintain therapeutic boundaries when
working with aggressive clients?
A) Encourage clients to express how the nurse can avoid causing emotional irritation.
B) Discuss difficult patient care situations with a supervisor.
C) Reflect on your actions that may have instigated the client's anger,
D) Do not personalize a client's anger
Ans: D
Feedback:
Do not take the client's anger or aggressive behavior personally or as a measure of your
effectiveness as a nurse. The client's aggressive behavior, however, does not necessarily
reflect the nurse's skills and abilities. Clients should not dictate nurses' behaviors. The
nurse is not responsible for angering the client. Individuals are responsible for their own
emotional control. If the nurse cannot maintain boundaries, assistance should be sought
form a supervisor.
32. Which of the following are important issues for nurses to be aware of when working
with angry, hostile, or aggressive clients? Select all that apply.
A) Nurses must be aware of their own feelings about anger and their use of assertive
communication and conflict resolution.
B) Nurses must not allow themselves to become angry under any circumstances.
C) Nurses must know that a client's anger or aggressive behavior is preventable by a
skilled nurse.
D) Nurses must discuss situations or the care of potentially aggressive clients with
experienced nurses.
E) Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to
control a client's aggressive behavior.
Ans: A, D, E
Feedback:
Nurses must identify how they handle angry feelings and assess their use of assertive
communication and conflict resolution. Increasing their skills in dealing with their angry
feelings will help the nurses to work more effectively with the client. Nurses must not
take the client's anger or aggressive behavior personally or as a measure of their
effectiveness as a nurse. Nurses must discuss situations or the care of potentially
aggressive clients with experienced nurses. Nurses must be calm, nonjudgmental, and
nonpunitive when using techniques to control a client's aggressive behavior.
Page 14
33. What a culture considers acceptable strongly influences the expression of anger. Which
culture-bound syndrome is a dissociative episode characterized by a period of brooding
followed by an outburst of violent, aggressive, or homicidal behavior directed at other
people and objects?
A) Hwa-Byung
B) Hwabyeong
C) Amok
D) BouffÈe delirante
Ans: C
Feedback:
BouffÈe delirante, a condition observed in West Africa and Haiti, is characterized by a
sudden outburst of agitated and aggressive behavior, marked confusion, and
psychomotor excitement. Hwa-Byung or hwabyeong is a culture-bound syndrome that
literally translates as anger syndrome, or fire illness, attributed to the suppression of
anger. Amok is a dissociative episode characterized by a period of brooding followed by
an outburst of violent, aggressive, or homicidal behavior directed at other people and
objects.
Chapter 16. Suicide Prevention
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A nurse discovers a client’s suicide note that details the time, place, and means to
commit suicide. What should be the priority nursing intervention and the rationale for this
action?
1.
Administering lorazepam (Ativan) prn, because the client is angry about the
discovery of the note
2.
Establishing room restrictions, because the client’s threat is an attempt to
manipulate the staff
3.
Placing this client on one-to-one suicide precautions, because the more specific the
plan, the more likely the client will attempt suicide
4.
Calling an emergency treatment team meeting, because the client’s threat must be
addressed
____ 2.
During the planning of care for a suicidal client, which correctly written outcome
should be a nurse’s first priority?
1.
The client will not physically harm self.
2.
The client will express hope for the future by day three.
3.
The client will establish a trusting relationship with the nurse.
4.
The client will remain safe during the hospital stay.
____ 3.
A client diagnosed with major depressive disorder with psychotic features hears
voices commanding self-harm. The client refuses to commit to developing a plan for safety.
What should be the nurse’s priority intervention at this time?
1.
Obtaining an order for locked seclusion until client is no longer suicidal
2.
Conducting 15-minute checks to ensure safety
3.
Placing the client on one-to-one observation while monitoring suicidal ideations
4.
Encouraging client to express feelings related to suicide
____ 4.
A client with a history of three suicide attempts has been taking fluoxetine
(Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is
much more communicative. Which action should be the nurse’s priority at this time?
1.
Give the client off-unit privileges as positive reinforcement.
2.
Encourage the client to share mood improvement in group.
3.
Increase frequency of client observation.
4.
Request that the psychiatrist reevaluate the current medication protocol.
____ 5.
A nurse admitted a client to an inpatient unit after a suicide attempt. A health-care
provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication
should be initiated to maintain this client’s safety upon discharge?
1.
Provide a 6-month supply of Elavil to ensure long-term compliance.
2.
Provide a 3-day supply of Elavil with refills contingent on follow-up appointments.
3.
Provide a pill dispenser as a memory aid.
4.
Provide education regarding the avoidance of foods containing tyramine.
____ 6.
During a one-to-one session with a client, the client states, “Nothing will ever get
better,” and “Nobody can help me.” Which nursing diagnosis is most appropriate for a nurse to
assign to this client at this time?
1.
Powerlessness R/T altered mood AEB client statements
2.
Risk for injury R/T altered mood AEB client statements
3.
Risk for suicide R/T altered mood AEB client statements
4.
Hopelessness R/T altered mood AEB client statements
____ 7.
The treatment team is making a discharge decision regarding a previously suicidal
client. Which client assessment information should a nurse recognize as contributing to the
team’s decision?
1.
No previous admissions for major depressive disorder
2.
Vital signs stable; no psychosis noted
3.
Able to comply with medication regimen; able to problem-solve life issues
4.
Able to participate in a plan for safety; family agrees to constant observation
____ 8.
The family of a suicidal client is very supportive and requests more facts related
to caring for their family member after discharge. Which information should the nurse provide?
1.
Address only serious suicide threats to avoid the possibility of secondary gain.
2.
Promote trust by verbalizing a promise to keep suicide attempt information within
the family.
3.
Offer a private environment to provide needed time alone at least once a day.
4.
Be available to actively listen, support, and accept feelings.
____ 9.
A stockbroker commits suicide after being convicted of insider trading. In
speaking with the family, which statement by the nurse demonstrates accurate and appropriate
sharing of information?
1.
“Your grieving will subside within 1 year; until then I recommend antidepressants.”
2.
“Support groups are available specifically for survivors of suicide, and I would be
glad to help you locate one in this area.”
3.
“The only way to deal effectively with this kind of grief is to write a letter to the
brokerage firm to express your anger with them.”
4.
“Since stigmatization often occurs in these situations, it would be best if you avoid
discussing the suicide with anyone.”
____ 10.
After years of dialysis, an 84-year-old states, “I’m exhausted, depressed, and done
with these attempts to keep me alive.” Which question should the nurse ask the spouse when
preparing a discharge plan of care?
1.
“Have there been any changes in appetite or sleep?”
2.
“How often is your spouse left alone?”
3.
“Has your spouse been following a diet and exercise program consistently?”
4.
“How would you characterize your relationship with your spouse?”
____ 11.
A nursing instructor is teaching about suicide in the elderly population. Which
information should the instructor include?
1.
Elderly people use less lethal means to commit suicide.
2.
Although the elderly comprise less than 13 percent of the population, they account
for 15 percent of all suicides.
3.
Suicide is the second leading cause of death among the elderly.
4.
It is normal for elderly individuals to express a desire to die, because they have
come to terms with their mortality.
____ 12.
A nurse is caring for a client who has threatened to commit suicide by hanging.
The client states, “I’m going to use a knotted shower curtain when no one is around.” Which
information would determine the nurse’s plan of care for this client?
1.
The more specific the plan is, the more likely the client will attempt suicide.
2.
Clients who talk about suicide never actually commit it.
3.
Clients who threaten suicide should be observed every 15 minutes.
4.
After a brief assessment, the nurse should avoid the topic of suicide.
____ 13.
A suicidal client says to a nurse, “There’s nothing to live for anymore.” Which is
the most appropriate nursing reply?
1.
“Why don’t you consider doing volunteer work in a homeless shelter?”
2.
“Let’s discuss the negative aspects of your life.”
3.
“Things will look better in the morning.”
4.
“It sounds like you are feeling pretty hopeless.”
1.
2.
3.
4.
“Why don’t you consider doing volunteer work in a homeless shelter?”
“Let’s discuss the negative aspects of your life.”
“Things will look better in the morning.”
“It sounds like you are feeling pretty hopeless.”
____ 14.
A new nursing graduate asks the psychiatric nurse manager how to best classify
suicide. Which is the nurse manager’s best reply?
1.
“Suicide is a DSM-5 diagnosis.”
2.
“Suicide is a mental disorder.”
3.
“Suicide is a behavior.”
4.
“Suicide is an antisocial affliction.”
____ 15.
A nursing student is developing a plan of care for a suicidal client. Which
documented intervention should the student implement first?
1.
Communicate therapeutically.
2.
Observe the client.
3.
Provide a hazard-free environment.
4.
Assess suicide risk.
____ 16.
Which is a correctly written, appropriate outcome for a client with a history of
suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self?
1.
The client will not physically harm self.
2.
The client will express three positive self-attributes by day four.
3.
The client will reveal a suicide plan.
4.
The client will establish a trusting relationship.
____ 17.
A nursing instructor is teaching about suicide. Which student statement indicates
that learning has occurred?
1.
“Suicidal threats and gestures should be considered manipulative and/or attentionseeking.”
2.
“Suicide is the act of a psychotic person.”
3.
“All suicidal individuals are mentally ill.”
4.
“Between 50 and 80 percent of all people who kill themselves have a history of a
previous attempt.”
____ 18.
A nurse is caring for four clients diagnosed with major depressive disorder. When
considering each client’s belief system, the nurse should conclude which client would potentially
be at highest risk for suicide?
1.
Roman Catholic
2.
Protestant
3.
Atheist
4.
Muslim
1.
2.
3.
4.
Roman Catholic
Protestant
Atheist
Muslim
____ 19.
Which nursing intervention strategy is most important to implement initially with
a suicidal client?
1.
Ask a direct question such as, “Do you ever think about killing yourself?”
2.
Ask client, “Please rate your mood on a scale from 1 to 10.”
3.
Establish a trusting nurse-client relationship.
4.
Apply the nursing process to the planning of client care.
____ 20.
A client is newly committed to an inpatient psychiatric unit. Which nursing
intervention best lowers this client’s risk for suicide?
1.
Encouraging participation in the milieu to promote hope
2.
Developing a strong personal relationship with the client
3.
Observing the client at intervals determined by assessed data
4.
Encouraging and redirecting the client to concentrate on happier times
____ 21.
Which client data indicates that a suicidal client is participating in a plan for
safety?
1.
Compliance with antidepressant therapy
2.
A mood rating of 9/10
3.
Disclosing a plan for suicide to staff
4.
Expressing feelings of hopelessness to nurse
____ 22.
A client is newly admitted to an inpatient psychiatric unit. Which of the following
is most critical to assess when determining risk for suicide?
1.
Family history of depression
2.
The client’s orientation to reality
3.
The client’s history of suicide attempts
4.
Family support systems
____ 23.
A client has been brought to the emergency department for signs and symptoms of
chronic obstructive pulmonary disease (COPD). The client has a history of a suicide attempt 1
year ago. Which nursing intervention would take priority in this situation?
1.
Assessing the client’s pulse oximetry and vital signs
2.
Developing a plan for safety for the client
3.
Assessing the client for suicidal ideations
4.
Establishing a trusting nurse-client relationship
1.
2.
3.
4.
Assessing the client’s pulse oximetry and vital signs
Developing a plan for safety for the client
Assessing the client for suicidal ideations
Establishing a trusting nurse-client relationship
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 24.
After a teenager reveals that he is gay, his father responds by beating him. The
next morning, the teenager is found hanging in his closet. Which paternal grief responses should
a nurse anticipate? Select all that apply.
1.
“I can’t believe this is happening.”
2.
“If only I had been more understanding.”
3.
“How dare he do this to me!”
4.
“I’m just going to have to accept that he was gay.”
5.
“Well, that was a selfish thing to do.”
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This action would not be appropriate and could be considered a restraint.
Establishing room restrictions does not keep the client safe in the immediate
situation.
The priority nursing action should be to place this client on one-to-one suicide
precautions, because the more specific the plan, the more likely the client will
attempt suicide. The appropriate nursing diagnosis for this client would be risk for
suicide.
The client’s immediate safety is a priority.
CON: Stress
2.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This answer choice is incorrectly written. Correctly written outcomes must be
client focused, measurable, realistic, and contain a time frame. Without a time
frame, an outcome cannot be correctly evaluated.
This option may take longer to achieve.
This option is important, but safety must be established first.
The nurse’s priority should be that the client will remain safe during the hospital
stay. Client safety should always be the nurse’s priority.
CON: Stress
3.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive
Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
1
2
3
4
Feedback
Seclusion may be excessive for this client.
Checks every 15 minutes would be inadequate for this client.
The nurse’s priority intervention when a client hears voices commanding selfharm is to place the client on one-to-one observation while continuing to monitor
suicidal ideation.
The client’s physical safety is the priority.
PTS: 1
CON: Stress
4.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client should not be given off-unit privileges, as this could be unsafe.
Group involvement is important, but client safety must take priority.
The nurse should be aware that a sudden increase in mood rating and change in
affect could indicate that the client is at risk for suicide and client observation
should be more frequent. Suicide risk may occur early during treatment with
antidepressants. The return of energy may bring about an increased ability to act
out self-destructive behaviors prior to attaining the full therapeutic effect of the
antidepressant medication.
Medication can be reevaluated after client safety has been established.
CON: Stress
5.
ANS: 2
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 237
Heading: Planning and Implementation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
Feedback
This amount of medication may be enough for the client to overdose.
The health-care provider should provide no more than a 3-day supply of Elavil
with refills contingent on follow-up appointments as an appropriate intervention to
maintain the client’s safety. Tricyclic antidepressants have a narrow therapeutic
range and can be used in overdose to commit suicide. Distributing limited amounts
of the medication decreases this potential. In addition, clients may gain energy to
carry out a suicide once they begin to have more energy from taking the
antidepressants.
1
2
3
4
PTS: 1
Feedback
This amount of medication may be enough for the client to overdose.
The health-care provider should provide no more than a 3-day supply of Elavil
with refills contingent on follow-up appointments as an appropriate intervention to
maintain the client’s safety. Tricyclic antidepressants have a narrow therapeutic
range and can be used in overdose to commit suicide. Distributing limited amounts
of the medication decreases this potential. In addition, clients may gain energy to
carry out a suicide once they begin to have more energy from taking the
antidepressants.
This option would not prevent the client from committing suicide.
This option does not prevent suicide.
CON: Stress
6.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client is experiencing hopelessness. This diagnosis would be inappropriate.
Risk for injury has not been identified.
Risk for suicide has not been identified.
The client’s statements indicate the problem of hopelessness. Prior to assigning
either risk for injury or risk for suicide, a further evaluation of the client’s suicidal
ideations and intent would be necessary.
CON: Stress
7.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
History of admissions does not focus on suicide prevention.
Assessment of vital signs does not focus on suicide prevention.
Compliance with medication regimen does not focus on suicide prevention.
Participation in a plan of safety and constant family observation will decrease the
risk for self-harm.
CON: Stress
8.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Interpersonal Support
System
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Addressing only serious suicide threats would not be helpful to the client.
Keeping suicide attempts a secret in the family does not help the client.
Providing alone time does not help the client.
Being available to actively listen, support, and accept feelings increases the
potential that a client would confide suicidal ideations to family members.
CON: Family Dynamics
9.
ANS: 2
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 240
Heading: Planning/Implementation > Presenting Symptoms/Medical-Psychiatric Diagnosis >
Presenting Symptoms and Medical-Psychiatric Diagnosis > Information for Family and Friends
of the Suicidal Client
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement is not therapeutic for the family or helpful.
Bereavement following suicide is complicated by the complex psychological
impact of the act on those close to the victim. Support groups for survivors can
provide a meaningful resource for grief work.
This statement provides inaccurate information to the family.
This statement is inaccurate and not therapeutic to the family.
CON: Family Dynamics
10.
ANS: 2
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 237
Heading: Planning and Implementation
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Changes in appetite or sleep do not accurately indicate risk for suicide.
This client has many risk factors for suicide. The client should have increased
supervision to decrease likelihood of self-harm.
Asking about diet and exercise do not assess risk for suicide.
Asking about the client’s relationship with his spouse does not accurately assess
the risk for suicide.
CON: Stress
11.
ANS: 2
Chapter: Chapter 0, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 234
Heading: Application of the Nursing Process with the Suicidal Client > Demographics
Integrated Processes: Teaching/Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The elderly do not necessarily use less lethal means of committing suicide.
Although the elderly comprise less than 13 percent of the population, they account
for 15 percent of all suicides.
Suicide is not the second leading cause of death among the elderly.
An expressed desire to die is not normal in any age group.
CON: Patient-Centered Care
12.
ANS: 1
Chapter: Chapter 0, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Clients who have specific plans are at greater risk for suicide.
Clients who talk about suicide should be taken seriously.
One-to-one supervision should be provided for any client who threatens suicide.
The nurse should be direct and upfront when discussing suicide with clients and
their families.
CON: Stress
13.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This question does not help the client open up about feelings.
This statement does not help the client discuss feelings.
This statement may be degrading to the client’s feelings.
This statement verbalizes the client’s implied feelings and allows him or her to
validate and explore them. This statement also shows empathy toward the client
and may help them open up and discuss their feelings.
CON: Stress
14.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Analysis of the Suicidal
Crisis
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Suicide is not a diagnosis.
Suicide is not a disorder.
Suicide is a behavior.
Suicide is not an affliction.
CON: Stress
15.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Presenting Symptoms and Medical-Psychiatric Diagnosis > Analysis of the Suicidal
Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
After assessing suicide risk, the nurse can communicate therapeutically.
After assessing suicide risk, the nurse can observe the client.
After assessing suicide risk, the nurse can provide a hazard-free environment.
Assessment is the first step of the nursing process to gain needed information to
determine further appropriate interventions. Suicide risk assessment should always
be the first step taken when working with depressed or suicidal patients.
CON: Stress
16.
ANS: 2
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 237
Heading: Application of the Nursing Process with the Suicidal Client > Diagnosis and Outcome
Identification
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Collaboration
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This outcome may take time for the client to commit to.
Although the client has a history of suicide attempts, the current problem is
isolative behaviors based on low self-esteem. Outcomes should be client-centered,
specific, realistic, and measurable and contain a time frame.
This outcome may be a big step for the client.
This outcome may not be realistic right away for the client.
CON: Collaboration
17.
ANS: 4
Chapter: Chapter 0, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 230–232
Heading: Risk Factors
Integrated Processes: Application of the Nursing Process with the Suicidal Client > Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement is inaccurate regarding suicide.
This statement is untrue regarding suicide.
This statement is a myth about suicide.
It is a fact that between 50 and 80 percent of all people who kill themselves have a
history with a previous attempt.
CON: Stress
18.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 231
Heading: Risk Factors > Religion
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Depressed men and women who consider themselves affiliated with a religion are
less likely to attempt suicide than their nonreligious counterparts because religions
teach that suicide is a sin.
Depressed men and women who consider themselves affiliated with a religion are
less likely to attempt suicide than their nonreligious counterparts because religions
teach that suicide is a sin.
An atheist does not believe in punishment for suicide by a higher power.
Depressed men and women who consider themselves affiliated with a religion are
less likely to attempt suicide than their nonreligious counterparts because religions
teach that suicide is a sin.
CON: Stress
19.
ANS: 1
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 237
Heading: Application of the Nursing Process with the Suicidal Client > Planning and
Implementation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The risk of suicide is greatly increased if the client has suicidal ideations, if the
client has developed a plan, and particularly if the means exist for the client to
execute the plan.
Asking the client to rate mood does not help assess suicide risk.
Establishing a nurse-client relationship does not help assess suicide risk.
Applying the nursing process to planning does not help assess suicide risk.
CON: Stress
20.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 238–239
Heading: Application of the Nursing Process with the Suicidal Client
Integrated Process: Nursing Process > Planning/Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
Feedback
Encouraging participation does not best lower the client’s risk for suicide.
Developing a personal relationship with the client does not best lower the client’s
risk for suicide.
The nurse should observe the actively suicidal client continuously for the first hour
after admission. After a full assessment the treatment team will determine the
observation status of the client. Observation of the client allows the nurse to
interrupt any observed suicidal behaviors.
Encouraging and redirecting the client does not best lower the client’s risk for
suicide.
PTS: 1
CON: Stress
21.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 238–239
Heading: Application of the Nursing Process with the Suicidal Client > Planning and
Implementation
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Compliance with antidepressant therapy does not indicate the client participating
in a plan for safety.
A mood rating of 9/10 does not indicate the client participating in a plan for safety.
A degree of the responsibility for the suicidal client’s safety is given to the client.
When a client shares with staff a plan for suicide, the client is participating in a
plan for safety by communicating thoughts of self-harm that would initiate
interventions to prevent suicide.
Expressing feelings of hopelessness do not indicate the client participating in a
plan for safety.
CON: Stress
22.
ANS: 3
Chapter: Chapter 0, Suicide Prevention
Objective: Differentiate between facts and fables regarding suicide.
Page: 232
Heading: Other Risk Factors
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
1
2
3
4
Feedback
Family history of depression is not critical to determining risk for suicide.
Client’s orientation to reality not critical to determining risk for suicide.
A history of suicide attempts places a client at a higher risk for current suicide
behaviors. Knowing this specific data will alert the nurse to the client’s risk. Of
those who commit suicide, 50–80 percent had a previous attempt.
Family support systems are not critical to determining risk for suicide.
1
2
3
4
PTS: 1
Feedback
Family history of depression is not critical to determining risk for suicide.
Client’s orientation to reality not critical to determining risk for suicide.
A history of suicide attempts places a client at a higher risk for current suicide
behaviors. Knowing this specific data will alert the nurse to the client’s risk. Of
those who commit suicide, 50–80 percent had a previous attempt.
Family support systems are not critical to determining risk for suicide.
CON: Stress
23.
ANS: 1
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 237
Heading: Application of the Nursing Process with the Suicidal Client > Planning and
Implementation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
It is important to prioritize client interventions that assess the symptoms of COPD
prior to any other nursing intervention. Physical needs must be prioritized
according to Maslow’s hierarchy of needs. This client’s problems with
oxygenation will take priority over assessing for current suicidal ideations as they
can lead to death more quickly if not reversed.
Developing a plan for safety can occur after physical needs have been met.
Assessing for suicidal ideation can occur after physical needs have been met.
Establishing a nurse-client relationship can occur after physical needs have been
met.
CON: Perfusion
MULTIPLE RESPONSE
24.
ANS: 1, 2, 3
Chapter: Chapter 0, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 239–240
Heading: Intervention for Family and Friends of Suicide Victims
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Family Dynamics
Difficulty: Moderate
Feedback
Suicide of a family member can induce a whole gamut of feelings in the
survivors, including shock.
Suicide of a family member can induce a whole gamut of feelings in the
survivors, including guilt.
Suicide of a family member can induce a whole gamut of feelings in the
survivors, including anger.
Stating, “I’m just going to have to accept that he was gay,” reflects acceptance
and understanding.
Stating, “Well, that was a selfish thing to do,” reflects acceptance and
understanding.
1.
2.
3.
4.
5.
PTS: 1
CON: Family Dynamics
[
-Chapter 17. Behavior Therapy- Chapter 19
Chapter 18. Cognitive Behavioral Therapy Chapter 19. Electroconvulsive Therapy
The nurse knows that attributions are perceived causes that:
•
Isolate family members from one another.
•
Promote rigidity and chaos.
•
May or may not be objectively accurate.
•
Support a loss of autonomy.
Correct Answer: 3
Rationale 1: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance or set of circumstances, we make
attributions. Attributions are perceived causes that may or may not be objectively
accurate. Depressed people often attribute failure to themselves and success to others.
We attribute associated features or characteristics to a circumstance, expect a certain
outcome from those circumstances, and behave consistently with that expectation.
Finally, we have feelings that match, or are congruent with the experience. The basic
idea is that thoughts and behaviors lead to feelings.
Rationale 2: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance or set of circumstances, we make
attributions. Attributions are perceived causes that may or may not be objectively
accurate. Depressed people often attribute failure to themselves and success to others.
We attribute associated features or characteristics to a circumstance, expect a certain
outcome from those circumstances, and behave consistently with that expectation.
Finally, we have feelings that match, or are congruent with the experience. The basic
idea is that thoughts and behaviors lead to feelings.
Rationale 3: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance or set of circumstances, we make
attributions. Attributions are perceived causes that may or may not be objectively
accurate. Depressed people often attribute failure to themselves and success to others.
We attribute associated features or characteristics to a circumstance, expect a certain
outcome from those circumstances, and behave consistently with that expectation.
Finally, we have feelings that match, or are congruent with the experience. The basic
idea is that thoughts and behaviors lead to feelings.
Rationale 4: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance or set of circumstances, we make
attributions. Attributions are perceived causes that may or may not be objectively
accurate. Depressed people often attribute failure to themselves and success to others.
We attribute associated features or characteristics to a circumstance, expect a certain
outcome from those circumstances, and behave
consistently with that expectation. Finally, we have feelings that match, or are congruent with
the experience. The basic idea is that thoughts and behaviors lead to feelings.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Explain the central features of cognitive behavioral interventions.
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MC
SA
During a group session, the nursing student notes one of the clients imitating another
clients manner of speaking and communicating. The client being imitated has actively
participated in all groups and is going home tomorrow. The nursing student suspects
the client doing the imitating is:
•
Modeling behavior.
•
Being a comedian.
•
Expecting an award.
•
Jealous of the other client.
Correct Answer: 1
Rationale 1: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Rationale 2: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Rationale 3: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Rationale 4: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Explain the central features of cognitive behavioral interventions.
Que
stio
n3
Typ
e:
MC
SA
Nurses are instrumental in helping clients during cognitive therapy. The nurse helps clients:
•
Correct the id and the superego in relation to self-awareness.
•
Examine connections of the mind, body, and spirit.
•
Determine the best course of treatment.
•
Identify unrealistic and negative thoughts.
Correct Answer: 4
Rationale 1: The purpose of cognitive therapy is first to identify thoughts that are
unrealistic, negative, or otherwise problematic. Once these thoughts are identified,
they are examined for their impact on the individual. Nurses are instrumental in
helping a client see how a particular set of thoughts can create a problem. When this
connection is made, substituting neutral or positive thoughts for the problematic
thinking schema takes place over time. Correcting automatic problematic thinking is a
retraining experience. The individual must unlearn the maladaptive cognitive style,
and then learn adaptive cognitions. The other choices are not relevant for cognitive
therapy.
Rationale 2: The purpose of cognitive therapy is first to identify thoughts that are
unrealistic, negative, or otherwise problematic. Once these thoughts are identified,
they are examined for their impact on the individual. Nurses are instrumental in
helping a client see how a particular set of thoughts can create a problem. When this
connection is made, substituting neutral or positive thoughts for the problematic
thinking schema takes place over time. Correcting automatic problematic thinking is a
retraining experience. The individual must unlearn the maladaptive cognitive style,
and then learn adaptive cognitions. The other choices are not relevant for cognitive
therapy.
Rationale 3: The purpose of cognitive therapy is first to identify thoughts that are
unrealistic, negative, or otherwise problematic. Once these thoughts are identified,
they are examined for their impact on the individual. Nurses are instrumental in
helping a client see how a particular set of thoughts can create a problem. When this
connection is made, substituting neutral or positive thoughts for the problematic
thinking schema takes place over time. Correcting automatic problematic thinking is a
retraining experience. The individual must unlearn the maladaptive cognitive style,
and then learn adaptive cognitions. The other choices are not relevant for cognitive
therapy.
Rationale 4: The purpose of cognitive therapy is first to identify thoughts that are
unrealistic, negative, or otherwise problematic. Once these thoughts are identified,
they are examined for their impact on the individual. Nurses are instrumental in
helping a client see how a particular set of thoughts can create a problem. When this
connection is made, substituting neutral or positive thoughts for the problematic
thinking schema takes place over time. Correcting automatic problematic thinking is a
retraining experience. The individual must unlearn the maladaptive
cognitive style, and then learn adaptive cognitions. The other choices are not relevant
for cognitive therapy.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Explain the central features of cognitive behavioral interventions.
Que
stio
n4
Typ
e:
MC
SA
The nurse is assessing a client with nicotine addiction. The nurse knows the client
plans to compete in a marathon several months away and asks the client to imagine
snapping a cigarette in half and winning the marathon whenever the urge to smoke
occurs. The nurse knows that shaping ones thoughts so that they have control over a
particular situation, thereby creating a successful behavior change, is called:
•
Communication.
•
Mastery imagery.
•
Image restructuring.
•
Positive imagery.
Correct Answer: 2
Rationale 1: Mastery imagery shapes the individuals thoughts about being in control
or having mastery over a particular situation. The point of this technique is to practice
imagining successful behavior change.
Rationale 2: Mastery imagery shapes the individuals thoughts about being in control
or having mastery over a particular situation. The point of this technique is to practice
imagining successful behavior change.
Rationale 3: Mastery imagery shapes the individuals thoughts about being in control
or having mastery over a particular situation. The point of this technique is to practice
imagining successful behavior change.
Rationale 4: Mastery imagery shapes the individuals thoughts about being in control
or having mastery over a particular situation. The point of this technique is to practice
imagining successful behavior change.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Explain the central features of cognitive behavioral interventions.
Que
stio
n5
Typ
e:
MC
SA
A client complains of feeling angry whenever he sees families relating well with
one another. During a family group session, the nursing student observes a family
member belittling every statement made by the client. The nursing student knows
that the clients thinking is often:
•
What leads the client to negative behaviors.
•
Erratic and problematic.
•
Conscious and deliberate.
•
Automatic, without active or conscious effort.
Correct Answer: 4
Rationale 1: The heart of cognitive therapy lies in recognizing how we think and
behave and in identifying problematic learning. People develop patterns of thinking
over time, often automatically, without active or conscious effort. Automatic thoughts
can develop into specific (and frequently solidly crystallized) sets of problematic
thinking. Clients automatic thinking may comprise a part of negative behaviors. The
clients thinking does not appear to be conscious, deliberate, or erratic.
Rationale 2: The heart of cognitive therapy lies in recognizing how we think and
behave and in identifying problematic learning. People develop patterns of thinking
over time, often automatically, without active or conscious effort. Automatic thoughts
can develop into specific (and frequently solidly crystallized) sets of problematic
thinking. Clients automatic thinking may comprise a part of negative behaviors. The
clients thinking does not appear to be conscious, deliberate, or erratic.
Rationale 3: The heart of cognitive therapy lies in recognizing how we think and
behave and in identifying problematic learning. People develop patterns of thinking
over time, often automatically, without active or conscious effort. Automatic thoughts
can develop into specific (and frequently solidly crystallized) sets of problematic
thinking. Clients automatic thinking may comprise a part of negative behaviors. The
clients thinking does not appear to be conscious, deliberate, or erratic.
Rationale 4: The heart of cognitive therapy lies in recognizing how we think and
behave and in identifying problematic learning. People develop patterns of thinking
over time, often automatically, without active or conscious effort. Automatic thoughts
can develop into specific (and frequently solidly crystallized) sets of problematic
thinking. Clients automatic thinking may comprise a part of negative behaviors. The
clients thinking does not appear to be conscious, deliberate, or erratic.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss how humans express themselves in cognitive and behavioral
ways.
Que
stio
n6
Typ
e:
MC
SA
A client diagnosed with depression states, Even in high school I was a failure. Its a
wonder I was associated with successful friends. The nurse knows this client is
making:
•
A hard situation worse.
•
Attributions about his life.
•
Excuses about his present behavior.
•
Assumptions about his friends.
Correct Answer: 4
Rationale 1: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance, or a set of circumstances, we make
attributions (I only got a grade of C. Im no good at anything. Sarah and Francisco got
As. They can do anything.). Think of attributions as perceived causes that may or may
not be objectively accurate. Depressed people often attribute failure to themselves and
success to others. Then, we attribute associated features or characteristics to that
circumstance (such as being a good student or knowing the material). Next, we expect
a certain outcome from that circumstance and we behave consistently
with that expectation. Finally, we have feelings that match, or are
congruent with, the experience. The basic idea is that thoughts and
behaviors lead to feelings.
Rationale 2: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance, or a set of circumstances, we make
attributions (I only got a grade of C. Im no good at anything. Sarah and Francisco got
As. They can do anything.). Think of attributions as perceived causes that may or may
not be objectively accurate. Depressed people often attribute failure to themselves and
success to others. Then, we attribute associated features or characteristics to that
circumstance (such as being a good student or knowing the material). Next, we expect
a certain outcome from that circumstance and we behave consistently with that
expectation. Finally, we have feelings that match, or are congruent with, the
experience. The basic idea is that thoughts and behaviors lead to feelings.
Rationale 3: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance, or a set of circumstances, we make
attributions (I only got a grade of C. Im no good at anything. Sarah and Francisco got
As. They can do anything.). Think of attributions as perceived causes that may or may
not be objectively accurate. Depressed people often attribute failure to themselves and
success to others. Then, we attribute associated features or characteristics to that
circumstance (such as being a good student or knowing the material). Next, we expect
a certain outcome from that circumstance and we behave consistently with that
expectation. Finally, we have feelings that match, or are congruent with, the
experience. The basic idea is that thoughts and behaviors lead to feelings.
Rationale 4: As humans, we constantly ascribe causes to the events in our lives. By
labeling or assigning meaning to a circumstance, or a set of circumstances, we make
attributions (I only got a grade of C. Im no good at anything. Sarah and Francisco got
As. They can do anything.). Think of attributions as perceived causes that may or may
not be objectively accurate. Depressed people often attribute failure to themselves and
success to others. Then, we attribute associated features or characteristics to that
circumstance (such as being a good student or knowing the material). Next, we expect
a certain outcome from that circumstance and we behave consistently with that
expectation. Finally, we have feelings that match, or are congruent with, the
experience. The basic idea is that thoughts and behaviors lead to feelings.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss how humans express themselves in cognitive and behavioral
ways.
Que
stio
n7
Typ
e:
MC
SA
A nursing student receiving Ds on quizzes decides to begin studying with a group
of students known to make As. The nursing instructor knows that the student is
exhibiting what type of behavior?
•
Modeling
•
Attributing
•
Self-efficacy
•
Assuming
Correct Answer: 1
Rationale 1: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Rationale 2: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Rationale 3: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Rationale 4: Modeling involves imitating others in the expectation that one will
receive rewards such as those other people seem to be getting.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss how humans express themselves in cognitive and behavioral
ways.
Que
stio
n8
Typ
e:
MC
SA
The nurse knows that when the mental health client has learned how to successfully
adapt in new or different circumstances, the client has developed a sense of:
•
Pride.
•
Self-efficacy.
•
Self.
•
Self-esteem.
Correct Answer: 2
Rationale 1: Human learning can occur through self-efficacy, which involves
feeling effective through ones own actions. People learn and adapt when they find
themselves in circumstances demanding new or different skills. People who tend to
believe that they can cope successfully with problems in living through acquiring
skills, practicing them, and observing successful outcomes will gain confidence and
a sense of self-efficacy.
Rationale 2: Human learning can occur through self-efficacy, which involves
feeling effective through ones own actions. People learn and adapt when they find
themselves in circumstances demanding new or different skills. People who tend to
believe that they can cope successfully with problems in living through acquiring
skills, practicing them, and observing successful outcomes will gain confidence and
a sense of self-efficacy.
Rationale 3: Human learning can occur through self-efficacy, which involves
feeling effective through ones own actions. People learn and adapt when they find
themselves in circumstances demanding new or different skills. People who tend to
believe that they can cope successfully with problems in living through acquiring
skills, practicing them, and observing successful outcomes will gain confidence and
a sense of self-efficacy.
Rationale 4: Human learning can occur through self-efficacy, which involves
feeling effective through ones own actions. People learn and adapt when they find
themselves in circumstances demanding new or different skills. People who tend to
believe that they can cope successfully with problems in living through acquiring
skills, practicing them, and observing successful outcomes will gain confidence and
a sense of self-efficacy.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss how humans express themselves in cognitive and behavioral
ways.
Que
stio
n9
Typ
e:
MC
SA
The nurse knows that obtaining a smoking cessation contract from a client will:
•
Help clients adapt through change.
•
Increase positive reinforcement through adaptation.
•
Facilitate change through contracts.
•
Formulate well-thought-out plans.
Correct Answer: 2
Rationale 1: The therapists goal in operant conditioning is to help the individual
increase positive reinforcement through more adaptive and effective behaviors.
The effort to change health-related behaviors can be facilitated with a behavioral
contract. An effective behavioral contract must be tailored for the individual, and
a comprehensive behavioral assessment is necessary to formulate such a contract,
as is the formulation of practical, measurable, and feasible objectives and goals.
Rationale 2: The therapists goal in operant conditioning is to help the individual
increase positive reinforcement through more adaptive and effective behaviors.
The effort to change health-related behaviors can be facilitated with a behavioral
contract. An effective behavioral contract must be tailored for the individual, and
a comprehensive behavioral assessment is necessary to formulate such a contract,
as is the formulation of practical, measurable, and feasible objectives and goals.
Rationale 3: The therapists goal in operant conditioning is to help the individual
increase positive reinforcement through more adaptive and effective behaviors.
The effort to change health-related behaviors can be facilitated with a behavioral
contract. An effective behavioral contract must be tailored for the individual, and
a comprehensive behavioral assessment is necessary to formulate such a contract,
as is the formulation of practical, measurable, and feasible objectives and goals.
Rationale 4: The therapists goal in operant conditioning is to help the individual
increase positive reinforcement through more adaptive and effective behaviors.
The effort to change health-related behaviors can be facilitated with a behavioral
contract. An effective behavioral contract must be tailored for the individual, and
a comprehensive behavioral assessment is necessary to formulate such a contract,
as is the formulation of practical, measurable, and feasible objectives and goals.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Relate conditioning and association to the process of human learning.
Que
stio
n 10
Typ
e:
MC
SA
The nurse therapist skilled in rational emotive therapy (RET) helps clients identify:
•
Cognitive causes for rational beliefs.
•
Health-damaging beliefs and practices.
•
Rational thoughts and healthy emotions.
•
Irrational thoughts and develop more rational life philosophies.
Correct Answer: 4
Rationale 1: Rational emotive therapy (RET) was originated by Albert Ellis (1975)
and emphasizes cognitive causes of emotional problems along with the importance of
taking personal responsibility for maintaining health-damaging thought habits and
irrational beliefs. An irrational belief is a belief that lacks reason and sound judgment.
The clinician who is skilled in RET helps identify irrational thought structures with
the client and then helps develop a plan to substitute more rational personal life
philosophies and attitudes based on accurately perceived realities (Ellis, 1997).
Healthy emotional consequences occur when rational thinking drives adequate
functional behaviors. Identifying health-damaging beliefs and cognitive causes for
rational beliefs are not the goals of RET.
Rationale 2: Rational emotive therapy (RET) was originated by Albert Ellis (1975)
and emphasizes cognitive causes of emotional problems along with the importance of
taking personal responsibility for maintaining health-damaging thought habits and
irrational beliefs. An irrational belief is a belief that lacks reason and sound judgment.
The clinician who is skilled in RET helps identify irrational thought structures with
the client and then helps develop a plan to substitute more rational personal life
philosophies and attitudes based on accurately perceived realities (Ellis, 1997).
Healthy emotional consequences occur when rational thinking drives adequate
functional behaviors. Identifying health-damaging beliefs and cognitive causes for
rational beliefs are not the goals of RET.
Rationale 3: Rational emotive therapy (RET) was originated by Albert Ellis (1975)
and emphasizes cognitive causes of emotional problems along with the importance of
taking personal responsibility for maintaining health-damaging thought habits and
irrational beliefs. An irrational belief is a belief that lacks reason and sound judgment.
The clinician who is skilled in RET helps identify irrational thought structures with
the client and then helps develop a plan to substitute more rational personal life
philosophies and attitudes based on accurately perceived realities (Ellis, 1997).
Healthy emotional consequences occur when rational thinking drives adequate
functional behaviors. Identifying health-damaging beliefs and cognitive causes for
rational beliefs are not the goals of RET.
Rationale 4: Rational emotive therapy (RET) was originated by Albert Ellis (1975)
and emphasizes cognitive causes of emotional problems along with the importance of
taking personal responsibility for maintaining health-damaging thought habits and
irrational beliefs. An irrational belief is a belief that lacks reason and sound judgment.
The clinician who is skilled in RET helps identify irrational thought structures with
the client and then helps develop a plan to substitute more rational personal life
philosophies and attitudes based on accurately perceived realities (Ellis, 1997).
Healthy emotional consequences occur when rational thinking drives adequate
functional behaviors. Identifying health-damaging beliefs and cognitive causes for
rational beliefs are not the goals of RET.
Global Rationale:
Cognitive Level:
Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Relate conditioning and association to the process of human learning.
Que
stio
n 11
Typ
e:
MC
SA
The nursing student knows that the therapists goal in behavior therapy is to:
•
Decrease classical conditioning.
•
Increase self-confidence.
•
Deny religiosity in mental health clients.
•
Increase social reasoning.
Correct Answer: 1
Rationale 1: In classical conditioning, people learn to associate a particular feeling
state with a particular circumstance that then becomes a conditioned stimulus for the
feeling. Over time, the association between the circumstance and the feeling is
strengthened through repetition and rehearsal. The therapists goal in behavior
therapy is to decrease or eliminate the association of a particular circumstance (the
conditioned stimulus) with a particular feeling. Denying religiosity, increasing selfconfidence, and increasing social reasoning are not goals of behavior therapy.
Rationale 2: In classical conditioning, people learn to associate a particular feeling
state with a particular circumstance that then becomes a conditioned stimulus for the
feeling. Over time, the association between the circumstance and the feeling is
strengthened through repetition and rehearsal. The therapists goal in behavior
therapy is to decrease or eliminate the association of a particular circumstance (the
conditioned stimulus) with a particular feeling. Denying religiosity, increasing selfconfidence, and increasing social reasoning are not goals of behavior therapy.
Rationale 3: In classical conditioning, people learn to associate a particular feeling
state with a particular circumstance that then becomes a conditioned stimulus for the
feeling. Over time, the association between the circumstance and the feeling is
strengthened through repetition and rehearsal. The therapists goal in behavior
therapy is to decrease or eliminate the association of a particular circumstance (the
conditioned stimulus) with a particular feeling. Denying religiosity, increasing selfconfidence, and increasing social reasoning are not goals of behavior therapy.
Rationale 4: In classical conditioning, people learn to associate a particular feeling
state with a particular circumstance that then becomes a conditioned stimulus for the
feeling. Over time, the association between the circumstance and the feeling is
strengthened through repetition and rehearsal. The therapists goal in behavior
therapy is to decrease or eliminate the association of a particular circumstance (the
conditioned stimulus) with a particular feeling. Denying religiosity, increasing selfconfidence, and increasing social reasoning are not goals of behavior therapy.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Relate conditioning and association to the process of human learning.
Que
stio
n 12
Typ
e:
MC
SA
Clients with mental disorders who form inferences from rational beliefs are:
•
Better supported by family members.
•
Significantly more functional than clients who hold irrational beliefs.
•
Able to control impulses.
•
On their way to feeling normal.
Correct Answer: 2
Rationale 1: Rational emotive behavior therapy (REBT) identifies and corrects
irrational beliefs. Rational and irrational beliefs, defined by REBT, form the basis of
inferences (conclusions based on reasoning) derived to explain life experiences. Those
inferences can be more or less functional, depending on the beliefs behind them.
People who hold rational beliefs form inferences that are significantly more functional
than those formed by people who hold irrational beliefs. The capacity to form
inferences from rational beliefs has not been shown to influence family support,
impulse control, or clients feelings of normalcy.
Rationale 2: Rational emotive behavior therapy (REBT) identifies and corrects
irrational beliefs. Rational and irrational beliefs, defined by REBT, form the basis of
inferences (conclusions based on reasoning) derived to explain life experiences. Those
inferences can be more or less functional, depending on the beliefs behind them.
People who hold rational beliefs form inferences that are significantly more functional
than those formed by people who hold irrational beliefs. The capacity to form
inferences from rational beliefs has not been shown to influence family support,
impulse control, or clients feelings of normalcy.
Rationale 3: Rational emotive behavior therapy (REBT) identifies and corrects
irrational beliefs. Rational and irrational beliefs, defined by REBT, form the basis of
inferences (conclusions based on reasoning) derived to explain life experiences. Those
inferences can be more or less functional, depending on the beliefs behind them.
People who hold rational beliefs form inferences that are significantly more functional
than those formed by people who hold irrational beliefs. The capacity to form
inferences from rational beliefs has not been shown to influence family support,
impulse control, or clients feelings of normalcy.
Rationale 4: Rational emotive behavior therapy (REBT) identifies and corrects
irrational beliefs. Rational and irrational beliefs, defined by REBT, form the basis of
inferences (conclusions based on reasoning) derived to explain life experiences. Those
inferences can be more or less functional, depending on the beliefs behind them.
People who hold rational beliefs form inferences that are significantly more functional
than those formed by people who hold irrational beliefs. The capacity to form
inferences from rational beliefs has not been shown to influence family support,
impulse control, or clients feelings of normalcy.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Relate conditioning and association to the process of human learning.
Que
stio
n 13
Typ
e:
MC
SA
The nursing student working on a group project brings healthy snacks to the
meeting so he and his fellow classmates will not gain unwanted pounds as they did
on a previous massive assignment. The student has employed:
•
Unobserved behaviors tracked in subjective measurable terms.
•
Behavior modification.
•
Process illumination.
•
Interactional group therapy.
Correct Answer: 2
Rationale 1: Behavior modification frequently focuses on a target behavior that is
problematic for the individual or for the community, in this case overeating. The
behavior was observed in objective and measurable terms of weight gained, then
addressed with a behavior modification plan. The student has not used interactional
group therapy. Process illumination is considering the process involved.
Rationale 2: Behavior modification frequently focuses on a target behavior that is
problematic for the individual or for the community, in this case overeating. The
behavior was observed in objective and measurable terms of weight gained, then
addressed with a behavior modification plan. The student has not used interactional
group therapy. Process illumination is considering the process involved.
Rationale 3: Behavior modification frequently focuses on a target behavior that is
problematic for the individual or for the community, in this case overeating. The
behavior was observed in objective and measurable terms of weight gained, then
addressed with a behavior modification plan. The student has not used interactional
group therapy. Process illumination is considering the process involved.
Rationale 4: Behavior modification frequently focuses on a target behavior that is
problematic for the individual or for the community, in this case overeating. The
behavior was observed in objective and measurable terms of weight gained, then
addressed with a behavior modification plan. The student has not used interactional
group therapy. Process illumination is considering the process involved.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Design nursing care plans for people with varied diagnoses
using cognitive behavioral therapies.
Que
stio
n 14
Typ
e:
MC
SA
A client admitted with borderline personality disorder complains during group
therapy that she, always falls for the bad guy. She has been in and out of
rehabilitation and abuse crisis centers. The nursing student knows this client would
benefit from:
•
Intrapsychic cognitive therapy.
•
Family conflict therapy.
•
Dialectical behavioral therapy.
•
Self-reflective therapy.
Correct Answer: 3
Rationale 1: Linehan specifically developed dialectical behavioral therapy (DBT) for
the outpatient treatment of chronically suicidal people with borderline personality
disorder. DBT is a specialized subset of the cognitive behavioral treatment modalities.
The client with borderline personality disorder tends to be crisis prone, with intense
relational episodes. In other words, interactions with others have the potential to
disrupt the client powerfully.
Rationale 2: Linehan specifically developed dialectical behavioral therapy (DBT) for
the outpatient treatment of chronically suicidal people with borderline personality
disorder. DBT is a specialized subset of the cognitive behavioral treatment modalities.
The client with borderline personality disorder tends to be crisis prone, with intense
relational episodes. In other words, interactions with others have the potential to
disrupt the client powerfully.
Rationale 3: Linehan specifically developed dialectical behavioral therapy (DBT) for
the outpatient treatment of chronically suicidal people with borderline personality
disorder. DBT is a specialized subset of the cognitive behavioral treatment modalities.
The client with borderline personality disorder tends to be crisis prone, with intense
relational episodes. In other words, interactions with others have the potential to
disrupt the client powerfully.
Rationale 4: Linehan specifically developed dialectical behavioral therapy (DBT) for
the outpatient treatment of chronically suicidal people with borderline personality
disorder. DBT is a specialized subset of the cognitive behavioral treatment modalities.
The client with borderline
personality disorder tends to be crisis prone, with intense relational episodes. In other words,
interactions with others have the potential to disrupt the client powerfully.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Design nursing care plans for people with varied diagnoses
using cognitive behavioral therapies.
Que
stio
n 15
Typ
e:
MC
SA
The nurse knows that being a competent provider of cognitive behavioral
interventions involves understanding and being aware of cultural considerations.
Characteristics that nurses must be aware of during assessment include:
•
Gender, sexual orientation, and age.
•
Illness prevention, disability, and gender.
•
Group expression, self-awareness, and religion.
•
Family matters, self-awareness, and age.
Correct Answer: 1
Rationale 1: Cultural considerations involve more than an individuals race or
ethnicity. Culture is an envelope that includes, among other characteristics, religion,
spirituality, gender, disability, sexual orientation and expression, social status, and age.
To be a competent provider of cognitive
behavioral interventions, the nurse must, at a minimum, understand these variables,
be self- aware, and be comfortable working with those from a culture that differs
from the nurses own. Self-awareness and illness prevention are not part of cultural
considerations.
Rationale 2: Cultural considerations involve more than an individuals race or
ethnicity. Culture is an envelope that includes, among other characteristics, religion,
spirituality, gender, disability, sexual orientation and expression, social status, and age.
To be a competent provider of cognitive behavioral interventions, the nurse must, at a
minimum, understand these variables, be self- aware, and be comfortable working
with those from a culture that differs from the nurses own.
Self-awareness and illness prevention are not part of cultural considerations.
Rationale 3: Cultural considerations involve more than an individuals race or
ethnicity. Culture is an envelope that includes, among other characteristics, religion,
spirituality, gender, disability, sexual orientation and expression, social status, and age.
To be a competent provider of cognitive behavioral interventions, the nurse must, at a
minimum, understand these variables, be self- aware, and be comfortable working
with those from a culture that differs from the nurses own.
Self-awareness and illness prevention are not part of cultural considerations.
Rationale 4: Cultural considerations involve more than an individuals race or
ethnicity. Culture is an envelope that includes, among other characteristics, religion,
spirituality, gender, disability, sexual orientation and expression, social status, and age.
To be a competent provider of cognitive behavioral interventions, the nurse must, at a
minimum, understand these variables, be self- aware, and be comfortable working
with those from a culture that differs from the nurses own.
Self-awareness and illness prevention are not part of cultural considerations.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Design nursing care plans for people with varied diagnoses
using cognitive behavioral therapies.
Que
stio
n 16
Typ
e:
MC
SA
The nurse knows that a client who has panic attacks when she sees waterfalls because
she had been physically assaulted in a park with a waterfall, would benefit from the
feature of cognitive and behavioral treatment of:
•
Suggesting alternative behavior.
•
Seeking social support.
•
Reframing.
•
Expressing affection.
Correct Answer: 3
Rationale 1: Cognitive and behavioral treatment consists of identifying and
recognizing maladaptive thinking styles and working toward the acquisition of new
skills for managing stressors. Features of treatment include teaching, interpreting,
reframing, and learning and practicing new behaviors. Once thoughts and behaviors
are realistically and rationally framed and implemented, emotional reactions will be
consistent with them. Seeking social support and expressing affection are not part of
cognitive and behavioral therapy. The clients need is to reframe, not just receive a
suggested alternative behavior.
Rationale 2: Cognitive and behavioral treatment consists of identifying and
recognizing maladaptive thinking styles and working toward the acquisition of new
skills for managing stressors. Features of treatment include teaching, interpreting,
reframing, and learning and practicing new behaviors. Once thoughts and behaviors
are realistically and rationally framed and implemented, emotional reactions will be
consistent with them. Seeking social support and expressing affection are not part of
cognitive and behavioral therapy. The clients need is to reframe, not just receive a
suggested alternative behavior.
Rationale 3: Cognitive and behavioral treatment consists of identifying and
recognizing maladaptive thinking styles and working toward the acquisition of new
skills for managing stressors. Features of treatment include teaching, interpreting,
reframing, and learning and practicing new behaviors. Once thoughts and behaviors
are realistically and rationally framed and implemented, emotional reactions will be
consistent with them. Seeking social support and expressing affection are not part of
cognitive and behavioral therapy. The clients need is to reframe, not just receive a
suggested alternative behavior.
Rationale 4: Cognitive and behavioral treatment consists of identifying and
recognizing maladaptive thinking styles and working toward the acquisition of new
skills for managing stressors. Features of treatment include teaching, interpreting,
reframing, and learning and practicing new behaviors. Once thoughts and behaviors
are realistically and rationally framed and implemented, emotional reactions will be
consistent with them. Seeking social support and expressing affection are not part of
cognitive and behavioral therapy. The clients need is to reframe, not just receive a
suggested alternative behavior.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Design nursing care plans for people with varied diagnoses
using cognitive behavioral therapies.
Que
stio
n 17
Typ
e:
MC
SA
A nursing student attempting to use a behavioral modification contract found in the
textbook is having trouble getting the client to follow through with everything in
the contract. The nursing instructor knows to tell the student that behavioral
contracts must be:
•
Affected by the functionality of the client.
•
Reflective of the clients mental illness.
•
Tailored for the individual.
•
Reflective of the characteristics within the clients family.
Correct Answer: 3
Rationale 1: A behavioral contract is a behavior modification plan arranged as a
specific agreement between the individual and the team of caregivers who identify
the behavior and design the plan. To be effective, the behavioral contract is
tailored for the individual client. A contract that is reflective of the clients illness,
considers the clients functionality, and reflects characteristics within the family
are all aspects of tailoring the contract for the individual.
Rationale 2: A behavioral contract is a behavior modification plan arranged as a
specific agreement between the individual and the team of caregivers who identify
the behavior and design the plan. To be effective, the behavioral contract is
tailored for the individual client. A contract that is reflective of the clients illness,
considers the clients functionality, and reflects characteristics within the family
are all aspects of tailoring the contract for the individual.
Rationale 3: A behavioral contract is a behavior modification plan arranged as a
specific agreement between the individual and the team of caregivers who identify
the behavior and design the plan. To be effective, the behavioral contract is
tailored for the individual client. A contract that is reflective of the clients illness,
considers the clients functionality, and reflects characteristics within the family
are all aspects of tailoring the contract for the individual.
Rationale 4: A behavioral contract is a behavior modification plan arranged as a
specific agreement between the individual and the team of caregivers who identify
the behavior and design the plan. To be effective, the behavioral contract is
tailored for the individual client. A contract that is reflective of the clients illness,
considers the clients functionality, and reflects characteristics within the family are
all aspects of tailoring the contract for the individual.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Analyze the effectiveness of a behavioral contract to promote
a change in health-related behaviors.
Que
stio
n 18
Typ
e:
MC
SA
A nursing student is praised for the comprehensive assessment of a client diagnosed
with suicidal ideation. Based on the assessment interview, the student develops a plan
to keep the client safe, and the client signs the resulting:
•
DNR contract.
•
Behavioral contract.
•
Patient bill of rights contract.
•
Acceptance letter.
Correct Answer: 2
Rationale 1: A comprehensive assessment interview is the first step in developing a
contract with the goal of behavioral change. The purpose of the interview is to
assemble a complete picture of the behavior and what maintains it or keeps it going,
so that strategies for changing the behavior have the best chance of success. A do-notresuscitate (DNR) contract, patient bill of rights, and acceptance letter do not apply to
the client in the scenario.
Rationale 2: A comprehensive assessment interview is the first step in developing a
contract with the goal of behavioral change. The purpose of the interview is to
assemble a complete
picture of the behavior and what maintains it or keeps it going, so that strategies for
changing the behavior have the best chance of success. A do-not-resuscitate (DNR)
contract, patient bill of rights, and acceptance letter do not apply to the client in the
scenario.
Rationale 3: A comprehensive assessment interview is the first step in developing a
contract with the goal of behavioral change. The purpose of the interview is to
assemble a complete picture of the behavior and what maintains it or keeps it going,
so that strategies for changing the behavior have the best chance of success. A do-notresuscitate (DNR) contract, patient bill of rights, and acceptance letter do not apply to
the client in the scenario.
Rationale 4: A comprehensive assessment interview is the first step in developing a
contract with the goal of behavioral change. The purpose of the interview is to
assemble a complete picture of the behavior and what maintains it or keeps it going,
so that strategies for changing the behavior have the best chance of success. A do-notresuscitate (DNR) contract, patient bill of rights, and acceptance letter do not apply to
the client in the scenario.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Analyze the effectiveness of a behavioral contract to promote
a change in health-related behaviors.
Que
stio
n 19
Typ
e:
MC
SA
The nurse knows that nursing diagnoses for cognitive behavioral assessment include:
•
Pseudohostility and Ineffective Coping.
•
Knowledge Deficit and Effective Coping.
•
Interrupted Family Processes and Hopelessness.
•
Hopelessness and Functional Family Processes.
Correct Answer: 3
Rationale 1: Examples of nursing diagnoses that may derive from a cognitive
behavioral assessment in preparation for the development of a behavioral contract
include Interrupted Family Processes and Hopelessness, Knowledge Deficit,
Ineffective Coping, and Dysfunctional Family Processes. Pseudohostility, Functional
Family Processes, and Effective Coping are not diagnoses related to cognitive
behavioral assessment.
Rationale 2: Examples of nursing diagnoses that may derive from a cognitive
behavioral assessment in preparation for the development of a behavioral contract
include Interrupted Family Processes and Hopelessness, Knowledge Deficit,
Ineffective Coping, and Dysfunctional Family Processes. Pseudohostility, Functional
Family Processes, and Effective Coping are not diagnoses related to cognitive
behavioral assessment.
Rationale 3: Examples of nursing diagnoses that may derive from a cognitive
behavioral assessment in preparation for the development of a behavioral contract
include Interrupted Family Processes and Hopelessness, Knowledge Deficit,
Ineffective Coping, and Dysfunctional Family Processes. Pseudohostility, Functional
Family Processes, and Effective Coping are not diagnoses related to cognitive
behavioral assessment.
Rationale 4: Examples of nursing diagnoses that may derive from a cognitive
behavioral assessment in preparation for the development of a behavioral contract
include Interrupted Family Processes and Hopelessness, Knowledge Deficit,
Ineffective Coping, and Dysfunctional Family Processes. Pseudohostility, Functional
Family Processes, and Effective Coping are not diagnoses related to cognitive
behavioral assessment.
Global Rationale:
Cognitive Level:
Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Analyze the effectiveness of a behavioral contract to promote
a change in health-related behaviors.
Que
stio
n 20
Typ
e:
MC
SA
A client diagnosed with schizoaffective disorder has threatened suicide. While
developing the care plan, the nurse puts in the nurses notes, The client, though
disheveled, is articulate and has a clear plan for suicide, but has made no current
attempts. The nursing note helps the nurse develop the behavioral contract by:
•
Orienting the client to the nursing process.
•
Considering interactions during the assessment process.
•
Observing essential information.
•
Cooperating with the family.
Correct Answer: 2
Rationale 1: The planning phase of the nursing process with behavioral contracting
requires taking into consideration interactions with the nurse during the assessment
interview including aspects of appearance, behavior, attitude, and responsiveness.
Obtaining family cooperation and signing behavioral contracts occur during
implementation. Orientation to the nursing process is not part of the planning phase.
Observations that contribute essential information would be included in interactions
during the assessment process.
Rationale 2: The planning phase of the nursing process with behavioral contracting
requires taking into consideration interactions with the nurse during the assessment
interview including
aspects of appearance, behavior, attitude, and responsiveness. Obtaining family
cooperation and signing behavioral contracts occur during implementation.
Orientation to the nursing process is not part of the planning phase. Observations
that contribute essential information would be included in interactions during the
assessment process.
Rationale 3: The planning phase of the nursing process with behavioral contracting
requires taking into consideration interactions with the nurse during the assessment
interview including aspects of appearance, behavior, attitude, and responsiveness.
Obtaining family cooperation and signing behavioral contracts occur during
implementation. Orientation to the nursing process is not part of the planning phase.
Observations that contribute essential information would be included in interactions
during the assessment process.
Rationale 4: The planning phase of the nursing process with behavioral contracting
requires taking into consideration interactions with the nurse during the assessment
interview including aspects of appearance, behavior, attitude, and responsiveness.
Obtaining family cooperation and signing behavioral contracts occur during
implementation. Orientation to the nursing process is not part of the planning phase.
Observations that contribute essential information would be included in interactions
during the assessment process.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Analyze the effectiveness of a behavioral contract to promote
a change in health-related behaviors.
Que
stio
n 21
Typ
e:
MC
SA
Involving families with the clients treatment is an important aspect of family nursing.
It is important to involve them as much as appropriate for the formulation and
implementation of:
•
Family identity.
•
Hope, support, and happiness.
•
Behavioral contracts.
•
Positive client behavior.
Correct Answer: 3
Rationale 1: Family involvement is a powerful and useful catalyst for promoting
and maintaining behavioral change. Significant others, particularly those with
whom the client resides or will reside, are likely to provide important input
regarding the level of contract adherence. It is, therefore, important to involve them
as much as appropriate in the formulation and implementation of the behavioral
contract. If the details of the contract do not work for the involved family, they will
not work for the client.
Rationale 2: Family involvement is a powerful and useful catalyst for promoting
and maintaining behavioral change. Significant others, particularly those with
whom the client resides or will reside, are likely to provide important input
regarding the level of contract adherence. It is, therefore, important to involve them
as much as appropriate in the formulation and implementation of the behavioral
contract. If the details of the contract do not work for the involved family, they will
not work for the client.
Rationale 3: Family involvement is a powerful and useful catalyst for promoting
and maintaining behavioral change. Significant others, particularly those with
whom the client resides or will reside, are likely to provide important input
regarding the level of contract adherence. It is, therefore, important to involve them
as much as appropriate in the formulation and implementation of the behavioral
contract. If the details of the contract do not work for the involved family, they will
not work for the client.
Rationale 4: Family involvement is a powerful and useful catalyst for
promoting and maintaining behavioral change. Significant others, particularly
those with whom the client
resides or will reside, are likely to provide important input regarding the level of
contract adherence. It is, therefore, important to involve them as much as appropriate
in the formulation and implementation of the behavioral contract. If the details of the
contract do not work for the involved family, they will not work for the client.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Modify a nursing care plan to promote and enhance positive
outcomes for cognitive behavioral therapies.
Que
stio
n 22
Typ
e:
MC
SA
The night nurse at the mental health clinic is designing a behavioral contract for a
client diagnosed with panic attacks. During the assessment phase, the client is
negative and exhibits low self-esteem. However, the nurse knows that in order to
develop an effective contract, the focus must be on:
•
Specific social weaknesses.
•
The clients abilities and strengths.
•
The clients family.
•
The goals of discharge.
Correct Answer: 2
Rationale 1: Evaluating client abilities and strengths, particularly with regard to
learning and making changes, will help in the design of the contract. Discover what
other situations requiring behavioral change the client has mastered and what specific
personal or social strengths the client employed in implementing the change.
Evaluate the clients weaknesses with regard to learning and making changes as well.
These interactions address specific problematic behaviors, rather than social
weaknesses or family issues. Goals of discharge are developed later in the treatment
process.
Rationale 2: Evaluating client abilities and strengths, particularly with regard to
learning and making changes, will help in the design of the contract. Discover what
other situations requiring behavioral change the client has mastered and what specific
personal or social strengths the client employed in implementing the change.
Evaluate the clients weaknesses with regard to learning and making changes as well.
These interactions address specific problematic behaviors, rather than social
weaknesses or family issues. Goals of discharge are developed later in the treatment
process.
Rationale 3: Evaluating client abilities and strengths, particularly with regard to
learning and making changes, will help in the design of the contract. Discover what
other situations requiring behavioral change the client has mastered and what specific
personal or social strengths the client employed in implementing the change.
Evaluate the clients weaknesses with regard to learning and making changes as well.
These interactions address specific problematic behaviors, rather than social
weaknesses or family issues. Goals of discharge are developed later in the treatment
process.
Rationale 4: Evaluating client abilities and strengths, particularly with regard to
learning and making changes, will help in the design of the contract. Discover what
other situations requiring behavioral change the client has mastered and what specific
personal or social strengths the client employed in implementing the change.
Evaluate the clients weaknesses with regard to learning and making changes as well.
These interactions address specific problematic behaviors, rather than social
weaknesses or family issues. Goals of discharge are developed later in the treatment
process.
Global Rationale:
Cognitive Level:
Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Modify a nursing care plan to promote and enhance positive
outcomes for cognitive behavioral therapies.
Que
stio
n 23
Typ
e:
MC
SA
The nurse student taking care of a client with schizophrenia has difficulty keeping
up with the clients music therapy and individual therapy times. The nurse knows,
however, that the case manager is helpful in maintaining the routines and
schedules of:
•
Self-study.
•
All clients on the unit.
•
Cognitive behavioral interventions..
•
Clients in music therapy.
Correct Answer: 3
Rationale 1: It is important to focus on maintaining the routines and schedules of
cognitive behavioral interventions once a plan of care has been established.
Homework assignments and practice using more competent responses will ensure
that the client retains the skills obtained in therapy. The case manager can be helpful
in sustaining that structure. The variety of interventions, such as group or individual
therapy, behavior modification, and self-study can all be promoted and supported
through case management.
Rationale 2: It is important to focus on maintaining the routines and schedules of
cognitive behavioral interventions once a plan of care has been established.
Homework assignments and practice using more competent responses will ensure
that the client retains the skills obtained in
therapy. The case manager can be helpful in sustaining that structure. The variety of
interventions, such as group or individual therapy, behavior modification, and selfstudy can all be promoted and supported through case management.
Rationale 3: It is important to focus on maintaining the routines and schedules of
cognitive behavioral interventions once a plan of care has been established.
Homework assignments and practice using more competent responses will ensure
that the client retains the skills obtained in therapy. The case manager can be helpful
in sustaining that structure. The variety of interventions, such as group or individual
therapy, behavior modification, and self-study can all be promoted and supported
through case management.
Rationale 4: It is important to focus on maintaining the routines and schedules of
cognitive behavioral interventions once a plan of care has been established.
Homework assignments and practice using more competent responses will ensure
that the client retains the skills obtained in therapy. The case manager can be helpful
in sustaining that structure. The variety of interventions, such as group or individual
therapy, behavior modification, and self-study can all be promoted and supported
through case management.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Modify a nursing care plan to promote and enhance positive
outcomes for cognitive behavioral therapies.
Que
stio
n 24
Typ
e:
MC
SA
A client being discharged from the mental health clinic is fearful about not being able
to keep up with therapy and treatments after leaving the clinic. The nurse knows that
to ensure client success after discharge, the clients behavioral contract should:
•
Support the clients family and friends.
•
Ensure client success.
•
Build and maintain treatments to help the community.
•
Address issues the client will face in community living.
Correct Answer: 4
Rationale 1: The behavioral contract can be designed to address inpatient issues and
community living and to enhance the transition from inpatient treatment to an
outpatient setting. Additional supports can be built into the contract to assure the
clients success after the transition. These interventions in the community maximize
both the quality of life and management of symptoms. No contract can ensure
success.
Rationale 2: The behavioral contract can be designed to address inpatient issues and
community living and to enhance the transition from inpatient treatment to an
outpatient setting. Additional supports can be built into the contract to assure the
clients success after the transition. These interventions in the community maximize
both the quality of life and management of symptoms. No contract can ensure
success.
Rationale 3: The behavioral contract can be designed to address inpatient issues and
community living and to enhance the transition from inpatient treatment to an
outpatient setting. Additional supports can be built into the contract to assure the
clients success after the transition. These interventions in the community maximize
both the quality of life and management of symptoms. No contract can ensure
success.
Rationale 4: The behavioral contract can be designed to address inpatient issues and
community living and to enhance the transition from inpatient treatment to an outpatient setting.
Additional supports can be built into the contract to assure the clients success after the
transition. These
interventions in the community maximize both the quality of life and management of
symptoms. No contract can ensure success.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Modify a nursing care plan to promote and enhance positive
outcomes for cognitive behavioral therapies.
Ques
tion
25
Type
:
MC
MA
During the assessment, the family nurse therapist inquires about weaknesses
regarding learning the client may have. The client becomes defensive and states, You
sure are nosy! Smiling, the nurse states, I dont mean to seem nosy, but I must ask
these questions to develop a plan that will work for you. The nurses therapeutic
response is an attempt to ascertain:
Standard Text: Select all that apply.
•
How the client interacts with family members.
•
Anecdotes from family and friends.
•
The psychiatrists progress notes.
•
Specific factors that have interfered with the success of a goal.
Correct Answer: 4
Rationale 1: Evaluating the client weaknesses with regard to learning and making
changes will help the nurse discover what other situations requiring behavioral change
the client has mastered, and what specific personal or social strengths the client
employed in implementing the change. It is helpful to know what the client attempted
to change without success, and the specific factors that interfered with the success, of
that goal. The questions may result in knowledge of the clients interaction with family
members. The questions to the client would not elicit anecdotes from family or
friends, or the psychiatrists progress notes.
Rationale 2: Evaluating the client weaknesses with regard to learning and making
changes will help the nurse discover what other situations requiring behavioral change
the client has mastered, and what specific personal or social strengths the client
employed in implementing the change. It is helpful to know what the client attempted
to change without success, and the specific factors that interfered with the success, of
that goal. The questions may result in knowledge of the clients interaction with family
members. The questions to the client would not elicit anecdotes from family or
friends, or the psychiatrists progress notes.
Rationale 3: Evaluating the client weaknesses with regard to learning and making
changes will help the nurse discover what other situations requiring behavioral change
the client has mastered, and what specific personal or social strengths the client
employed in implementing the change. It is helpful to know what the client attempted
to change without success, and the specific factors that interfered with the success, of
that goal. The questions may result in knowledge of the clients interaction with family
members. The questions to the client would not elicit anecdotes from family or
friends, or the psychiatrists progress notes.
Rationale 4: Evaluating the client weaknesses with regard to learning and making
changes will help the nurse discover what other situations requiring behavioral change
the client has mastered, and what specific personal or social strengths the client
employed in implementing the change. It is helpful to know what the client attempted
to change without success, and the specific factors that interfered with the success, of
that goal. The questions may result in knowledge of the clients interaction with family
members. The questions to the client would not elicit anecdotes from family or
friends, or the psychiatrists progress notes.
Global
Rationale:
Cognitive Level:
Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe how your personal characteristics might
influence your effectiveness in using cognitive behavioral therapies.
Que
stio
n 26
Typ
e:
MC
SA
A nurse skillful in the writing process knows that this talent may benefit the
client because a well-written behavioral contract:
•
Teaches the client about past mistakes to lead to a successful outcome.
•
Provides everything needed for a cure.
•
Teaches the client to embrace the future helps overcome past misdeeds.
•
Can promote successful outcomes.
Correct Answer: 4
Rationale 1: For a contract to lead to a successful outcome, it must be carefully
crafted. A contract does not provide everything needed for a cure, or teach the client
to embrace the future. The contract is framed in positive terms (e.g., will maintain
abstinence) rather than past mistakes (e.g., will not relapse into use).
Rationale 2: For a contract to lead to a successful outcome, it must be carefully
crafted. A contract does not provide everything needed for a cure, or teach the client
to embrace the future. The contract is framed in positive terms (e.g., will maintain
abstinence) rather than past mistakes (e.g., will not relapse into use).
Rationale 3: For a contract to lead to a successful outcome, it must be carefully
crafted. A contract does not provide everything needed for a cure, or teach the client
to embrace the future. The contract is framed in positive terms (e.g., will maintain
abstinence) rather than past mistakes (e.g., will not relapse into use).
Rationale 4: For a contract to lead to a successful outcome, it must be carefully
crafted. A contract does not provide everything needed for a cure, or teach the client
to embrace the future. The contract is framed in positive terms (e.g., will maintain
abstinence) rather than past mistakes (e.g., will not relapse into use).
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe how your personal characteristics might
influence your effectiveness in using cognitive behavioral therapies.
Que
stio
n 27
Typ
e:
MC
SA
When speaking with a client who has a mental illness, the nurse uses medical
terminology and is condescending. This type of behavior negates the basic rules of
negotiating a behavioral contract and:
•
Encourages the client to ask questions.
•
Causes the client to feel uncomfortable with the contract.
•
Appropriately introduces the client to important terminology.
•
Helps the client understand behavioral contracts on his/her terms.
Correct Answer: 2
Rationale 1: The basic rules for negotiating a behavioral contract include engaging
the client as a colleague, avoiding complex terminology or coercive formats, and
making sure the client completely understands, agrees to, and, to the extent possible,
feels comfortable with the contract. The nurses condescending attitude will not
encourage the client to ask questions.
Complex or medical terminology will not help the client understand the contract.
Rationale 2: The basic rules for negotiating a behavioral contract include engaging
the client as a colleague, avoiding complex terminology or coercive formats, and
making sure the client completely understands, agrees to, and, to the extent possible,
feels comfortable with the contract. The nurses condescending attitude will not
encourage the client to ask questions.
Complex or medical terminology will not help the client understand the contract.
Rationale 3: The basic rules for negotiating a behavioral contract include engaging
the client as a colleague, avoiding complex terminology or coercive formats, and
making sure the client completely understands, agrees to, and, to the extent possible,
feels comfortable with the contract. The nurses condescending attitude will not
encourage the client to ask questions.
Complex or medical terminology will not help the client understand the contract.
Rationale 4: The basic rules for negotiating a behavioral contract include engaging
the client as a colleague, avoiding complex terminology or coercive formats, and
making sure the client completely understands, agrees to, and, to the extent possible,
feels comfortable with the contract. The nurses condescending attitude will not
encourage the client to ask questions.
Complex or medical terminology will not help the client understand the contract.
Global
Rationale:
Cognitive Level:
Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe how your personal characteristics might
influence your effectiveness in using cognitive behavioral therapies.
Que
stio
n 28
Typ
e:
MC
SA
A client diagnosed with bipolar disorder is hyperverbal during the initial assessment.
In an effort to help the client understand what is required in treatment, the nurse has a
calm demeanor, decreases stimuli, and talks to the client one-on-one. The nurse is
responding to the clients:
•
Cognitive style.
•
Negative behavior.
•
Positive behavior style.
•
Mania.
Correct Answer: 1
Rationale 1: How people think and react and remember is their cognitive style or
overall pattern of thought. The nurses actions indicate an understanding of the way
the client thinks. The clients behavior is neither positive nor negative. The client
being hyperverbal may or may not indicate mania.
Rationale 2: How people think and react and remember is their cognitive style or
overall pattern of thought. The nurses actions indicate an understanding of the way
the client thinks. The clients behavior is neither positive nor negative. The client
being hyperverbal may or may not indicate mania.
Rationale 3: How people think and react and remember is their cognitive style or
overall pattern of thought. The nurses actions indicate an understanding of the way
the client thinks. The clients behavior is neither positive nor negative. The client
being hyperverbal may or may not indicate mania.
Rationale 4: How people think and react and remember is their cognitive style or
overall pattern of thought. The nurses actions indicate an understanding of the way
the client thinks. The clients behavior is neither positive nor negative. The client
being hyperverbal may or may not indicate mania.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe how your personal characteristics might
influence your effectiveness in using cognitive behavioral therapies.
Que
stio
n 29
Typ
e:
MC
SA
A nurse comes to the mental health clinic tired, angry, and in a hurry. After making
several minor mistakes, the nurse realizes that in order to help clients and improve
their functioning through the development of behavioral contracts, he/she must first
take his/her time and change his/her attitude in order to:
•
Formulate practical and measurable objectives.
•
Develop goals based on client and family needs.
•
Normalize the familys experience.
•
Teach the client communication skills.
Correct Answer: 1
Rationale 1: Formulating practical and measurable objectives and goals is the
next step in developing a behavioral contract. Objectives are small steps leading to
goal attainment; goals represent the overall desired outcomes. Learning
communication skills may be a result of a successful behavioral contract.
Normalizing the familys experience is not part of a behavioral contract.
Rationale 2: Formulating practical and measurable objectives and goals is the
next step in developing a behavioral contract. Objectives are small steps leading to
goal attainment; goals represent the overall desired outcomes. Learning
communication skills may be a result of a successful behavioral contract.
Normalizing the familys experience is not part of a behavioral contract.
Rationale 3: Formulating practical and measurable objectives and goals is the
next step in developing a behavioral contract. Objectives are small steps leading to
goal attainment; goals represent the overall desired outcomes. Learning
communication skills may be a result of a successful behavioral contract.
Normalizing the familys experience is not part of a behavioral contract.
Rationale 4: Formulating practical and measurable objectives and goals is the
next step in developing a behavioral contract. Objectives are small steps leading to
goal attainment; goals represent the overall desired outcomes. Learning
communication skills may be a result of a successful behavioral contract.
Normalizing the familys experience is not part of a behavioral contract.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe how your personal characteristics might
influence your effectiveness in using cognitive behavioral therapies.
Que
stio
n 30
Typ
e:
MC
SA
The nursing instructor notes a nursing student is very imaginative. When teaching students
about designing and adjusting behavioral contracts, the nursing instructor knows that this
particular student will have an advantage in developing contracts because:
•
Monitoring nonverbal communication is a secondary goal.
•
Effective communication skill is the key negotiating tool.
•
Reprioritization of goals is the most important issue.
•
Creativity is an essential component.
Correct Answer: 4
Rationale 1: Designing a contract to which the client can adhere will maximize
the chance of success. Creativity is an essential component in negotiating an
effective behavioral contract. Effective communication skills and reprioritization
are important, but are not necessarily the most important aspects of developing
behavioral contracts. The students inventiveness is not related to monitoring
nonverbal communication.
Rationale 2: Designing a contract to which the client can adhere will maximize
the chance of success. Creativity is an essential component in negotiating an
effective behavioral contract. Effective communication skills and reprioritization
are important, but are not necessarily the most important aspects of developing
behavioral contracts. The students inventiveness is not related to monitoring
nonverbal communication.
Rationale 3: Designing a contract to which the client can adhere will maximize
the chance of success. Creativity is an essential component in negotiating an
effective behavioral contract. Effective communication skills and reprioritization
are important, but are not necessarily the most important aspects of developing
behavioral contracts. The students inventiveness is not related to monitoring
nonverbal communication.
Rationale 4: Designing a contract to which the client can adhere will maximize
the chance of success. Creativity is an essential component in negotiating an
effective behavioral contract. Effective communication skills and reprioritization
are important, but are not necessarily the most important aspects of developing
behavioral contracts. The students inventiveness is not related to monitoring
nonverbal communication.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe how your personal characteristics might
influence your effectiveness in using cognitive behavioral therapies.
Chapter 20. The Recovery Model
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A nursing instructor is teaching about recovery as it applies to mental illness.
Which student statement indicates that further teaching is needed?
1.
“The goal of recovery is improved health and wellness.”
2.
“The goal of recovery is expedient, comprehensive behavioral change.”
3.
“The goal of recovery is the ability to live a self-directed life.”
4.
“The goal of recovery is the ability to reach full potential.”
____
1.
2.
3.
4.
2.
Which situation presents an example of the basic concept of a recovery model?
The client’s family is encouraged to make decisions in order to facilitate discharge.
A social worker, discovering the client’s income, changes the client’s discharge
placement.
A psychiatrist prescribes an antipsychotic drug based on observed symptoms.
A client diagnosed with schizophrenia schedules follow-up appointments and group
therapy.
1.
2.
3.
4.
The client’s family is encouraged to make decisions in order to facilitate discharge.
A social worker, discovering the client’s income, changes the client’s discharge
placement.
A psychiatrist prescribes an antipsychotic drug based on observed symptoms.
A client diagnosed with schizophrenia schedules follow-up appointments and group
therapy.
____ 3.
A nursing instructor is teaching about the guiding principles of the recovery
model, as described by SAMHSA. Which student statement indicates that further teaching is
needed?
1.
“Recovery occurs via many pathways.”
2.
“Recovery emerges from strong religious affiliations.”
3.
“Recovery is supported by peers and allies.”
4.
“Recovery is culturally based and influenced.”
____ 4.
A client diagnosed with alcohol abuse disorder is referred to a residential care
facility after discharge. According to SAMHSA, which dimension of recovery is supporting this
client?
1.
Health
2.
Home
3.
Purpose
4.
Community
____ 5.
A client diagnosed with obsessive-compulsive disorder states, “I really think my
future will improve because of my successful treatment choices. I’m going to make my life
better.” Which guiding principle of recovery has assisted this client?
1.
Recovery emerges from hope.
2.
Recovery is person-driven.
3.
Recovery occurs via many pathways.
4.
Recovery is holistic.
____ 6.
A nurse maintains a client’s confidentiality, addressed the client appropriately, and
does not discriminate based on gender, age, race, or religion. Which guiding principle of
recovery has this nurse employed?
1.
Recovery is culturally based and influenced.
2.
Recovery is based on respect.
3.
Recovery involves individual, family, and community strengths and responsibility.
4.
Recovery is person-driven.
____ 7.
A nurse on an inpatient unit helps a client understand the significance of
treatments, and provides the client with copies of all documents related to the plan of care. This
nurse is employing which commitment in the “Tidal Model of Recovery?”
1.
Know that Change Is Constant
2.
Reveal Personal Wisdom
3.
Be Transparent
4.
Give the Gift of Time
____
1.
2.
3.
4.
8.
Which is the priority focus of recovery models?
Empowerment of the health-care team to bring their expertise to decision-making
Empowerment of the client to make decisions related to individual health care
Empowerment of the family system to provide supportive care
Empowerment of the physician to provide appropriate treatments
____ 9.
A client experiences an exacerbation of psychiatric symptoms to the point of
threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model
should be employed, and what action reflects this step?
1.
Step 3: Triggers that cause distress or discomfort are listed.
2.
Step 4: Signs indicating relapse are identified and plans for responding are
developed.
3.
Step 5: A specific plan to help with symptoms is formulated.
4.
Step 6: Following client-designed plan, caregivers now become decision-makers.
____ 10.
A nursing instructor is teaching about components present in the recovery process
as described by Andresen and associates that led to the development of the Psychological
Recovery Model. Which student statement indicates that further teaching is needed?
1.
“A client has a better chance of recovery if he or she truly believes that recovery
can occur.”
2.
“If a client is willing to give the responsibility of treatment to the health-care team,
they are likely to recover.”
3.
“A client who has a positive sense of self and a positive identity is likely to
recover.”
4.
“A client has a better chance of recovery if he or she has purpose and meaning in
life.”
____ 11.
A client states, “My illness is so devastating, I feel like my life is on hold.” The
nurse recognizes that this client is in which stage of the Psychological Recovery Model as
described by Andersen and associates?
1.
Moratorium
2.
Awareness
3.
Preparation
4.
Rebuilding
1.
2.
3.
4.
Moratorium
Awareness
Preparation
Rebuilding
____ 12.
A client states, “I have come to the conclusion that this disease has not paralyzed
me.” The nurse recognizes that this client is in which stage of the Psychological Recovery Model
as described by Andresen and associates?
1.
Moratorium
2.
Awareness
3.
Preparation
4.
Rebuilding
____ 13.
A psychiatrist who embraces the Psychological Recovery Model tells the nurse
that a client is in the Growth stage. What should the nurse expect to find when assessing this
client?
1.
A client feeling confident about achieving goals in life.
2.
A client who is aware of the need to set goals in life.
3.
A client who has mobilized personal and external resources.
4.
A client who begins to actively take control of his or her life.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 14.
Which of the following has SAMHSA described as major dimensions of support
for a life of recovery? (Select all that apply)
1.
Health
2.
Community
3.
Home
4.
Religious affiliation
5.
Purpose
____ 15.
A nurse uses the commitments of the Tidal Model of Recovery in psychiatric
nursing practice. Which of the following nursing actions reflect the use of the Develop Genuine
Curiosity commitment? (Select all that apply.)
1.
The nurse expresses interest in the client’s story.
2.
The nurse asks for clarification of certain points.
3.
The nurse encourages the client to speak his own words in his own unique way.
4.
The nurse assists the client to unfold the story at his or her own rate.
5.
The nurse provides the clients with copies of all documents relevant to care.
Other
16.
Order the six steps of The Wellness Recovery Action Plan (WRAP) Model as
described by Copeland et al.
________ Daily Maintenance List
________ Things Are Breaking Down or Getting Worse
________ Crisis Planning
________ Develop a Wellness Toolbox
________ Early Warning Signs
________ Triggers
Completion
Complete each statement.
17.
_________________________ from mental health disorders and substance use
disorders is a process of change through which individuals improve their health and wellness,
live a self-directed life, and strive to reach their full potential.
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance Abuse
and Mental Health Services Administration.
Page: 216
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
The Substance Abuse and Mental Health Services Administration (SAMHSA)
defines recovery from mental health disorders and substance use disorders as a
process of change through which individuals improve their health and wellness.
Change in recovery is not an expedient process. It occurs incrementally over time.
SAMHSA defines recovery from mental health disorders and substance use
disorders as a process of change through which individuals live a self-directed life.
SAMHSA defines recovery from mental health disorders and substance use
disorders as a process of change through which individuals strive to reach their full
potential.
PTS: 1
CON: Health Promotion
2.
ANS: 4
Chapter: Chapter 0, The Recovery Model
Objective: Define recovery.
Page: 216
Heading: Guiding Principles of Recovery
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client’s family making decisions for the client does not show empowerment of
the consumer.
The social worker making decisions for the client does not show empowerment of
the consumer.
The psychiatrist prescribing medication is not an example of empowerment by the
consumer.
The basic concept of a recovery model is empowerment of the consumer. The
recovery model is designed to allow consumers primary control over decisions
about their own care.
CON: Health Promotion
3.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance Abuse
and Mental Health Services Administration.
Page: 217
Heading: Guiding Principles of Recovery
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
The statement indicates understanding of the recovery model.
Recovery emerges from hope but affiliation with any particular religion would
have little bearing on the recovery process.
This statement indicates that the student has adequate understanding of the
recovery model.
This statement is accurate regarding the recovery model.
1
2
3
4
PTS: 1
Feedback
The statement indicates understanding of the recovery model.
Recovery emerges from hope but affiliation with any particular religion would
have little bearing on the recovery process.
This statement indicates that the student has adequate understanding of the
recovery model.
This statement is accurate regarding the recovery model.
CON: Health Promotion
4.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Define recovery.
Page: 216
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The dimension of health is not supporting this client.
SAMHSA describes the dimension of home as a stable and safe place to live.
The dimension of purpose is not supporting this client.
The dimension of community is not supporting this client.
CON: Health Promotion
5.
ANS: 1
Chapter: Chapter 0, The Recovery Process
Objective: Define recovery.
Page: 216
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
SAMHSA lists the following as guiding principles for the recovery model:
Recovery emerges from hope.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is person-driven.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery occurs via many pathways.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is holistic.
1
2
3
4
PTS: 1
Feedback
SAMHSA lists the following as guiding principles for the recovery model:
Recovery emerges from hope.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is person-driven.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery occurs via many pathways.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is holistic.
CON: Health Promotion
6.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance Abuse
and Mental Health Services Administration.
Page: 218
Heading: Guiding Principles of Recovery
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is culturally based and influenced.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is based on respect.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery involves individual, family, and community strengths and responsibility.
SAMHSA lists the following as guiding principles for the recovery model:
Recovery is person-driven.
CON: Health Promotion
7.
ANS: 3
Chapter: Chapter 0, The Recovery Model
Objective: Describe Three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 218
Heading: Models of Recovery > The Tidal Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments upon which the Tidal Model is based. They include: Know
That Change Is Constant.
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments upon which the Tidal Model is based. They include: Reveal
Personal Wisdom.
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments upon which the Tidal Model is based. They include: Be
Transparent.
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments upon which the Tidal Model is based. They include: Give the
Gift of Time.
CON: Health Promotion
8.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 216
Heading: Models of Recovery
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Empowerment of the health-care team is not the priority focus of the recovery
model.
The basic concept of a recovery model is empowerment of the client. The recovery
model is designed to allow clients primary control over decisions about their own
care.
Empowerment of the family system is not the priority focus of the recovery model.
Empowerment of the physician is not the priority focus of the recovery model.
CON: Health Promotion
9.
ANS: 4
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 221
Heading: Models of Recovery > The Wellness Recovery Action Plan
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The WRAP recovery model is a step-wise process through which an individual is
able to monitor and manage distressing symptoms that occur in daily life. The six
steps include: Step 3. Triggers.
The WRAP recovery model is a step-wise process through which an individual is
able to monitor and manage distressing symptoms that occur in daily life. The six
steps include: Step 4. Early Warning Signs.
The WRAP recovery model is a step-wise process through which an individual is
able to monitor and manage distressing symptoms that occur in daily life. The six
steps include: Step 5. Things Are Breaking Down or Getting Worse.
The WRAP recovery model is a step-wise process through which an individual is
able to monitor and manage distressing symptoms that occur in daily life. The six
steps include: In step 6 (Crisis Planning), clients can no longer care for
themselves, make independent decisions, or keep themselves safe. Caregivers take
an active role in this step on behalf of the client and implement the plan that the
client has previously developed.
CON: Health Promotion
10.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 220
Heading: The Wellness Recovery Action Plan (WRAP)
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement is true regarding recovery.
In examining a number of studies, Andresen and associates identified four
components that were consistently evident in the recovery process. These
components are hope, responsibility, self and identity, and meaning and purpose.
Under responsibility, this model tasks the client, not the health-care team, with
taking responsibility for his or her life and well-being.
This statement indicates that teaching has been effective.
This statement indicates that no further teaching is necessary.
CON: Health Promotion
11.
ANS: 1
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 222
Heading: The Psychological Recovery Model
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 1:
Moratorium.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 2: Awareness.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 3:
Preparation.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 4:
Rebuilding.
CON: Health Promotion
12.
ANS: 2
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 222
Heading: The Psychological Recovery Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 1:
Moratorium.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 2: Awareness.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 3:
Preparation.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 4:
Rebuilding.
CON: Health Promotion
13.
ANS: 1
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 224
Heading: The Psychological Recovery Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. In the growth stage, the individual feels
a sense of optimism and hope of a rewarding future. Skills that have been nurtured
in the previous stages are applied with confidence, and the individual strives for
higher levels of well-being.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 2: Awareness.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 3:
Preparation.
Andresen and associates have conceptualized a five-stage model of recovery
1
2
3
4
PTS: 1
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. In the growth stage, the individual feels
a sense of optimism and hope of a rewarding future. Skills that have been nurtured
in the previous stages are applied with confidence, and the individual strives for
higher levels of well-being.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 2: Awareness.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 3:
Preparation.
Andresen and associates have conceptualized a five-stage model of recovery
called the Psychological Recovery Model. The stages include: Stage 4:
Rebuilding.
CON: Health Promotion
MULTIPLE RESPONSE
14.
ANS: 1, 2, 3, 5
Chapter: Chapter 0, The Recovery Model
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance Abuse
and Mental Health Services Administration.
Page: 216
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
SAMHSA suggests that a life in recovery is supported by four major dimensions,
which include health, home, purpose, and community.
SAMHSA suggests that a life in recovery is supported by four major dimensions,
which include health, home, purpose, and community.
SAMHSA suggests that a life in recovery is supported by four major dimensions,
which include health, home, purpose, and community.
Religious affiliation is not included in the listed dimensions.
SAMHSA suggests that a life in recovery is supported by four major dimensions,
which include health, home, purpose, and community.
CON: Health Promotion
15.
ANS: 1, 2, 4
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 219
Heading: The Tidal Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments, upon which the Tidal Model is based. They include: Value
the Voice, Respect the Language, Develop Genuine Curiosity, Become the
Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of
Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be
Transparent.
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments, upon which the Tidal Model is based. They include: Value
the Voice, Respect the Language, Develop Genuine Curiosity, Become the
Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of
Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be
Transparent.
Encouraging the client to speak his own words in his own unique way is not
included in the Tidal Model.
Barker & Buchanan-Barker developed a set of essential values termed The 10
Tidal Commitments, upon which the Tidal Model is based. They include: Value
the Voice, Respect the Language, Develop Genuine Curiosity, Become the
Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of
Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be
Transparent.
Providing the clients with copies of all documents relevant to care is not included
in the Tidal Model.
CON: Health Promotion
ORDERED RESPONSE
16.
ANS:
The correct order is 2, 5, 6, 1, 4, 3
Chapter: Chapter 0, The Recovery Model
Objective: Describe three Models of Recovery: The Tidal Model, the WRAP Model, and the
Psychological Recovery Model.
Page: 220–222
Heading: The Wellness Recovery Action Plan (WRAP)
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
Feedback: The WRAP model is a step-wise process, through which an individual is able to
monitor and manage distressing symptoms that occur in daily life. The six steps include: Step 1.
Develop a Wellness Toolbox; Step 2. Daily Maintenance List; Step 3. Triggers; Step 4. Early
Warning Signs; Step 5. Things Are Breaking Down or Getting Worse; Step 6. Crisis Planning.
PTS: 1
CON: Health Promotion
COMPLETION
17.
ANS:
Recovery
Chapter: Chapter 0, The Recovery Model
Objective: Define recovery.
Page: 216
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
Feedback: Recovery from mental health disorders and substance use disorders is a process of
change through which individuals improve their health and wellness, live a self-directed life, and
strive to reach their full potential. Recovery is the restoration to a former or better state or
condition.
PTS: 1
CON: Health Promotion
Chapter 21 Caring for Patients with Mental Illness and Substance Use Disorders in General
Practice Settings
MULTIPLE CHOICE
•
When asked, What causes alcoholism? the nurses response will be based on the fact that:
•
The response to alcohol is a result of a brain-based disorder.
•
Alcoholism is believed to be an allergic response to the alcohol.
•
Every individual has the same susceptibility for developing alcoholism.
•
It is a physical response to alcohol but its etiology is not fully understood.
ANS: A
It has been determined that alcoholism is not an allergy but rather it is recognized as
a partial brain-based disorder that some brains are more susceptible to than others.
•
Which patient response would support the conclusion that the patient has
moved into the dark side of a narcotic addition?
•
Ive been abusing drugs for at least 10 years.
•
Drugs makes me feel good; that why I use them.
•
I dont like the way I feel when I dont use drugs.
•
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.
•
A substance use disorder (SUD) is a likely comorbid mental illness in which patient?
•
The soldier diagnosed with posttraumatic stress disorder
•
The teenager demonstrating symptoms of poor impulse control
•
The older adult diagnosed with early stage Alzheimers disease
•
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.
•
Which group would be the target population for educational material on the
dangers of binge drinking?
•
Full-time college students
•
Blue-collared young adults
•
Older widows and widowers
•
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.
•
Which social factor has the greatest impact on the changing nature of alcohol abuse
treatment?
•
Development of new pharmaceutical treatment options
•
Dramatic increase of alcoholism among young adult males
•
Raising cost of both inpatient and outpatient treatment programs
•
Womens substance abuse only recently acknowledge by society
ANS: D
The existence of an alcohol abuse problem among women has only been recently
recognized and this has dramatically affected treatments and services being provided.
Although the other options are true, they do not have the impact on treatment modalities
as much as the correct option.
•
Which assessment data poses the greatest risk for injury in a patient who abuses alcohol?
•
Takes a baby aspirin each morning
•
Uses over-the-counter antihistamines for seasonal allergies
•
Has been taking a tricyclic antidepressant for more than 2 years
•
Took a narcotic for 1 week to manage postdental surgery pain
ANS: C
Tricyclic antidepressants are strictly contraindicated with alcohol consumption because of their
potential effect on cardiac function. Although aspirin increases bleeding times and antihistamines
and narcotics increase sedation, the outcome of combining alcohol and these drugs is not as
dangerous as that of the correct option.
•
If an individual is admitted with a diagnosis of Wernicke-Korsakoffs
syndrome, the nurse would expect to assess:
•
Peptic ulcer
•
Vivid illusions
•
Cognitive deficits
•
Auditory hallucinations
ANS: C
Wernicke-Korsakoffs syndrome includes a severe form of amnesia and an inability to
learn new skills which reflects a cognitive impairment. The other options are not
associated with the syndrome.
•
Which sociological aspect, vital to relapse prevention, is greatly affected
when a patient is found to have a dual diagnosis of psychosis and
alcoholism?
•
Ability to afford the cost of outpatient services
•
A supportive, reliable, accessible support system
•
Protection from both physical and emotional abuse
•
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.
•
Which nursing intervention best demonstrates an understanding of the
relationship between confirmed intravenous drug abuse and specific
infections?
•
Screening the patient for hepatitis B virus (HBV)
•
Assessing the patient for potentially infected injection sites
•
Determining if the patient has ever been tested for human
immunodeficiency virus (HIV)
•
Evaluating the patients understanding of the increased
risk for developing sexually transmitted diseases
ANS: A
Injecting drug users have one of the highest HBV rates among all risk groups and
account for at least half of all new HCV cases, so screening for such infections
demonstrates that the nurse understands the severity of the problem. Although the other
options reflect potential infection risks, they are not as commonly seen in patients with
this diagnosis.
•
Which assessment data would bring into question a patients statement that, I
have only a few drinks on special occasions.?
•
History of treatment for glaucoma
•
Fasting serum blood glucose level of 182 mg/dL
•
Patient reports numbness in hands and feet bilaterally
•
Red rash observed over neck, shoulders, and upper chest
ANS: C
Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake.
Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking
causing the nurse to question the patients statement. The remaining options do not
reflect symptomology generally associated with alcoholism.
•
Which intervention has priority when a nurse suspects a staff member of
providing patient care while being impaired by alcohol or drugs?
•
Asking the staff member to explain their suspicious behavior
•
Adjust the staff members assignment to minimize patient contact
•
Providing the staff member with material regarding alcohol abuse and treatment
•
Reporting the staff members suspicious behavior to the
nursing supervisor on duty
ANS: D
It is a professional obligation to report suspected impaired practice. The remaining
options do not have prior in this situation since the concern is patient safety.
•
Which nursing intervention demonstrates an understanding regarding the
primary form of substance use disorder among older adults?
•
Assessing the patients hands and feet for the presence of
both numbness and tingling
•
Having the patient, describe your relationship with
you adult children, co- workers, and friends.
•
Asking, Please identify for me all the medications both
prescribed and over the counter you regularly take.
•
Evaluate the patients understanding of the possible health
risks that alcohol and medication abuse has on ones health
ANS: C
Misuse of prescription medications is the most common form of drug abuse among
older adults. This population is especially vulnerable because of the multiple drugs that
are often prescribed for medical conditions. The remaining options do not help identify
the presence of multiple medications.
•
Which assessment demonstrates the nurses understanding of the
relationship between substance abuse and the development of symptoms
characteristic of delirium?
•
Determining the patients age and gender
•
Evaluating the patients food and fluid intake over the last 48 hours
•
Observing the patient for fine tremors of the hands, especially the fingers
•
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.
•
Which protocol should guide the nurse responsible for administering
pharmacologic interventions for a patient who is experiencing alcohol
intoxication?
•
Medication interventions are based on the presence of withdrawal symptoms.
•
Medications are prescribed at appropriate intervals for at least one full week.
•
Symptoms are managed with medications for only
the initial 24 hours of hospitalization.
•
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.
•
A patient recently discharged from an alcohol rehabilitation program is brought
to the hospital in a state of prostration with severe throbbing headache,
tachycardia, a beet-red face, dyspnea, and continuous vomiting. The patients
significant other states the patient got sick about 15 minutes after drinking a
glass of wine. The nurse should be guided in assessment by the suspicion that
the patient:
•
Is having a stroke
•
Has alcohol intoxication
•
Is reacting to disulfiram (Antabuse)
•
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.
•
Which question is most appropriate when assessing a patient who is exhibiting
symptoms of a systemic infection including a fever of unknown origin?
•
Are you an intravenous drug user?
•
Have you been told that you drink too much alcohol?
•
Have you been diagnosed with an acute bacterial infection before?
•
Are you familiar with an infection of the heart called endocarditis?
ANS: A
Intravenous drug users are at risk for subacute bacterial endocarditis and other
circulatory compromise created by foreign substances introduced during the process of
intravenous use. Regardless of the setting, nurses need to ask about intravenous drug use
whenever a patient presents with fever of unexplained origin. Assessing the patients
knowledge related to bacterial infections and endocarditis will not address the possible
cause of the fever. Alcohol consumption is not relevant in this situation.
•
Which observation seen in a teenage patient supports the suspicion of anabolic steroid
abuse?
•
Lack of facial hair
•
Ritualized hand washing
•
Stealing and hiding a magazine belonging to another patient
•
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.
•
A patients wife has chronic alcoholism, and the husband is concerned about
the possibility that their children may develop the disease. He asks the nurse
what the risk is. The nurses best response is:
•
The risk for developing alcoholism is increased if there is
a family history of alcoholism.
•
Studies have confirmed that individuals with dependent
personality traits are at high risk for this disease.
•
Cultures that include alcohol as part of the ritualized
behavior have a higher rate of alcoholism.
•
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.
•
Which observation best supports the patients success with achieving long-term sobriety?
•
Asking a family member to, get rid of all the alcohol before I come home
•
Identifying all the problems alcoholism has caused the family over the years
•
Being able to discuss the importance of attending a support group for alcoholics
•
Promising to, stop the drinking so I can be a good parent and raise a good child
ANS: B
One of the most prominent factors that leads an individual to recovery is the patients
recognition that substance use has caused or influenced his or her lifes problems and
interrupted his or her functioning. The remaining options lack that element of selfreflection.
•
Which principle of recovery is the basis of the nurses response when a patient
relapses and is hospitalized for alcohol detox treatment?
•
Alcoholism requires a lifelong commitment to control.
•
Most people who are serious about treatment achieve sobriety.
•
Relapsing is an expected occurrence for the patient diagnosed with alcohol abuse.
•
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.
Chapter 22. Neurocognitive Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A geriatric nurse is teaching the client’s family about the possible cause of
delirium. Which statement by the nurse is most accurate?
1.
“Taking multiple medications may lead to adverse interactions or toxicity.”
2.
“Age-related cognitive changes may lead to alterations in mental status.”
3.
“Lack of rigorous exercise may lead to decreased cerebral blood flow.”
4.
“Decreased social interaction may lead to profound isolation and psychosis.”
____ 2.
A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to
home under the care of his wife. Which information should cause the nurse to question the
client’s safety?
1.
His wife works from home in telecommunication.
2.
The client has worked the nightshift his entire career.
3.
His wife has minimal family support.
4.
The client smokes one pack of cigarettes per day.
____ 3.
A client diagnosed with Alzheimer’s disease (AD) can no longer ambulate, does
not recognize family members, and communicates with agitated behaviors and incoherent
verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness?
1.
Stage 4: Mild-to-Moderate Cognitive Decline
2.
Stage 5: Moderate Cognitive Decline
3.
Stage 6: Moderate-to-Severe Cognitive Decline
4.
Stage 7: Severe Cognitive Decline
____ 4.
A client is diagnosed in stage 7 of AD. To address the client’s symptoms, which
nursing intervention should take priority?
1.
Improve cognitive status by encouraging involvement in social activities.
2.
Decrease social isolation by providing group therapies.
3.
Promote dignity by providing comfort, safety, and self-care measures.
4.
Facilitate communication by providing assistive devices.
1.
2.
3.
4.
____
1.
2.
3.
4.
Improve cognitive status by encouraging involvement in social activities.
Decrease social isolation by providing group therapies.
Promote dignity by providing comfort, safety, and self-care measures.
Facilitate communication by providing assistive devices.
5.
Which is the reason for the proliferation of the diagnosis of NCDs?
Increased numbers of neurotransmitters have been implicated in the proliferation of
NCD.
Similar symptoms of NCD and depression lead to misdiagnoses, increasing
numbers of NCD.
Societal stress contributes to the increase in this diagnosis.
More people now survive into the high-risk period for neurocognitive disorders.
____ 6.
A client diagnosed recently with AD is prescribed donepezil (Aricept). The
client’s spouse inquires, “How does this work? Will this cure him?” Which is the appropriate
nursing response?
1.
“This medication delays the destruction of acetylcholine, a chemical in the brain
necessary for memory processes. Although most effective in the early stages, it
serves to delay, but not stop, the progression of the disease.”
2.
“This medication encourages production of acetylcholine, a chemical in the brain
necessary for memory processes. It delays the progression of the disease.”
3.
“This medication delays the destruction of dopamine, a chemical in the brain
necessary for memory processes. Although most effective in the early stages, it
serves to delay, but not stop, the progression of the disease.”
4.
“This medication encourages production of dopamine, a chemical in the brain
necessary for memory processes. It delays the progression of the disease.”
____ 7.
A client diagnosed with AD exhibits progressive memory loss, diminished
cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing
intervention is most appropriate?
1.
Organize a group activity to present reality.
2.
Minimize environmental lighting.
3.
Schedule structured daily routines.
4.
Explain the consequences for aggressive behaviors.
____ 8.
After one week of continuous mental confusion, an older African American client
is admitted with a preliminary diagnosis of AD. What should cause the nurse to question this
diagnosis?
1.
AD does not typically occur in African American clients.
2.
The symptoms presented are more indicative of Parkinsonism.
3.
AD does not develop suddenly.
4.
There has been no T3- or T4-level evaluation ordered.
____ 9.
A client diagnosed with AD has impairments of memory and judgment and is
incapable of performing activities of daily living. Which nursing intervention should take
priority?
1.
Present evidence of objective reality to improve cognition.
2.
Design a bulletin board to represent the current season.
3.
Label the client’s room with name and number.
4.
Assist with bathing and toileting.
____ 10.
A client diagnosed with major NCD is exhibiting behavioral problems on a daily
basis. At change of shift, the client’s behavior escalates from pacing to screaming and flailing.
Which action should be a nursing priority?
1.
Consult the psychologist regarding behavior-modification techniques.
2.
Medicate the client with prn antianxiety medications.
3.
Assess environmental triggers and potential unmet needs.
4.
Anticipate the behavior and restrain when pacing begins.
____ 11.
A client with a history of cerebrovascular accident is brought to an emergency
department experiencing memory problems, confusion, and disorientation. Based on this client’s
assessment data, which diagnosis would the nurse expect the physician to assign?
1.
Delirium due to adverse effects of cardiac medications
2.
Vascular neurocognitive disorder
3.
Altered thought processes
4.
Alzheimer’s disease
____ 12.
An older client has recently moved to a nursing home. The client has trouble
concentrating and socially isolates. A physician believes the client would benefit from
medication therapy. Which medication should the nurse expect the physician to prescribe?
1.
Haloperidol (Haldol)
2.
Donepezil (Aricept)
3.
Diazepam (Valium)
4.
Sertraline (Zoloft)
____ 13.
A client diagnosed with NCD is disoriented, ataxic and wanders. Which is the
priority nursing diagnosis?
1.
Disturbed thought processes
2.
Self-care deficit
3.
Risk for trauma
4.
Altered health-care maintenance
____
1.
2.
3.
4.
14.
Which statement accurately differentiates mild NCD from major NCD?
Major NCD involves disorientation that develops suddenly, whereas mild NCD
develops more slowly.
Major NCD involves impairment of abstract thinking and judgment, whereas mild
NCD does not.
Major NCD criteria requires substantial cognitive decline from a previous level of
performance, and mild NCD requires modest decline.
Major NCD criteria requires decline from a previous level of performance in three
of the listed domains, and mild NCD requires only one.
____ 15.
Which statement accurately differentiates NCD from pseudodementia
(depression)?
1.
NCD has a rapid onset, whereas pseudodementia does not.
2.
NCD symptoms include disorientation to time and place, and pseudodementia does
not.
3.
NCD symptoms improve as the day progresses, but symptoms of pseudodementia
worsen.
4.
NCD causes decreased appetite, whereas pseudodementia does not.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 16.
Which of the following conditions have been known to precipitate delirium in
some individuals? (Select all that apply.)
1.
Febrile illness
2.
Seizures
3.
Migraine headaches
4.
Herniated brain stem
5.
Temporomandibular joint syndrome
____ 17.
Which of the following medications that have been known to precipitate
delirium? (Select all that apply.)
1.
Antineoplastic agents
2.
H2-receptor antagonists
3.
4.
5.
Antihypertensives
Corticosteroids
Lipid-lowering agents
Completion
Complete each statement.
18.
Major NCD constitutes what was previously described as
_______________________ in the DSM-IV-TR.
Chapter 0: Neurocognitive Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 1
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Discuss predisposing factors implicated in the etiology of NCDs.
Page: 249
Heading: Predisposing Factors
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should identify that taking multiple medications that may lead to
adverse reactions or toxicity is a risk factor for the development of delirium in
older adults.
Age-related cognitive changes do not lead to delirium.
Lack of vigorous exercise does not lead to delirium.
Decreased social interaction does not lead to delirium.
CON: Cognition
2.
ANS: 4
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Identify topics for client and family teaching relevant to NCDs.
Page: 267
Heading: Client/Family Education
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Collaboration
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Working from home does not suggest that the client could be injured.
Working the night shift does not suggest that the client could be injured.
Minimal family support does not suggest that the client could be injured.
The nurse should question the client’s safety at home if the client smokes
cigarettes. Patients with this disorder become confused and are at risk for injury.
CON: Collaboration
3.
ANS: 4
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with NCDs.
Page: 252–253
Heading: Clinical Findings, Epidemiology, and Course
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client’s symptoms do not indicate stage 4 of the illness.
The client’s symptoms do not indicate stage 5 of the illness.
The client’s symptoms do not indicate stage 6 of the illness.
The nurse should recognize that a client exhibiting these symptoms is in the severe
cognitive decline, seventh stage, of AD.
CON: Nursing
4.
ANS: 3
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with NCDs.
Page: 253
Heading: Clinical Findings, Epidemiology, and Course
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
Feedback
Encouraging involvement in social activities does not address the client’s
symptoms.
Decreasing social isolation does not address the client’s symptoms.
The most appropriate intervention in the seventh stage of AD is to promote the
client’s dignity by providing comfort, safety, and self-care measures. Stage 7 is
characterized by severe cognitive decline in which the client is unable to recognize
1
2
3
4
PTS: 1
Feedback
Encouraging involvement in social activities does not address the client’s
symptoms.
Decreasing social isolation does not address the client’s symptoms.
The most appropriate intervention in the seventh stage of AD is to promote the
client’s dignity by providing comfort, safety, and self-care measures. Stage 7 is
characterized by severe cognitive decline in which the client is unable to recognize
family members and is most commonly bedfast and aphasic.
Facilitating communication does not address the client’s symptoms.
CON: Nursing
5.
ANS: 4
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Discuss predisposing factors implicated in the etiology of NCDs.
Page: 250
Heading: Clinical Findings, Epidemiology, and Course
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The increased number of neurotransmitters is not the reason for the proliferation of
the diagnosis of NCDs
Similar symptoms of NCD and depression does not lead to increasing numbers of
NCD.
Societal stress does not contribute to the increase in this diagnosis.
The proliferation of NCD has occurred because more people now survive into the
high-risk period for neurocognitive disorder, which is middle age and beyond.
Previously, many more people died in their 50s, 60s, and early 70s.
CON: Nursing
6.
ANS: 1
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Describe various treatment modalities relevant to care of clients with NCDs.
Page: 269–270
Heading: Cognitive Impairment
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The most appropriate response by the nurse is to explain that donepezil delays the
destruction of acetylcholine, a chemical in the brain necessary for memory
processes. Although most effective in the early stages, it serves to delay, but not
stop, the progression of the AD. Some side effects include dizziness, headache,
gastrointestinal upset, and elevated transaminase.
The statement is inaccurate for donepezil (Aricept).
This statement provides the client with inaccurate information about donepezil
(Aricept).
This statement regarding donepezil (Aricept) is false.
CON: Nursing
7.
ANS: 3
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with NCDs.
Page: 266
Heading: Application of the Nursing Process > Planning/Implementation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Organizing a group activity to present reality is not likely to reduce verbal
aggression.
Minimizing environmental lighting will not likely reduce verbal aggression.
The most appropriate nursing intervention for this client is to schedule structured
daily routines. A structured routine will reduce frustration and thereby reduce
verbal aggression.
Explaining the consequences for aggressive behaviors will not likely reduce verbal
aggression.
CON: Nursing
8.
ANS: 3
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with NCDs.
Page: 259
Heading: Application of the Nursing Process > Assessment
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This option does not accurately reflect AD.
Presentation mirroring Parkinson’s disease does not accurately reflect AD.
The nurse should recognize that AD does not develop suddenly and should
question this diagnosis. The onset of AD symptoms is slow and insidious. The
disease is generally progressive and deteriorating.
This option would not cause the nurse to question the diagnosis.
CON: Nursing
9.
ANS: 4
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Identify nursing diagnoses common to clients with NCDs, and select appropriate
nursing interventions for each.
Page: 266
Heading: Application of the Nursing Process > Planning and Implementation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Presenting evidence of objective reality to improve cognition is incorrect because
it is not an activity of daily living.
Designing a bulletin board to represent the current season is incorrect because it is
not an activity of daily living.
Labeling the client’s room with name and number is not an activity of daily living.
The priority nursing intervention for this client is to assist with bathing and
toileting. A client who is incapable of performing activities of daily living requires
assistance in these areas to ensure health and safety.
CON: Nursing
10.
ANS: 2
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Describe various treatment modalities relevant to care of clients with NCDs.
Page: 265
Heading: Application of the Nursing Process > Planning and Implementation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Consulting the psychologist is not the priority, because it does not keep the client
safe.
The priority nursing action is to first medicate the client to avoid injury to self or
others.
It is important to assess environmental triggers and potential unmet needs in order
to address these problems in the future, but interventions to ensure safety must
take priority. Because of the cognitive decline experienced in clients diagnosed
with this disorder, communication skills and orientation may limit assessment and
teaching interventions.
Restraining the client may make behavioral problems worse.
CON: Nursing
11.
ANS: 2
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Define and differentiate among various neurocognitive disorders (NCDs).
Page: 250, 252–253
Heading: Neurocognitive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
Feedback
It is not known whether or not the client is taking cardiac medications.
The nurse should expect that the client will be diagnosed with vascular NCD,
which is caused by significant cerebrovascular disease. Vascular NCD often has an
abrupt onset. Progression of this disease often occurs in a fluctuating pattern.
Based on symptoms and progression of the disease, the physician would not
diagnose altered thought process.
The physician would not likely diagnose Alzheimer’s disease.
2
3
4
PTS: 1
The nurse should expect that the client will be diagnosed with vascular NCD,
which is caused by significant cerebrovascular disease. Vascular NCD often has an
abrupt onset. Progression of this disease often occurs in a fluctuating pattern.
Based on symptoms and progression of the disease, the physician would not
diagnose altered thought process.
The physician would not likely diagnose Alzheimer’s disease.
CON: Nursing
12.
ANS: 4
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Define and differentiate among various neurocognitive disorders (NCDs).
Page: 272–273
Heading: Neurocognitive Disorder (NCD)
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application (Application)
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client would most benefit from an antidepressant; haloperidol (Haldol) is not
an antidepressant.
The client would most benefit from an antidepressant; donepezil (Aricept) is not
an antidepressant.
The client would most benefit from an antidepressant; diazepam (Valium) is not an
antidepressant.
The nurse should expect the physician to prescribe sertraline to improve the
client’s social functioning and concentration levels. Sertraline is a selective
serotonin reuptake inhibitor antidepressant. Depression is the most common
mental illness in older adults and is often misdiagnosed as a neurocognitive
disorder.
CON: Nursing
13.
ANS: 3
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Identify nursing diagnoses common to clients with NCDs, and select appropriate
nursing interventions for each.
Page: 251
Heading: Neurocognitive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Disturbed thought process is an important diagnosis, but safety is the priority.
Self-care deficit is an important diagnosis, but safety is the priority.
The priority nursing diagnosis for this client is risk for injury. The client who is
ataxic suffers from motor coordination deficits and is at an increased risk for falls.
Clients that wander are at a higher risk for injury.
Altered health-care maintenance is an important diagnosis, but safety is the
priority.
CON: Nursing
14.
ANS: 3
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Define and differentiate among various neurocognitive disorders (NCDs).
Page: 251
Heading: Neurocognitive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The progression of the disorder is not a criterion for determining the severity of an
NCD.
Abstract thinking and judgment can be affected in both mild NCD and major
NCD.
Major NCD criteria requires substantial cognitive decline, and mild NCD requires
modest decline.
Both major and mild NCD classifications require decline from a previous level of
performance in only one of the listed domains.
CON: Nursing
15.
ANS: 2
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Define and differentiate among various neurocognitive disorders (NCDs).
Page: 259
Heading: Application of the Nursing Process
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nursing
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
NCD has a slow progression of symptoms, whereas pseudodementia has a rapid
progression of symptoms.
NCD symptoms include disorientation to time and place, and pseudodementia
does not.
NCD symptoms’ severity worsens as the day progresses, whereas in
pseudodementia, symptoms improve as the day progresses.
In NCD the appetite remains unchanged, whereas in pseudodementia, the appetite
diminishes.
CON: Nursing
MULTIPLE RESPONSE
16.
ANS: 1, 2, 3
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Discuss predisposing factors implicated in the etiology of NCDs.
Page: 249–250
Heading: Predisposing Factors
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
Delirium most commonly occurs in individuals with serious medical, surgical, or
neurological conditions. Some examples of conditions that have been known to
precipitate delirium in some individuals include the following: febrile illness.
Delirium most commonly occurs in individuals with serious medical, surgical, or
neurological conditions. Some examples of conditions that have been known to
precipitate delirium in some individuals include the following: seizures.
Delirium most commonly occurs in individuals with serious medical, surgical, or
neurological conditions. Some examples of conditions that have been known to
precipitate delirium in some individuals include the following: migraine
headaches.
A herniated brain stem would most likely result in death, not delirium.
Temporomandibular joint syndrome is marked by limited movement of the joint
during chewing, not delirium.
PTS: 1
CON: Nursing
17.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Discuss predisposing factors implicated in the etiology of NCDs.
Page: 250
Heading: Predisposing Factors
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
Medications that have been known to precipitate delirium include antineoplastic
agents.
Medications that have been known to precipitate delirium include H2-receptor
antagonists (e.g., cimetidine).
Medications that have been known to precipitate delirium include
antihypertensives.
Medications that have been known to precipitate delirium include corticosteroids.
There have been no reports of delirium ascribed to the use of lipid-lowering
agents.
PTS: 1
CON: Nursing
COMPLETION
18.
ANS:
dementia
Chapter: Chapter 0, Neurocognitive Disorders
Objective: Define and differentiate among various neurocognitive disorders (NCDs).
Page: 250
Heading: Neurocognitive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Nursing
Difficulty: Moderate
Feedback: NCD is classified in the DSM-5 as either mild or major, with the distinction primarily
being one of severity of symptomatology. Major NCD constitutes what was previously described
as dementia in the DSM-5-TR.
PTS: 1
CON: Nursing
Chapter 23. Substance-Related and Addictive Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
What should be the priority nursing diagnosis for a client experiencing alcohol
withdrawal?
1.
Risk for injury R/T central nervous system stimulation
2.
Disturbed thought processes R/T tactile hallucinations
3.
Ineffective coping R/T powerlessness over alcohol use
4.
Ineffective denial R/T continued alcohol use despite negative consequences
____ 2.
A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices
100 attempts within a 30-minute period. Which is the best rationale for assessing this client for
substance addiction?
1.
Narcotic pain medication is contraindicated for all clients with active substance use
disorders.
2.
Clients who are addicted to alcohol or benzodiazepines may develop crosstolerance to analgesics and require increased doses to achieve effective pain control.
3.
There is no need to assess the client for substance addiction. There is an obvious
PCA malfunction, because these clients have a higher pain tolerance.
4.
The client is experiencing alcohol withdrawal symptoms and needs accurate
assessment.
____ 3.
On the first day of a client’s alcohol detoxification, which nursing intervention
should take priority?
1.
Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in
90 days.
2.
Educate the client about the biopsychosocial consequences of alcohol abuse.
3.
Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
4.
Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
____ 4.
Which client statement indicates a knowledge deficit related to a substance use
disorder?
1.
“Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
2.
“Tolerance to heroin develops quickly.”
3.
“Flashbacks from lysergic acid diethylamide (LSD) use may reoccur
spontaneously.”
4.
“Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”
1.
2.
3.
4.
“Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
“Tolerance to heroin develops quickly.”
“Flashbacks from lysergic acid diethylamide (LSD) use may reoccur
spontaneously.”
“Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”
____ 5.
A lonely, depressed divorcée has been self-medicating with small amounts of
cocaine for the past year. Which term should a nurse use to best describe this individual’s
situation?
1.
Psychological addiction
2.
Codependence
3.
Substance induced disorder
4.
Social induced disorder
____ 6.
Which term should a nurse use to describe the administration of a central nervous
system (CNS) depressant during the substance induced disorder of alcohol withdrawal?
1.
Antagonist therapy
2.
Deterrent therapy
3.
Codependency therapy
4.
Substitution therapy
____ 7.
A client diagnosed with chronic alcohol addiction is being discharged from an
inpatient treatment facility after detoxification. Which client outcome, related to AA, would be
most appropriate for a nurse to discuss with the client during discharge teaching?
1.
After discharge, the client will immediately attend 90 AA meetings in 90 days.
2.
After discharge, the client will rely on an AA sponsor to help control alcohol
cravings.
3.
After discharge, the client will incorporate family in AA attendance.
4.
After discharge, the client will seek appropriate deterrent medications through AA.
____ 8.
A client with a history of heavy alcohol use is brought to an emergency
department (ED) by family members who state that the client has had nothing to drink in the last
48 hours. When the nurse reports to the ED physician, which client symptom should be the
nurse’s first priority?
1.
Hearing and visual impairment
2.
Blood pressure of 180/100 mm Hg
3.
Mood rating of 2/10 on numeric scale
4.
Dehydration
____ 9.
Which client statement demonstrates positive progress toward recovery from a
substance use disorder?
1.
“I have completed detox and therefore am in control of my drug use.”
2.
“I will faithfully attend Narcotic Anonymous when I can’t control my cravings.”
3.
“As a church deacon, my focus will now be on spiritual renewal.”
4.
“Taking those pills got out of control. It cost me my job, marriage, and children.”
____ 10.
A nurse holds the hand of a client who is withdrawing from alcohol. What is the
nurse’s rationale for this intervention?
1.
To assess for emotional strength
2.
To assess for Wernicke-Korsakoff syndrome
3.
To assess for tachycardia
4.
To assess for fine tremors
____ 11.
A client presents with symptoms of alcohol withdrawal and states, “I haven’t
eaten in three days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F
(36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing
diagnosis?
1.
Knowledge deficit
2.
Fluid volume excess
3.
Imbalanced nutrition: less than body requirements
4.
Ineffective individual coping
____ 12.
A client’s wife has been making excuses for her alcoholic husband’s work
absences. In family therapy, she states, “His problems at work are my fault.” Which is the
appropriate nursing response?
1.
“Why do you assume responsibility for his behaviors?”
2.
“I think you should start to confront his behavior.”
3.
“Your husband needs to deal with the consequences of his drinking.”
4.
“Do you understand what the term enabler means?”
____ 13.
Which medication orders should a nurse anticipate for a client who has a history
of benzodiazepine-withdrawal delirium?
1.
Haloperidol (Haldol) and fluoxetine (Prozac)
2.
Carbamazepine (Tegretol) and donepezil (Aricept)
3.
Disulfiram (Antabuse) and lorazepan (Ativan)
4.
Chlordiazepoxide (Librium) and phenytoin (Dilantin)
____ 14.
A nurse is reviewing the stat laboratory data of a client in the emergency
department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
1.
50 mg/dL
2.
100 mg/dL
3.
250 mg/dL
4.
300 mg/dL
____ 15.
A client diagnosed with major depressive episode and substance use disorder has
an altered sleep pattern and demands a psychiatrist to prescribe a sedative. Which rationale
explains why a nurse should encourage the client to first try nonpharmacological interventions?
1.
Sedative-hypnotics are potentially addictive, and their effectiveness will be
compromised owing to tolerance.
2.
Sedative-hypnotics are expensive and have numerous side effects.
3.
Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
4.
Sedative-hypnotics are known not to be as effective in promoting sleep as
antidepressant medications.
____ 16.
A client diagnosed with a gambling disorder asks the nurse about medications that
may be ordered by the client’s physician to treat this disorder. The nurse would give the client
information on which medications?
1.
Escitalopram (Lexapro) and clozapine (Clozaril)
2.
Citalopram (Celexa) and olanzapine (Zyprexa)
3.
Lithium carbonate (Lithobid) and sertraline (Zoloft)
4.
Naltrexone (ReVia) and ziprasidone (Geodon)
____ 17.
A nurse is assessing a pathological gambler. What would differentiate this client’s
behaviors from the behaviors of a non-pathological gambler?
1.
Pathological gamblers have abnormal levels of neurotransmitters, whereas nonpathological gamblers do not.
2.
Pathological gambling occurs more commonly among women, whereas nonpathological gambling occurs more commonly among men.
3.
Pathological gambling generally runs an acute course, whereas non-pathological
gambling runs a chronic course.
4.
Pathological gambling is not related to stress relief, whereas non-pathological
gambling is related to stress relief.
____ 18.
A nursing instructor is teaching about the impaired nurse and the consequences of
this impairment. Which statement by a student indicates that further instruction is needed?
1.
2.
3.
4.
“The state board of nursing must be notified with factual documentation of
impairment.”
“All state boards of nursing have passed laws that, under any circumstances, do not
allow impaired nurses to practice.”
“Many state boards of nursing require an impaired nurse to successfully complete
counseling treatment programs prior to a return to work.”
“After a return to practice, a recovering nurse may be closely monitored for several
years.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 19.
Which of the following nursing statements exemplify the cognitive process that
must be completed by a nurse prior to caring for clients diagnosed with a substance-related
disorder? (Select all that apply.)
1.
“I am easily manipulated and need to work on this prior to caring for these clients.”
2.
“Because of my father’s alcoholism, I need to examine my attitude toward these
clients.”
3.
“I need to review the side effects of the medications used in the withdrawal
process.”
4.
“I’ll need to set boundaries to maintain a therapeutic relationship.”
5.
“I need to take charge when dealing with clients diagnosed with substance
disorders.”
____ 20.
A nursing instructor is teaching nursing students about cirrhosis of the liver.
Which of the following statements about the complications of hepatic encephalopathy should
indicate to the nursing instructor that further student teaching is needed? (Select all that apply.)
1.
“A diet rich in protein will promote hepatic healing.”
2.
“This condition results from a rise in serum ammonia, leading to impaired mental
functioning.”
3.
“In this condition, an excessive amount of serous fluid accumulates in the
abdominal cavity.”
4.
“Neomycin and lactulose are used in the treatment of this condition.”
5.
“This condition is caused by the inability of the liver to convert ammonia to urea.”
____ 21.
A clinic nurse is about to meet with a client diagnosed with a gambling disorder.
Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that
apply.)
1.
Stressful situations precipitate gambling behaviors.
2.
Anxiety and restlessness can only be relieved by placing a bet.
3.
Winning brings about feelings of sexual satisfaction.
4.
Gambling is used as a coping strategy.
5.
Losing at gambling meets the client’s need for self-punishment.
1.
2.
3.
4.
5.
Stressful situations precipitate gambling behaviors.
Anxiety and restlessness can only be relieved by placing a bet.
Winning brings about feelings of sexual satisfaction.
Gambling is used as a coping strategy.
Losing at gambling meets the client’s need for self-punishment.
____ 22.
A nursing supervisor is about to meet with a staff nurse suspected of diverting
client medications. Which of the following assessment data would lead the supervisor to suspect
that the staff nurse is impaired? (Select all that apply.)
1.
The staff nurse is frequently absent from work.
2.
The staff nurse experiences mood swings.
3.
The staff nurse makes elaborate excuses for behavior.
4.
The staff nurse frequently uses the restroom.
5.
The staff nurse has a flushed face.
____ 23.
A nursing supervisor is offering an impaired staff member information regarding
employee assistance programs. Which of the following facts should the supervisor include?
(Select all that apply.)
1.
A hotline number will be available in order to call for peer assistance.
2.
A verbal contract detailing the method of treatment will be initiated prior to the
program.
3.
Peer support is provided through regular contact with the impaired nurse.
4.
Contact to provide peer support will last for one year.
5.
One of the program goals is to intervene early in order to reduce hazards to clients.
____ 24.
A nursing counselor is about to meet with a client suffering from codependency.
Which of the following data would further support the assessment of this dysfunctional
behavior? (Select all that apply.)
1.
The client has a long history of focusing thoughts and behaviors on other people.
2.
The client, as a child, experienced overindulgent and overprotective parents.
3.
The client is a people pleaser and does almost anything to gain approval.
4.
The client exhibits helpless behaviors but actually feels very competent.
5.
The client can achieve a sense of control only through fulfilling the needs of others.
Other
25.
Order the following stages of the codependency recovery process according to
Cermak.
________ The Core Issues Stage
________ The Reintegration Stage
________ The Survival Stage
________ The Reidentification Stage
Completion
Complete each statement.
26.
The concept of _______________________ arose out of a need to define the
dysfunctional behaviors that are evident among members of the family of a chemically
dependent person.
Answer Section
MULTIPLE CHOICE
1.
ANS: 1
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify nursing diagnoses common to clients with substance-related and addictive
disorders, and select appropriate nursing interventions for each.
Page: 284
Heading: Substance Use Disorder, Defined > Substance Withdrawal
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The priority nursing diagnosis for a client experiencing alcohol withdrawal should
be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may
include the following symptoms: course tremors of hands, tongue, or eyelids;
nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood
pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.
Disturbed thought processes R/T tactile hallucinations is important, but is not the
priority nursing diagnosis.
Ineffective coping R/T powerlessness over alcohol use is important, but is not the
priority nursing diagnosis.
Ineffective denial R/T continued alcohol use despite negative consequences is
important, but is not the priority nursing diagnosis.
CON: Addiction and Behaviors
2.
ANS: 2
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify nursing diagnoses common to clients with substance-related and addictive
disorders, and select appropriate nursing interventions for each.
Page: 287
Heading: Alcohol Use Disorder > Patterns of Use
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Narcotic pain medication should never be held because a client has a substance
abuse disorder.
The nurse should assess the client for substance addiction, because clients who are
addicted to alcohol or benzodiazepines may have developed cross-tolerance to
analgesics and require increased doses to achieve effective pain control. Crosstolerance is exhibited when one drug results in a lessened response to another
drug.
The client should be assessed for a substance abuse disorder as needed, so that
proper follow up can be arranged for the client.
In this scenario, the client is not exhibiting signs of substance abuse withdrawal.
CON: Addiction and Behaviors
3.
ANS: 3
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify nursing diagnoses common to clients with substance-related and addictive
disorders, and select appropriate nursing interventions for each.
Page: 284
Heading: Substance Use Disorder, Defined > Substance Withdrawal
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
Feedback
Encouraging AA meetings is important, but the administration of medication to
prevent alcohol withdrawal takes priority due to client safety.
Education is important, but the administration of medication to prevent alcohol
withdrawal takes priority due to client safety.
The priority nursing intervention for this client should be to administer ordered
chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a
benzodiazepine and is often used for substitution therapy in alcohol withdrawal to
reduce life-threatening complications.
Vitamin B1 administration is important, but the administration of medication to
prevent alcohol withdrawal takes priority due to client safety.
3
4
PTS: 1
withdrawal takes priority due to client safety.
The priority nursing intervention for this client should be to administer ordered
chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a
benzodiazepine and is often used for substitution therapy in alcohol withdrawal to
reduce life-threatening complications.
Vitamin B1 administration is important, but the administration of medication to
prevent alcohol withdrawal takes priority due to client safety.
CON: Addiction and Behaviors
4.
ANS: 4
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 307
Heading: Cannabis Intoxication
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Cannabis is the second most widely abused drug in the United States.
This statement does not indicate a knowledge deficit.
This statement is true regarding LSD.
The nurse should determine that the client has a knowledge deficit related to
substance use disorders when the client compares marijuana to smoking cigarettes
and claims it to be harmless.
CON: Addiction and Behaviors
5.
ANS: 1
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Discuss predisposing factors implicated in the etiology of substance-related and
addictive disorders.
Page: 294
Heading: Stimulant Use Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should use the term psychological addiction to best describe the client’s
situation. A client is considered to be psychologically addicted to a substance when
there is an overwhelming desire to use a drug in order to produce pleasure or avoid
discomfort.
Codependence describes depending on others for decision-making.
Substance induced disorders are induced by the use of a drug or substance.
Social induced disorders describe using a drug or substance in the presence of
1
2
3
4
PTS: 1
Feedback
The nurse should use the term psychological addiction to best describe the client’s
situation. A client is considered to be psychologically addicted to a substance when
there is an overwhelming desire to use a drug in order to produce pleasure or avoid
discomfort.
Codependence describes depending on others for decision-making.
Substance induced disorders are induced by the use of a drug or substance.
Social induced disorders describe using a drug or substance in the presence of
others, or socially.
CON: Addiction and Behaviors
6.
ANS: 4
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 291
Heading: Substance Use Disorder, Defined > Alcohol Withdrawal
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Antagonist therapy does not accurately describe this CNS depressant medication.
Deterrent therapy does not accurately describe this CNS depressant medication.
Codependency therapy does not accurately describe this CNS depressant
medication.
Various medications have been used to decrease the intensity of symptoms in an
individual who is withdrawing from, or who is experiencing the effects of
excessive use of, alcohol and other drugs. This is called substitution therapy and
may be required to reduce the life-threatening effects of alcohol withdrawal.
CON: Addiction and Behaviors
7.
ANS: 1
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 307, 312, 314–316
Heading: Application of the Nursing Process
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The most appropriate client outcome for the nurse to discuss during discharge
teaching is attending 90 AA meetings in 90 days after discharge. AA is a major
self-help organization for the treatment of alcohol addiction. It accepts alcohol
addiction as an illness and promotes total abstinence as the only cure.
Relying on a sponsor does not hold the client accountable.
Encouraging family attendance at AA meetings does not hold the client
accountable.
Seeking further deterrent medications does not hold the client accountable.
CON: Addiction and Behaviors
8.
ANS: 2
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify symptomatology and use the information in assessment of clients with
various substance related and addictive disorders.
Page: 291
Heading: Alcohol Use Disorder > Alcohol Withdrawal
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Hearing and visual impairment are not life threatening and do not indicate alcohol
withdrawal.
The nurse should recognize that high blood pressure is a symptom of alcohol
withdrawal syndrome and should promptly report this finding to the physician.
Complications associated with alcohol withdrawal syndrome may progress to
alcohol withdrawal delirium in about the second or third day following cessation
of prolonged alcohol use.
A mood rating of 2/10 on numeric scale is not life threatening and does not
indicate alcohol withdrawal.
Dehydration is not life threatening and does not indicate alcohol withdrawal.
CON: Addiction and Behaviors
9.
ANS: 4
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 316–317
Heading: Application of the Nursing Process > Diagnosis and Outcome Identification
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement does not demonstrate positive progress in recovery.
Attending meetings infrequently puts the client at risk for relapse.
This statement does not indicate reflection and understanding on the impact of
substance abuse.
A client who takes responsibility for the consequences of substance use disorder or
substance addiction is making positive progress toward recovery. This would
indicate completion of the first step of a 12-step program.
CON: Addiction and Behaviors
10.
ANS: 4
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify symptomatology and use the information in assessment of clients with
Various substance-related and addictive disorders.
Page: 315
Heading: Application of the Nursing Process
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
Feedback
The nurse is not checking for emotional strength by holding the client’s hand.
The nurse is not assessing for Wernicke-Korsakoff syndrome.
The nurse is not assessing for tachycardia.
The nurse is most likely assessing the client for fine tremors secondary to alcohol
withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient
hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating,
tachycardia, malaise, and coarse tremors.
1
2
3
4
PTS: 1
Feedback
The nurse is not checking for emotional strength by holding the client’s hand.
The nurse is not assessing for Wernicke-Korsakoff syndrome.
The nurse is not assessing for tachycardia.
The nurse is most likely assessing the client for fine tremors secondary to alcohol
withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient
hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating,
tachycardia, malaise, and coarse tremors.
CON: Addiction and Behaviors
11.
ANS: 3
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify symptomatology and use the information in assessment of clients with
various substance-related and addictive disorders.
Page: 312
Heading: Application of the Nursing Process
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Knowledge deficit is incorrect because it does not address the client’s statement
regarding lack of nutritional intake for three days.
Fluid volume excess is incorrect because it does not address the client’s statement
regarding lack of nutritional intake for three days.
The nurse should assess that the priority nursing diagnosis is imbalanced nutrition:
less than body requirements. The client is exhibiting signs and symptoms of
malnutrition, as well as alcohol withdrawal. The nurse should consult a dietitian,
restrict sodium intake to minimize fluid retention, and provide small, frequent
feedings of nonirritating foods.
Ineffective individual coping is incorrect because it does not address the client’s
statement regarding lack of nutritional intake for three days.
CON: Nutrition
12.
ANS: 3
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 323–324
Heading: Codependency
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Stating, “Why do you assume responsibility for his behaviors?” may come across
as confrontational, and may cause the client’s wife to avoid interaction with the
nurse.
Stating, “I think you should start to confront his behavior.” may come across as
confrontational, and may cause the client’s wife to avoid interaction with the
nurse.
The appropriate nursing response is to use confrontation with caring. The nurse
should understand that the client’s wife may be in denial and enabling the
husband’s behavior. Codependency is a typical behavior of spouses of alcoholics.
Partners of clients with substance addiction must come to realize that the only
behavior they can control is their own.
Stating, “Do you understand what the term enabler means?” may come across as
confrontational, and may cause the client’s wife to avoid interaction with the
nurse.
CON: Addiction and Behaviors
13.
ANS: 4
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 291
Heading: Sedative, Hypnotic and Anxiolytic Use Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
Feedback
Haloperidol (Haldol) and fluoxetine (Prozac) would not effectively treat the client
and are not appropriate.
Carbamazepine (Tegretol) and donepezil (Aricept) would not effectively treat the
client and are not appropriate.
Disulfiram (Antabuse) and lorazepan (Ativan) would not effectively treat the client
and are not appropriate.
The nurse should anticipate that a physician would order chlordiazepoxide and
phenytoin for a client who has a history of benzodiazepine-withdrawal delirium. It
is common for long-lasting benzodiazepines to be prescribed for substitution
therapy.
2
3
4
PTS: 1
and are not appropriate.
Carbamazepine (Tegretol) and donepezil (Aricept) would not effectively treat the
client and are not appropriate.
Disulfiram (Antabuse) and lorazepan (Ativan) would not effectively treat the client
and are not appropriate.
The nurse should anticipate that a physician would order chlordiazepoxide and
phenytoin for a client who has a history of benzodiazepine-withdrawal delirium. It
is common for long-lasting benzodiazepines to be prescribed for substitution
therapy.
CON: Addiction and Behaviors
14.
ANS: 2
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify symptomatology and use the information in assessment of clients with
various substance related and addictive disorders.
Page: 291
Heading: Alcohol Use Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Intoxication would not occur at this blood alcohol level.
The nurse should expect that 100 mg/dL is the minimum blood alcohol level at
which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/
dL.
Blood alcohol would have to be higher for intoxication to occur.
While the client would be intoxicated, this is not the minimum level at which
intoxication would occur.
CON: Addiction and Behaviors
15.
ANS: 1
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 291
Heading: Sedative, Hypnotic and Anxiolytic Use Disorder
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should recommend nonpharmacological interventions to this client
because sedative-hypnotics are potentially addictive, and their effectiveness will
be compromised owing to tolerance. The effects of central nervous system
depressants are additive with one another, capable of producing physiological and
psychological addiction.
These drugs do not have numerous side effects.
The drugs do not interfere with REM sleep.
These drugs are effective for inducing sleep.
CON: Addiction and Behaviors
16.
ANS: 3
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 332
Heading: Gambling Disorder
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Escitalopram (Lexapro) and clozapine (Clozaril) would not effectively treat this
client.
Citalopram (Celexa) and olanzapine (Zyprexa) are not treatments of choice for this
disorder.
Lithium carbonate (Lithobid) and sertraline (Zoloft) have been used successfully
in the treatment of pathological gambling as a form of obsessive-compulsive
disorder.
Naltrexone (ReVia) and ziprasidone (Geodon) would not appropriately treat this
client.
CON: Addiction and Behaviors
17.
ANS: 1
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 330–331
Heading: Gambling Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Moderate
Feedback
There is a correlation between pathological gambling and abnormalities in the
serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. This is
not the case with non-pathological gambling.
Pathological gambling occurs more commonly among men not women and
generally runs a chronic, not acute course.
This statement is inaccurate regarding the pathological gambler.
For a pathological gambler, the preoccupation with and impulse to gamble
intensifies when the individual is under stress.
1
2
3
4
PTS: 1
CON: Addiction and Behaviors
18.
ANS: 2
2
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Describe various modalities relevant to treatment of individuals with substancerelated and addictive disorders.
Page: 283–284
Heading: Substance Use Disorder, Defined > Substance Addiction
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1
2
3
4
Feedback
This is an accurate statement regarding impaired nurses.
Several state boards of nursing have passed diversionary laws that allow impaired
nurses to avoid disciplinary action by agreeing to seek treatment. This may require
successful completion of inpatient, outpatient, group, or individual counseling
treatment program(s); evidence of regular attendance at nurse support groups or
12-step program; random negative drug screens; and employment or volunteer
activities during the suspension period.
This statement does not indicate that further education is required.
This statement indicates that teaching has been effective.
PTS: 1
CON: Addiction and Behaviors
MULTIPLE RESPONSE
19.
ANS: 1, 2, 4
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Discuss the issue of substance-related and addictive disorders within the profession of
nursing.
Page: 312
Heading: Application of the Nursing Process
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should complete a cognitive process prior to caring for clients
diagnosed with substance-abuse disorders.
It is important for nurses to identify potential areas of need within their own
cognitions that may affect their relationships with clients diagnosed with this
problem.
This statement does not exemplify the cognitive process that must be completed
by a nurse prior to client care.
Determining the need to set boundaries is an example of a cognitive process that
must be completed by a nurse prior to client care.
This statement does not exemplify the cognitive process that must be completed
by a nurse prior to client care.
CON: Addiction and Behaviors
20.
ANS: 1
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 289
Heading: Alcohol Use Disorder > Alcoholic Hepatitis
Integrated Processes: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
PTS: 1
Feedback
The nursing instructor should understand that further teaching is needed if the
nursing student states that a diet rich in protein will promote hepatic healing. The
treatment of hepatic encephalopathy requires abstention from alcohol and
temporary elimination of protein from the diet.
This statement indicates that teaching has been effective.
This statement indicates that no further education is required.
The instructor should interpret this statement as accurate.
CON: Addiction and Behaviors
21.
ANS: 1, 2, 4, 5
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 330–331
Heading: Gambling Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
In gambling disorder, the preoccupation with and impulse to gamble intensifies
when the individual is under stress.
Many impulsive gamblers describe a physical sensation of restlessness and
anticipation that can only be relieved by placing a bet.
Winning brings feelings of special status, power, and omnipotence, not sexual
satisfaction.
Gambling is used as a coping strategy for dealing with stress and disappointments.
The gambler increasingly depends on this activity to cope with disappointments,
problems, and negative emotional states.
CON: Addiction and Behaviors
22.
ANS: 2, 3, 4, 5
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 322–323
Heading: The Chemically Impaired Nurse
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
There may be high absenteeism if the person’s source is outside the work area.
Mood swings can be a sign of substance abuse.
The impaired nurse may make elaborate excuses for behavior.
The impaired nurse will frequently use the restroom.
A flushed face is a sign of drug use.
CON: Addiction and Behaviors
23.
ANS: 1, 3, 5
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Identify topics for client and family teaching relevant to substance-related and
addictive disorders.
Page: 322–323
Heading: The Chemically Impaired Nurse
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
Most states provide either a hotline number that the impaired nurse may call or
phone numbers of peer assistance committee members, which are made available
for the same purpose.
Typically, a written, not verbal, contract is drawn up, detailing the method of
treatment, which may be obtained from various sources, such as employee
assistance programs, Alcoholics Anonymous, Narcotics Anonymous, private
counseling, or outpatient clinics.
Peer support is provided through regular contact with the impaired nurse.
Peer support is usually for a period of two years, not one year.
The peer assistance programs strive to intervene early, to reduce hazards to clients,
and increase prospects for the nurse’s recovery.
CON: Addiction and Behaviors
24.
ANS: 1, 3, 5
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Define codependency and identify behavioral characteristics associated with the
disorder.
Page: 323–324
Heading: Codependency
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The codependent person has a long history of focusing thoughts and behavior on
other people and is able to achieve a sense of control only through fulfilling the
needs of others.
They usually have experienced abuse or emotional neglect as a child.
Codependent clients are “people pleasers” and will do almost anything to get the
approval of others.
They outwardly appear very competent, but actually feel quite needy, helpless, or
perhaps nothing at all.
Codependent clients achieve a sense of control when they are fulfilling the needs
of others.
CON: Addiction and Behaviors
ORDERED RESPONSE
25.
ANS:
The correct order is 3, 4, 1, 2
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Define codependency and identify behavioral characteristics associated with the
disorder.
Page: 324
Heading: Codependency
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Moderate
Feedback: Cermak in 1986 identified four stages in the recovery process for individuals with
codependent personality. During the survival stage, the codependent must begin to let go of
denial. During the reidentification stage, the individual begins to glimpse their true selves.
During the core issues stage, the individual must face the fact that relationships cannot be
managed by force or will. During the reintegration stage, control is achieved through selfdiscipline and self-confidence.
1. The Survival Stage
2. The Reidentification Stage
3. The Core Issues Stage
4. The Reintegration Stage
PTS: 1
CON: Addiction and Behaviors
COMPLETION
26.
ANS:
codependency
Chapter: Chapter 0, Substance Use and Addictive Disorders
Objective: Define codependency and identify behavioral characteristics associated with the
disorder.
Page: 323
Heading: Codependency
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
Feedback: The concept of codependency arose out of a need to define the dysfunctional
behaviors that are evident among members of the family of a chemically dependent person. The
term has been expanded to include all individuals from families that harbor secrets of physical or
emotional abuse, other cruelties, or pathological conditions.
PTS: 1
CON: Addiction and Behaviors
Chapter 24. Schizophrenia Spectrum and Other Psychotic Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A paranoid client presents with bizarre behaviors, neologisms, and thought
insertion. Which nursing action should be prioritized to maintain this client’s safety?
1.
Assess for medication nonadherence.
2.
Note escalating behaviors and intervene immediately.
3.
Interpret attempts at communication.
4.
Assess triggers for bizarre, inappropriate behaviors.
1.
2.
3.
4.
Assess for medication nonadherence.
Note escalating behaviors and intervene immediately.
Interpret attempts at communication.
Assess triggers for bizarre, inappropriate behaviors.
____ 2.
A client diagnosed with schizoaffective disorder is admitted for social skills
training. Which information should be included in the nurse’s teaching?
1.
The side effects of medications
2.
Deep breathing techniques to decrease stress
3.
How to make eye contact when communicating
4.
How to be a leader
____ 3.
A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences
command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices
come from?” Which is the appropriate nursing response?
1.
“Your child has a chemical imbalance of the brain, which leads to altered
perceptions.”
2.
“Your child’s hallucinations are caused by medication interactions.”
3.
“Your child has too little serotonin in the brain, causing delusions and
hallucinations.”
4.
“Your child’s abnormal hormonal changes have precipitated auditory
hallucinations.”
____ 4.
Parents ask a nurse how they should reply when their child, diagnosed with
schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is
the appropriate nursing response?
1.
“Tell him to stop discussing the voices.”
2.
“Ignore what he is saying, while attempting to discover the underlying cause.”
3.
“Focus on the feelings generated by the hallucinations and present reality.”
4.
“Present objective evidence that the voices are not real.”
____ 5.
A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The
nurse asks the client, “Do you receive special messages from certain sources, such as the
television or radio?” The nurse is assessing which potential symptom of this disorder?
1.
Thought insertion
2.
Paranoid delusions
3.
Magical thinking
4.
Delusions of reference
____ 6.
A client diagnosed with schizophrenia spectrum disorder states, “Can’t you hear
him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate nursing
response?
1.
“Did you take your medicine this morning?”
2.
“You are not going to hell. You are a good person.”
3.
“The voices must sound scary, but the devil is not talking to you. This is part of
your illness.”
4.
“The devil only talks to people who are receptive to his influence.”
____ 7.
A client diagnosed with schizophrenia spectrum disorder tells a nurse about
voices commanding him to kill the president. Which is the priority nursing diagnosis for this
client?
1.
Disturbed sensory perception
2.
Altered thought processes
3.
Risk for violence: directed toward others
4.
Risk for injury
____ 8.
Which nursing intervention would be most appropriate when caring for an acutely
agitated paranoid client diagnosed with schizophrenia spectrum disorder?
1.
Provide neon lights and soft music.
2.
Maintain continual eye contact throughout the interview.
3.
Use therapeutic touch to increase trust and rapport.
4.
Provide personal space to respect the client’s boundaries.
____ 9.
Which nursing behavior will enhance the establishment of a trusting relationship
with a client diagnosed with schizophrenia spectrum disorder?
1.
Establishing personal contact with family members
2.
Being reliable, honest, and consistent during interactions
3.
Sharing limited personal information
4.
Sitting close to the client to establish rapport
____ 10.
A paranoid client diagnosed with schizophrenia spectrum disorder states, “My
psychiatrist is out to get me. I’m sad that the voice is telling me to stop him.” What symptom is
the client exhibiting, and what is the nurse’s legal responsibility related to this symptom?
1.
Magical thinking; administer an antipsychotic medication.
2.
Persecutory delusions; orient the client to reality.
3.
Command hallucinations; warn the psychiatrist.
4.
Altered thought processes; call an emergency treatment team meeting.
____
11.
A client is diagnosed with schizophrenia spectrum disorder. A physician orders
haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg
HS. Which client behavior would warrant the nurse to administer benztropine?
1.
Tactile hallucinations
2.
Tardive dyskinesia
3.
Restlessness and muscle rigidity
4.
Reports of hearing disturbing voices
____ 12.
A nurse is caring for a client who is experiencing a flat affect, paranoid delusions,
anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the
client’s positive and negative symptoms of schizophrenia?
1.
Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.
2.
Paranoid delusions, neologisms, and echolalia are positive symptoms of
schizophrenia.
3.
Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
4.
Paranoid delusions, flat affect, and anhedonia are negative symptoms of
schizophrenia.
____ 13.
An aging client diagnosed with schizophrenia spectrum disorder takes an
antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the
combined side effects of these drugs, which statement by a nurse is most appropriate?
1.
“Make sure you concentrate on taking slow, deep, cleansing breaths.”
2.
“Watch your diet and try to engage in some regular physical activity.”
3.
“Rise slowly when you change position from lying to sitting or sitting to standing.”
4.
“Wear sunscreen and try to avoid midday sun exposure.”
____ 14.
A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine
(Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a
nurse to intervene immediately?
1.
Sore throat, fever, and malaise
2.
Akathisia and hypersalivation
3.
Akinesia and insomnia
4.
Dry mouth and urinary retention
____ 15.
A client has been assigned an admission diagnosis of brief psychotic disorder.
Which assessment information would alert the nurse to question this diagnosis?
1.
The client has experienced impaired reality testing for a 24-hour period.
2.
The client has experienced auditory hallucinations for the past 3 hours.
3.
The client has experienced bizarre behavior for 1 day.
4.
The client has experienced confusion for 3 weeks.
____ 16.
A nurse is assessing a client diagnosed with substance induced psychotic disorder
(SIPD). What would differentiate this client’s symptoms from the symptoms of a client
diagnosed with brief psychotic disorder (BPD)?
1.
Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with
BPD do not.
2.
Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed
with SIPD do not.
3.
Catatonic features may be associated with SIPD, whereas BPD has no catatonic
features.
4.
Catatonic features may be associated with BPD, whereas SIPD has no catatonic
features.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 17.
Which of the following components should a nurse recognize as an integral part
of a rehabilitative program when planning care for clients diagnosed with schizophrenia
spectrum disorder? (Select all that apply.)
1.
Group therapy
2.
Medication management
3.
Deterrent therapy
4.
Supportive family therapy
5.
Social skills training
____ 18.
The diagnosis of catatonic disorder associated with another medical condition is
made when the client’s medical history, physical examination, or laboratory findings provide
evidence that symptoms are directly attributed to which of the following? (Select all that apply.)
1.
Hyperthyroidism
2.
Hypothyroidism
3.
Hyperadrenalism
4.
Hypoadrenalism
5.
Hyperaphia
Other
19.
Order the spectrum of schizophrenic and other psychotic disorders as described
by the DSM-5 on a gradient of psychopathology from least to most severe.
________ Delusional disorder
________ Schizotypal personality disorder
________ Schizophrenia
________ Brief psychotic disorder
________ Psychotic disorder associated with another medical condition
________ Catatonic disorder associated with another medical condition
________ Schizoaffective disorder
________ Schizophreniform disorder
________ Substance-induced psychotic disorder
Completion
Complete each statement.
20.
___________________________ disorder is manifested by schizophrenic
behaviors, with a strong element of symptomatology associated with the mood disorders
(depression or mania).
21.
___________________________ are false sensory perceptions not associated
with real external stimuli and may involve any of the five senses.
Chapter 0: Schizophrenia Spectrum and Other Psychotic Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Identify symptomatology associated with these disorders and use this information in
client assessment.
Page: 350–351
Heading: Application of the Nursing Process > Positive Symptoms
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Assessing for medication nonadherence does not indicate that the client’s safety
may be at risk.
The nurse should note escalating behaviors and intervene immediately, to maintain
this client’s safety. Early intervention may prevent an aggressive response and
keep the client and others safe.
Interpreting attempts at communication does not indicate that the client’s safety
may be at risk.
Assessing triggers for bizarre, inappropriate behaviors does not indicate that the
client’s safety may be at risk.
PTS: 1
CON: Cognition
2.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss various modalities relevant to treatment of schizophrenia and other psychotic
disorders.
Page: 365
Heading: Treatment Modalities for Schizophrenia and Other Psychotic Disorders > Social Skills
Training
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Teaching the side effects of medication does not help the client obtain better social
skills.
Teaching deep breathing exercises does not help the client obtain better social
skills.
The nurse should plan to teach the client how to make eye contact when
communicating. Social skills, such as making eye contact, can assist clients to
communicate needs and to establish relationships.
Teaching leadership skills do not help the client obtain better social skills.
CON: Cognition
3.
ANS: 1
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 342–343
Heading: Nature of the Disorder > Phase III: Schizophrenia
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should explain that a chemical imbalance of the brain leads to altered
perceptions.
The client hearing voices is experiencing an auditory hallucination, which is not
caused by medication.
Serotonin excess is thought to cause hallucinations.
Abnormal hormonal changes have not precipitated auditory hallucinations.
1
2
3
4
PTS: 1
Feedback
The nurse should explain that a chemical imbalance of the brain leads to altered
perceptions.
The client hearing voices is experiencing an auditory hallucination, which is not
caused by medication.
Serotonin excess is thought to cause hallucinations.
Abnormal hormonal changes have not precipitated auditory hallucinations.
CON: Cognition
4.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 342–343
Heading: Nature of the Disorder > Phase III: Schizophrenia
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This option could cause the client to shut down.
The client should not be ignored, but should be encouraged to discuss what is
occurring.
The most appropriate response by the nurse is to instruct the parents to focus on
the feelings generated by the hallucinations and present reality. The parents should
accept that their child is experiencing the hallucination but should not reinforce
this unreal sensory perception.
This option would not be appropriate in the care of the schizophrenic client.
CON: Cognition
5.
ANS: 4
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 350–351
Heading: Application of the Nursing Process > Positive Symptoms
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Thought insertion is not a potential symptom of schizophrenia.
The client with paranoid delusions is very suspicious of others and their intentions.
The client with magical thinking believes that thoughts have power over others.
The nurse is assessing for the potential symptom of delusions of reference. A client
that believes he or she receives messages through the radio is experiencing
1
2
3
4
PTS: 1
Feedback
Thought insertion is not a potential symptom of schizophrenia.
The client with paranoid delusions is very suspicious of others and their intentions.
The client with magical thinking believes that thoughts have power over others.
The nurse is assessing for the potential symptom of delusions of reference. A client
that believes he or she receives messages through the radio is experiencing
delusions of reference. These delusions involve the client interpreting events
within the environment as being directed toward himself or herself. Clients with
delusions of reference believe that others are trying to send them messages in
various ways, or they must break a code to receive a message.
CON: Cognition
6.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 342–343
Heading: Nature of the Disorder > Phase III: Schizophrenia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Questioning the client about medications does not validate the client’s feelings.
This statement does not validate the client’s feelings or redirect the client back to
reality.
The most appropriate nursing response is to reassure the client while not
reinforcing the hallucination. Reminding the client that “the voices” are a part of
the illness is a way to help the client accept that the hallucinations are not real. It is
also important for the nurse to connect with the client’s fears and inner feelings.
This statement does not validate the client’s feelings.
CON: Cognition
7.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 342–343
Heading: Nature of the Disorder > Phase III: Schizophrenia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
Disturbed sensory perception does not accurately capture the client’s risk based on
the client’s current statements.
Altered thought processes do not accurately capture the client’s risk based on the
client’s current statements.
The nurse should prioritize the diagnosis risk for violence: directed toward others.
A client who hears voices commanding him to kill someone is at risk for otherdirected violence. Other risk factors for violence include aggressive body
language, verbal aggression, catatonic excitement, and rage reactions.
Risk for injury does not accurately capture the client’s risk based on the client’s
current statements.
1
2
3
4
PTS: 1
CON: Cognition
8.
ANS: 4
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 355
Heading: Table 15-4 Care Plan for the Client with Schizophrenia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
Changing lighting and providing music does not reduce the client’s risk for
violence.
Maintaining eye contact does not reduce the client’s risk for violence.
Therapeutic touch does not reduce the client’s risk for violence.
The most appropriate nursing intervention is to provide personal space to respect
the client’s boundaries. Providing personal space may serve to reduce anxiety and
thus reduce the client’s risk for violence. The nurse should observe the patient
while carrying out routine tasks.
1
2
3
4
PTS: 1
9.
CON: Cognition
ANS: 2
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 355–360
Heading: Table 15-4 Care Plan for the Client with Schizophrenia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Establishing personal contact with family is important, but the nurse must first
establish a relationship with the client.
The nurse can enhance the establishment of a trusting relationship with a client
diagnosed with schizophrenia spectrum disorder by being reliable, honest, and
consistent during interactions. The nurse should also convey acceptance of the
client’s needs and maintain a calm attitude when dealing with agitated behavior.
Sharing limited personal information can occur after a relationship has been
established with the client.
Sitting close to the client is important, but it does not establish rapport.
CON: Cognition
10.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 342–343
Heading: Nature of the Disorder > Phase III: Schizophrenia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The nurse is not legally responsible for reporting magical thinking.
The nurse is not legally responsible for reporting persecutory delusions.
The nurse should determine that the client is exhibiting command hallucinations.
The nurse’s legal responsibility is to warn the psychiatrist of the potential for
harm. Clients demonstrating a risk for violence could potentially be physically,
emotionally, and/or sexually harmful to others or to self.
Altered thought process is not a legally reportable assessment finding.
PTS: 1
CON: Cognition
11.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 370
Heading: Table 15-6 Antiparkinsonian Agents Used to Treat Extrapyramidal Side Effects of
Antipsychotic Drugs
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The symptom of tactile hallucinations would be addressed by an antipsychotic
medication, such as haloperidol.
Tardive dyskinesia, a potentially irreversible condition, would warrant the
discontinuation of an antipsychotic medication such as haloperidol.
An anticholinergic medication such as benztropine would be used to treat the
extrapyramidal symptoms of restlessness and muscle rigidity.
Reports of hearing disturbing voices would be addressed by an antipsychotic
medication such as haloperidol.
CON: Cognition
12.
ANS: 2
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss various modalities relevant to treatment of schizophrenia and other psychotic
disorders.
Page: 351
Heading: Box 15-2 Positive and Negative Symptoms of Schizophrenia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Anhedonia and anergia are negative symptoms of schizophrenia.
The nurse should recognize that positive symptoms of schizophrenia include, but
are not limited to, paranoid delusions, neologisms, and echolalia.
Echolalia and paranoid delusions are positive symptoms.
Paranoid delusions are a positive symptom.
1
2
3
4
PTS: 1
Feedback
Anhedonia and anergia are negative symptoms of schizophrenia.
The nurse should recognize that positive symptoms of schizophrenia include, but
are not limited to, paranoid delusions, neologisms, and echolalia.
Echolalia and paranoid delusions are positive symptoms.
Paranoid delusions are a positive symptom.
CON: Cognition
13.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss various modalities relevant to treatment of schizophrenia and other psychotic
disorders.
Page: 368–369
Heading: Organic Treatment
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Slow, deep breaths do not reduce the client’s risk of a syncopal episode.
Watching diet and physical activity does not reduce the client’s risk of a syncopal
episode.
The most appropriate statement by the nurse is to instruct the client to rise slowly
when changing positions. Antipsychotic medications and beta blockers cause a
decrease in blood pressure. When given in combination, the additive effect of
these drugs places the client at risk for developing orthostatic hypotension.
Wearing sunscreen does not reduce the client’s risk of a syncopal episode.
CON: Cognition
14.
ANS: 1
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss various modalities relevant to treatment of schizophrenia and other psychotic
disorders.
Page: 348
Heading: Treatment Modalities for Schizophrenia and Other Psychotic Disorders>Client and
Family Education Related to Antipsychotics
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should intervene immediately if the client experiences signs of an
infectious process—such as a sore throat, fever, and malaise—when taking the
atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of
agranulocytosis, in which a potentially fatal drop in white blood cells can occur,
leading to infection.
Akathisia and hypersalivation does not indicate the client’s risk for infection.
Akinesia and insomnia does not indicate the client’s risk for infection.
Dry mouth and urinary retention does not indicate the client’s risk for infection.
CON: Cognition
15.
ANS: 2
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Identify symptomatology associated with these disorders and use this information in
client assessment.
Page: 348
Heading: Types of Schizophrenia and Other Psychotic Disorders>Brief Psychotic Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Impaired reality testing for a 24-hour period is typical of brief psychotic disorder
and would not cause the nurse to question this diagnosis.
This disorder is identified by the sudden onset of psychotic symptoms that may or
may not be preceded by a severe psychosocial stressor. These symptoms last at
least 1 day but less than 1 month.
Bizarre behavior for 1 day is typical of brief psychotic disorder and would not
cause the nurse to question this diagnosis.
Confusion for 3 weeks is typical of brief psychotic disorder and would not cause
the nurse to question this diagnosis.
CON: Cognition
16.
ANS: 3
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Identify symptomatology associated with these disorders and use this information in
client assessment.
Page: 348
Heading: Types of Schizophrenia and Other Psychotic Disorders > Substance/Medication
Induced Psychotic Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Hallucinations and delusions are associated with SIPD and BPD.
Hallucinations and delusions are associated with BPD and SIPD.
Catatonic features may be associated with SIPD, whereas BPD has no catatonic
features.
Catatonic features may be associated with SIPD.
CON: Cognition
MULTIPLE RESPONSE
17.
ANS: 1, 2, 4, 5
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Identify symptomatology associated with these disorders and use this information in
client assessment.
Page: 365–368
Heading: Treatment Modalities for Schizophrenia and Other Psychotic Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The nurse should recognize that group therapy plays an integral part of
rehabilitative programs for clients diagnosed with schizophrenia spectrum
disorder.
The nurse should recognize that medication management plays an integral part of
rehabilitative programs for clients diagnosed with schizophrenia spectrum
disorder.
Deterrent therapy is not a part of rehabilitative programs.
The nurse should recognize that supportive family therapy plays an integral part of
rehabilitative programs for clients diagnosed with schizophrenia spectrum
disorder.
The nurse should recognize that social skills training plays an integral part of
rehabilitative programs for clients diagnosed with schizophrenia spectrum
disorder.
3.
4.
5.
PTS: 1
disorder.
Deterrent therapy is not a part of rehabilitative programs.
The nurse should recognize that supportive family therapy plays an integral part of
rehabilitative programs for clients diagnosed with schizophrenia spectrum
disorder.
The nurse should recognize that social skills training plays an integral part of
rehabilitative programs for clients diagnosed with schizophrenia spectrum
disorder.
CON: Cognition
18.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Identify symptomatology associated with these disorders and use this information in
client assessment.
Page: 348–349
Heading: Catatonic Disorder Due to Another Medical Condition
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The diagnosis of catatonic disorder associated with another medical condition is
made when the symptomatology is evidenced from medical history, physical
examination, or laboratory findings to be directly attributable to the physiological
consequences of a general medical condition. Types of medical conditions that
have been associated with catatonic disorder include metabolic disorders such as
hyperthyroidism.
The diagnosis of catatonic disorder associated with another medical condition is
made when the symptomatology is evidenced from medical history, physical
examination, or laboratory findings to be directly attributable to the physiological
consequences of a general medical condition. Types of medical conditions that
have been associated with catatonic disorder include metabolic disorders, such as
hypothyroidism.
The diagnosis of catatonic disorder associated with another medical condition is
made when the symptomatology is evidenced from medical history, physical
examination, or laboratory findings to be directly attributable to the physiological
consequences of a general medical condition. Types of medical conditions that
have been associated with catatonic disorder include metabolic disorders, such as
hyperadrenalism.
The diagnosis of catatonic disorder associated with another medical condition is
made when the symptomatology is evidenced from medical history, physical
examination, or laboratory findings to be directly attributable to the physiological
consequences of a general medical condition. Types of medical conditions that
have been associated with catatonic disorder include metabolic disorders, such as
hypoadrenalism.
Hyperaphia is an excessive sensitivity to touch.
5.
made when the symptomatology is evidenced from medical history, physical
examination, or laboratory findings to be directly attributable to the physiological
consequences of a general medical condition. Types of medical conditions that
have been associated with catatonic disorder include metabolic disorders, such as
hypoadrenalism.
Hyperaphia is an excessive sensitivity to touch.
PTS: 1
CON: Cognition
ORDERED RESPONSE
19.
ANS:
The correct order is 2, 1, 9, 3, 5, 6, 8, 7, 4
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 347–348
Heading: Types of Schizophrenia and Other Psychotic Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: A spectrum of schizophrenic and other psychotic disorders has been identified in the
DSM-5. These include (on a gradient of psychopathology from least to most severe): schizotypal
personality disorder, delusional disorder, brief psychotic disorder, substance-induced psychotic
disorder, psychotic disorder associated with another medical condition, catatonic disorder
associated with another medical condition, schizophreniform disorder, schizoaffective disorder,
and schizophrenia.
1. Schizotypal personality disorder
2. Delusional disorder
3. Brief psychotic disorder
4. Substance-induced psychotic disorder
5. Psychotic disorder associated with another medical condition
6. Catatonic disorder associated with another medical condition
7. Schizophreniform disorder
8. Schizoaffective disorder
9. Schizophrenia
PTS: 1
CON: Cognition
COMPLETION
20.
ANS:
Schizoaffective
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 349
Heading: Types of Schizophrenia and Other Psychotic Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Schizoaffective disorder is manifested by schizophrenic behaviors, with a strong
element of symptomatology associated with the mood disorders (depression or mania). The
decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations or
delusions that occur for at least 2 weeks in the absence of a major mood episode.
PTS: 1
CON: Cognition
21.
ANS:
Hallucinations
Chapter: Chapter 0, Schizophrenia Spectrum and Other Psychotic Disorders
Objective: Discuss the concepts of schizophrenia and other psychotic disorders.
Page: 352
Heading: Application of the Nursing Process>Positive Symptoms>Content of Thought
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Hallucinations are false sensory perceptions not associated with real external stimuli
and may involve any of the five senses. Types of hallucinations include auditory, visual, tactile,
gustatory, and olfactory.
PTS: 1
CON: Cognition
Chapter 25. Depressive Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
The nurse educator is lecturing a group of nursing students on depression in
adolescents. Which statement indicates that teaching has been effective?
1.
“Adolescents are not likely to suffer from depression.”
2.
“Depressed adolescents always seek immediate treatment.”
3.
“Many symptoms are attributed to normal adjustments of adolescents.”
4.
“Suicide is not common among depressed adolescents.”
____ 2.
When planning care for a depressed client, which correctly written outcome
should be a nurse’s first priority?
1.
The client will promise not to physically harm self.
2.
The client will discuss feelings with staff and family by day three.
3.
The client will establish a trusting relationship with the nurse.
4.
The client will remain safe during hospital stay.
____ 3.
A nurse administers 100 percent oxygen to a client during and after
electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?
1.
To prevent increased intracranial pressure resulting from anoxia
2.
To prevent decreased blood pressure, pulse, and respiration owing to electrical
stimulation
3.
To prevent anoxia resulting from medication-induced paralysis of respiratory
muscles
4.
To prevent blocked airway, resulting from seizure activity
____ 4.
Immediately after electroconvulsive therapy (ECT), in which position should a
nurse place the client?
1.
On his or her side, to prevent aspiration
2.
In high Fowler’s position, to prevent increased intracranial pressure
3.
In Trendelenburg’s position, to promote blood flow to vital organs
4.
In prone position, to prevent airway blockage
____ 5.
A client is diagnosed with major depressive episode. Which nursing diagnosis
should a nurse assign to this client, to address a behavioral symptom of this disorder?
1.
Altered communication R/T feelings of worthlessness AEB anhedonia
2.
Social isolation R/T poor self-esteem AEB secluding self in room
3.
Altered thought processes R/T hopelessness AEB persecutory delusions
4.
Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
____ 6.
A client diagnosed with major depressive episode hears voices commanding selfharm. Which should be the nurse’s priority intervention at this time?
1.
Obtaining an order for locked seclusion until client is no longer suicidal
2.
Conducting 15-minute checks to ensure safety
3.
Placing the client on one-to-one observation while continuing to monitor suicidal
ideations
4.
Encouraging client to express feelings related to suicide
____ 7.
A nurse assesses a client suspected of having the diagnosis of major depressive
episode. Which client symptom would rule out this diagnosis?
1.
The client is disheveled and malodorous.
2.
The client refuses to interact with others and isolates self in room.
3.
The client is unable to feel any pleasure.
4.
The client has maxed-out charge cards and exhibits promiscuous behaviors.
____ 8.
A client who has been newly diagnosed with depression is beginning tricyclic
antidepressant therapy. The nurse has just completed teaching with this client. Which statement
by the client indicates the need for further education?
1.
“I will continue to take this medication even if the symptoms have not subsided.”
2.
“I may experience drowsiness or dizziness while taking this medication.”
3.
“I do not need to quit smoking.”
4.
“I will stop drinking alcohol now that I am taking this medication.”
____ 9.
A nurse reviews the laboratory data of a client suspected of having the diagnosis
of major depressive episode. Which lab value would potentially rule out this diagnosis?
1.
Thyroid-stimulating hormone (TSH) level of 25 U/mL
2.
Potassium (K+) level of 4.2 mEq/L
3.
4.
Sodium (Na+) level of 140 mEq/L
Calcium (Ca2+) level of 9.5 mg/dL
____ 10.
A depressed client reports to a nurse a history of divorce, job loss, family
estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this
client’s depressive symptoms?
1.
According to psychoanalytic theory, depression is a result of negative perceptions.
2.
According to object-loss theory, depression is a result of overprotection.
3.
According to learning theory, depression is a result of repeated failures.
4.
According to cognitive theory, depression is a result of anger turned inward.
____ 11.
What is the rationale for a nurse to perform a full physical health assessment on a
client admitted with a diagnosis of major depressive episode?
1.
The attention during the assessment is beneficial in decreasing social isolation.
2.
Depression can generate somatic symptoms that can mask actual physical disorders.
3.
Physical health complications are likely to arise from antidepressant therapy.
4.
Depressed clients avoid addressing physical health and ignore medical problems.
____ 12.
A nurse is planning care for a 13-year-old client who is experiencing depression.
Which medication is approved by the Food and Drug Administration (FDA) for the treatment of
depression in adolescents?
1.
Paroxetine (Paxil)
2.
Sertraline (Zoloft)
3.
Citalopram (Celexa)
4.
Escitalopram (Lexapro)
____ 13.
A nurse admits an older client with memory loss, confused thinking, and apathy. A
psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental
status exam?
1.
To rule out bipolar disorder
2.
To rule out schizophrenia
3.
To rule out neurocognitive disorder
4.
To rule out personality disorder
____ 14.
A nurse is working with a client who has just been prescribed buproprion
(Wellbutrin). Which statement by the client indicates that further education is necessary?
1.
“I will begin using sunblock when outdoors.”
2.
“If I miss a dose, I will just take two pills the next day to catch up.”
3.
“I will only discontinue the medication under the guidance of my physician.”
4.
“I will use caution when driving and using dangerous machinery.”
____ 15.
An older client has recently been prescribed sertraline (Zoloft). The client’s
spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness,
tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?
1.
Neuroleptic malignant syndrome; caused by ingestion of two different serotonin
reuptake inhibitors (SSRIs)
2.
Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine
oxidase inhibitor (MAOI)
3.
Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI
4.
Serotonin syndrome; possibly caused by ingestion of two different SSRIs
____ 16.
A client who has been taking fluvoxamine (Luvox) without significant
improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor
(MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing
response?
1.
“This combination of drugs can lead to delirium tremens.”
2.
“A combination of an MAOI and Luvox can lead to a life-threatening hypertensive
crisis.”
3.
“That’s a good idea. There have been good results with the combination of these
two drugs.”
4.
“The only disadvantage would be the exorbitant cost of the MAOI.”
1.
2.
3.
4.
“This combination of drugs can lead to delirium tremens.”
“A combination of an MAOI and Luvox can lead to a life-threatening hypertensive
crisis.”
“That’s a good idea. There have been good results with the combination of these
two drugs.”
“The only disadvantage would be the exorbitant cost of the MAOI.”
____ 17.
A number of assessment rating scales are available for measuring severity of
depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client?
1.
Zung Depression Scale
2.
Hamilton Depression Rating Scale
3.
Beck Depression Inventory
4.
AIMS Depression Rating Scale
____ 18.
The severity of depressive symptoms in the postpartum period varies from a
feeling of the “blues,” to moderate depression, to psychotic depression or melancholia. Which
disorder is correctly matched with its presenting symptoms?
1.
Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude
toward bodily functions)
2.
Postpartum depression (irritability, loss of libido, sleep disturbances, expresses
concern about inability to care for baby)
3.
Postpartum melancholia (overprotection of infant, expresses concern about inability
to care for baby, mysophobia)
4.
Postpartum depressive psychosis (transient depressed mood, agitation, abnormal
fear of child abduction, suicidal ideations)
____ 19.
A staff nurse is counseling a depressed client. The nurse determines that the client
is using the cognitive distortion of “automatic thoughts.” Which client statement is evidence of
the “automatic thought” of discounting positives?
1.
“It’s all my fault for trusting him.”
2.
“I don’t play games. I never win.”
3.
“She never visits, because she thinks I don’t care.”
4.
“I don’t have a green thumb. Any old fool can grow a rose.”
____ 20.
A client, who is taking transdermal selegiline (Emsam) for depressive symptoms,
states, “My physician told me there was no need to worry about dietary restrictions.” Which
would be the most appropriate nursing response?
1.
“Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not
recommended.”
2.
“You must have misunderstood. An MAOI like Emsam always has dietary
restrictions.”
3.
“Only oral MAOIs require dietary restrictions.”
4.
“All transdermal MAOIs do not require dietary modifications.”
1.
2.
3.
4.
“Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not
recommended.”
“You must have misunderstood. An MAOI like Emsam always has dietary
restrictions.”
“Only oral MAOIs require dietary restrictions.”
“All transdermal MAOIs do not require dietary modifications.”
____ 21.
After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client
complains that the medication doesn’t seem as effective as before. Which question should the
nurse ask to determine the cause of this problem?
1.
“Are you consuming foods high in tyramine?”
2.
“How many packs of cigarettes do you smoke daily?”
3.
“Do you drink any alcohol?”
4.
“Are you taking St. John’s wort?”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 22.
A nursing home resident has a diagnosis of dysthymic disorder. When planning
care for this client, which of the following symptoms should a nurse expect the client to exhibit?
(Select all that apply.)
1.
Sad mood on most days
2.
Mood rating of 2 out of 10 for the past 6 months
3.
Labile mood
4.
Sad mood for the past 3 years after spouse’s death
5.
Pressured speech when communicating
____ 23.
An individual experiences sadness and melancholia in September continuing
through November. Which of the following factors should a nurse identify as most likely to
contribute to the etiology of these symptoms? (Select all that apply.)
1.
Gender differences in social opportunities that occur with age
2.
Drastic temperature and barometric pressure changes
3.
A seasonal increase in social interactions
4.
Variations in serotonergic functioning
5.
Inaccessibility of resources for dealing with life stressors
____ 24.
A client is prescribed phenelzine (Nardil). Which of the following statements by
the client should indicate to a nurse that the discharge teaching about this medication has been
successful? (Select all that apply.)
1.
“I’ll have to let my surgeon know about this medication before I have my
cholecystectomy.”
2.
“I guess I will have to give up my glass of red wine with dinner.”
3.
“I’ll have to be very careful about reading food and medication labels.”
4.
“I’m going to miss my caffeinated coffee in the morning.”
5.
“I’ll be sure not to stop this medication abruptly.”
1.
2.
3.
4.
5.
“I’ll have to let my surgeon know about this medication before I have my
cholecystectomy.”
“I guess I will have to give up my glass of red wine with dinner.”
“I’ll have to be very careful about reading food and medication labels.”
“I’m going to miss my caffeinated coffee in the morning.”
“I’ll be sure not to stop this medication abruptly.”
____ 25.
A nursing instructor is teaching about the new DSM-5 diagnostic category of
disruptive mood dysregulation disorder (DMDD). Which of the following information should the
instructor include? (Select all that apply.)
1.
Symptoms include verbal rages or physical aggression toward people or property.
2.
Temper outbursts must be present in at least two settings (at home, at school, or
with peers).
3.
DMDD is characterized by severe recurrent temper outbursts.
4.
The temper outbursts are manifested only behaviorally.
5.
Symptoms of DMDD must be present for 18 or more months to meet diagnostic
criteria.
Other
26.
Order the depressive disorders and their predominant affective symptoms
according to level of severity.
________ Dysthymic disorder (pessimistic outlook, low self-esteem)
________ Grief (feelings of anger, anxiety, guilt, helplessness)
________ Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia)
________ Transient depression (sadness, dejection, feeling downhearted, having “the blues”)
Completion
Complete each statement.
27.
___________________________ is a pervasive and sustained emotion that may
have a major influence on a person’s perception of the world.
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomology associated with depression and use this information in client
assessment.
Page: 388
Heading: Adolescence
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluation [Evaluating]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Adolescents commonly suffer from depression.
Depressed adolescents may not immediately seek treatment.
Many symptoms of depression may attributed to normal adjustments of
adolescents.
Suicide is common among depressed adolescents.
CON: Cognition
2.
ANS: 4
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 393
Heading: Table 16-2 Care Plan for the Depressed Client
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The outcome should be specific.
The outcome should be realistic.
The outcome should have a time frame.
The nurse’s first priority should be that the client will remain safe during the
hospital stay. Client safety should always be the nurse’s first priority.
CON: Cognition
3.
ANS: 3
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 405–406
Heading: Treatment Modalities for Depression > Electroconvulsive Therapy
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Oxygen is not administered to prevent increased intracranial pressure.
Oxygen is not administered to prevent diminished vital signs.
The nurse administers 100 percent oxygen during and after ECT to prevent anoxia
resulting from medication-induced paralysis of respiratory muscles.
Oxygen is not administered to prevent a blocked airway.
CON: Perfusion
4.
ANS: 1
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 405–406
Heading: Treatment Modalities for Depression > Electroconvulsive Therapy
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should place a client who has received ECT on his or her side to prevent
aspiration.
High Fowler’s does not prevent aspiration.
Trendelenburg does not prevent aspiration.
Prone position does not prevent aspiration.
CON: Cognition
5.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Formulate nursing diagnoses and goals of care for clients with depression.
Page: 380
Heading: Types of Depressive Disorders > Major Depressive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
Feedback
Altered communication R/T feelings of worthlessness AEB anhedonia does not
address a behavioral symptom of this disorder.
A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in
room addresses a behavioral symptom of major depressive episode. Other
behavioral symptoms include psychomotor retardation, virtually nonexistent
1
2
3
4
PTS: 1
Feedback
Altered communication R/T feelings of worthlessness AEB anhedonia does not
address a behavioral symptom of this disorder.
A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in
room addresses a behavioral symptom of major depressive episode. Other
behavioral symptoms include psychomotor retardation, virtually nonexistent
communication, curled-up position, and no attention to personal hygiene and
grooming.
Altered thought processes R/T hopelessness AEB persecutory delusions does not
address a behavioral symptom of this disorder.
Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
does not address a behavioral symptom of this disorder.
CON: Cognition
6.
ANS: 3
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 380
Heading: Types of Depressive Disorders > Major Depressive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Obtaining an order for locked seclusion until client is no longer suicidal is not
therapeutic for the client.
Conducting 15-minute checks to ensure safety would not keep the client safe at all
times.
The nurse’s priority intervention when a depressed client hears voices
commanding self-harm is to place the client on one-to-one observation while
continuing to monitor suicidal ideations. By providing one-to-one observation, the
nurse will be able to interrupt any attempts at suicide.
Encouraging client to express feelings related to suicide does not keep the client
safe.
CON: Cognition
7.
ANS: 4
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 380
Heading: Types of Depressive Disorders > Major Depressive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client being disheveled and malodorous meets the diagnosis requirements of
major depressive episode.
The client refusing to interact with others meets the diagnosis requirements of
major depressive episode.
The client being unable to feel any pleasure meets the diagnosis requirements of
major depressive episode.
The nurse should assess that a client who has maxed-out credit cards and exhibits
promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that
there must never have been a manic episode or a hypomanic episode to meet the
criteria for the diagnosis of major depressive episode.
CON: Cognition
8.
ANS: 3
Chapter: Chapter 0, Depressive Disorders
Objective: Discuss various modalities relevant to the treatment of depression.
Page: 405–407
Heading: Table Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Clients should continue to take the medication even if symptoms have not
subsided.
Clients may experience drowsiness and dizziness while taking this medication,
therefore care should be used when driving or operating dangerous machinery.
Clients should not smoke when taking this medication, as smoking increases the
metabolism of tricyclic antidepressants.
The client should avoid alcohol while taking this medication.
PTS: 1
CON: Cognition
9.
ANS: 1
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 380
Heading: Types of Depressive Disorders > Major Depressive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
A diagnosis of major depressive episode may be ruled out if the client’s lab results
reveal a TSH level of 25 U/mL. Normal levels of TSH range from 2 to 10 U/mL.
High levels of TSH indicate low thyroid function. The client’s high TSH value
may indicate hypothyroidism, which can lead to depressive symptoms. The
DSM-5 criteria for the diagnosis of major depressive episode states that this
diagnosis must not be attributable to the direct physiological effects of another
medical condition.
Potassium levels do not lead to depression.
Sodium levels do not lead to depression.
Calcium levels do not lead to depression.
CON: Cognition
10.
ANS: 3
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 381–382
Heading: Box 16-2 Diagnostic Criteria for Major Depressive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The psychoanalytic theory does not best explain the etiology of the client’s
depression.
The object-loss theory does not best explain the etiology of the client’s depression.
The nurse should assess that, according to learning theory, this client’s depressive
symptoms may have resulted from repeated failures. The learning theory is a
model of “learned helplessness” in which multiple life failures cause the client to
abandon future attempts to succeed.
The cognitive theory does not best explain the etiology of the client’s depression.
1
2
3
4
PTS: 1
Feedback
The psychoanalytic theory does not best explain the etiology of the client’s
depression.
The object-loss theory does not best explain the etiology of the client’s depression.
The nurse should assess that, according to learning theory, this client’s depressive
symptoms may have resulted from repeated failures. The learning theory is a
model of “learned helplessness” in which multiple life failures cause the client to
abandon future attempts to succeed.
The cognitive theory does not best explain the etiology of the client’s depression.
CON: Cognition
11.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 382
Heading: Types of Depressive Disorder > Major Depressive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The assessment does not decrease social isolation.
The nurse should determine that a client with a diagnosis of major depressive
episode needs a full physical health assessment, because depression can generate
somatic symptoms that can mask actual physical disorders.
Physical health complications are not likely to arise from antidepressant therapy.
Not all depressed clients avoid addressing health and medical problems.
CON: Cognition
12.
ANS: 4
Chapter: Chapter 0, Depressive Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with depression.
Page: 390
Heading: Developmental Implications
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Paroxetine (Paxil) is not approved to treat depression in adolescents.
Sertraline (Zoloft) is not approved to treat depression in adolescents.
Citalopram (Celexa) is not approved to treat depression in adolescents.
Fluoxetine (Prozac) has been approved by the FDA to treat depression in children
and adolescents, and escitalopram was approved in 2009 for treatment of
depression in adolescents aged 12 to 17 years. All antidepressants carry an FDA
1
2
3
4
PTS: 1
Feedback
Paroxetine (Paxil) is not approved to treat depression in adolescents.
Sertraline (Zoloft) is not approved to treat depression in adolescents.
Citalopram (Celexa) is not approved to treat depression in adolescents.
Fluoxetine (Prozac) has been approved by the FDA to treat depression in children
and adolescents, and escitalopram was approved in 2009 for treatment of
depression in adolescents aged 12 to 17 years. All antidepressants carry an FDA
warning for increased risk of suicide in children and adolescents.
CON: Cognition
13.
ANS: 3
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 388–392
Heading: Types of Depressive Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
A mini-mental exam is not completed to rule out bipolar disorder.
A mini-mental exam is not completed to rule out schizophrenia.
A mini-mental status exam should be performed to rule out neurocognitive
disorder. The client may be experiencing reversible dementia, which can occur as a
result of depression.
A mini-mental exam is not completed to rule out personality disorder.
CON: Cognition
14.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Discuss various modalities relevant to treatment of depression.
Page: 405–407
Heading: Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client should use sunblock or protective clothing as skin sensitivity may occur.
Clients should never double up on a dose if they miss a day, as this could increase
the risk of seizures or other adverse reactions.
Clients should only discontinue any medication under the guidance of their
physician.
Clients should use caution when driving or operating dangerous machinery, as
drowsiness and dizziness can occur.
CON: Cognition
15.
ANS: 4
Chapter: Chapter 0, Depressive Disorders
Objective: Discuss various modalities relevant to treatment of depression.
Page: 408
Heading: Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client would have serotonin syndrome.
The nurse would not anticipate this to be the cause.
The nurse would not expect ingestion of an SSRI and MAOI.
The nurse should suspect that the client is suffering from serotonin syndrome;
possibly caused by ingesting two different SSRI’s (sertraline and paroxetine).
Symptoms of serotonin syndrome include confusion, agitation, tachycardia,
hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating,
and tremor.
CON: Cognition
16.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Discuss various modalities relevant to treatment of depression.
Page: 408
Heading: Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The combination would not lead to delirium tremens.
The nurse should explain to the client that combining an MAOI and fluvoxamine,
an SSRI, can lead to a life-threatening hypertensive crisis. Symptoms of
hypertensive crisis include severe occipital and/or temporal pounding headaches,
with occasional photophobia, sensations of choking, palpitations, and a feeling of
“dread.”
This statement by the nurse would be inappropriate, and potentially life
threatening.
This statement by the nurse is not accurate.
CON: Cognition
17.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 392
Heading: Background Assessment Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The Zung Self-rating Depression Scale is a self-rating scale.
One of the most widely used clinician-administered scales is the Hamilton
Depression Rating Scale.
The Beck Depression Inventory is a self-rating scale.
The Abnormal Involuntary Movement Scale is a rating scale that measures
involuntary movements associated with tardive dyskinesia.
CON: Cognition
18.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 391–392
Heading: Developmental Implications > Postpartum Depression
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The symptoms of the maternity blues include tearfulness, despondency, anxiety,
and subjectively impaired concentration appearing in the early puerperium.
Symptoms of postpartum depression are associated with fatigue, irritability, loss of
appetite, sleep disturbances, loss of libido, and expressions of great concern about
her inability to care for her baby.
Postpartum melancholia is characterized by a lack of interest in, or rejection of, the
baby, or a morbid fear that the baby may be harmed.
Postpartum depressive psychosis is characterized by a lack of interest in, or
rejection of, the baby, or a morbid fear that the baby may be harmed.
CON: Cognition
19.
ANS: 4
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 392
Heading: Background Assessment Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Stating, “It’s all my fault for trusting him,” is not an example of a discounting
positive.
Stating, “I don’t play games. I never win,” is not an example of a discounting
positive.
Stating, “She never visits because she thinks I don’t care,” is not an example of a
discounting positive.
Examples of automatic thoughts in depression include discounting positives; for
example, “The other questions were so easy. Any dummy could have gotten them
right.”
PTS: 1
CON: Cognition
20.
ANS: 1
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 408–410
Heading: Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Dietary restrictions at this dose are not recommended.
Dietary modifications are recommended, however, at the 9 mg/24 hr and 12 mg/24
hr dosages.
All forms of Emsam require dietary modification at dosages of 9 mg/24 hr and 12
mg/24 hr.
This statement is inaccurate regarding transdermal MAOIs.
CON: Cognition
21.
ANS: 2
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 408–410
Heading: Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Tyramine is only an issue when MAOI medications are prescribed.
Imipramine is a tricyclic antidepressant. Smoking should be avoided while
receiving tricyclic therapy. Smoking increases the metabolism of tricyclics,
requiring an adjustment in dosage to achieve the therapeutic effect.
Alcohol potentiates the effects of antidepressants.
Concomitant use of St. John’s wort and SSRIs, not tricyclics, increases, not
decreases the effects of the drug.
1
2
3
4
PTS: 1
Feedback
Tyramine is only an issue when MAOI medications are prescribed.
Imipramine is a tricyclic antidepressant. Smoking should be avoided while
receiving tricyclic therapy. Smoking increases the metabolism of tricyclics,
requiring an adjustment in dosage to achieve the therapeutic effect.
Alcohol potentiates the effects of antidepressants.
Concomitant use of St. John’s wort and SSRIs, not tricyclics, increases, not
decreases the effects of the drug.
CON: Cognition
MULTIPLE RESPONSE
22.
ANS: 1, 4
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 382
Heading: Types of Depressive Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should anticipate that a client with a diagnosis of dysthymic disorder
would experience a sad mood on most days for more than two years.
The client would need to be sad on most days for more than two years to meet the
requirements for dysthymic disorder.
The client would not have a labile mood.
The essential feature of dysthymia is a chronically depressed mood, which can
have an early or late onset.
The client would not experience pressured speech when communicating.
CON: Cognition
23.
ANS: 2, 3, 4
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 379
Heading: Epidemiology > Seasonality
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
Gender differences are not likely to contribute to the client’s sadness and
melancholia.
The nurse should identify drastic temperature and barometric pressure changes as
contributing to the etiology of the client’s symptoms.
A number of studies have examined seasonal patterns associated with mood
disorders and have revealed two prevalent periods of seasonal involvement: spring
(March, April, May) and fall (September, October, November).
Variations in serotonergic functioning are not likely to contribute to the client’s
sadness and melancholia.
Inaccessibility of resources for dealing with life stressors is not likely to contribute
to the client’s sadness and melancholia.
1.
2.
3.
4.
5.
PTS: 1
CON: Cognition
24.
ANS: 1, 2, 3, 5
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 408, 410
Heading: Treatment Modalities for Depression > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
The client needs to tell other physicians about taking MAOIs, because of the risk
of drug interactions.
The nurse should evaluate that teaching has been successful when the client states
that phenelzine should not be taken in conjunction with the use of alcohol.
The nurse should evaluate that teaching has been successful when the client states
that phenelzine should not be taken in conjunction with foods high in tyramine.
The client will not have to give up caffeinated coffee with this medication.
This medication should not be stopped abruptly.
1.
2.
3.
4.
5.
PTS: 1
25.
CON: Cognition
ANS: 1, 2, 3
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 389
Heading: Box 16-5 Diagnostic Criteria for Disruptive Mood Dysregulation Disorder
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The APA has included a new diagnostic category in the Depressive Disorders
chapter of the DSM-5. This childhood disorder is called disruptive mood
dysregulation disorder. Criteria for the diagnosis include, but are not limited to, the
following: verbal rages or physical aggression toward people or property.
The APA has included a new diagnostic category in the Depressive Disorders
chapter of the DSM-5. This childhood disorder is called disruptive mood
dysregulation disorder. Criteria for the diagnosis include, but are not limited to, the
following: verbal rages or physical aggression toward people or property.
DMDD is characterized by severe recurrent temper outbursts.
The temper outbursts are manifested both behaviorally and/or verbally.
Symptoms of DMDD must be present for 12 months, not 18 or more months, to
meet diagnostic criteria.
CON: Cognition
ORDERED RESPONSE
26.
ANS:
The correct order is 3, 2, 4, 1
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 392
Heading: Developmental Implications > Figure 16-2
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
Feedback: Symptoms of transient depression are not necessarily dysfunctional. Affective
symptoms include sadness, dejection, feeling downhearted, having the “blues.” Symptoms at the
mild level of depression are identified by those associated with uncomplicated grieving. Affective
symptoms include denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness,
despondency. Dysthymic disorder, which is an example of moderate depression, represents a
more problematic disturbance. Affective symptoms include feelings of sadness, dejection,
helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem;
difficulty experiencing pleasure in activities. Severe depression is characterized by an
intensification of the symptoms described for moderate depression. Examples of severe
depression include major depressive episode. Affective symptoms include feelings of total
despair, hopelessness, and worthlessness; flat (unchanging) affect, appearing devoid of emotional
tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to
feel pleasure.
1. Transient depression (sadness, dejection, feeling downhearted, having “the blues”)
2. Grief (feelings of anger, anxiety, guilt, helplessness)
3. Dysthymic disorder (pessimistic outlook, low self-esteem)
4. Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia)
PTS: 1
CON: Cognition
COMPLETION
27.
ANS:
Mood
Chapter: Chapter 0, Depressive Disorders
Objective: Identify symptomatology associated with depression and use this information in client
assessment.
Page: 378
Heading: Core Concept > Mood
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Mood is a pervasive and sustained emotion that may have a major influence on a
person’s perception of the world. Examples of mood include depression, joy, elation, anger, and
anxiety. Affect is described as the emotional reaction associated with an experience.
PTS: 1
CON: Cognition
Chapter 26. Bipolar and Related Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A highly agitated client paces the unit and states, “I could buy and sell this place.”
The client’s mood fluctuates from fits of laughter to outbursts of anger. Which is the most
accurate documentation of this client’s behavior?
1.
“Rates mood 8/10. Exhibiting looseness of association. Euphoric.”
2.
“Mood euthymic. Exhibiting magical thinking. Restless.”
3.
“Mood labile. Exhibiting delusions of reference. Hyperactive.”
4.
“Agitated and pacing. Exhibiting grandiosity. Mood labile.”
____ 2.
A client diagnosed with bipolar disorder is distraught over insomnia experienced
over the last 3 nights and a 12-lb. weight loss over the past 2 weeks. Which should be this
client’s priority nursing diagnosis?
1.
Knowledge deficit R/T bipolar disorder AEB concern about symptoms
2.
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
3.
Risk for suicide R/T powerlessness AEB insomnia and anorexia
4.
Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
____ 3.
A nurse is planning care for a client diagnosed with bipolar disorder: manic
episode. In which order should the nurse prioritize the client outcomes in the exhibit? The
following are the outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers.
3. Remains free from injury. 4. Sleeps 6 to 8 hours a night.
1.
2, 1, 3, 4
2.
4, 1, 2, 3
3.
3, 1, 4, 2
4.
1, 4, 2, 3
____ 4.
A client diagnosed with bipolar disorder: depressive episode intentionally
overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia,
insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize?
1.
Risk for suicide R/T hopelessness
2.
Anxiety: severe R/T hyperactivity
3.
Imbalanced nutrition: less than body requirements R/T refusal to eat
4.
Dysfunctional grieving R/T loss of employment
____ 5.
A client diagnosed with bipolar I disorder: manic episode refuses to take lithium
carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which
medication should a nurse anticipate that a physician may prescribe?
1.
Sertraline (Zoloft)
2.
Valproic acid (Depakote)
3.
Trazodone (Desyrel)
4.
Paroxetine (Paxil)
1.
2.
3.
4.
Sertraline (Zoloft)
Valproic acid (Depakote)
Trazodone (Desyrel)
Paroxetine (Paxil)
____ 6.
A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A
physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse
asks the nurse how Zyprexa works. Which is the appropriate nursing response?
1.
“Zyprexa in combination with Eskalith cures manic symptoms.”
2.
“Zyprexa prevents extrapyramidal side effects.”
3.
“Zyprexa increases the effectiveness of the immune system.”
4.
“Zyprexa calms hyperactivity until the Eskalith takes effect.”
____ 7.
A client began taking lithium carbonate (Lithobid) for the treatment of bipolar
disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in
this time frame. Which is the appropriate nursing response?
1.
“That’s strange. Weight loss is the typical pattern.”
2.
“What have you been eating? Weight gain is not usually associated with lithium.”
3.
“Weight gain is a common, but troubling, side effect.”
4.
“Weight gain only occurs during the first month of treatment with this drug.”
____ 8.
A client diagnosed with bipolar disorder has been taking lithium carbonate
(Lithobid) for one year. The client presents in an emergency department with a temperature of
101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these
symptoms?
1.
Symptoms indicate consumption of foods high in tyramine.
2.
Symptoms indicate lithium carbonate discontinuation syndrome.
3.
Symptoms indicate the development of lithium carbonate tolerance.
4.
Symptoms indicate lithium carbonate toxicity.
____ 9.
A nursing instructor is discussing various challenges in the treatment of clients
diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the
most critical challenge in the care of these clients?
1.
“Treatment is compromised when clients can’t sleep.”
2.
“Treatment is compromised when irritability interferes with social interactions.”
3.
“Treatment is compromised when clients have no insight into their problems.”
4.
“Treatment is compromised when clients choose not to take their medications.”
____ 10.
A client is diagnosed with bipolar disorder: manic episode. Which nursing
intervention would be implemented to achieve the outcome of “Client will gain 2 lbs. by the end
of the week?”
1.
Provide client with high-calorie finger foods throughout the day.
2.
Accompany client to cafeteria to encourage adequate dietary consumption.
3.
Initiate total parenteral nutrition to meet dietary needs.
4.
Teach the importance of a varied diet to meet nutritional needs.
____ 11.
A nursing instructor is teaching about bipolar disorders. Which statement
differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?
1.
During a manic episode, clients may experience an inflated self-esteem or
grandiosity, and these symptoms are absent in hypomania.
2.
During a manic episode, clients may experience a decreased need for sleep, and this
symptom is absent in hypomania.
3.
During a manic episode, clients may experience psychosis, and this symptom is
absent in hypomania.
4.
During a manic episode, clients may experience flight of ideas and racing thoughts,
and these symptoms are absent in hypomania.
____ 12.
A client has been diagnosed with major depressive episode. After treatment with
fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this
symptom change, which physician action would the nurse anticipate?
1.
Increase the dosage of fluoxetine.
2.
Discontinue the fluoxetine and rethink the client’s diagnosis.
3.
Order benztropine (Cogentin) to address extrapyramidal symptoms.
4.
Order olanzapine (Zyprexa) to address altered thoughts.
____ 13.
Which is the basic premise of a recovery model used to treat clients diagnosed
with bipolar disorder?
1.
Medication adherence
2.
Empowerment of the consumer
3.
Total absence of symptoms
4.
Improved psychosocial relationships
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 14.
Which of the following instructions regarding lithium therapy should be included
in a nurse’s discharge teaching? (Select all that apply.)
1.
Avoid excessive use of beverages containing caffeine.
2.
Maintain a consistent sodium intake.
3.
Consume at least 2,500 to 3,000 mL of fluid per day.
4.
Restrict sodium content.
5.
Restrict fluids to 1,500 mL per day.
1.
2.
3.
4.
5.
Avoid excessive use of beverages containing caffeine.
Maintain a consistent sodium intake.
Consume at least 2,500 to 3,000 mL of fluid per day.
Restrict sodium content.
Restrict fluids to 1,500 mL per day.
____ 15.
A nurse is assessing an adolescent client diagnosed with cyclothymic disorder.
Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet?
(Select all that apply.)
1.
Symptoms lasting for a minimum of two years
2.
Numerous periods with manic symptoms
3.
Possible comorbid diagnosis of a delusional disorder
4.
Symptoms cause clinically significant impairment in important areas of functioning
5.
Depressive symptoms that do not meet the criteria for major depressive episode
____ 16.
Which of the following rationales by a nurse explain to parents why it is difficult
to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.)
1.
Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.
2.
Children are naturally active, energetic, and spontaneous.
3.
Neurotransmitter levels vary considerably in accordance with age.
4.
The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.
5.
Genetic predisposition is not a reliable diagnostic determinant.
Completion
Complete each statement.
17.
___________________________ is an alteration in mood that is expressed by
feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated
thinking and speaking.
Chapter 0: Bipolar and Other Related Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 4
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Identify symptomatology associated with bipolar disorder and use this information in
client assessment.
Page: 419–422
Heading: Types of Bipolar Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
Exhibiting looseness of association and being euphoric is not associated with
bipolar disorder.
Magical thinking is not associated with bipolar disorder.
Labile mood and delusions of reference are not associated with bipolar disorder.
The nurse should document that this client’s behavior is “Agitated and pacing.
Exhibiting grandiosity. Mood labile.” The client is exhibiting mood swings from
euphoria to irritability. Grandiosity refers to the attitude that one’s abilities are
better than everyone else’s.
1
2
3
4
PTS: 1
CON: Cognition
2.
ANS: 2
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Identify symptomatology associated with bipolar disorder and use this information in
client assessment.
Page: 419–422
Heading: Types of Bipolar Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
Feedback
Knowledge deficit R/T bipolar disorder AEB concern about symptoms does not
identify the client’s sudden 12-lb. weight loss.
The nurse should identify that the priority nursing diagnosis for this client is
altered nutrition: less than body requirements R/T hyperactivity AEB weight loss.
Because of the client’s rapid weight loss, the nurse should prioritize interventions
to ensure proper nutrition and physical health.
Risk for suicide R/T powerlessness AEB insomnia and anorexia does not identify
the client’s sudden 12-lb. weight loss.
Altered sleep patterns R/T mania AEB insomnia for the past 3 nights does not
identify the client’s sudden 12-lb. weight loss.
1
2
3
4
PTS: 1
3.
CON: Cognition
ANS: 3
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Identify symptomatology associated with bipolar disorder and use this information in
client assessment.
Page: 419–422
Heading: Types of Bipolar Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client’s safety and physical health is the most important.
Safety is the priority.
The nurse should order client outcomes based on priority in the following order:
Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and
interacts appropriately with peers. The nurse should prioritize the client’s safety
and physical health as most important
The nurse should always prioritize safety.
CON: Cognition
4.
ANS: 1
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Identify symptomatology associated with bipolar disorder and use this information in
client assessment.
Page: 427–430
Heading: Table 17-2 Care Plan for the Client Experiencing a Manic Episode
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The priority nursing diagnosis for this client should be risk for suicide R/T
hopelessness. The nurse should always prioritize client safety. This client is at risk
for suicide because of his or her recent suicide attempt.
Anxiety: severe R/T hyperactivity does not address the client’s risk for suicide.
Imbalanced nutrition: less than body requirements R/T refusal to eat does not
address the client’s risk for suicide.
Dysfunctional grieving R/T loss of employment does not address the client’s risk
for suicide.
PTS: 1
CON: Cognition
5.
ANS: 2
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Identify symptomatology associated with bipolar disorder and use this information in
client assessment.
Page: 435–438
Heading: Table 17-3 Mood Stabilizing Agents
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Sertraline (Zoloft) does not counteract the weight-increasing effects of lithium.
The nurse should anticipate that the physician may prescribe valproic acid in order
to increase this client’s medication adherence. Valproic acid is an anticonvulsant
medication that can be used to treat bipolar disorder. One of the side effects of this
medication is weight loss.
Trazodone (Desyrel) does not counteract the weight increasing effects of lithium.
Paroxetine (Paxil) does not counteract the weight increasing effects of lithium.
CON: Cognition
6.
ANS: 4
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Identify symptomatology associated with bipolar disorder and use this information in
client assessment.
Page: 435–438
Heading: Table 17-3 Mood Stabilizing Agents
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Zyprexa calms hyperactivity.
Zyprexa does not prevent extrapyramidal side effects.
Zyprexa does not increase the effectiveness of the immune system.
The nurse should explain to the client’s spouse that olanzapine can calm
hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take
1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional
mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine,
has been determined to be the first-line treatment for bipolar I disorder.
1
2
3
4
PTS: 1
Feedback
Zyprexa calms hyperactivity.
Zyprexa does not prevent extrapyramidal side effects.
Zyprexa does not increase the effectiveness of the immune system.
The nurse should explain to the client’s spouse that olanzapine can calm
hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take
1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional
mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine,
has been determined to be the first-line treatment for bipolar I disorder.
CON: Cognition
7.
ANS: 3
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 427
Heading: Planning and Implementation
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Weight loss is not typical with this drug.
Clients gain weight regardless of diet with Lithium therapy.
The nurse should explain to the client that weight gain is a common side effect of
lithium carbonate. The nurse should educate the client on the importance of
medication adherence and discuss concerns with the prescribing physician if the
client does not wish to continue taking the medication.
Weight gain is a common side effect with this medication.
CON: Cognition
8.
ANS: 4
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 434, 439
Heading: Psychopharmacology with Mood-Stabilizing Agents > Client and Family Education for
Lithium
Integrated Processes: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
These symptoms do not indicate consumption of foods high in tyramine.
These symptoms do not indicate lithium carbonate discontinuation syndrome.
These symptoms do not indicate development of lithium carbonate tolerance.
The nurse should interpret that the client’s symptoms indicate lithium carbonate
toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea,
nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly
with maintenance therapy to ensure proper dosage.
CON: Cognition
9.
ANS: 4
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Formulate nursing diagnoses and goals of care for clients experiencing a manic
episode.
Page: 426
Heading: Application of the Nursing Process to Bipolar Disorder (Mania) > Diagnosis and
Outcome Identification
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The most critical challenge is not when clients can’t sleep.
The most critical challenge is not when irritability interferes with social
interactions.
The most critical challenge is not when clients have no insight into their problems.
The nursing student is accurate when stating that the most critical challenge in the
care of clients diagnosed with bipolar disorder is that treatment is often
compromised when clients choose not to take their medications. Clients diagnosed
with bipolar disorder feel most productive and creative during manic episodes.
This may lead to purposeful medication nonadherence. Symptoms of bipolar
disorder will reemerge if medication is stopped.
CON: Cognition
10.
ANS: 1
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Formulate nursing diagnoses and goals of care for clients experiencing a manic
episode.
Page: 427–430
Heading: Table 17-2 Care Plan for the Client Experiencing a Manic Episode
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should provide the client with high-calorie finger foods throughout the
day to help the client achieve the outcome of gaining 2 lbs. by the end of the week.
Because of the hyperactive state, the client will have difficulty sitting still to
consume large meals.
Accompanying the client to the cafeteria is not realistic.
Initiating total parenteral nutrition is not realistic.
Education is important, but is unrealistic to help the client gain weight by the end
of the week.
CON: Cognition
11.
ANS: 3
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Describe various types of bipolar disorders.
Page: 425–426
Heading: Application of the Nursing Process to Bipolar Disorder > Background Assessment Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
These symptoms are present in both hyper- and hypomania.
Decreased need for sleep can be present in hypomania.
Three or more of the following symptoms may be experienced in both hypomanic
and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep
(e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure
to keep talking, flight of ideas and racing thoughts, distractibility, increase in goaldirected activity (either socially, at work or school, or sexually) or psychomotor
agitation, excessive involvement in pleasurable activities that have a high potential
for painful consequences (e.g., the person engages in unrestrained buying sprees,
sexual indiscretions, or foolish business investments). If there are psychotic
features, the episode is, by definition, manic.
These symptoms can be present in hypomania.
4
PTS: 1
directed activity (either socially, at work or school, or sexually) or psychomotor
agitation, excessive involvement in pleasurable activities that have a high potential
for painful consequences (e.g., the person engages in unrestrained buying sprees,
sexual indiscretions, or foolish business investments). If there are psychotic
features, the episode is, by definition, manic.
These symptoms can be present in hypomania.
CON: Cognition
12.
ANS: 2
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 424–425
Heading: Treatment Modalities for Bipolar Disorder (Mania) > Treatment Strategies
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Increasing the dosage would not help this client.
A full manic episode emerging during antidepressant treatment (medication,
electroconvulsive therapy, etc.), but persisting beyond the physiological effect of
that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I
diagnosis. It would be inappropriate to increase the dosage of fluoxetine.
The client is not having extrapyramidal symptoms.
The client is not having altered thoughts.
CON: Cognition
13.
ANS: 2
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 433–434
Heading: Treatment Modalities for Bipolar Disorder (Mania) > The Recovery Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
Feedback
Medication adherence is not the basic premise of the recovery model for bipolar
disorder.
The basic premise of a recovery model is empowerment of the consumer. The
recovery model is designed to allow consumers primary control over decisions
about their own care and to enable a person with a mental health problem to live a
meaningful life in a community of his or her choice while striving to achieve his or
her full potential.
Absence of symptoms is not the basic premise of the recovery model for bipolar
disorder.
1
2
3
4
PTS: 1
Feedback
Medication adherence is not the basic premise of the recovery model for bipolar
disorder.
The basic premise of a recovery model is empowerment of the consumer. The
recovery model is designed to allow consumers primary control over decisions
about their own care and to enable a person with a mental health problem to live a
meaningful life in a community of his or her choice while striving to achieve his or
her full potential.
Absence of symptoms is not the basic premise of the recovery model for bipolar
disorder.
Improved psychosocial relationships is not the basic premise of the recovery
model for bipolar disorder.
CON: Cognition
MULTIPLE RESPONSE
14.
ANS: 1, 2, 3
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 434, 439–440
Heading: Treatment Modalities for Bipolar Disorder (Mania) > Psychopharmacology with
Mood-Stabilizing Agents
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should instruct the client taking lithium to avoid excessive use of
caffeine.
The nurse should instruct the client taking lithium to maintain a consistent sodium
intake.
The nurse should instruct the client taking lithium to consume at least 2,500 to
3,000 mL of fluid per day.
Fluid restriction can impact lithium levels.
Sodium restriction can impact lithium levels.
CON: Cognition
15.
ANS: 4, 5
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 420–421
Heading: Types of Bipolar Disorders > Cyclothymic Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
Symptoms last at least one year.
Clients have numerous periods with hypomanic episodes.
The symptoms are not better accounted for by schizoaffective disorder and are not
superimposed on schizophrenia, schizophreniform disorder, delusional disorder,
or psychotic disorder not elsewhere classified.
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Depressive symptoms that do not meet the criteria for a major depressive episode.
PTS: 1
CON: Cognition
16.
ANS: 1, 2
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Discuss various modalities relevant to treatment of bipolar disorder.
Page: 424–425
Heading: Developmental Implications
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
It is difficult to diagnose a child or adolescent with bipolar disorder, because
bipolar symptoms mimic attention deficit hyperactivity disorder symptoms.
Children are naturally active, energetic, and spontaneous.
Neurotransmitters levels do not vary according to age.
Bipolar disorder can be diagnosed for the age of 18.
Genetic predisposition can be a reliable diagnostic determinant.
PTS: 1
COMPLETION
CON: Cognition
17.
ANS:
Mania
Chapter: Chapter 0, Bipolar and Other Related Disorders
Objective: Describe various types of bipolar disorders.
Page: 419
Reference Core Concept > Mania
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Mania is an alteration in mood that is expressed by feelings of elation, inflated selfesteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Mania can
occur as a biological (organic) or psychological disorder, or as a response to substance use or a
general medical condition.
PTS: 1
CON: Cognition
Chapter 27. Anxiety, Obsessive-Compulsive, and Related Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A nursing instructor is teaching about specific phobias. Which student statement
indicates to the instructor that teaching has been effective?
1.
“These clients recognize their fear as excessive and frequently seek treatment.”
2.
“These clients have a panic level of fear that is overwhelming and unreasonable.”
3.
“These clients experience symptoms that mirror a cerebrovascular accident.”
4.
“These clients experience the symptoms of tachycardia, dysphagia, and
diaphoresis.”
____ 2.
Which nursing statement to a client about social anxiety disorder versus schizoid
personality disorder (SPD) is most accurate?
1.
“Clients diagnosed with social anxiety disorder can manage anxiety without
medications, whereas clients diagnosed with SPD can only manage anxiety with
medications.”
2.
“Clients diagnosed with SPD are distressed by the symptoms experienced in social
settings, whereas clients diagnosed with social anxiety disorder are not.”
3.
“Clients diagnosed with social anxiety disorder avoid interactions only in social
settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”
4.
“Clients diagnosed with SPD avoid interactions only in social settings, whereas
clients diagnosed with social anxiety disorder tend to avoid interactions in all areas
of life.”
2.
3.
4.
medications.”
“Clients diagnosed with SPD are distressed by the symptoms experienced in social
settings, whereas clients diagnosed with social anxiety disorder are not.”
“Clients diagnosed with social anxiety disorder avoid interactions only in social
settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”
“Clients diagnosed with SPD avoid interactions only in social settings, whereas
clients diagnosed with social anxiety disorder tend to avoid interactions in all areas
of life.”
____ 3.
What symptoms should the nurse recognize that differentiate a client diagnosed
with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?
1.
GAD is acute in nature, and panic disorder is chronic.
2.
Chest pain is a common GAD symptom, whereas this symptom is absent in panic
disorders.
3.
Hyperventilation is a common symptom in GAD and rare in panic disorder.
4.
Depersonalization is commonly seen in panic disorder and absent in GAD.
____ 4.
Which treatment should the nurse identify as most appropriate for clients
diagnosed with generalized anxiety disorder?
1.
Long-term treatment with diazepam (Valium)
2.
Acute symptom control with citalopram (Celexa)
3.
Long-term treatment with buspirone (BuSpar)
4.
Acute symptom control with ziprasidone (Geodon)
____ 5.
Which symptoms should the nurse recognize that differentiate a client diagnosed
with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive
personality disorder?
1.
Clients diagnosed with OCD experience both obsessions and compulsions, and
clients diagnosed with obsessive-compulsive personality disorder do not.
2.
Clients diagnosed with obsessive-compulsive personality disorder experience both
obsessions and compulsions, and clients diagnosed with OCD do not.
3.
Clients diagnosed with obsessive-compulsive personality disorder experience only
obsessions, and clients diagnosed with OCD experience only compulsions.
4.
Clients diagnosed with OCD experience only obsessions, and clients diagnosed
with obsessive-compulsive personality disorder experience only compulsions.
____ 6.
A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic,
tachycardic, and dyspneic. A work-up in an emergency department reveals no pathology. Which
medical diagnosis should the nurse suspect, and what nursing diagnosis should be the nurse’s
first priority?
1.
Generalized anxiety disorder and a nursing diagnosis of fear
2.
Mild anxiety disorder and a nursing diagnosis of anxiety
3.
Pain disorder and a nursing diagnosis of altered role performance
4.
Panic disorder and a nursing diagnosis of anxiety
____ 7.
A client diagnosed with panic disorder states, “When an attack happens, I feel like
I am going to die.” Which is the most appropriate nursing response?
1.
“I know it’s frightening, but try to remind yourself that this will only last a short
time.”
2.
“Death from a panic attack happens so infrequently that there is no need to worry.”
3.
“Most people who experience panic attacks have feelings of impending doom.”
4.
“Tell me why you think you are going to die every time you have a panic attack.”
____ 8.
A nursing instructor is teaching about the medications used to treat panic disorder.
Which student statement indicates that teaching has been effective?
1.
“Clonazepam (Klonopin) is particularly effective in the treatment of panic
disorder.”
2.
“Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.”
3.
“Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic
attacks.”
4.
“Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic
attacks.”
____ 9.
A family member is seeking advice about an older parent who seems to worry
unnecessarily about everything. The family member states, “Should I seek psychiatric help for
my mother?” Which is an appropriate nursing response?
1.
“My mother also worries unnecessarily. I think it is part of the aging process.”
2.
“Anxiety is considered abnormal when it is out of proportion to the stimulus
causing it and when it impairs functioning.”
3.
“From what you have told me, you should get her to a psychiatrist as soon as
possible.”
4.
“Anxiety is a complex phenomenon and is effectively treated only with
psychotropic medications.”
____ 10.
A client is experiencing a severe panic attack. Which nursing intervention would
meet this client’s physiological need?
1.
Teach deep breathing relaxation exercises.
2.
Place the client in a Trendelenburg position.
3.
Have the client breathe into a paper bag.
4.
Administer the ordered prn buspirone (BuSpar).
____ 11.
A college student is unable to take a final exam due to severe test anxiety. Instead
of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis
should the campus nurse assign for this client?
1.
2.
3.
4.
Non-adherence R/T test taking
Ineffective role performance R/T helplessness
Altered coping R/T anxiety
Powerlessness R/T fear
____ 12.
A client living in a beachfront community is seeking help with an extreme fear of
bridges, which is interfering with daily functioning. The psychiatric nurse practitioner decides to
try systematic desensitization. Which explanation of this treatment should the nurse provide?
1.
“Using your imagination, we will attempt to achieve a state of relaxation.”
2.
“Because anxiety and relaxation are mutually exclusive states, we can attempt to
substitute a relaxation response for the anxiety response.”
3.
“Through a series of increasingly anxiety-provoking steps, we will gradually
increase your tolerance to anxiety.”
4.
“In one intense session, you will be exposed to a maximum level of anxiety that you
will learn to tolerate.”
____ 13.
A client diagnosed with obsessive-compulsive disorder is admitted to a
psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an
appropriate initial client outcome during the first week of hospitalization?
1.
The client will refrain from ritualistic behaviors during daylight hours.
2.
The client will wake early enough to complete rituals prior to breakfast.
3.
The client will participate in three unit activities by day three.
4.
The client will substitute a productive activity for rituals by day one.
____ 14.
A nurse is providing discharge teaching to a client taking a benzodiazepine.
Which client statement would indicate a need for further follow-up instructions?
1.
“I will need scheduled blood work in order to monitor for toxic levels of this drug.”
2.
“I won’t stop taking this medication abruptly because there could be serious
complications.”
3.
“I will not drink alcohol while taking this medication.”
4.
“I won’t take extra doses of this drug because I can become addicted.”
____ 15.
The nurse is providing education to a client diagnosed with anxiety. Which
statement by the client indicates that teaching has been effective?
1.
“There is nothing that I can do to that will reduce anxiety.”
2.
“Medication is available, but only for those who have had anxiety for a year or
more.”
3.
“If I ignore the symptoms of anxiety, it will go away.”
4.
“Practicing yoga or meditation may help reduce my anxiety.”
____ 16.
A client is newly diagnosed with obsessive-compulsive disorder and spends 45
minutes folding clothes and rearranging them in drawers. Which nursing intervention would best
address this client’s problem?
1.
Distract the client with other activities whenever ritual behaviors begin.
2.
Report the behavior to the psychiatrist to obtain an order for medication dosage
increase.
3.
Lock the room to discourage ritualistic behavior.
4.
Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
____ 17.
A nursing student questions an instructor regarding the order for fluvoxamine
(Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder. Which
instructor response is most accurate?
1.
High doses of tricyclic medications will be required for effective treatment of OCD.
2.
Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective
for treating depression, may be required for OCD.
3.
The dose of Luvox is low because of the side effect of daytime drowsiness.
4.
The dose of this SSRI is outside the therapeutic range and needs to be questioned.
____ 18.
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history
should cause a nurse to question this order?
1.
History of alcohol use disorder
2.
History of personality disorder
3.
History of schizophrenia
4.
History of hypertension
____ 19.
During her aunt’s wake, a 4-year-old child runs up to the casket before her mother
can stop her. An appointment is made with a nurse practitioner when the child starts twisting and
pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child?
1.
Complicated grieving
2.
Altered family processes
3.
Ineffective coping
4.
Body image disturbance
____ 20.
A nursing instructor is teaching about the symptoms of agoraphobia. Which
student statement indicates that teaching has been effective?
1.
Onset of symptoms most commonly occurs in early adolescence and persists until
midlife.
2.
Onset of symptoms most commonly occurs in the 20s and 30s and persists for many
years.
3.
Onset of symptoms most commonly occurs in the 40s and 50s and persists until
death.
4.
Onset of symptoms most commonly occurs after the age of 60 and persists for at
least 6 years.
1.
2.
3.
4.
Onset of symptoms most commonly occurs in early adolescence and persists until
midlife.
Onset of symptoms most commonly occurs in the 20s and 30s and persists for many
years.
Onset of symptoms most commonly occurs in the 40s and 50s and persists until
death.
Onset of symptoms most commonly occurs after the age of 60 and persists for at
least 6 years.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21.
A college student has been diagnosed with generalized anxiety disorder. Which of
the following symptoms should the campus nurse expect this client to exhibit? (Select all that
apply.)
1.
Fatigue
2.
Anorexia
3.
Hyperventilation
4.
Insomnia
5.
Irritability
____ 22.
A nurse is discussing treatment options with a client whose life has been
negatively impacted by claustrophobia. Which of the following commonly used behavioral
therapies for phobias should the nurse explain to the client? (Select all that apply.)
1.
Benzodiazepine therapy
2.
Systematic desensitization
3.
Imploding (flooding)
4.
Assertiveness training
5.
Aversion therapy
____ 23.
A nurse has been caring for a client diagnosed with generalized anxiety disorder.
Which of the following nursing interventions would address this client’s symptoms? (Select all
that apply.)
1.
Encourage the client to recognize the signs of escalating anxiety.
2.
Encourage the client to avoid any situation that causes stress.
3.
Encourage the client to employ newly learned relaxation techniques.
4.
Encourage the client to cognitively reframe thoughts about situations that generate
anxiety.
5.
Encourage the client to avoid caffeinated products.
____
24.
An attractive female client presents with high anxiety levels because of her belief
that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected.
Which of the following additional symptoms would support this diagnosis? (Select all that
apply.)
1.
Mirror checking
2.
Excessive grooming
3.
History of an eating disorder
4.
History of delusional thinking
5.
Skin picking
Completion
Complete each statement.
25.
Traits associated with schizoid, obsessive-compulsive, and
_____________________ personality disorders are commonly seen in clients with the diagnosis
of BDD.
26.
Antianxiety drugs are also called ______________________ and minor
tranquilizers.
Chapter 0: Anxiety, Obsessive-Compulsive, and Related Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Differentiate among the terms stress, anxiety and fear.
Page: 449
Heading: Core Concept > Panic
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluating
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
This statement does not indicate understanding.
The nursing instructor should evaluate that learning has occurred when the student
knows that clients with phobias have a panic level of fear that is overwhelming
and unreasonable. Phobia is fear cued by a specific object or situation in which
exposure to the stimuli produces an immediate anxiety response. Even though the
disorder is relatively common among the general population, people seldom seek
treatment unless the phobia interferes with ability to function.
This statement indicates that further teaching is necessary.
This statement indicates that teaching has not been effective.
3
4
PTS: 1
and unreasonable. Phobia is fear cued by a specific object or situation in which
exposure to the stimuli produces an immediate anxiety response. Even though the
disorder is relatively common among the general population, people seldom seek
treatment unless the phobia interferes with ability to function.
This statement indicates that further teaching is necessary.
This statement indicates that teaching has not been effective.
CON: Patient-Centered Care
2.
ANS: 3
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Differentiate among the terms stress, anxiety and fear.
Page: 451–453
Heading: Application of the Nursing Process—Assessment > Phobias
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluating
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Clients with social anxiety disorder may need medication to manage symptoms.
Clients with SPD are distressed by symptoms experienced in all settings.
Clients diagnosed with social anxiety disorder avoid interactions only in social
settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.
Social anxiety disorder is an excessive fear of situations in which a person might
do something embarrassing or be evaluated negatively by others.
This statement in not accurate regarding SPD.
CON: Patient-Centered Care
3.
ANS: 4
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Differentiate among the terms stress, anxiety and fear.
Page: 449–451
Heading: Application of the Nursing Process—Assessment
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Evaluating
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Generalized anxiety disorder is chronic in nature.
Clients do not often experience chest pain or hyperventilation with GAD, but do
with panic disorder.
Hyperventilation occurs with panic disorder.
The nurse should recognize that a client diagnosed with panic disorder experiences
depersonalization, whereas a client diagnosed with GAD would not.
Depersonalization refers to being detached from oneself when experiencing
extreme anxiety.
1
2
3
4
PTS: 1
Feedback
Generalized anxiety disorder is chronic in nature.
Clients do not often experience chest pain or hyperventilation with GAD, but do
with panic disorder.
Hyperventilation occurs with panic disorder.
The nurse should recognize that a client diagnosed with panic disorder experiences
depersonalization, whereas a client diagnosed with GAD would not.
Depersonalization refers to being detached from oneself when experiencing
extreme anxiety.
CON: Patient-Centered Care
4.
ANS: 3
The other options are not appropriate treatment for clients diagnosed with generalized anxiety
disorder.
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Discuss various modalities relevant to treatment of anxiety, obsessive-compulsive,
and related disorders.
Page: 470
Heading: Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Long-term treatment with diazepam (Valium) is not appropriate treatment for
clients diagnosed with generalized anxiety disorder.
Acute symptom control with citalopram (Celexa) is not appropriate treatment for
clients diagnosed with generalized anxiety disorder.
The nurse should identify that an appropriate treatment for clients diagnosed with
GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication
that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10
to 14 days for alleviation of symptoms but does not have the dependency concerns
of other anxiolytics.
Acute symptom control with ziprasidone (Geodon) is not appropriate treatment for
clients diagnosed with generalized anxiety disorder.
CON: Patient-Centered Care
5.
ANS: 1
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 455–456
Heading: Obsessive-Compulsive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
A client diagnosed with OCD experiences both obsessions and compulsions.
Clients with obsessive-compulsive personality disorder exhibit a pervasive pattern
of preoccupation with orderliness, perfectionism, mental and interpersonal control,
but do not experience obsessions and compulsions.
Clients with OCD experience obsessions and compulsions. Clients with obsessivecompulsive personality disorder do not.
The nurse would not recognize these symptoms as differentiating the disorders.
This statement is inaccurate regarding these disorders.
CON: Patient-Centered Care
6.
ANS: 4
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 449–450
Heading: Panic Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Generalized anxiety disorder and a nursing diagnosis of fear does not capture the
client’s symptoms.
Mild anxiety disorder and a nursing diagnosis of anxiety does not capture the
client’s symptoms.
Pain disorder and a nursing diagnosis of altered role performance does not capture
the client’s symptoms.
The nurse should suspect that the client has exhibited signs and symptoms of a
panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is
characterized by recurrent, sudden-onset panic attacks in which the person feels
intense fear, apprehension, or terror.
PTS: 1
CON: Patient-Centered Care
7.
ANS: 1
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 449–450
Heading: Panic Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The most appropriate nursing response to the client’s concerns is to empathize
with the client and provide encouragement that panic attacks only last a short
period. Panic attacks usually last minutes but can, rarely, last hours.
This statement is not the most appropriate nursing response.
When the nurse states that “Most people who experience panic attacks…” the
nurse depersonalizes and belittles the client’s feeling.
This statement is not therapeutic for the client.
CON: Patient-Centered Care
8.
ANS: 1
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 470–472
Heading: Medications for Specific Disorders > For Panic and Generalized Anxiety Disorders
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
The student indicates learning has occurred when he or she states that clonazepam
is a particularly effective treatment for panic disorder. Clonazepam is a type of
benzodiazepine in which the major risk is physical dependence and tolerance,
which may encourage abuse. It can be used on an as-needed basis to reduce
anxiety and its related symptoms.
This statement indicates that teaching has not been effective.
This statement indicates that further teaching is necessary.
This statement does not indicate understanding.
1
2
3
4
PTS: 1
The student indicates learning has occurred when he or she states that clonazepam
is a particularly effective treatment for panic disorder. Clonazepam is a type of
benzodiazepine in which the major risk is physical dependence and tolerance,
which may encourage abuse. It can be used on an as-needed basis to reduce
anxiety and its related symptoms.
This statement indicates that teaching has not been effective.
This statement indicates that further teaching is necessary.
This statement does not indicate understanding.
CON: Patient-Centered Care
9.
ANS: 2
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 449–450
Heading: Application of the Nursing Process—Assessment > Panic Disorder
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement is not therapeutic to the family member.
The most appropriate response by the nurse is to explain to the family member that
anxiety is considered abnormal when it is out of proportion and impairs
functioning. Anxiety is a normal reaction to a realistic danger or threat to
biological integrity or self-concept.
This statement is misleading to the family member.
This statement is inaccurate and misleading.
CON: Patient-Centered Care
10.
ANS: 3
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 461–462
Heading: Table 18-3 Care Plan for the Client with Anxiety, Obsessive-Compulsive, and Related
Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
Relaxations exercises would not replace needed carbon dioxide in the blood.
Placing the client in Trendelenburg would not be an effective measure.
The nurse can meet this client’s physiological need by having the client breathe
into a paper bag. Hyperventilation may occur during periods of extreme anxiety.
Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to
1
2
3
decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of
breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation
occurs, assist the client to breathe into a small paper bag held over the mouth and
nose. Six to 12 natural breaths should be taken, alternating with short periods of
diaphragmatic breathing.
BuSpar is not a fast acting antianxiety medication, and, therefore, would not help
the client’s anxiety.
4
PTS: 1
CON: Patient-Centered Care
11.
ANS: 3
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 463
Heading: Table 18-3 Care Plan for the Client with Anxiety, Obsessive-Compulsive, and Related
Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
Non-adherence R/T test taking does not accurately capture what the client is
experiencing.
Ineffective role performance R/T helplessness does not accurately capture what the
client is experiencing.
The priority nursing diagnosis for this client is altered coping R/T anxiety. The
nurse should assist in implementing interventions that will improve the client’s
healthy coping skills and reduce anxiety.
Powerlessness R/T fear does not accurately capture what the client is experiencing.
1
2
3
4
PTS: 1
12.
CON: Patient-Centered Care
ANS: 3
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 461–465
Heading: Table 18-3 Care Plan for the Client with Anxiety, Obsessive-Compulsive, and Related
Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client does not use imagination during the process of systematic
desensitization.
This statement is not accurate regarding systematic desensitization.
The nurse should explain to the client that when participating in systematic
desensitization, he or she will go through a series of increasingly anxietyprovoking steps that will gradually increase tolerance. Systematic desensitization
was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning
principles.
Systematic desensitization does not occur in only one session.
CON: Patient-Centered Care
13.
ANS: 2
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 455–456
Heading: Obsessive-Compulsive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
This may not be realistic for the client.
An appropriate initial client outcome is for the client to wake early enough to
complete rituals prior to breakfast.
Participating in three activities on the first day may not be realistic for this client.
The nurse should plan realistic outcomes for the client.
PTS: 1
CON: Patient-Centered Care
14.
ANS: 1
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 470
Heading: Psychopharmacology
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client indicates a need for additional information about taking
benzodiazepines when stating the need for blood work to monitor for toxic levels.
This intervention is used when taking lithium (Eskalith) for the treatment of
bipolar disorder.
The client should not be stopped abruptly.
The drug should not be taken in conjunction with alcohol.
The client should understand that taking extra doses of a benzodiazepine may
result in addiction.
CON: Patient-Centered Care
15.
ANS: 4
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Discuss various treatment modalities relevant to treatment of anxiety, obsessivecompulsive, and related disorders.
Page: 464
Heading: Obsessive-Compulsive Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
There are many actions that the client can take to reduce anxiety.
Medication is available for the treatment of anxiety, regardless of time that the
client has been diagnosed.
Ignoring the symptoms of anxiety does not make it go away.
Practicing yoga or meditation may help reduce the symptoms of anxiety.
1
2
3
4
PTS: 1
Feedback
There are many actions that the client can take to reduce anxiety.
Medication is available for the treatment of anxiety, regardless of time that the
client has been diagnosed.
Ignoring the symptoms of anxiety does not make it go away.
Practicing yoga or meditation may help reduce the symptoms of anxiety.
CON: Patient-Centered Care
16.
ANS: 4
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 463
Heading: Table 18-3 Care Plan for the Client with Anxiety, Obsessive-Compulsive, and Related
Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Attempting to distract the client is not an appropriate intervention, because it does
not help the client gain insight.
Seeking medication increase is not an appropriate intervention, because it does not
help the client gain insight.
Locking the client’s room is not an appropriate intervention, because it does not
help the client gain insight.
The nurse should discuss with the client the anxiety-provoking triggers that
precipitate the ritualistic behavior. If the client is going to be able to control
interrupting anxiety, he or she must first learn to recognize precipitating factors.
CON: Patient-Centered Care
17.
ANS: 2
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 472
Heading: Medications for Specific Disorders > For Obsessive-Compulsive Disorder
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
High doses of tricyclic medications are not required for treatment of OCD.
The most accurate instructor response is that SSRI doses in excess of what is
effective for treating depression may be required in the treatment of OCD. SSRIs
have been approved by the Food and Drug Administration for the treatment of
OCD.
Common side effects include headache, sleep disturbances, and restlessness.
The dosage is needed for effective treatment.
CON: Patient-Centered Care
18.
ANS: 1
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 471
Heading: Table 18-4 Antianxiety Agents
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should question a prescription of alprazolam for acute anxiety if the
client has a history of alcohol use disorder. Alprazolam is a benzodiazepine used in
the treatment of anxiety and has an increased risk for physiological dependence
and tolerance. A client with a history of substance use disorder may be more likely
to abuse other addictive substances.
History of personality disorder would not cause the nurse to question the order.
History of schizophrenia would not cause the nurse to question the order.
History of hypertension would not cause the nurse to question the order.
CON: Patient-Centered Care
19.
ANS: 3
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 461
Heading: Table 18-2 Assigning Nursing Diagnoses to Behaviors Commonly Associated with
Anxiety, Obsessive-Compulsive, and Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The child is not suffering from complicated grieving.
The child is not suffering from altered family process.
Ineffective coping is defined as an inability to form a valid appraisal of the
stressors, inadequate choices of practiced responses, or inability to use available
resources. This child is coping with the anxiety generated by viewing her deceased
aunt by pulling out hair. If this behavior continues, a diagnosis of hair-pulling
disorder, or trichotillomania, may be assigned.
The client is not suffering from body image disturbance.
CON: Patient-Centered Care
20.
ANS: 2
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 451
Heading: Phobias
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement indicates that teaching has not been effective.
The onset of the symptoms of agoraphobia most commonly occurs in the 20s and
30s and persists for many years.
This statement indicates that further teaching is necessary.
This statement is inaccurate and indicates a need for further education.
CON: Patient-Centered Care
MULTIPLE RESPONSE
21.
ANS: 1, 4, 5
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 450
Heading: Generalized Anxiety Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should expect that a client diagnosed with GAD would experience
fatigue.
The client would not likely experience anorexia.
The client would not likely experience hyperventilation.
The nurse should expect that a client diagnosed with GAD would experience
insomnia.
The nurse should expect that a client diagnosed with GAD would experience
irritability.
CON: Patient-Centered Care
22.
ANS: 2, 3
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 468
Heading: Treatment Modalities > Behavior Therapy
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
Feedback
Benzodiazepine therapy would not be an appropriate treatment option for the
client and could possibly worsen the client’s phobia.
The nurse should explain to the client that systematic desensitization and
imploding are the most common behavioral therapies used for treating phobias.
Systematic desensitization involves the gradual exposure of the client to anxietyprovoking stimuli.
The nurse should explain to the client that systematic desensitization and
imploding are the most common behavioral therapies used for treating phobias.
1.
2.
3.
4.
5.
PTS: 1
Feedback
Benzodiazepine therapy would not be an appropriate treatment option for the
client and could possibly worsen the client’s phobia.
The nurse should explain to the client that systematic desensitization and
imploding are the most common behavioral therapies used for treating phobias.
Systematic desensitization involves the gradual exposure of the client to anxietyprovoking stimuli.
The nurse should explain to the client that systematic desensitization and
imploding are the most common behavioral therapies used for treating phobias.
Imploding is the intervention used in which the client is exposed to extremely
frightening stimuli for prolonged periods of time.
Assertiveness training would not be an appropriate treatment option for the client
and could possibly worsen the client’s phobia.
Aversion therapy would not be an appropriate treatment option for the client and
could possibly worsen the client’s phobia.
CON: Patient-Centered Care
23.
ANS: 1, 3, 4, 5
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 461–465
Heading: Table 18-3 Care Plan for the Client with Anxiety, Obsessive-Compulsive, and Related
Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
Nursing interventions that address GAD symptoms should include encouraging the
client to recognize signs of escalating anxiety.
Avoiding situations that cause stress is not an appropriate intervention. Avoidance
does not help the client overcome anxiety and not all situations are easily
avoidable.
Nursing interventions that address GAD symptoms should include encouraging the
client to employ relaxation techniques.
Nursing interventions that address GAD symptoms should include encouraging the
client to cognitively reframe thoughts about anxiety-provoking situations.
Nursing interventions that address GAD symptoms should include encouraging the
client to avoid caffeinated products.
CON: Patient-Centered Care
24.
ANS: 1, 2, 5
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 456–457
Heading: Body Dysmorphic Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The DSM-5 lists preoccupation with one or more perceived defects or flaws in
physical appearance that are not observable or appear slight to others as a
diagnostic criterion for the diagnosis of BDD. Also listed is that at some point
during the course of the disorder, the person has performed repetitive behaviors,
such as mirror checking.
The DSM-5 lists preoccupation with one or more perceived defects or flaws in
physical appearance that are not observable or appear slight to others as a
diagnostic criterion for the diagnosis of BDD. Also listed is that at some point
during the course of the disorder, the person has performed repetitive behaviors,
such as excessive grooming.
History of eating disorders is not a symptom that support the diagnosis of body
dysmorphic disorder.
History of delusional thinking is not a symptom that support the diagnosis of body
dysmorphic disorder.
The DSM-5 lists preoccupation with one or more perceived defects or flaws in
physical appearance that are not observable or appear slight to others as a
diagnostic criterion for the diagnosis of BDD. Also listed is that at some point
during the course of the disorder, the person has performed repetitive behaviors,
such as skin picking.
PTS: 1
CON: Patient-Centered Care
COMPLETION
25.
ANS:
narcissistic
Page: 456–457
Heading: Body Dysmorphic Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: Traits associated with schizoid, obsessive-compulsive, and narcissistic personality
disorders are not uncommon in clients with the diagnosis of BDD.
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
PTS: 1
CON: Patient-Centered Care
26.
ANS:
anxiolytics
Chapter: Chapter 0, Anxiety, Obsessive-Compulsive, and Related Disorders
Objective: Describe various types of anxiety, obsessive-compulsive, and related disorders and
identify symptomatology associated with each.
Page: 470
Heading: Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: Antianxiety drugs are also called anxiolytics and minor tranquilizers. Antianxiety
agents are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol
withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative
sedation.
PTS: 1
CON: Patient-Centered Care
Chapter 28. Trauma and Stressor-Related Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A nursing instructor is teaching about trauma and stressor-related disorders.
Which statement by one of the students indicates that further instruction is needed?
1.
“The trauma that women experience is more likely to be sexual assault and child
sexual abuse.”
2.
“The trauma that men experience is more likely to be accidents, physical assaults,
combat, or viewing death or injury.”
3.
“After exposure to a traumatic event, only 10 percent of victims develop
posttraumatic stress disorder (PTSD).”
4.
“Research shows that PTSD is more common in men than in women.”
1.
2.
3.
4.
“The trauma that women experience is more likely to be sexual assault and child
sexual abuse.”
“The trauma that men experience is more likely to be accidents, physical assaults,
combat, or viewing death or injury.”
“After exposure to a traumatic event, only 10 percent of victims develop
posttraumatic stress disorder (PTSD).”
“Research shows that PTSD is more common in men than in women.”
____ 2.
Which factors differentiate the diagnosis of PTSD from the diagnosis of
adjustment disorder (AD)?
1.
PTSD results from exposure to an extreme traumatic event, whereas AD results
from exposure to “normal” daily events.
2.
AD results from exposure to an extreme traumatic event, whereas PTSD results
from exposure to “normal” daily events.
3.
Depressive symptoms occur in PTSD and not in AD.
4.
Depressive symptoms occur in AD and not in PTSD.
____ 3.
Which client would a nurse recognize as being at highest risk for the development
of an adjustment disorder?
1.
A young married woman
2.
An elderly unmarried man
3.
A young unmarried woman
4.
A young unmarried man
____ 4.
A nursing instructor is explaining the etiology of trauma-related disorders from a
learning theory perspective. Which student statement indicates that teaching has been effective?
1.
“How clients perceive events and view the world affect their response to trauma.”
2.
“The psychic numbing in PTSD is a result of negative reinforcement.”
3.
“The individual becomes addicted to the trauma owing to an endogenous opioid
response.”
4.
“Believing that the world is meaningful and controllable can protect an individual
from PTSD.”
____ 5.
As the sole survivor of a roadside bombing, a veteran is experiencing extreme
guilt. Which nursing diagnosis would address this client’s symptom?
1.
Anxiety
2.
Altered thought processes
3.
Complicated grieving
4.
Altered sensory perception
____ 6.
A client has been assigned a nursing diagnosis of complicated grieving related to
the death of multiple family members in a motor vehicle accident. Which intervention should the
nurse initially employ?
1.
Encourage the journaling of feelings.
2.
Assess for the stage of grief in which the client is fixed.
3.
Provide community resources to address the client’s concerns.
4.
Encourage attending a grief therapy group.
____ 7.
Which clinical presentation is associated with the most commonly diagnosed
adjustment disorder (AD)?
1.
Anxiety, feelings of hopelessness, and worry
2.
Truancy, vandalism, and fighting
3.
Nervousness, worry, and jitteriness
4.
Depressed mood, tearfulness, and hopelessness
____ 8.
Both situational and intrapersonal factors most likely contribute to an individual’s
stress response. Which factor would a nurse categorize as intrapersonal?
1.
Occupational opportunities
2.
Economic conditions
3.
Degree of flexibility
4.
Availability of social supports
____ 9.
A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/
T divorce. Which correctly written outcome addresses this client’s problem?
1.
Rates anxiety as 4 out of 10 by discharge
2.
States anxiety level has decreased by day one
3.
Accomplishes activities of daily living independently
4.
Demonstrates ability for adequate social functioning by day three
____ 10.
Eye movement desensitization and reprocessing (EMDR) has been empirically
validated for which disorder?
1.
Adjustment disorder
2.
Generalized anxiety disorder
3.
Panic disorder
4.
Posttraumatic stress disorder
____ 11.
After a teaching session about grief, a client says to the nurse, “I seem to be stuck
in the anger stage of grieving over the loss of my son.” How would the nurse assess this
statement, and in what phase of the nursing process would this occur?
1.
Assessment phase; nursing actions have been successful in achieving the objectives
of care.
2.
Evaluation phase; nursing actions have been successful in achieving the objectives
of care.
3.
Implementation phase; nursing actions have been successful in achieving the
objectives of care.
4.
Diagnosis phase; nursing actions have been successful in achieving the objectives
of care.
____
1.
2.
3.
4.
12.
By which biological mechanism does EMDR achieve its therapeutic effect?
EMDR achieves its therapeutic effect, but the exact biological mechanism is
unknown.
EMDR achieves its therapeutic effect by causing a decrease in imagery vividness.
EMDR achieves its therapeutic effect by causing an increase in memory access.
EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.
____ 13.
A client receiving EMDR therapy says, “After only two sessions of my therapy, I
am feeling great. Now I can stop and get on with my life.” Which of the following nursing
responses is most appropriate?
1.
“I am thrilled that you have responded so rapidly to EMDR.”
2.
“To achieve lasting results, all eight phases of EMDR must be completed.”
3.
“If I were you, I would complete the EMDR and comply with doctor’s orders.”
4.
“How do you feel about continuing the therapy?”
____ 14.
A nurse recognizes which treatment as most commonly used for AD and its
appropriate rationale?
1.
Psychotherapy; to examine the stressor and confront unresolved issues
2.
Fluoxetine (Prozac); to stabilize mood and resolve symptoms
3.
Eye movement desensitization therapy; to reprocess traumatic events
4.
Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety
____ 15.
A nurse has been caring for a client diagnosed with PTSD. Which realistic goal
should be included in this client’s plan of care?
1.
The client will have no flashbacks.
2.
The client will be able to feel a full range of emotions by discharge.
3.
The client will not require zolpidem (Ambien) to obtain adequate sleep by
discharge.
4.
The client will refrain from discussing the traumatic event.
____ 16.
A client, who recently delivered a stillborn baby, has a diagnosis of adjustment
disorder unspecified. The nurse case manager should expect which client presentation that is
characteristic of this diagnosis?
1.
The client worries continually and appears nervous and jittery.
2.
The client complains of a depressed mood, is tearful, and feels hopeless.
3.
The client is belligerent, violates others’ rights, and defaults on legal
responsibilities.
4.
The client complains of many physical ailments, refuses to socialize, and quits her
job.
____ 17.
A client has been extremely nervous ever since a person died as a result of the
client’s drunk driving. When assessing for the diagnosis of AD, within what time frame should
the nurse expect the client to exhibit symptoms?
1.
To meet the DSM-5 criteria for adjustment disorder, the client should exhibit
symptoms within 1 year of the accident.
2.
To meet the DSM-5 criteria for adjustment disorder, the client should exhibit
symptoms within 3 months of the accident.
3.
To meet the DSM-5 criteria for adjustment disorder, the client should exhibit
symptoms within 6 months of the accident.
4.
To meet the DSM-5 criteria for adjustment disorder, the client should exhibit
symptoms within 9 months of the accident.
____ 18.
A 20-year-old client and a 60-year-old client have had drunk driving accidents
and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of
these clients would be predisposed to the diagnosis of adjustment disorder?
1.
The 60-year-old, because of memory deficits
2.
The 60-year-old, because of decreased cognitive processing ability
3.
The 20-year-old, because of limited cognitive experiences
4.
The 20-year-old, because of lack of developmental maturity
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 19.
A client diagnosed with an adjustment disorder says to the nurse, “Tell me about
medications that will cure this problem.” Which of the following are appropriate nursing
responses? (Select all that apply.)
1.
“Medications can interfere with your ability to find a more permanent solution.”
2.
“Medications may mask the real problem at the root of this diagnosis.”
3.
“Adjustment disorders are not commonly treated with medications.”
4.
“Psychoactive drugs carry the potential for physiological and psychological
dependence.”
5.
“Psychoactive drugs will be prescribed only if your problems persist for more than
three months.”
1.
2.
3.
4.
5.
“Medications can interfere with your ability to find a more permanent solution.”
“Medications may mask the real problem at the root of this diagnosis.”
“Adjustment disorders are not commonly treated with medications.”
“Psychoactive drugs carry the potential for physiological and psychological
dependence.”
“Psychoactive drugs will be prescribed only if your problems persist for more than
three months.”
____ 20.
A nurse is admitting a client who has been diagnosed with PTSD. Which of the
following symptoms might the nurse expect to assess? (Select all that apply.)
1.
Feelings of guilt that precipitate social isolation
2.
Aggressive behavior that affects job performance
3.
Relationship problems
4.
High levels of anxiety
5.
Escalating symptoms lasting less than one month
____ 21.
A family asks the nurse why their son was diagnosed with PTSD and others in the
accident were not. Which of the following information should the nurse offer? (Select all that
apply.)
1.
An individual’s religious affiliation can affect response to trauma.
2.
Responses are affected by how an individual handled previous trauma.
3.
Protectiveness of family and friends can help an individual deal with trauma.
4.
Control over the possibility of recurrence can affect the response to trauma.
5.
The time in which the trauma occurred can affect the individual’s response.
____ 22.
A nurse recognizes which of the following as the best predictors of PTSD in
Vietnam veterans? (Select all that apply.)
1.
The severity of the stressor
2.
The degree of ego strength
3.
The degree of psychosocial isolation in the recovery environment
4.
The attitudes of society regarding the experience
5.
The presence of preexisting psychopathology
____ 23.
A client diagnosed with posttraumatic stress disorder (PTSD) states, “Why did my
doctor prescribe an antidepressant rather than an antianxiety drug for me?” Which of the
following are the most appropriate nursing responses? (Select all that apply.)
1.
“I’m not sure, because antianxiety drugs have been approved by the FDA for
PTSD.”
2.
“Antidepressants are now considered first-line treatment choice for PTSD.”
3.
“Many people have adverse reactions to antianxiety drugs.”
4.
“Because of their addictive properties, antianxiety drugs are less desirable.”
5.
“There have been no controlled studies on the effect of antianxiety drugs on PTSD.”
Other
24.
Order the eight-phase process of eye movement desensitization and reprocessing
(EMDR).
________ Instillation
________ Body scan
________ Closure
________ Reevaluation
________ Preparation
________ History and treatment planning
________ Desensitization
________ Assessment
Completion
Complete each statement.
25.
An extremely distressing experience that causes severe emotional shock and may
have long-lasting psychological effects is called _________________.
Chapter 0: Trauma and Stressor-Related Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 476
Heading: Historical and Epidemiological Data
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
This statement indicates that teaching has been effective.
This statement is correct, indicating that no further teaching is needed.
This statement is accurate, indicating the teaching has been effective.
Research shows that PTSD is more common in women than in men. This student
statement indicates a need for further instruction.
PTS: 1
CON: Patient-Centered Care
2.
ANS: 1
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 476–477
Heading: Historical and Epidemiological Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
PTSD results from exposure to an extreme traumatic event, whereas AD results
from exposure to “normal” daily events, such as divorce, failure, or rejection.
PTSD results from exposure to an extreme traumatic event.
Depressive symptoms can also occur in AD.
Depressive symptoms can also occur in PTSD.
CON: Patient-Centered Care
3.
ANS: 3
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 477
Heading: Historical and Epidemiological Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
AD is not common in this group.
Although more common in the young, it can occur at any age.
Adjustment disorders are more common in women, unmarried persons, and
younger people.
AD is more common in women.
PTS: 1
CON: Patient-Centered Care
4.
ANS: 2
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 480
Heading: Application of the Nursing Process—Trauma-Related Disorders > Theories of Etiology
Related to Trauma-Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement indicates that further education is necessary.
Learning theorists view negative reinforcement as behavior that leads to a
reduction in an aversive experience, thereby reinforcing and resulting in repetition
of the behavior. Psychic numbing decreases or protects an individual from
emotional pain and, therefore, the learned response is the repetition of this
behavior.
This statement is incorrect, indicating that further teaching is needed.
This statement indicates that teaching has not been effective.
CON: Patient-Centered Care
5.
ANS: 3
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 489
Heading: Diagnosis and Outcome Identification
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Although the client may also experience anxiety, the symptom presented in the
question is extreme guilt.
There is no evidence presented in the question to indicate altered thought
processes.
The client’s survivor guilt is disrupting the normal process of grieving.
There is no evidence presented in the question to indicate altered sensory
perception.
1
2
3
4
PTS: 1
Feedback
Although the client may also experience anxiety, the symptom presented in the
question is extreme guilt.
There is no evidence presented in the question to indicate altered thought
processes.
The client’s survivor guilt is disrupting the normal process of grieving.
There is no evidence presented in the question to indicate altered sensory
perception.
CON: Patient-Centered Care
6.
ANS: 2
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 485–486
Heading: Table 19-2 Care Plan for the Client with an Adjustment Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
After the nurse has assessed the stage of grief, the client can be encouraged to
journal feelings.
Prior to implementing all other nursing interventions presented, the nurse must
assess the stage of grief in which the client is fixed. Appropriate nursing
interventions are always based on accurate assessments.
After the nurse has assessed the stage of grief, the client can be given community
resources.
After the nurse has assessed the stage of grief, the client can be encouraged to
attend a grief therapy group.
CON: Patient-Centered Care
7.
ANS: 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 477
Heading: Posttraumatic Stress Disorder and Acute Stress Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Anxiety and worry would not be expected.
Truancy, vandalism, and fighting would not be expected.
Nervousness and jitteriness would not be expected.
AD with depressed mood is the most commonly diagnosed adjustment disorder.
The clinical presentation is one of predominant mood disturbance, although less
pronounced than that of major depression. The symptoms—such as depressed
mood, tearfulness, and feelings of hopelessness—exceed what is an expected or
normative response to an identified stressor.
CON: Patient-Centered Care
8.
ANS: 3
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 489
Heading: Theories of Etiology Related to Adjustment Disorders > Transactional Model of Stress
and Adaptation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Occupational opportunities would not be categorized as intrapersonal.
Economic conditions would not be categorized as intrapersonal.
Intrapersonal factors that might influence an individual’s ability to adjust to a
painful life change include social skills, coping strategies, the presence of
psychiatric illness, degree of flexibility, and level of intelligence.
Availability of social supports would not be categorized as intrapersonal.
CON: Patient-Centered Care
9.
ANS: 1
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Describe various types of trauma- and stressor-related disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 482–483
Heading: Table 19-1 Care Plan for the Client with a Trauma-Related Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
An outcome statement must be client-centered, specific, measurable, and contain a
time frame, so that it can be evaluated effectively.
A “decrease” in anxiety is vague rather than specific, and expecting an anxiety
decrease by day one may also be unrealistic.
Accomplishing activities of daily living independently does not address the
anxiety nursing diagnosis.
Demonstrating the ability for adequate social functioning does not address the
anxiety nursing diagnosis.
CON: Patient-Centered Care
10.
ANS: 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 494
Heading: Treatment Modalities > Trauma-Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
EMDR has not been empirically validated for adjustment disorder.
EMDR has not been empirically validated for generalized anxiety disorder.
EMDR has not been empirically validated for panic disorder.
EMDR has been used for depression, adjustment disorder, phobias, addictions,
generalized anxiety disorder, and panic disorder. However, at present, EMDR has
only been empirically validated for trauma-related disorders, such as PTSD and
acute stress disorder.
CON: Patient-Centered Care
11.
ANS: 2
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 481, 484
Heading: Application of the Nursing Process—Trauma-Related Disorders > Evaluation
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement is assessed in the evaluation phase, not the assessment phase.
In the evaluation phase of the nursing process, reassessment is conducted to
determine if the nursing actions have been successful in achieving the objectives
of care. The implementation of client teaching has enabled the client to verbalize
an understanding of the grief process and his or her position in the process.
Therefore, the nurse’s actions can be evaluated as successful. Without the
evaluation phase, it would be difficult for the nurse to determine if actions have
been successful.
This statement is assessed in the evaluation phase, not the implementation phase.
This statement is assessed in the evaluation phase, not the diagnosis phase.
CON: Patient-Centered Care
12.
ANS: 1
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 494
Heading: Treatment Modalities > Trauma-Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Some studies have indicated that eye movements cause a decrease in imagery
vividness and distress, as well as an increase in memory access. EMDR is thought
to relieve anxiety associated with the traumatic event. However, the exact
biological mechanisms by which EMDR achieves its therapeutic effects are
unknown.
EMDR does not achieve its effect by decreasing imagery vividness.
EMDR does not achieve its effect by increasing memory access.
EMDR does not achieve its effect by decreasing trauma associated with anxiety.
1
2
3
4
PTS: 1
Feedback
Some studies have indicated that eye movements cause a decrease in imagery
vividness and distress, as well as an increase in memory access. EMDR is thought
to relieve anxiety associated with the traumatic event. However, the exact
biological mechanisms by which EMDR achieves its therapeutic effects are
unknown.
EMDR does not achieve its effect by decreasing imagery vividness.
EMDR does not achieve its effect by increasing memory access.
EMDR does not achieve its effect by decreasing trauma associated with anxiety.
CON: Patient-Centered Care
13.
ANS: 2
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 495
Heading: Treatment Modalities > Trauma-Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement does not educate the client about completing all phases of EMDR.
Clients often feel relief quite rapidly with EMDR. However, to achieve lasting
results, it is important that each of the eight phases be completed. The nurse’s most
appropriate response should be to give information to correct the client’s
misconceptions about the therapy.
In this answer, the nurse is subjectively giving advice rather than providing
objective information.
This statement is inappropriate because the client has already stated feelings about
continuing EMDR.
CON: Patient-Centered Care
14.
ANS: 1
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 496
Heading: Adjustment Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Psychotherapy is the most common treatment used for AD.
AD is not commonly treated with medications.
Eye movement desensitization and reprocessing therapy is not used to treat
adjustment disorders.
Anxiolytic and antidepressant medications may be prescribed as adjuncts to
psychotherapy but should not be given as the first line of treatment.
CON: Patient-Centered Care
15.
ANS: 3
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 482–483
Heading: Table 19-1 Care Plan for the Client with a Trauma-Related Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Having no flashbacks by discharge is an unrealistic goal.
Experiencing a full range of emotions by discharge is an unrealistic goal.
Obtaining adequate sleep without zolpidem by discharge is a goal that should be
included in the client’s plan of care.
Clients are encouraged, not discouraged, to discuss the traumatic event.
CON: Patient-Centered Care
16.
ANS: 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 487, 489
Heading: Adjustment Disorders—Background Assessment Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Constant worrying and appearing jittery are not symptoms of adjustment disorder.
Depressed mood, tearfulness and feeling hopeless are not symptoms of adjustment
disorder.
The client who is belligerent, violates others’ rights, and defaults on legal
responsibilities, is not showing symptoms of an adjustment disorder.
The diagnosis of adjustment disorder unspecified is assigned when the
maladaptive reaction is not consistent with any of the other categories.
Manifestations may include physical complaints, social withdrawal, or work or
academic inhibition, without significant depressed or anxious mood.
CON: Patient-Centered Care
17.
ANS: 2
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Identify predisposing factors in the development of trauma- and stressor-related
disorders.
Page: 484
Heading: Adjustment Disorders—Background Assessment Data
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Exhibiting symptoms within 1 year does not meet the DSM-5 diagnostic criteria
for adjustment disorders.
According to the DSM-5 diagnostic criteria for adjustment disorders, the
development of emotional or behavioral symptoms in response to an identifiable
stressor occurs within 3 months of the onset of the stressor.
Exhibiting symptoms within 6 months does not meet the DSM-5 diagnostic criteria
for adjustment disorders.
Exhibiting symptoms within 9 months does not meet the DSM-5 diagnostic criteria
for adjustment disorders.
PTS: 1
CON: Patient-Centered Care
18.
ANS: 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Identify predisposing factors in the development of trauma- and stressor-related
disorders.
Page: 489
Heading: Theories of Etiology Related to Adjustment Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The 60-year-old client is less likely to be diagnosed with adjustment disorder,
regardless of memory deficits.
The 60-year-old client is less likely to be diagnosed with adjustment disorder,
regardless of cognitive processing ability
The 60-year-old client is less likely to be diagnosed with adjustment disorder,
regardless of limited cognitive experiences.
Research indicates that there is a predisposition to the diagnosis of adjustment
disorder when there is limited developmental maturity. By comparison, the 20year-old does not have the developmental maturity, life experiences, and coping
mechanisms that the 60-year-old might possess.
CON: Patient-Centered Care
MULTIPLE RESPONSE
19.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Identify predisposing factors in the development of trauma- and stressor-related
disorders.
Page: 495–496
Heading: Treatment Modalities > Adjustment Disorders
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
Adjustment disorders are not commonly treated with medications because of
interfering with finding a permanent solution.
2.
Adjustment disorders are not commonly treated with medications because of
masking the real problem.
3.
Adjustment disorder is not commonly treated with medication.
1.
2.
3.
4.
5.
PTS: 1
Feedback
Adjustment disorders are not commonly treated with medications because of
interfering with finding a permanent solution.
Adjustment disorders are not commonly treated with medications because of
masking the real problem.
Adjustment disorder is not commonly treated with medication.
Adjustment disorders are not commonly treated with medications because of the
potential for addiction.
Adjustment disorder is not commonly treated with medication.
CON: Patient-Centered Care
20.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Identify predisposing factors in the development of trauma- and stressor-related
disorders.
Page: 477
Heading: Posttraumatic Stress Disorder and Acute-Stress Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
Characteristic symptoms of PTSD include guilt feelings.
2.
Characteristic symptoms of PTSD include aggressive behaviors.
3.
Characteristic symptoms of PTSD include relationship problems.
4.
Characteristic symptoms of PTSD include high levels of anxiety.
5.
PTS: 1
The full-symptom picture must present for more than 1 month and cause
significant interference with social, occupational, and other areas of functioning.
CON: Patient-Centered Care
21.
ANS: 2, 3, 4, 5
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Identify predisposing factors in the development of trauma- and stressor-related
disorders.
Page: 477, 479–480
Heading: Theories of Etiology Related to Trauma-Related Disorders
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
However, an individual’s specific religious affiliation should have no bearing or
influence.
2.
3.
4.
5.
PTS: 1
Variables that affect whether an individual exposed to massive trauma develops
trauma-related disorders are grouped into characteristics of (2) the individual.
Variables that affect whether an individual exposed to massive trauma develops
trauma-related disorders are grouped into characteristics of (3) the recovery
environment.
Variables that affect whether an individual exposed to massive trauma develops
trauma-related disorders are grouped into characteristics of (3) the recovery
environment.
Variables that affect whether an individual exposed to massive trauma develops
trauma-related disorders are grouped into characteristics of (1) the traumatic
experience.
CON: Patient-Centered Care
22.
ANS: 1, 3
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Identify predisposing factors in the development of trauma- and stressor-related
disorders.
Page: 477, 479–480
Heading: Theories of Etiology Related to Trauma-Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
In research with Vietnam veterans, it was shown that the best predictors of PTSD
were the severity of the stressor.
2.
Ego strength is not the best predictor of PTSD in Vietnam veterans.
3.
In research with Vietnam veterans, it was shown that the best predictors of PTSD
were the degree of psychosocial isolation in the recovery environment.
4.
Attitudes of society is not the best predictor of PTSD in Vietnam veterans.
5.
Preexisting psychopathology is not the best predictor of PTSD in Vietnam
veterans.
PTS: 1
CON: Patient-Centered Care
23.
ANS: 2, 4, 5
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 495
Heading: Psychopharmacology
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
Paroxetine and sertraline (antidepressant drugs), not antianxiety drugs, have been
approved by the FDA for the treatment of PTSD.
2.
Antidepressants are now considered the first-line treatment of choice for PTSD.
3.
Adverse reactions can occur with the use of anxiolytic drugs, but these reactions
are not common.
4.
Their addictive properties make them less desirable than other medications used
in the treatment of PTSD.
5.
There has been an absence of controlled studies demonstrating the efficacy of
benzodiazepines for the treatment of PTSD.
PTS: 1
CON: Patient-Centered Care
ORDERED RESPONSE
24.
ANS:
The correct order is 5, 6, 7, 8, 2, 1, 4, 3
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 494–495
Heading: Treatment Modalities > Trauma-Related Disorders
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: EMDR is an integrative psychotherapy approach with a theoretical model that
emphasizes the brain’s information processing system and memories of disturbing experiences as
the basis of pathology. EMDR has been shown to be an effective therapy for PTSD and other
trauma-related disorders.
1. History and treatment planning
2. Preparation
3. Assessment
4. Desensitization
5. Instillation
6. Body scan
7. Closure
8. Reevaluation
PTS: 1
CON: Patient-Centered Care
COMPLETION
25.
ANS:
trauma
Chapter: Chapter 0, Trauma and Stressor-Related Disorders
Objective: Discuss various modalities relevant to treatment of trauma-and stressor-related
disorders.
Page: 477
Heading: Core Concept > Trauma
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: An extremely distressing experience that causes severe emotional shock and may have
long-lasting psychological effects is called trauma. PTSD can occur following exposure to an
identifiable stressor or to an extreme traumatic event.
PTS: 1
CON: Patient-Centered Care
Chapter 29. Somatic Symptom and Dissociative Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A client diagnosed with somatic symptom disorder (SSD) is most likely to exhibit
which personality disorder characteristics?
1.
2.
3.
4.
Experiences intense and chaotic relationships with fluctuating attitudes toward
others
Socially irresponsible, exploitative, guiltless, and disregards rights of others
Self-dramatizing, attention seeking, overly gregarious, and seductive
Uncomfortable in social situations, perceived as timid, withdrawn, cold, and strange
____ 2.
A nurse is working with a client diagnosed with SSD. What criteria would
differentiate this diagnosis from illness anxiety disorder (IAD)?
1.
The client diagnosed with SSD experiences physical symptoms in various body
systems, and the client diagnosed with IAD does not.
2.
The client diagnosed with SSD experiences a change in the quality of selfawareness, and the client diagnosed with IAD does not.
3.
The client diagnosed with SSD disorder has a perceived disturbance in body image
or appearance, and the client diagnosed with IAD does not.
4.
The client diagnosed with SSD only experiences anxiety about the possibility of
illness, and the client diagnosed with IAD does not.
____ 3.
Which would be considered an appropriate outcome when planning care for an
inpatient client diagnosed with SSD?
1.
The client will admit to fabricating physical symptoms to gain benefits by day
three.
2.
The client will list three potential adaptive coping strategies to deal with stress by
day two.
3.
The client will comply with medical treatments for physical symptoms by day three.
4.
The client will openly discuss physical symptoms with staff by day four.
____ 4.
Which are examples of primary and secondary gains that clients diagnosed with
SSD: predominately pain, may experience?
1.
Primary: chooses to seek a new doctor; Secondary: euphoric feeling from new
medications
2.
Primary: euphoric feeling from new medications; Secondary: chooses to seek a new
doctor
3.
Primary: receives get-well cards; Secondary: pain prevents attending stressful
family reunion
4.
Primary: pain prevents attending stressful family reunion; Secondary: receives getwell cards
____ 5.
A nursing instructor is teaching about the etiology of IAD from a psychodynamic
perspective. What student statement about clients diagnosed with this disorder indicates that
learning has occurred?
1.
2.
3.
4.
“They tend to have a familial predisposition to this disorder.”
“When the sick role relieves them from stressful situations, their physical symptoms
are reinforced.”
“They misinterpret and cognitively distort their physical symptoms.”
“They express personal worthlessness through physical symptoms, because physical
problems are more acceptable than psychological problems.”
____ 6.
An inpatient client is newly diagnosed with dissociative identity disorder (DID)
stemming from severe childhood sexual abuse. Which nursing intervention takes priority?
1.
Encourage exploration of sexual abuse.
2.
Encourage guided imagery.
3.
Establish trust and rapport.
4.
Administer antianxiety medications.
____ 7.
A client diagnosed with DID switches personalities when confronted with
destructive behavior. The nurse recognizes that this dissociation serves which function?
1.
It is a means to attain secondary gain.
2.
It is a means to explore feelings of excessive and inappropriate guilt.
3.
It serves to isolate painful events so that the primary self is protected.
4.
It serves to establish personality boundaries and limit inappropriate impulses.
____
client?
1.
2.
3.
4.
8.
A client is diagnosed with DID. What is the primary goal of therapy for this
To recover memories and improve thinking patterns
To prevent social isolation
To decrease anxiety and need for secondary gain
To collaborate among sub-personalities to improve functioning
____ 9.
According to the DSM-5 diagnostic criteria for dissociative amnesia (DA), what
symptom would be essential to meet the criteria for the subcategory of dissociative fugue?
1.
An inability to recall important autobiographical information
2.
Clinically significant distress in social and occupational functioning
3.
Sudden unexpected travel or bewildered wandering
4.
“Blackouts” related to alcohol toxicity
____
1.
2.
3.
4.
10.
Which situation is an example of selective amnesia?
A client cannot relate any lifetime memories.
A client can describe driving to Ohio but cannot remember the car accident that
occurred.
A client often wanders aimlessly after sunset.
A client cannot provide personal demographic information during admission
assessment.
1.
2.
3.
4.
A client cannot relate any lifetime memories.
A client can describe driving to Ohio but cannot remember the car accident that
occurred.
A client often wanders aimlessly after sunset.
A client cannot provide personal demographic information during admission
assessment.
____ 11.
Neurological tests have ruled out pathology in a client’s sudden lower-extremity
paralysis. Which nursing care should be included for this client?
1.
Deal with physical symptoms in a detached manner.
2.
Challenge the validity of physical symptoms.
3.
Meet dependency needs until the physical limitations subside.
4.
Encourage a discussion of feelings about the lower-extremity problem.
____ 12.
Which combination of diagnoses and appropriate pharmacological treatments are
correctly matched?
1.
SSD: predominantly pain; treated with venlafaxine (Effexor)
2.
IAD; treated with cefadroxil (Duricef)
3.
Conversion disorder; treated with cyclobenzaprine (Flexeril)
4.
Depersonalization-derealization disorder; treated with mometasone (Elocom)
____ 13.
A nurse is reviewing progress notes on a newly admitted client. One progress note
reveals that the client purposefully inserted a contaminated catheter into the urethra, leading to a
urinary tract infection. The nurse recognizes this behavior as characteristic of which mental
disorder?
1.
Illness anxiety disorder
2.
Factitious disorder
3.
Functional neurological symptom disorder
4.
Depersonalization-derealization disorder
____ 14.
A nursing instructor is teaching about the DSM-5 diagnosis of depersonalizationderealization disorder (D-DD). Which student statement indicates a need for further instruction?
1.
“Clients with this disorder can experience emotional and/or physical numbing and a
distorted sense of time.”
2.
“Clients with this disorder can experience unreality or detachment with respect to
their surroundings.”
3.
“During the course of this disorder, individuals or objects are experienced as
dreamlike, foggy, lifeless, or visually distorted.”
4.
“During the course of this disorder, the client is out of touch with reality and is
impaired in social, occupational, or other areas of functioning.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 15.
A client is diagnosed with IAD. Which of the following symptoms is the client
most likely to exhibit? (Select all that apply.)
1.
Obsessive-compulsive behaviors
2.
Pseudocyesis
3.
Anxiety
4.
Flat affect
5.
Depression
____ 16.
A client is diagnosed with functional neurological symptom disorder (FNSD).
Which of the following symptoms is the client most likely to exhibit? (Select all that apply.)
1.
Anosmia
2.
Anhedonia
3.
Akinesia
4.
Aphonia
5.
Amnesia
____ 17.
A client is exhibiting symptoms of generalized amnesia. Which of the following
questions should the nurse ask to confirm this diagnosis? (Select all that apply.)
1.
“Have you taken any new medications recently?”
2.
“Have you recently traveled away from home?”
3.
“Have you recently experienced any traumatic event?”
4.
“Have you ever felt detached from your environment?”
5.
“Have you had any history of memory problems?”
Completion
Complete each statement.
18.
The DSM-5 diagnosis of functional neurological symptom disorder can also be
identified as ____________________ disorder.
Chapter 0: Somatic Symptom and Dissociative Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 506
Heading: Application of the Nursing Process > Somatic Symptom Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client is not likely to experience intense and chaotic relationships.
The client is not likely to be socially irresponsible or exploitive.
The nurse should anticipate that a client diagnosed with SSD would be selfdramatizing, attention seeking, and overly gregarious. It has been suggested that,
in somatic symptom disorder, there may be some overlapping of personality
characteristics and features associated with histrionic personality disorder. These
symptoms include heightened emotionality, impressionistic thought and speech,
seductiveness, strong dependency needs, and a preoccupation with symptoms and
oneself.
The client is not likely to be perceived as timid or withdrawn.
CON: Patient-Centered Care
2.
ANS: 1
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 505
Heading: Epidemiological Statistics
Integrated Processes: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Individuals experiencing somatic symptoms without corroborating pathology are
considered to have SSD, and those with minimal or no somatic symptoms would
be diagnosed with IAD, a diagnosis new to the DSM-5.
Clients with IAD experience a change in self-awareness
Clients with IAD experience a change in body image.
Clients with SSD experience corroborating pathology.
PTS: 1
CON: Patient-Centered Care
3.
ANS: 2
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 515–518
Heading: Table 20-2 Care Plan for the Client with a Somatic Symptom Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client is experiencing real symptoms and is not likely to admit to fabricating
symptoms.
The nurse should determine that an appropriate outcome for a client diagnosed
with SSD would be for the client to list three potential adaptive coping strategies
to deal with stress by day two.
The outcome may not be realistic for this client, and may require more time.
This outcome may not be realistic for the client.
CON: Patient-Centered Care
4.
ANS: 4
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 506
Heading: Application of the Nursing Process > Somatic Symptom Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Choosing a new doctor and euphoric feelings do not accurately describe primary
and secondary gains for this client.
These feelings listed do not accurately describe primary and secondary gains for
this client.
The primary and secondary gains listed do not accurately describe primary and
secondary gains for this client.
The nurse should identify that primary gains are those that allow the client to
avoid an unpleasant activity (stressful family reunion) and that secondary gains are
1
2
3
4
PTS: 1
Feedback
Choosing a new doctor and euphoric feelings do not accurately describe primary
and secondary gains for this client.
These feelings listed do not accurately describe primary and secondary gains for
this client.
The primary and secondary gains listed do not accurately describe primary and
secondary gains for this client.
The nurse should identify that primary gains are those that allow the client to
avoid an unpleasant activity (stressful family reunion) and that secondary gains are
those in which the client receives emotional support or attention (get-well cards).
CON: Patient-Centered Care
5.
ANS: 4
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 506–507
Heading: Application of the Nursing Process > Illness Anxiety Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
These clients do not tend to have familial disposition for the disorder.
Physical symptoms are not reinforced when the sick role relieves them from
stressful situations.
They do not misinterpret or cognitively distort their physical symptoms.
The nurse should understand that from a psychoanalytical perspective, IAD occurs
because physical problems are more acceptable than psychological problems.
CON: Patient-Centered Care
6.
ANS: 3
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 518–520
Heading: Table 20-3 Care Plan for the Client with a Dissociative Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Encouraging exploration of sexual abuse can occur after establishing rapport.
Encouraging guided imagery can occur after establishing rapport.
The nurse should prioritize establishing trust and rapport when beginning to work
with a client diagnosed with DID. DID was formerly called multiple personality
disorder. Trust is the basis of every therapeutic relationship. Each personality
views itself as a separate entity and must be treated as such to establish rapport.
Administering antianxiety medications can occur after establishing rapport.
CON: Patient-Centered Care
7.
ANS: 3
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 511–512
Heading: Application of the Nursing Process > Dissociative Identity Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The switch is not to attain secondary gain.
The switch is not to explore feelings of excessive and inappropriate guilt.
The nurse should anticipate that a client who switches personalities when
confronted with destructive behavior is dissociating in order to isolate painful
events so that the primary self is protected. The transition between personalities is
usually sudden, dramatic, and precipitated by stress.
The switch is not to establish personality boundaries and limit inappropriate
impulses.
CON: Patient-Centered Care
8.
ANS: 4
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 518–520
Heading: Table 20-3 Care Plan for the Client with a Dissociative Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
To recover memories and improve thinking patterns is not the primary goal of
therapy.
To prevent social isolation is not the primary goal of therapy.
To decrease anxiety and need for secondary gain is not the primary goal of
therapy.
The nurse should anticipate that the primary therapeutic goal for a client diagnosed
with DID is to collaborate among sub-personalities to improve functioning. Some
clients choose to pursue a lengthy therapeutic regimen to achieve integration, a
blending of all the personalities into one. The goal is to optimize the client’s
functioning and potential.
CON: Patient-Centered Care
9.
ANS: 3
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 510–511
Heading: Background Assessment Data: Types of Dissociative Disorders > Dissociative Amnesia
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
An inability to recall important autobiographical information is a basic criterion
for the diagnosis of DA.
Clinically significant distress in social and occupational functioning is a basic
criterion for the diagnosis of DA.
Dissociative fugue is characterized by a sudden, unexpected travel away from
customary place of daily activities, or by bewildered wandering, with the inability
to recall some or all of one’s past.
The DSM-5 also states that symptoms cannot be attributable to the direct
physiological effects of a substance (e.g., alcohol, a drug of abuse, a medication).
PTS: 1
CON: Patient-Centered Care
10.
ANS: 2
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 510
Heading: Background Assessment Data: Types of Dissociative Disorders > Dissociative Amnesia
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
In the generalized type, the individual has amnesia for his or her identity and total
life history.
In selective amnesia, the individual can recall only certain incidents associated
with a stressful event for a specific period after the event.
Wandering aimlessly is not an example of selective amnesia.
This is not an example of selective amnesia.
CON: Patient-Centered Care
11.
ANS: 1
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 518–520
Heading: Table 20-3 Care Plan for the Client with a Dissociative Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should assist the client in dealing with physical symptoms in a detached
manner. This client should be diagnosed with a conversion disorder in which
symptoms affect voluntary motor or sensory functioning with or without apparent
impairment of consciousness. Examples include paralysis, aphonia, seizures,
coordination disturbance, difficulty swallowing, urinary retention, akinesia,
blindness, deafness, double vision, anosmia, and hallucinations.
The nurse should not challenge the validity of the symptoms.
The nurse should encourage the client to be as independent as possible.
The nurse should deal with the physical symptoms in a detached manner.
1
2
3
4
PTS: 1
Feedback
The nurse should assist the client in dealing with physical symptoms in a detached
manner. This client should be diagnosed with a conversion disorder in which
symptoms affect voluntary motor or sensory functioning with or without apparent
impairment of consciousness. Examples include paralysis, aphonia, seizures,
coordination disturbance, difficulty swallowing, urinary retention, akinesia,
blindness, deafness, double vision, anosmia, and hallucinations.
The nurse should not challenge the validity of the symptoms.
The nurse should encourage the client to be as independent as possible.
The nurse should deal with the physical symptoms in a detached manner.
CON: Patient-Centered Care
12.
ANS: 1
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 524
Heading: Treatment Modalities > Psychopharmacology
Integrated Processes: Implementation (Nursing Process)
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should anticipate that the diagnosis of SSD: predominantly pain can be
effectively treated with venlafaxine. Antidepressants are often used with somatic
symptom disorder when the predominant symptom is pain. They have been shown
to be effective in relieving pain, independent of influences on mood.
Treatment with cefadroxil (Duricef) is not appropriate for this client.
Treatment with cyclobenzaprine (Flexeril) is not appropriate for this client.
Treatment with mometasone (Elocom) is not appropriate.
CON: Patient-Centered Care
13.
ANS: 2
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 508–509
Heading: Application of the Nursing Process > Factitious Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Illness anxiety disorder is the fear of having an illness or disease.
Factitious disorders involve conscious, intentional feigning of physical or
psychological symptoms. Individuals with factitious disorder pretend to be ill in
order to receive emotional care and support commonly associated with the role of
“patient.” Individuals become very inventive in their quest to produce symptoms.
Examples include self-inflicted wounds, injection or insertion of contaminated
substances, manipulating a thermometer to feign a fever, urinary tract
manipulation, and surreptitious use of medications.
Functional neurological symptom disorder, or conversion disorder, is the loss of
body function with no known medical cause.
Depersonalization-derealization disorder occurs when an individual switches
between different personalities.
CON: Patient-Centered Care
14.
ANS: 4
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 512
Heading: Background Assessment Data: Types of Dissociative Disorders > DepersonalizationDerealization Disorder
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
This statement is correct, indicating that further education is not necessary.
This statement does not indicate a need for further education.
This statement indicates that teaching has been effective.
D-DD is characterized by a temporary change in the quality of self-awareness,
which often takes the form of feelings of unreality, changes in body image,
feelings of detachment from the environment, or a sense of observing oneself from
outside the body. Depersonalization (a disturbance in the perception of oneself) is
differentiated from derealization, which describes an alteration in the perception of
the external environment. The DSM-5 states that during the depersonalization and/
or derealization experiences, reality testing remains intact. This student statement
indicates a need for further instruction.
1
2
3
4
PTS: 1
Feedback
This statement is correct, indicating that further education is not necessary.
This statement does not indicate a need for further education.
This statement indicates that teaching has been effective.
D-DD is characterized by a temporary change in the quality of self-awareness,
which often takes the form of feelings of unreality, changes in body image,
feelings of detachment from the environment, or a sense of observing oneself from
outside the body. Depersonalization (a disturbance in the perception of oneself) is
differentiated from derealization, which describes an alteration in the perception of
the external environment. The DSM-5 states that during the depersonalization and/
or derealization experiences, reality testing remains intact. This student statement
indicates a need for further instruction.
CON: Patient-Centered Care
MULTIPLE RESPONSE
15.
ANS: 1, 3, 5
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 506–507
Heading: Application of the Nursing Process > Illness Anxiety Disorder
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should expect that a client diagnosed with IAD would exhibit obsessivecompulsive behaviors.
The client would not likely exhibit pseudocyesis.
The nurse should expect that a client diagnosed with IAD would exhibit anxiety.
The client would not likely exhibit a flat affect.
The nurse should expect that a client diagnosed with IAD would exhibit
depression.
CON: Patient-Centered Care
16.
ANS: 1, 3, 4
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 507
Heading: Application of the Nursing Process > Conversion Disorder (Functional Neurological
Symptom Disorder)
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
FNSD can also be termed conversion disorder. Conversion symptoms affect
voluntary motor or sensory functioning suggestive of neurological disease. The
client would likely exhibit anosmia.
The client would not likely exhibit anhedonia.
FNSD can also be termed conversion disorder. Conversion symptoms affect
voluntary motor or sensory functioning suggestive of neurological disease. The
client would likely exhibit akinesia.
FNSD can also be termed conversion disorder. Conversion symptoms affect
voluntary motor or sensory functioning suggestive of neurological disease. The
client would likely exhibit aphonia.
The client would not likely exhibit amnesia.
CON: Patient-Centered Care
17.
ANS: 1, 3, 5
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 518–520
Heading: Table 20-3 Care Plan for the Client with a Dissociative Disorder
Integrated Processes: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The nurse should assess the client for possible causes of amnesia, which may
include side effects of new medications.
This question would not help confirm the diagnosis.
The nurse should assess the client for possible causes of amnesia, which may
include experiencing a traumatic event.
This question would not be beneficial in helping the nurse confirm the diagnosis.
The nurse should assess the client for possible causes of amnesia, which may
include having a history of memory problems.
1.
2.
3.
4.
5.
The nurse should assess the client for possible causes of amnesia, which may
include side effects of new medications.
This question would not help confirm the diagnosis.
The nurse should assess the client for possible causes of amnesia, which may
include experiencing a traumatic event.
This question would not be beneficial in helping the nurse confirm the diagnosis.
The nurse should assess the client for possible causes of amnesia, which may
include having a history of memory problems.
PTS: 1
CON: Patient-Centered Care
COMPLETION
18.
ANS:
conversion
Chapter: Chapter 0, Somatic Symptom and Dissociative Disorders
Objective: Describe various types of somatic symptom and dissociative disorders and identify
symptomatology associated with each; use this information in client assessment.
Page: 507
Heading: Background Assessment Data: Types of Somatic Symptom Disorders > Conversion
Disorder (Functional Neurological Symptom Disorder)
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: The DSM-5 diagnosis of functional neurological symptom disorder can also be
identified as conversion disorder. Conversion disorder is a loss of or change in body function that
cannot be explained by any known medical disorder or pathophysiological mechanism. There is
most likely a psychological component involved in the initiation, exacerbation, or perpetuation
of the symptom, although it may or may not be obvious or identifiable.
PTS: 1
CON: Patient-Centered Care
Chapter 30. Eating Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
Family dynamics are thought to be a major influence in the development of
anorexia nervosa. Which statement regarding a client’s home environment should a nurse
associate with the development of anorexia nervosa?
1.
The home environment maintains loose personal boundaries.
2.
The home environment places an overemphasis on food.
3.
The home environment is overprotective and demands perfection.
4.
The home environment condones corporal punishment.
____ 2.
A client’s altered body image is evidenced by claims of “feeling fat,” even though
the client is emaciated. Which is the appropriate outcome criterion for this client’s problem?
1.
The client will consume adequate calories to sustain normal weight.
2.
The client will cease strenuous exercise programs.
3.
The client will perceive personal ideal body weight and shape as normal.
4.
The client will not express a preoccupation with food.
____ 3.
A nurse is counseling a client diagnosed with bulimia nervosa about the symptom
of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa should
the nurse provide?
1.
The emesis produced during purging is acidic and corrodes the tooth enamel.
2.
Purging causes the depletion of dietary calcium.
3.
Food is rapidly ingested without proper mastication.
4.
Poor dental and oral hygiene leads to dental caries.
____ 4.
A nurse is teaching a client diagnosed with an eating disorder about behaviormodification programs. Why is this intervention the treatment of choice?
1.
It helps the client correct a distorted body image.
2.
It addresses the underlying client anger.
3.
It manages the client’s uncontrollable behaviors.
4.
It allows clients to maintain control.
____ 5.
A potential Olympic figure skater collapses during practice and is hospitalized for
severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight
related to this disorder?
1.
“Skaters need to be thin to improve their daily performance.”
2.
“All the skaters on the team are following an approved 1,200-calorie diet.”
3.
“The exercise of skating reduces my appetite but improves my energy level.”
4.
“I am angry at my mother. I can only get her approval when I win competitions.”
____ 6.
The family of a client diagnosed with anorexia nervosa becomes defensive when
the treatment team calls for a family meeting. Which is the appropriate nursing response?
1.
“Tell me why this family meeting is causing you to be defensive. All clients are
required to participate in two family sessions.”
2.
“Eating disorders have been correlated to certain familial patterns; without
addressing these, your child’s condition will not improve.”
3.
“Family dynamics are not linked to eating disorders. The meeting is to provide your
child with family support.”
4.
“Clients diagnosed with anorexia nervosa are part of the family system, and any
alteration in family processes needs to be addressed.”
1.
2.
3.
4.
“Tell me why this family meeting is causing you to be defensive. All clients are
required to participate in two family sessions.”
“Eating disorders have been correlated to certain familial patterns; without
addressing these, your child’s condition will not improve.”
“Family dynamics are not linked to eating disorders. The meeting is to provide your
child with family support.”
“Clients diagnosed with anorexia nervosa are part of the family system, and any
alteration in family processes needs to be addressed.”
____ 7.
A client diagnosed with bulimia nervosa has been attending a mental health clinic
for several months. Which factor should a nurse identify as an appropriate indicator of a positive
client behavioral change?
1.
The client gained two pounds in one week.
2.
The client focused conversations on nutritious food.
3.
The client demonstrated healthy coping mechanisms that decreased anxiety.
4.
The client verbalized an understanding of the etiology of the disorder.
____ 8.
The nurse is working with a client diagnosed with binge eating disorder. Which
medication should the nurse expect to teach the client about?
1.
Lisdexamfetamine (Vyvanse)
2.
Dexfenfluramine (Redux)
3.
Sibutramine (Meridia)
4.
Pemoline (Cylert)
____ 9.
A nurse is attempting to differentiate between the symptoms of anorexia nervosa
and the symptoms of bulimia. Which statement delineates the difference between these two
disorders?
1.
Clients diagnosed with anorexia nervosa experience extreme nutritional deficits,
whereas clients diagnosed with bulimia nervosa do not.
2.
Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients
diagnosed with anorexia nervosa do not.
3.
Clients diagnosed with bulimia nervosa experience hypotension, edema, and
lanugo, whereas clients diagnosed with anorexia nervosa do not.
4.
Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients
diagnosed with bulimia nervosa do not.
____ 10.
A client diagnosed with a history of anorexia nervosa comes to an outpatient
clinic after being medically cleared. The client states, “My parents watch me like a hawk and
never let me out of their sight.” Which nursing diagnosis would take priority at this time?
1.
Altered nutrition less than body requirements
2.
Altered social interaction
3.
Impaired verbal communication
4.
Altered family processes
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 11.
A nurse should identify topiramate (Topamax) as the drug of choice for which of
the following conditions? (Select all that apply.)
1.
Binge eating with a diagnosis of obesity
2.
Bingeing and purging with a diagnosis of bulimia nervosa
3.
Weight loss with a diagnosis of anorexia nervosa
4.
Amenorrhea with a diagnosis of anorexia nervosa
5.
Emaciation with a diagnosis of bulimia nervosa
____ 12.
A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of
binge-eating disorder. Which of the following student statements indicates that further instruction
is needed? (Select all that apply.)
1.
“In this disorder, binge eating occurs exclusively during the course of bulimia
nervosa.”
2.
“In this disorder, binge eating occurs, on average, at least once a week for three
months.”
3.
“In this disorder, binge eating occurs, on average, at least two days a week for six
months.”
4.
“In this disorder, distress regarding binge eating is present.”
5.
“In this disorder, distress regarding binge eating is absent.”
Completion
Complete each statement.
13.
The diagnosis of __________________ ___________________includes the
symptoms of gross distortion of body image, preoccupation with food, and refusal to eat.
14.
The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food
over a short period of time is termed ________________________.
15.
To rid the body of excessive calories, a client diagnosed with bulimia nervosa
may engage in ______________________ behaviors, which include self-induced vomiting, or
the misuse of laxatives, diuretics, or enemas.
Chapter 0: Eating Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Chapter: Chapter 0, Eating Disorders
Objective: Identify predisposing factors in the development of eating disorders.
Page: 572
Heading: Predisposing Factors and Theories of Etiology Associated With Anorexia Nervosa,
Bulimia Nervosa, and BED > Family Influences
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Home environments that maintain loose personal boundaries do not typically lead
to anorexia nervosa.
Home environments that place an overemphasis on food do not typically lead to
anorexia nervosa.
The nurse should assess that a home environment that is overprotective and
demands perfection may be a major influence in the development of anorexia
nervosa. In adolescence, distorted eating patterns may represent a rebellion against
the parents viewed by the child as a means of gaining and remaining in control.
Home environments that condone corporal punishment do not typically lead to
anorexia nervosa.
CON: Nutrition
2.
ANS: 3
Chapter: Chapter 0, Eating Disorders
Objective: Identify predisposing factors in the development of eating disorders.
Page: 575–577
Heading: Table 22-3 Care Plan for Client with Eating Disorders: Anorexia Nervosa and Bulimia
Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
Feedback
Consuming adequate calories to sustain a normal weight may be unrealistic for
this client.
Ceasing strenuous exercise programs may be unrealistic for this client.
The nurse should identify that the appropriate outcome for this client is to perceive
personal ideal body weight and shape as normal.
Not expressing a preoccupation with food may be unrealistic for this client.
1
2
3
4
PTS: 1
Feedback
Consuming adequate calories to sustain a normal weight may be unrealistic for
this client.
Ceasing strenuous exercise programs may be unrealistic for this client.
The nurse should identify that the appropriate outcome for this client is to perceive
personal ideal body weight and shape as normal.
Not expressing a preoccupation with food may be unrealistic for this client.
CON: Nutrition
3.
ANS: 1
Chapter: Chapter 0, Eating Disorders
Objective: Identify predisposing factors in the development of eating disorders.
Page: 570
Heading: Background Assessment Data: Bulimia Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should explain to the client diagnosed with bulimia nervosa that his or
her teeth will eventually deteriorate, because the emesis produced during purging
is acidic and corrodes the tooth enamel. Excessive vomiting may also lead to
dehydration and electrolyte imbalance.
This does not correlate with tooth enamel deterioration.
This does not lead to tooth enamel deterioration.
This statement does not educate the client about tooth enamel deterioration caused
by vomiting.
CON: Nutrition
4.
ANS: 4
Chapter: Chapter 0, Eating Disorders
Objective: Describe appropriate interventions for behaviors associated with eating disorders.
Page: 584
Heading: Treatment Modalities > Behavior Modification
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
Feedback
Behavior modification does not help the client correct distorted body image.
Behavior modification does not help the client address underlying client anger.
Behavior modification does not help the client manage uncontrollable behaviors.
Behavior modification programs are the treatment of choice for clients diagnosed
with eating disorders, because these programs allow clients to maintain control.
Issues of control are central to the etiology of these disorders. Behavior
1
2
3
4
PTS: 1
Feedback
Behavior modification does not help the client correct distorted body image.
Behavior modification does not help the client address underlying client anger.
Behavior modification does not help the client manage uncontrollable behaviors.
Behavior modification programs are the treatment of choice for clients diagnosed
with eating disorders, because these programs allow clients to maintain control.
Issues of control are central to the etiology of these disorders. Behavior
modification techniques function to restore healthy weight.
CON: Nutrition
5.
ANS: 4
Chapter: Chapter 0, Eating Disorders
Objective: Describe appropriate interventions for behaviors associated with eating disorders.
Page: 572
Heading: Predisposing Factors and Theories of Etiology Associated With Anorexia Nervosa,
Bulimia Nervosa, and BED > Family Influences
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Stating that skaters need to be thin is not likely to contribute to the development of
anorexia nervosa.
Stating that all skaters are following an approved diet is not likely to contribute to
the development of anorexia nervosa.
This statement is not likely to contribute to the development of anorexia nervosa.
The client reflects insight when referring to feelings toward family dynamics that
may have influenced the development of the disease. Families who are
overprotective and perfectionistic can contribute to the development of anorexia
nervosa.
CON: Nutrition
6.
ANS: 2
Chapter: Chapter 0, Eating Disorders
Objective: Describe appropriate interventions for behaviors associated with eating disorders.
Page: 572
Heading: Predisposing Factors and Theories of Etiology Associated With Anorexia Nervosa,
Bulimia Nervosa, and BED > Family Influences
Heading: Application of the Nursing Process > Planning/Implementation
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
This statement is not therapeutic to the family.
The nurse should educate the family on the correlation between certain familial
patterns and anorexia nervosa. Families engaging in conflict avoidance and
struggling with issues of power and control may contribute to the development of
anorexia nervosa.
This statement is untrue, as family dynamics are linked to eating disorders.
This statement may cause family members to become defensive.
1
2
3
4
PTS: 1
CON: Nutrition
7.
ANS: 3
Chapter: Chapter 0, Eating Disorders
Objective: Describe appropriate interventions for behaviors associated with eating disorders.
Page: 574
Heading: Diagnosis and Outcome Identification > The Client
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback
Gaining two pounds in one week is not an appropriate indicator of a positive client
behavioral change.
Focusing on conversations on nutritious foods is not an appropriate indicator of a
positive client behavioral change.
The nurse should identify that a client who demonstrates healthy coping
mechanisms to decrease anxiety indicates a positive behavioral change. Stress and
anxiety can increase bingeing, which is followed by inappropriate compensatory
behavior.
Verbalizing an understanding of eating disorders in important, but is not
appropriate indicator of a positive client behavioral change.
1
2
3
4
PTS: 1
8.
CON: Nutrition
ANS: 1
Chapter: Chapter 0, Eating Disorders
Objective: Discuss various modalities relevant to treatment of eating disorders.
Page: 584–585
Heading: Treatment Modalities > Psychopharmacology
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should teach the client about Lisdexamfetamine (Vyvanse). This
medication has shown to be successful in the treatment of binge eating disorder.
Dexfenfluramine has been removed from the market because of its association
with serious heart and lung disease.
Several deaths have been associated with the use of sibutramine by high-risk
clients. Based on pressure from the U.S. Food and Drug Administration, the
manufacturer issued a recall of the drug in October 2010.
Withdrawal from anorexiants can result in rebound weight gain, lethargy, and
depression.
CON: Nutrition
9.
ANS: 1
Chapter: Chapter 0, Eating Disorders
Objective: Identify and differentiate among several eating disorders.
Page: 569
Heading: Application of the Nursing Process > Background Assessment Data: Anorexia Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should understand that clients diagnosed with anorexia nervosa
experience nutritional deficits, whereas clients diagnosed with bulimia do not.
Clients with anorexia can experience amenorrhea.
Clients with bulimia nervosa typically do not experience these symptoms.
Clients with bulimia often have tooth enamel erosion.
CON: Nutrition
10.
ANS: 4
Chapter: Chapter 0, Eating Disorders
Objective: Formulate nursing diagnoses and outcomes of care for clients with eating disorders.
Page: 575–577
Heading: Table 22-3 Care Plan for Client with Eating Disorders: Anorexia Nervosa and Bulimia
Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Nutrition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Altered nutrition less than body requirements is not the priority at this time.
Altered social interaction is not the priority at this time.
Impaired verbal communication is not the priority at this time.
The nurse should determine that once the client has been medically cleared, the
diagnosis of altered family process should take priority. Clients diagnosed with
anorexia nervosa have a need to control and feel in charge of their own treatment
choices. Behavioral-modification therapy allows the client to maintain control of
eating.
CON: Nutrition
MULTIPLE RESPONSE
11.
ANS: 1, 2
Chapter: Chapter 0, Eating Disorders
Objective: Discuss various modalities relevant to treatment of eating disorders.
Page: 585
Heading: Treatment Modalities > Psychopharmacology
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1.
2.
3.
Feedback
The nurse should identify that topiramate is the drug of choice when treating binge
eating with a diagnosis of obesity. Topiramate is an anticonvulsant that produces a
significant decline in binge frequency and reduction in body weight.
The nurse should identify that topiramate is the drug of choice when treating
bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an
anticonvulsant that produces a significant decline in binge frequency and reduction
in body weight.
Topiramate (Topamax) is not the drug of choice for weight loss with a diagnosis of
anorexia nervosa.
1.
2.
3.
4.
5.
Feedback
The nurse should identify that topiramate is the drug of choice when treating binge
eating with a diagnosis of obesity. Topiramate is an anticonvulsant that produces a
significant decline in binge frequency and reduction in body weight.
The nurse should identify that topiramate is the drug of choice when treating
bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an
anticonvulsant that produces a significant decline in binge frequency and reduction
in body weight.
Topiramate (Topamax) is not the drug of choice for weight loss with a diagnosis of
anorexia nervosa.
Topiramate (Topamax) is not the drug of choice for amenorrhea with a diagnosis
of anorexia nervosa.
Topiramate (Topamax) is not the drug of choice for emaciation with a diagnosis of
bulimia nervosa.
PTS: 1
CON: Nutrition
12.
ANS: 1, 3, 5
Chapter: Chapter 0, Eating Disorders
Objective: Identify and differentiate among several eating disorders.
Page: 571
Heading: Box 22-3 Diagnostic Criteria for Binge Eating Disorder
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
According to the DSM-5 criteria for the diagnosis of binge-eating disorder, binge
eating should not occur exclusively during the course of anorexia nervosa or
bulimia nervosa.
This statement regarding binge eating is accurate, indicating that teaching has been
effective.
The new time frame criteria in the DSM-5 states that binge eating must occur, on
average, at least once a week for three months not two days a week for six months.
This statement indicates that teaching has been effective.
The DSM-5 criteria states that distress regarding binge eating would be present.
PTS: 1
CON: Nutrition
COMPLETION
13.
ANS:
anorexia nervosa
Chapter: Chapter 0, Eating Disorders
Objective: Identify and differentiate among several eating disorders.
Page: 569
Heading: Application of the Nursing Process > Background Assessment Data: Anorexia Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback: Anorexia nervosa is characterized by a morbid fear of obesity. Symptoms include
gross distortion of body image, preoccupation with food, and refusal to eat.
PTS: 1
CON: Nutrition
14.
ANS:
bingeing
Chapter: Chapter 0, Eating Disorders
Objective: Identify and differentiate among several eating disorders.
Page: 569
Heading: Application of the Nursing Process > Background Assessment Data: Bulimia Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback: The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food
over a short period of time is termed bingeing. Bingeing is a classic symptom of the eating
disorder defined as bulimia nervosa.
PTS: 1
CON: Nutrition
15.
ANS:
purging
Chapter: Chapter 0, Eating Disorders
Objective: Identify and differentiate among several eating disorders.
Page: 569–570
Heading: Application of the Nursing Process > Background Assessment Data: Bulimia Nervosa
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback: To rid the body of excessive calories, a client diagnosed with bulimia nervosa may
engage in purging behaviors, which include self-induced vomiting or the misuse of laxatives,
diuretics, or enemas. In addition to these behaviors, other inappropriate compensatory behaviors,
such as fasting or excessive exercise, may be noted.
PTS: 1
CON: Nutrition
Chapter 31. Personality Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
During an assessment interview, a client diagnosed with antisocial personality
disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response
to this behavior?
1.
“You are very disrespectful. You need to learn to control yourself.”
2.
“I understand that you are angry, but this behavior will not be tolerated.”
3.
“What behaviors could you modify to improve this situation?”
4.
“What antipersonality disorder medications have helped you in the past?”
____ 2.
At 11 p.m. a client diagnosed with antisocial personality disorder demands to
phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10
p.m. Which nursing response is most appropriate?
1.
“Go ahead and use the phone. I know this pending divorce is stressful.”
2.
“You know better than to break the rules. I’m surprised at you.”
3.
“It is after the 10 p.m. phone curfew. You will be able to call tomorrow.”
4.
“A divorce shouldn’t be considered until you have had a good night’s sleep.”
____ 3.
A client diagnosed with paranoid personality disorder becomes violent on a unit.
Which nursing intervention is most appropriate?
1.
Provide objective evidence that reasons for violence are unwarranted.
2.
Initially restrain the client to maintain safety.
3.
Use clear, calm statements and a confident physical stance.
4.
Empathize with the client’s paranoid perceptions.
____ 4.
A client diagnosed with borderline personality disorder brings up a conflict with
the staff in a community meeting and develops a following of clients who unreasonably demand
modification of unit rules. How can the nursing staff best handle this situation?
1.
Allow the clients to apply the democratic process when developing unit rules.
2.
Maintain consistency of care by open communication to avoid staff manipulation.
3.
Allow the client spokesman to verbalize concerns during a unit staff meeting.
4.
Maintain unit order by the application of autocratic leadership.
1.
2.
3.
4.
Allow the clients to apply the democratic process when developing unit rules.
Maintain consistency of care by open communication to avoid staff manipulation.
Allow the client spokesman to verbalize concerns during a unit staff meeting.
Maintain unit order by the application of autocratic leadership.
____ 5.
Which nursing approach should be used to maintain a therapeutic relationship
with a client diagnosed with borderline personality disorder (BPD)?
1.
Being firm, consistent, and empathic, while addressing specific client behaviors
2.
Promoting client self-expression by implementing laissez-faire leadership
3.
Using authoritative leadership to help clients learn to conform to society norms
4.
Overlooking inappropriate behaviors to avoid providing secondary gains
____ 6.
Which adult client should a nurse identify as exhibiting the characteristics of a
dependent personality disorder?
1.
A physically healthy client who is dependent on meeting social needs by contact
with 15 cats.
2.
A physically healthy client who has a history of depending on intense relationships
to meet basic needs.
3.
A physically healthy client who lives with parents and depends on public
transportation.
4.
A physically healthy client who is serious, inflexible, perfectionistic, lacks
spontaneity, and depends on rules to provide security.
____ 7.
A client expresses low self-worth, has much difficulty making decisions, avoids
positions of responsibility, and has a behavioral pattern of “suffering” in silence. Which
statement best explains the etiology of this client’s personality disorder?
1.
Childhood nurturance was provided from many sources, and independent behaviors
were encouraged.
2.
Childhood nurturance was provided exclusively from one source, and independent
behaviors were discouraged.
3.
Childhood nurturance was provided exclusively from one source, and independent
behaviors were encouraged.
4.
Childhood nurturance was provided from many sources, and independent behaviors
were discouraged.
____ 8.
Family members of a client ask the nurse to explain the difference between
schizoid and avoidant personality disorders. Which is the appropriate nursing response?
1.
Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and
clients diagnosed with schizoid personality disorder prefer to be alone.
2.
Clients diagnosed with schizoid personality disorder exhibit delusions and
hallucinations, while clients diagnosed with avoidant personality disorder do not.
3.
Clients diagnosed with avoidant personality disorder are eccentric, and clients
diagnosed with schizoid personality disorder are dull and vacant.
4.
Clients diagnosed with schizoid personality disorder have a history of psychosis,
while clients diagnosed with avoidant personality disorder remain based in reality.
2.
3.
4.
clients diagnosed with schizoid personality disorder prefer to be alone.
Clients diagnosed with schizoid personality disorder exhibit delusions and
hallucinations, while clients diagnosed with avoidant personality disorder do not.
Clients diagnosed with avoidant personality disorder are eccentric, and clients
diagnosed with schizoid personality disorder are dull and vacant.
Clients diagnosed with schizoid personality disorder have a history of psychosis,
while clients diagnosed with avoidant personality disorder remain based in reality.
____ 9.
Which nursing diagnosis should a nurse identify as appropriate when working
with a client diagnosed with schizoid personality disorder?
1.
Altered thought processes R/T increased stress
2.
Risk for suicide R/T loneliness
3.
Risk for violence: directed toward others R/T paranoid thinking
4.
Social isolation R/T inability to relate to others
____ 10.
Looking at a slightly bleeding paper cut, the client screams, “Somebody help me
quick! I’m bleeding. Call 911!” A nurse should identify this behavior as characteristic of which
personality disorder?
1.
Schizoid personality disorder
2.
Obsessive-compulsive personality disorder
3.
Histrionic personality disorder
4.
Paranoid personality disorder
____ 11.
When planning care for a client diagnosed with borderline personality disorder,
which self-harm behavior should a nurse expect the client to exhibit?
1.
The use of highly lethal methods to commit suicide
2.
The use of suicidal gestures to elicit a rescue response from others
3.
The use of isolation and starvation as suicidal methods
4.
The use of self-mutilation to decrease endorphins in the body
____ 12.
A nurse tells a client that the nursing staff will start alternating weekend shifts.
Which response should a nurse identify as characteristic of clients diagnosed with obsessivecompulsive personality disorder?
1.
“You really don’t have to go by that schedule. I’d just stay home sick.”
2.
“There has got to be a hidden agenda behind this schedule change.”
3.
“Who do you think you are? I expect to interact with the same nurse every
Saturday.”
4.
“You can’t make these kinds of changes! Isn’t there a rule that governs this
decision?”
____ 13.
Which reaction to a compliment from another client should a nurse identify as a
typical response from a client diagnosed with avoidant personality disorder?
1.
Interpreting the compliment as a secret code used to increase personal power
2.
Feeling the compliment was well deserved
3.
Being grateful for the compliment but fearing later rejection and humiliation
4.
Wondering what deep meaning and purpose is attached to the compliment
1.
2.
3.
4.
Interpreting the compliment as a secret code used to increase personal power
Feeling the compliment was well deserved
Being grateful for the compliment but fearing later rejection and humiliation
Wondering what deep meaning and purpose is attached to the compliment
____ 14.
Which factors differentiate a client diagnosed with social phobia from a client
diagnosed with schizoid personality disorder?
1.
Clients diagnosed with social phobia are treated with cognitive behavioral therapy,
whereas clients diagnosed with schizoid personality disorder need medications.
2.
Clients diagnosed with schizoid personality disorder experience anxiety only in
social settings, whereas clients diagnosed with social phobia experience generalized
anxiety.
3.
Clients diagnosed with social phobia avoid attending birthday parties, whereas
clients diagnosed with schizoid personality disorder would isolate self on a
continual basis.
4.
Clients diagnosed with schizoid personality disorder avoid attending birthday
parties, whereas clients diagnosed with social phobia would isolate self on a
continual basis.
____ 15.
Which client symptoms should lead a nurse to suspect a diagnosis of obsessivecompulsive personality disorder?
1.
The client experiences unwanted, intrusive, and persistent thoughts.
2.
The client experiences unwanted, repetitive behavior patterns.
3.
The client experiences inflexibility and lack of spontaneity when dealing with
others.
4.
The client experiences obsessive thoughts that are externally imposed.
____ 16.
Which client is a nurse most likely to admit to an inpatient facility for selfdestructive behaviors?
1.
A client diagnosed with antisocial personality disorder.
2.
A client diagnosed with borderline personality disorder.
3.
A client diagnosed with schizoid personality disorder.
4.
A client diagnosed with paranoid personality disorder.
____ 17.
When planning care for clients diagnosed with personality disorders, what should
be the goal of treatment?
1.
To stabilize the client’s pathology by using the correct combination of psychotropic
medications
2.
To change the characteristics of the dysfunctional personality
3.
To reduce personality trait inflexibility that interferes with functioning and
relationships
4.
To decrease the prevalence of neurotransmitters at receptor sites
1.
2.
3.
4.
To stabilize the client’s pathology by using the correct combination of psychotropic
medications
To change the characteristics of the dysfunctional personality
To reduce personality trait inflexibility that interferes with functioning and
relationships
To decrease the prevalence of neurotransmitters at receptor sites
____ 18.
Which client situation would reflect the impulsive behavior that is commonly
associated with borderline personality disorder?
1.
As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm and
whispers, “The night nurse is evil. You have to stay.”
2.
As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm and
states, “I will be up all night if you don’t stay with me.”
3.
As the day-shift nurse leaves the unit, the client suddenly hugs the nurse’s arm,
yelling, “Please don’t go! I can’t sleep without you being here.”
4.
As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody
arm and states, “I cut myself because you are leaving me.”
____ 19.
Which nursing diagnosis should be prioritized when providing nursing care to a
client diagnosed with paranoid personality disorder?
1.
Risk for violence: directed toward others R/T paranoid thinking
2.
Risk for suicide R/T altered thought
3.
Altered sensory perception R/T increased levels of anxiety
4.
Social isolation R/T inability to relate to others
____ 20.
From a behavioral perspective, which nursing intervention is appropriate when
caring for a client diagnosed with borderline personality disorder?
1.
Seclude the client when inappropriate behaviors are exhibited.
2.
Contract with the client to reinforce positive behaviors with unit privileges.
3.
Teach the purpose of anti-anxiety medications to improve medication compliance.
4.
Encourage the client to journal feelings to improve awareness of abandonment
issues.
____ 21.
A highly emotional client presents at an outpatient clinic appointment and states,
“My dead husband returned to me during a séance.” Which personality disorder should a nurse
associate with this behavior?
1.
Obsessive-compulsive personality disorder
2.
Schizotypal personality disorder
3.
Narcissistic personality disorder
4.
Borderline personality disorder
____ 22.
A nursing instructor is teaching students about clients diagnosed with histrionic
personality disorder and the quality of their relationships. Which student statement indicates that
learning has occurred?
1.
“Their dramatic style tends to make their interpersonal relationships quite
interesting and fulfilling.”
2.
“Their interpersonal relationships tend to be shallow and fleeting, serving their
dependency needs.”
3.
“They tend to develop few relationships because they are strongly independent but
generally maintain deep affection.”
4.
“They pay particular attention to details, which can interfere with the development
of relationships.”
____ 23.
During an interview, which client statement should indicate to a nurse a potential
diagnosis of schizotypal personality disorder?
1.
“I don’t have a problem. My family is inflexible, and my relatives are out to get
me.”
2.
“I am so excited about working with you. Have you noticed my new nail polish,
‘Ruby Red Roses’?”
3.
“I spend all my time tending my bees. I know a whole lot of information about
bees.”
4.
“I am getting a message from the beyond that we have been involved with each
other in a previous life.”
____ 24.
Which nursing diagnosis should be prioritized when providing nursing care to a
client diagnosed with avoidant personality disorder?
1.
Risk for violence: directed toward others R/T paranoid thinking
2.
Risk for suicide R/T altered thought
3.
Altered sensory perception R/T increased levels of anxiety
4.
Social isolation R/T inability to relate to others
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 25.
A nurse is admitting a client with a new diagnosis of a personality disorder.
Which of the following would make the nurse question this diagnosis? (Select all that apply.)
1.
The client has been diagnosed with sickle cell anemia.
2.
The client has an inflated self-appraisal and feels a sense of entitlement.
3.
The client has a history of a substance use disorder.
4.
The client is odd and eccentric but not delusional.
5.
The client has an intellectual developmental disorder.
____ 26.
Which statements represent positive outcomes for clients diagnosed with
narcissistic personality disorder? (Select all that apply.)
1.
The client will relate one empathetic statement to another client in group by day
two.
2.
The client will identify one personal limitation by day one.
3.
The client will acknowledge one strength that another client possesses by day two.
4.
The client will list four personal strengths by day three.
5.
The client will list two lifetime achievements by discharge.
____ 27.
A nurse is caring for a client diagnosed with antisocial personality disorder.
Which factors should the nurse consider when planning this client’s care? (Select all that apply.)
1.
This client has personality traits that are deeply ingrained and difficult to modify.
2.
This client needs medication to treat the underlying physiological pathology.
3.
This client uses manipulation, making the implementation of treatment problematic.
4.
This client has poor impulse control that hinders compliance with a plan of care.
5.
This client is likely to have secondary diagnoses of substance abuse and depression.
____ 28.
A client is being assessed for antisocial personality disorder. According to the
DSM-5, which of the following symptoms must the client meet in order to be assigned this
diagnosis? (Select all that apply.)
1.
Ego-centrism and goal setting based on personal gratification.
2.
Incapacity for mutually intimate relationships.
3.
Frequent feelings of being down, miserable, or hopeless.
4.
Disregard for and failure to honor financial and other obligations.
5.
Intense feelings of nervousness, tenseness, or panic.
Completion
Complete each statement.
29.
_______________________ personality disorder is characterized by a profound
defect in the ability to form personal relationships or to respond to others in any meaningful
emotional way.
30.
_____________________ personality disorder is characterized by colorful,
dramatic, and extroverted behavior in excitable, emotional people.
31.
________________________________ personality disorder is characterized by a
pervasive and excessive need to be taken care of that leads to submissive and clinging behavior
and fears of separation.
32.
_____________________ personality disorder is a pervasive distrust and
suspiciousness of others, such that their motives are interpreted as malevolent.
Chapter 0: Personality Disorders
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 613–614
Heading: Planning and Implementation > Risk for Other-Directed Violence > Interventions
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement may escalate the client’s behavior.
The appropriate nursing response is to reflect the client’s feeling while setting firm
limits on behavior. Clients diagnosed with antisocial personality disorder have a
low tolerance for frustration, see themselves as victims, and use projection as a
primary ego defense mechanism.
The nurse should set limits on the client’s behavior.
This statement is not therapeutic to the client.
CON: Cognition
2.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 613–614
Heading: Planning and Implementation > Risk for Other-Directed Violence > Interventions
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should remain consistent with the unit rules.
This statement may escalate the client’s behavior.
The most appropriate response by the staff is to restate the unit rules in a calm,
assertive manner. The nurse can encourage the client to verbalize frustration while
maintaining an accepting attitude. The nurse may also help the client to identify
the true source of frustration.
This statement is not therapeutic to the client.
1
2
3
4
PTS: 1
Feedback
The nurse should remain consistent with the unit rules.
This statement may escalate the client’s behavior.
The most appropriate response by the staff is to restate the unit rules in a calm,
assertive manner. The nurse can encourage the client to verbalize frustration while
maintaining an accepting attitude. The nurse may also help the client to identify
the true source of frustration.
This statement is not therapeutic to the client.
CON: Cognition
3.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 593
Heading: Types of Personality Disorders > Paranoid Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This approach may not be effective with this client at this time, because the
paranoid client does not accept responsibility for actions.
This approach may escalate the client’s behavior, and increase feelings of fear and
mistrust.
The most appropriate nursing intervention is to use clear, calm statements and to
assume a confident physical stance. A calm attitude provides the client with a
feeling of safety and security.
The nurse should present reality at all times.
CON: Cognition
4.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with borderline
personality disorder and antisocial personality disorder.
Page: 605–608
Heading: Table 23-3 Care Plan for the Client With Borderline Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nursing staff should maintain consistency and maintain authority.
The nursing staff can best handle this situation by maintaining consistency of care
by open communication to avoid staff manipulation. Clients with borderline
personality disorder can exhibit negative patterns of interaction, such as clinging
and distancing, splitting, manipulation, and self-destructive behaviors.
This approach does not best handle the situation.
The nursing staff should maintain consistency and order.
CON: Cognition
5.
ANS: 1
Chapter: Chapter 0, Personality Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with borderline
personality disorder and antisocial personality disorder.
Page: 605–608
Heading: Table 23-3 Care Plan for the Client With Borderline Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The best nursing approach when working with a client diagnosed with borderline
personality disorder is to be firm, consistent, and empathetic while addressing
specific client behaviors. Individuals with borderline personality disorder always
seem to be in a state of crisis and can often have negative patterns of interaction,
such as manipulation and splitting.
This type of leadership style would not be therapeutic to the client with BPD.
The best approach is a firm, consistent and empathetic approach to client needs.
These actions would not be therapeutic to the client.
CON: Cognition
6.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 599
Heading: Types of Personality Disorders > Dependent Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Having contact with cats or other animals is not characteristic of a client with
dependent personality disorder.
Using relationships to meet basic needs is not characteristic of a client with
dependent personality disorder.
A physically healthy adult client who lives with parents and depends on public
transportation exhibits signs of dependent personality disorder. Dependent
personality disorder is characterized by a pervasive and excessive need to be taken
care of that leads to submissive and clinging behaviors.
Having a serious personality is not characteristics of a client with dependent
personality disorder.
CON: Cognition
7.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 599
Heading: Types of Personality Disorders > Dependent Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Nurturance from many sources does not lead to the development of dependent
personality disorder.
The behaviors presented in the question represent symptoms of dependent
personality disorder. Nurturance provided from one source and discouragement of
independent behaviors can contribute to the development of this personality
disorder. Dependent behaviors may be rewarded by a parent who is overprotective
and discourages autonomy.
Encouragement of independent behaviors does not lead to dependent personality
disorder.
This scenario does not lead to dependent personality disorder.
PTS: 1
CON: Cognition
8.
ANS: 1
Chapter:
, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 594, 598
Heading: Types of Personality Disorders > Schizoid Personality Disorder, Avoidant
Personality Disorder
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
Feedback
1
The nurse should educate the family that clients diagnosed with avoidant
personality disorder desire intimacy but fear it, while clients diagnosed with
schizoid personality disorder prefer to be alone.
2
Schizoid personality disorder is characterized by a profound deficit in the ability to
form personal relationships.
3
Clients diagnosed with schizoid personality disorder may exhibit odd and
eccentric behaviors but not to the extent of psychosis.
4
Clients with schizoid personality disorder do not have a history of psychosis.
PTS: 1
CON: Cognition
9.
ANS: 4
Chapter: Chapter 0, Personality Disorders
Objective: Formulate nursing diagnoses and goals of care for clients with borderline personality
disorder and antisocial personality disorder.
Page: 594
Heading: Box 23-2 Diagnostic Criteria for Schizoid Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Altered thought processes R/T increased stress would not be an appropriate
diagnosis.
Risk for suicide R/T loneliness would not be an appropriate diagnosis.
Risk for violence: directed toward others R/T paranoid thinking would not be an
appropriate diagnosis.
An appropriate nursing diagnosis when working with a client diagnosed with
schizoid personality disorder is social isolation R/T inability to relate to others.
Clients diagnosed with schizoid personality disorder appear cold, aloof, and
indifferent to others. They prefer to work in isolation and are not sociable.
1
2
3
4
PTS: 1
Feedback
Altered thought processes R/T increased stress would not be an appropriate
diagnosis.
Risk for suicide R/T loneliness would not be an appropriate diagnosis.
Risk for violence: directed toward others R/T paranoid thinking would not be an
appropriate diagnosis.
An appropriate nursing diagnosis when working with a client diagnosed with
schizoid personality disorder is social isolation R/T inability to relate to others.
Clients diagnosed with schizoid personality disorder appear cold, aloof, and
indifferent to others. They prefer to work in isolation and are not sociable.
CON: Cognition
10.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 596
Heading: Types of Personality Disorders > Histrionic Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Clients with schizoid personality disorder have a difficult time forming personal
relationships.
Clients with obsessive-compulsive disorder perform ritualistic behavior.
The nurse should identify this behavior as characteristic of histrionic personality
disorder. Individuals with this disorder tend to be self-dramatizing, attention
seeking, over-gregarious, and seductive.
Clients with paranoid personality disorder have mistrust and are suspicious of
others.
CON: Cognition
11.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Describe symptomatology associated with borderline personality disorder and
antisocial personality disorder, and use these date in client assessment.
Page: 601
Heading: Box 23-9 Diagnostic Criteria for BPD
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Using highly lethal methods of suicide are not typical of clients with borderline
personality disorders.
The nurse should expect that a client diagnosed with borderline personality
disorder may use suicidal gestures to elicit a rescue response from others.
Repetitive, self-mutilating behaviors are common in borderline personality
disorders that result from feelings of abandonment following separation from
significant others.
The use of isolation and starvation is not typical of clients with borderline
personality disorders.
Self-mutilation is not typical of clients with borderline personality disorders.
CON: Cognition
12.
ANS: 4
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 599–600
Heading: Types of Personality Disorder > Obsessive-Compulsive Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The statement, “You really don’t have to go by that schedule. I’d just stay home
sick,” is not typical of the client with obsessive-compulsive disorder
The statement, “There has got to be a hidden agenda behind this schedule change,”
is not typical of the client with obsessive-compulsive disorder
The statement, “Who do you think you are? I expect to interact with the same
nurse every Saturday,” is not typical of the client with obsessive-compulsive
disorder.
The nurse should identify that a client with obsessive-compulsive personality
disorder would have a difficult time accepting changes. This disorder is
characterized by inflexibility and lack of spontaneity. Individuals with this
disorder are very serious, formal, over-disciplined, perfectionistic, and
preoccupied with rules.
CON: Cognition
13.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 598
Heading: Types of Personality Disorders > Avoidant Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Interpreting the compliment as a secret code used to increase personal power is not
a typical response for this client.
Feeling the compliment was well deserved is not a typical response for this client.
The nurse should identify that a client diagnosed with avoidant personality
disorder would be grateful for the compliment but would fear later rejection and
humiliation. Individuals diagnosed with avoidant personality disorder are
extremely sensitive to rejection and are often awkward and uncomfortable in
social situations.
Wondering what deep meaning and purpose is attached to the compliment is not a
typical response for this client.
CON: Cognition
14.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 594
Heading: Types of Personality Disorders > Schizoid Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
This statement is untrue regarding these disorders.
Clients with schizoid personality disorder experience anxiety in many different
settings.
A client diagnosed with schizoid personality disorder exhibits a profound deficit in
the ability to form personal relationships. Clients diagnosed with schizoid
personality disorder prefer being alone to being with others and avoid social
situations, social contacts, and activities.
Clients with schizoid personality disorder would isolate on a continual basis.
1
2
3
4
PTS: 1
Feedback
This statement is untrue regarding these disorders.
Clients with schizoid personality disorder experience anxiety in many different
settings.
A client diagnosed with schizoid personality disorder exhibits a profound deficit in
the ability to form personal relationships. Clients diagnosed with schizoid
personality disorder prefer being alone to being with others and avoid social
situations, social contacts, and activities.
Clients with schizoid personality disorder would isolate on a continual basis.
CON: Cognition
15.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 599–600
Heading: Types of Personality Disorders > Obsessive-Compulsive Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Experiencing unwanted and intrusive thoughts is not consistent with the diagnosis
of obsessive-compulsive personality disorder.
Unwanted, repetitive behaviors is not consistent with a diagnosis of obsessivecompulsive personality disorder.
The nurse should suspect a diagnosis of obsessive-compulsive personality disorder
when a client experiences inflexibility and lack of spontaneity. Individuals with
this disorder are very serious, formal, and have difficulty expressing emotions.
They are perfectionistic and preoccupied with rules.
Externally imposed obsessive thoughts are not consistent with a diagnosis of
obsessive-compulsive personality disorder.
CON: Cognition
16.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 602–603
Heading: Application of the Nursing Process > BPD (Background Assessment Data) > Patterns
of Interaction > Self-Destructive Behaviors
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
A client diagnosed with antisocial personality disorder would not likely admit to
an inpatient facility for self-destructive behaviors.
The nurse should expect that a client diagnosed with borderline personality
disorder would be most likely to be admitted to an inpatient facility for selfdestructive behaviors. Clients diagnosed with this disorder often exhibit repetitive,
self-mutilating behaviors. Most gestures are designed to elicit a rescue response.
A client diagnosed with schizoid personality disorder would not likely admit to an
inpatient facility for self-destructive behaviors.
A client diagnosed with paranoid personality disorder would not likely admit to an
inpatient facility for self-destructive behaviors.
1
2
3
4
PTS: 1
CON: Cognition
17.
ANS: 3
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 615, 617
Heading: Treatment Modalities
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
There are no psychotropic medications approved specifically for the treatment of
personality disorders.
Personality disorders are often difficult and, in some cases, seem impossible to
treat.
The goal of treatment for clients diagnosed with personality disorders should be to
reduce inflexibility of personality traits that interfere with functioning and
relationships.
Decreasing the prevalence of neurotransmitters at receptor sites is not the goal of
treatment.
1
2
3
4
PTS: 1
18.
CON: Cognition
ANS: 4
Chapter: Chapter 0, Personality Disorders
Objective: Describe symptomatology associated with borderline personality disorder and
antisocial personality disorder, and use these data in client assessment.
Page: 603
Heading: Application of the Nursing Process > BPD (Background Assessment Data) > Patterns
of Interaction
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Stating, “The night nurse is evil. You have to stay,” is not a behavior associated
with a client with borderline personality disorder.
Stating, “I will be up all night if you don’t stay with me,” is not a behavior
associated with a client with borderline personality disorder.
Stating, “Please don’t go! I can’t sleep without you being here.”
The client who states, “I cut myself because you are leaving me” reflects
impulsive behavior that is commonly associated with borderline personality
disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed
with borderline personality disorders that result from feelings of abandonment
following separation from significant others.
CON: Cognition
19.
ANS: 1
Chapter: Chapter 0, Personality Disorders
Objective: Formulate nursing diagnoses and goals of care for clients with borderline personality
disorder and antisocial personality disorder.
Page: 593
Heading: Types of Personality Disorders > Paranoid Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The priority nursing diagnosis for a client diagnosed with paranoid personality
disorder should be risk for violence: directed toward others R/T paranoid thinking.
Clients diagnosed with paranoid personality disorder have a pervasive distrust and
suspiciousness of others that result in a constant threat readiness. They are often
tense and irritable, which increases the likelihood of violent behavior.
Risk for suicide R/T altered thought is not the priority nursing diagnosis.
Altered sensory perception R/T increased levels of anxiety is not the priority
nursing diagnosis.
Social isolation R/T inability to relate to others is not the priority nursing
1
2
3
4
PTS: 1
Feedback
The priority nursing diagnosis for a client diagnosed with paranoid personality
disorder should be risk for violence: directed toward others R/T paranoid thinking.
Clients diagnosed with paranoid personality disorder have a pervasive distrust and
suspiciousness of others that result in a constant threat readiness. They are often
tense and irritable, which increases the likelihood of violent behavior.
Risk for suicide R/T altered thought is not the priority nursing diagnosis.
Altered sensory perception R/T increased levels of anxiety is not the priority
nursing diagnosis.
Social isolation R/T inability to relate to others is not the priority nursing
diagnosis.
CON: Cognition
20.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Describe appropriate nursing interventions for behaviors associated with borderline
personality disorder and antisocial personality disorder.
Page: 605–608
Heading: Table 23-3 Care Plan for the Client with Borderline Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client should not be secluded, as this may trigger more inappropriate
behaviors and lead to mistrust of health care staff.
The most appropriate nursing intervention from a behavioral perspective is to
contract with the client to reinforce positive behaviors with unit privileges.
Behavioral strategies offer reinforcement for positive change.
Teaching the client about medications is important, but reinforcing behaviors is the
most appropriate.
Encouraging the client to journal feelings is not the most appropriate nursing
intervention.
CON: Cognition
21.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 595
Heading: Types of Personality Disorders > Schizotypal Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This type of behavior is not typical of clients with obsessive-compulsive disorder.
The nurse should associate schizotypal personality disorder with this behavior. The
behaviors of people diagnosed with schizotypal personality disorder are odd and
eccentric but do not decompensate to the level of schizophrenia.
This type of behavior is not typical of clients with narcissistic personality disorder.
This type of behavior is not typical of clients with borderline personality disorder.
CON: Cognition
22.
ANS: 2
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 596
Heading: Types of Personality Disorders > Histrionic Personality Disorder
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement indicates that further education is necessary.
The instructor should evaluate that learning has occurred when the student
describes clients diagnosed with histrionic personality disorder as having
relationships that are shallow and fleeting. These types of relationships tend to
serve their dependency needs.
This statement indicates a need for further teaching.
This statement indicates that learning has not occurred.
CON: Cognition
23.
ANS: 4
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders
Page: 595
Heading: Types of Personality Disorders > Schizotypal Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Stating, “I don’t have a problem. My family is inflexible, and relatives are out to
get me,” is not typical of schizotypal personality disorder.
Stating, “I am so excited about working with you. Have you noticed my new nail
polish, ‘Ruby Red Roses’?” is not typical of schizotypal personality disorder.
“I spend all my time tending my bees. I know a whole lot of information about
bees,” is not typical of schizotypal personality disorder.
The nurse should assess that a client who states that he or she is getting a message
from beyond indicates a potential diagnosis of schizotypal personality disorder.
Individuals with schizotypal personality disorder are aloof and isolated and behave
in a bland and apathetic manner. The person experiences magical thinking, ideas of
reference, illusions, and depersonalization as part of daily life.
CON: Cognition
24.
ANS: 4
Chapter: Chapter 0, Personality Disorders
Objective: Formulate nursing diagnoses and goals of care for clients with borderline personality
disorder and antisocial personality disorder.
Page: 598–599
Heading: Types of Personality Disorders > Avoidant Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Risk for violence: directed toward others R/T paranoid thinking is not the priority
nursing diagnosis.
Risk for suicide R/T altered thought is not the priority nursing diagnosis.
Altered sensory perception R/T increased levels of anxiety is not the priority
nursing diagnosis.
The priority nursing diagnosis for a client diagnosed with avoidant personality
disorder should be social isolation R/T inability to relate to others. These clients
avoid close or romantic relationships, interpersonal attachments, and intimate
sexual relationships.
1
2
3
4
PTS: 1
Risk for violence: directed toward others R/T paranoid thinking is not the priority
nursing diagnosis.
Risk for suicide R/T altered thought is not the priority nursing diagnosis.
Altered sensory perception R/T increased levels of anxiety is not the priority
nursing diagnosis.
The priority nursing diagnosis for a client diagnosed with avoidant personality
disorder should be social isolation R/T inability to relate to others. These clients
avoid close or romantic relationships, interpersonal attachments, and intimate
sexual relationships.
CON: Cognition
MULTIPLE RESPONSE
25.
ANS: 1, 3, 5
Chapter: Chapter 0, Personality Disorders
Objective: Formulate nursing diagnoses and goals of care for clients with borderline personality
disorder and antisocial personality disorder.
Page: 591
Heading: Introduction
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The DSM-5 states that impairments in personality functioning and the individual’s
personality trait expression are not better understood as normative for the
individual’s developmental stage or sociocultural environment. The impairments
in personality functioning and the individual’s personality trait expression are not
solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma). The nurse
would question the diagnosis of a personality disorder in a client with sickle cell
anemia.
This nurse would not question this diagnosis.
The DSM-5 states that impairments in personality functioning and the individual’s
personality trait expression are not better understood as normative for the
individual’s developmental stage or sociocultural environment. The impairments
in personality functioning and the individual’s personality trait expression are not
solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma). The nurse
would question the diagnosis of a personality disorder in a client with substance
use disorder.
The nurse would not likely question this diagnosis, due to the client’s behavior.
The DSM-5 states that impairments in personality functioning and the individual’s
personality trait expression are not better understood as normative for the
individual’s developmental stage or sociocultural environment. The impairments
in personality functioning and the individual’s personality trait expression are not
solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma). The nurse
would question the diagnosis of a personality disorder in a client with intellectual
developmental disorder.
4.
5.
PTS: 1
solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma). The nurse
would question the diagnosis of a personality disorder in a client with substance
use disorder.
The nurse would not likely question this diagnosis, due to the client’s behavior.
The DSM-5 states that impairments in personality functioning and the individual’s
personality trait expression are not better understood as normative for the
individual’s developmental stage or sociocultural environment. The impairments
in personality functioning and the individual’s personality trait expression are not
solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma). The nurse
would question the diagnosis of a personality disorder in a client with intellectual
developmental disorder.
CON: Cognition
26.
ANS: 1, 2, 3
Chapter: Chapter 0, Personality Disorders
Objective: Discuss various modalities relevant to treatment of personality disorders.
Page: 597
Heading: Types of Personality Disorders > Narcissistic Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should determine that appropriate outcomes for a client diagnosed with
narcissistic personality disorder include relating empathetic statements to other
clients.
The nurse should determine that appropriate outcomes for a client diagnosed with
narcissistic personality disorder include identifying one personal limitation.
The nurse should determine that appropriate outcomes for a client diagnosed with
narcissistic personality disorder include acknowledging one strength in another
client.
Narcissistic personality disorder is characterized by an exaggerated sense of selfworth, a lack of empathy, and exploitation of others.
Asking the client to discussed lifetime achievements is not therapeutic due to the
inflated sense of self.
CON: Cognition
27.
ANS: 1, 3, 4, 5
Chapter: Chapter 0, Personality Disorders
Objective: Discuss various modalities relevant to treatment of personality disorders.
Page: 611
Heading: Application of the Nursing Process > Antisocial Personality Disorder (Background
Assessment Data) > Clinical Picture
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should consider that individuals diagnosed with antisocial personality
disorders have deeply ingrained personality traits.
This client does not require medication to treat this disorder.
The nurse should consider that individuals diagnosed with antisocial personality
disorders use manipulation.
The nurse should consider that individuals diagnosed with antisocial personality
disorders have poor impulse control.
The nurse should consider that individuals diagnosed with antisocial personality
disorders often have secondary diagnoses of substance abuse or depression.
CON: Cognition
28.
ANS: 1, 2, 4
Chapter: Chapter 0, Personality Disorders
Objective: Discuss various modalities relevant to treatment of personality disorders.
Page: 611
Heading: Box 23-10 Diagnostic Criteria for Antisocial Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
According to the DSM-5, the client must exhibit egocentrism and goal setting
based on personal gratification.
The client does not need to have an incapacity for mutually intimate relationships.
According to the DSM-5, the client must frequently feel down and hopeless.
The client needs to have a disregard for and failure to honor financial and other
obligations.
The client does not need to experience intense feelings of nervousness, tenseness,
or panic.
PTS: 1
CON: Cognition
COMPLETION
29.
ANS:
Schizoid
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 594
Heading: Types of Personality Disorders > Schizoid Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Persons diagnosed with schizoid personality disorder have a profound defect in the
ability to form personal relationships or to respond to others in any meaningful emotional way.
These individuals display a life-long pattern of social withdrawal, and their discomfort with
human interaction is apparent.
PTS: 1
CON: Cognition
30.
ANS:
Histrionic
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 596
Heading: Types of Personality Disorders > Histrionic Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Histrionic personality disorder is characterized by colorful, dramatic, and extraverted
behavior in excitable, emotional people. They have difficulty maintaining long-lasting
relationships, although they require constant affirmation of approval and acceptance from others.
PTS: 1
CON: Cognition
31.
Dependent
ANS:
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 599
Heading: Types of Personality Disorders > Dependent Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Dependent personality disorder is characterized by a pervasive and excessive need to
be taken care of that leads to submissive and clinging behavior and fears of separation. These
characteristics are evident in the tendency to allow others to make decisions, to feel helpless
when alone, to act submissively, to subordinate needs to others, to tolerate mistreatment by
others, to demean oneself to gain acceptance, and to fail to function adequately in situations that
require assertive or dominant behavior.
PTS: 1
CON: Cognition
32.
ANS:
Paranoid
Chapter: Chapter 0, Personality Disorders
Objective: Identify various types of personality disorders.
Page: 593
Heading: Types of Personality Disorders > Paranoid Personality Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: Paranoid personality disorder is a pervasive distrust and suspiciousness of others such
that their motives are interpreted as malevolent. This disorder begins in early adulthood and
presents in a variety of contexts.
PTS: 1
CON: Cognition
Chapter 32. Children and Adolescents
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
Which developmental characteristic should a nurse identify as typical of a client
diagnosed with severe intellectual developmental disorder (IDD)?
1.
The client can perform some self-care activities independently.
2.
The client has more advanced speech development.
3.
Other than possible coordination problems, the client’s psychomotor skills are not
affected.
4.
The client communicates wants and needs by “acting out” behaviors.
____ 2.
Which nursing intervention related to self-care would be most appropriate for a
teenager diagnosed with moderate IDD?
1.
Meeting all of the client’s self-care needs to avoid injury to the client
2.
Providing simple directions and praising client’s independent self-care efforts
3.
Avoid interfering with the client’s self-care efforts in order to promote autonomy
4.
Encouraging family to meet the client’s self-care needs to promote bonding
____ 3.
A child has been diagnosed with autistic spectrum disorder. The distraught mother
cries out, “I’m such a terrible mother. What did I do to cause this?” Which nursing response is
most appropriate?
1.
“Researchers really don’t know what causes autistic spectrum disorder, but the
relationship between autistic disorder and fetal alcohol syndrome is being
explored.”
2.
“Poor parenting doesn’t cause autistic spectrum disorder. Research has shown that
abnormalities in brain structure or function are to blame. This is beyond your
control.”
3.
“Research has shown that the mother appears to play a greater role in the
development of autistic spectrum disorder than the father.”
4.
“Lack of early infant bonding with the mother has shown to be a cause of autistic
spectrum disorder. Did you breastfeed or bottle-feed?”
____ 4.
In planning care for a child diagnosed with autistic spectrum disorder, which
would be a realistic client outcome?
1.
The client will communicate all needs verbally by discharge.
2.
The client will participate with peers in a team sport by day four.
3.
The client will establish trust with at least one caregiver by day five.
4.
The client will perform most self-care tasks independently.
____ 5.
After an adolescent diagnosed with attention deficit/hyperactivity disorder
(ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10
pounds in a 2-month period. What is the best explanation for this weight loss?
1.
2.
3.
4.
The pharmacological action of Ritalin causes a decrease in appetite.
Hyperactivity seen in ADHD causes increased caloric expenditure.
Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased.
Increased ability to concentrate allows the client to focus on activities rather than
food.
____ 6.
A nurse assesses an adolescent client diagnosed with conduct disorder who, at the
age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment
data?
1.
Childhood-onset conduct disorder is more severe than the adolescent-onset type,
and these individuals likely develop antisocial personality disorder in adulthood.
2.
Childhood-onset conduct disorder is caused by a difficult temperament, and the
child is likely to outgrow these behaviors by adulthood.
3.
Childhood-onset conduct disorder is diagnosed only when behaviors emerge before
the age of 5, and, therefore, improvement is likely.
4.
Childhood-onset conduct disorder has no treatment or cure, and children diagnosed
with this disorder are likely to develop progressive oppositional defiant disorder.
____ 7.
Which finding should a nurse expect when assessing a child diagnosed with
separation anxiety disorder?
1.
The child has a history of antisocial behaviors.
2.
The child’s mother is diagnosed with an anxiety disorder.
3.
The child previously had an extroverted temperament.
4.
The child’s mother and father have an inconsistent parenting style.
____ 8.
A child has been recently diagnosed with mild IDD. What information about this
diagnosis should the nurse include when teaching the child’s mother?
1.
Children with mild IDD need constant supervision.
2.
Children with mild IDD develop academic skills up to a sixth-grade level.
3.
Children with mild IDD appear different from their peers.
4.
Children with mild IDD have significant sensory-motor impairment.
____ 9.
A nursing instructor is teaching about the developmental characteristics of clients
diagnosed with moderate IDD. Which student statement indicates that further instruction is
needed?
1.
“These clients can work in a sheltered workshop setting.”
2.
“These clients can perform some personal care activities.”
3.
“These clients may have difficulties relating to peers.”
4.
“These clients can successfully complete elementary school.”
____ 10.
A preschool child is admitted to a psychiatric unit with a diagnosis of autism
spectrum disorder. To help the child feel more secure on the unit, which intervention should a
nurse include in this client’s plan of care?
1.
Encourage and reward peer contact.
2.
Provide consistent caregivers.
3.
Provide a variety of safe daily activities.
4.
Maintain close physical contact throughout the day.
____ 11.
A preschool child diagnosed with autistic spectrum disorder has been engaging in
constant head-banging behavior. Which nursing intervention is appropriate?
1.
Place client in restraints until the aggression subsides.
2.
Sedate the client with neuroleptic medications.
3.
Hold client’s head steady and apply a helmet.
4.
Distract the client with a variety of games and puzzles.
____ 12.
When planning care for a client, which medication classification should a nurse
recognize as effective in the treatment of Tourette’s syndrome?
1.
Neuroleptic medications
2.
Antimanic medications
3.
Tricyclic antidepressant medications
4.
Monoamine oxidase inhibitor medications
____ 13.
Which behavioral approach should a nurse use when caring for children
diagnosed with disruptive behavior disorders?
1.
Involving parents in designing and implementing the treatment process
2.
Reinforcing positive actions to encourage repetition of desirable behaviors
3.
Providing opportunities to learn appropriate peer interactions
4.
Administering psychotropic medications to improve quality of life
____ 14.
A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis
disturbed personal identity. Which outcome would best address this client diagnosis?
1.
The client will name own body parts as separate from others by day five.
2.
The client will establish a means of communicating personal needs by discharge.
3.
The client will initiate social interactions with caregivers by day four.
4.
The client will not harm self or others by discharge.
____ 15.
A nursing instructor presents a case study in which a three-year-old child is in
constant motion and is unable to sit still during story time. She asks a student to evaluate this
child’s behavior. Which student response indicates an appropriate evaluation of the situation?
1.
“This child’s behavior must be evaluated according to developmental norms.”
2.
“This child has symptoms of attention deficit/hyperactivity disorder.”
3.
“This child has symptoms of the early stages of autistic disorder.”
4.
“This child’s behavior indicates possible symptoms of oppositional defiant
disorder.”
____ 16.
A client has an IQ of 47. Which nursing diagnosis best addresses a client problem
associated with this degree of IDD?
1.
Risk for injury R/T self-mutilation
2.
Altered social interaction R/T nonadherence to social convention
3.
Altered verbal communication R/T delusional thinking
4.
Social isolation R/T severely decreased gross motor skills
____ 17.
A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD.
Which information about this medication should the nurse provide to the parents?
1.
If one dose of Ritalin is missed, double the next dose.
2.
Administer Ritalin to the child after breakfast.
3.
Administer Ritalin to the child just prior to bedtime.
4.
A side effect of Ritalin is decreased ability to learn.
____ 18.
Which should be the priority nursing intervention when caring for a child
diagnosed with conduct disorder?
1.
Modify environment to decrease stimulation and provide opportunities for quiet
reflection.
2.
Convey unconditional acceptance and positive regard.
3.
Recognize escalating aggressive behavior and intervene before violence occurs.
4.
Provide immediate positive feedback for appropriate behaviors.
____ 19.
A mother questions the decreased effectiveness of methylphenidate (Ritalin)
prescribed for her child’s ADHD. Which nursing response best addresses the mother’s concern?
1.
“The physician will probably switch from Ritalin to a central nervous system
stimulant.”
2.
“The physician may prescribe an antihistamine with the Ritalin to improve
effectiveness.”
3.
“Your child has probably developed a tolerance to Ritalin and may need a higher
dosage.”
4.
“Your child has developed sensitivity to Ritalin and may be exhibiting an allergy.”
2.
3.
4.
stimulant.”
“The physician may prescribe an antihistamine with the Ritalin to improve
effectiveness.”
“Your child has probably developed a tolerance to Ritalin and may need a higher
dosage.”
“Your child has developed sensitivity to Ritalin and may be exhibiting an allergy.”
____ 20.
After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which
listed symptom would a student nurse recognize?
1.
Arguing and annoying older sibling over the past year
2.
Angry and resentful behavior over a 3-month period
3.
Initiating physical fights for more than 18 months
4.
Arguing with authority figures for more than 6 months
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 21.
Which of the following risk factors, if noted during a family history assessment,
should a nurse associate with the development of IDD? (Select all that apply.)
1.
A family history of Tay-Sachs disease
2.
Childhood meningococcal infection
3.
Deprivation of nurturance and social contact
4.
History of maternal multiple motor and verbal tics
5.
A diagnosis of maternal major depressive disorder
____ 22.
Which of the following findings should a nurse identify that would contribute to a
client’s development of ADHD? (Select all that apply.)
1.
The client’s father was a smoker.
2.
The client had a low birth weight.
3.
The client is lactose intolerant.
4.
The client has a sibling diagnosed with ADHD.
5.
The client has been diagnosed with dyslexia.
Completion
Complete each statement.
23.
The DSM-5 criteria for ODD specifies that: A persistent pattern of angry/irritable
mood, argumentative/defiant behavior, or vindictiveness must be evident and last at least
______________ months.
Answer Section
MULTIPLE CHOICE
1.
ANS: 4
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 629
Heading: Table 24-1 Developmental Characteristics of Intellectual Developmental Disorder by
Degree of Severity
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client would not be able to perform self-care activities independently.
The client will not necessarily have advanced speech development.
Individuals diagnosed with severe IDD require complete supervision and have
minimal verbal skills and poor psychomotor development.
The nurse should identify that a client diagnosed with severe IDD may
communicate wants and needs by “acting out” behaviors. Severe IDD indicates an
IQ between 20 and 34.
CON: Cognition
2.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 630–631
Heading: Table 24-2 Care Plan for the Child with Intellectual Disability
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should allow the client to perform self-care activities independently, but
should intervene when necessary.
Providing simple directions and praise is an appropriate intervention for a teenager
diagnosed with moderate IDD. Individuals with moderate mental retardation can
perform some activities independently and may be capable of academic skill to a
second-grade level.
The nurse should intervene when necessary.
The client’s independence should be encouraged.
1
2
3
4
PTS: 1
Feedback
The nurse should allow the client to perform self-care activities independently, but
should intervene when necessary.
Providing simple directions and praise is an appropriate intervention for a teenager
diagnosed with moderate IDD. Individuals with moderate mental retardation can
perform some activities independently and may be capable of academic skill to a
second-grade level.
The nurse should intervene when necessary.
The client’s independence should be encouraged.
CON: Cognition
3.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 631-633
Heading: Neurodevelopmental Disorder > Autism Spectrum Disorder
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement may place unintentional blame on the mother.
The most appropriate response by the nurse is to explain to the parent that autistic
spectrum disorder is believed to be caused by abnormalities in brain structure or
function, not poor parenting.
This statement is not therapeutic.
This statement is inaccurate and may place unintentional blame on the mother.
CON: Cognition
4.
ANS: 3
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 634-635
Heading: Table 24-3 Care Plan for the Child with Autism Spectrum Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
It may not be realistic for the client to communicate all needs verbally by
discharge.
It may not be realistic for the client to participate in a team sport.
The most realistic client outcome for a child diagnosed with autistic spectrum
disorder is for the client to establish trust with at least one caregiver. Trust should
be evidenced by facial responsiveness and eye contact. This outcome relates to the
nursing diagnosis impaired social interaction.
It may not be realistic for the client to perform self-care tasks independently.
CON: Cognition
5.
ANS: 1
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 637–638
Heading: Figure 24-1 Neurobiology of Attention Deficit/Hyperactivity Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The pharmacological action of Ritalin causes a decrease in appetite, which often
leads to weight loss.
While hyperactivity causes an increased caloric expenditure, it is caused by the use
of Ritalin, with decreases appetite.
Ritalin does not cause nausea.
Methylphenidate is a central nervous symptom stimulant that serves to increase
attention span, control hyperactive behaviors, and improve learning ability.
CON: Cognition
6.
ANS: 1
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 653
Heading: Disruptive Behavior Disorders > Conduct Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should determine that childhood-onset conduct disorder is more severe
than adolescent-onset type. These individuals are likely to develop antisocial
personality disorder in adulthood.
Individuals with this subtype are usually boys and frequently display physical
aggression and have disturbed peer relationships.
Childhood-onset conduct disorder is not diagnosed before the age of 5, but rather
when symptoms emerge.
Childhood-onset conduct disorder has treatment options available.
CON: Cognition
7.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 657–658
Heading: Anxiety Disorders > Separation Anxiety Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not expect a history of antisocial behaviors.
The nurse should expect to find a mother diagnosed with an anxiety disorder when
assessing a child with separation anxiety. Some parents instill anxiety in their
children by being overprotective or by exaggerating dangers. Research studies
speculate that there is a hereditary influence in the development of separation
anxiety disorder.
The nurse would not expect a history of an extroverted temperament.
The nurse would not expect a history of an inconsistent parenting style.
CON: Cognition
8.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 629
Heading: Table 24-1 Developmental Characteristics of Intellectual Developmental Disorder by
Degree of Severity
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The child may not need constant supervision.
The nurse should inform the child’s mother that children with mild IDD develop
academic skills up to a sixth-grade level.
The child may not appear different than peers.
The child may not have a significant sensory-motor impairment.
CON: Cognition
9.
ANS: 4
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 629
Heading: Table 24-1 Developmental Characteristics of Intellectual Developmental Disorder by
Degree of Severity
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
This statement indicates that teaching has been effective.
This statement indicates understanding.
This statement indicates that learning has occurred.
The nursing student needs further instruction about moderate IDD, because
individuals diagnosed with moderate IDD are capable of academic skill up to a
second-grade level. Moderate IDD reflects an IQ range of 35 to 49.
PTS: 1
CON: Cognition
10.
ANS: 2
Chapter: Chapter 24, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 634–635
Heading: Table 24-3 Care Plan for the Child with Autism Spectrum Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Encouraging and rewarding peer contact does not help the child feel more secure.
The nurse should provide consistent caregivers as part of the plan of care for a
child diagnosed with autistic spectrum disorder. Children diagnosed with autistic
spectrum disorder have an inability to trust. Providing consistent caregivers allows
the client to develop trust and a sense of security.
Providing a variety of safe daily activities does not make the child feel more
secure.
Maintain close physical contact throughout the day does not help the child feel
more secure.
CON: Cognition
11.
ANS: 3
Chapter: Chapter 0, Children and Adolescents
Objective: Identify symptomatology and use the information in the assessment of clients with the
aforementioned disorders.
Page: 634–635
Heading: Table 24-3 Care Plan for the Child with Autism Spectrum Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
Feedback
The client should not be placed in restraints as this may cause further agitation or
injury.
Sedating the client is not indicated, and is usually the treatment for Tourette’s
syndrome.
The most appropriate intervention for head banging is to hold the client’s head
steady and apply a helmet. The helmet is the least restrictive intervention and will
serve to protect the client’s head from injury.
1
2
3
4
PTS: 1
Feedback
The client should not be placed in restraints as this may cause further agitation or
injury.
Sedating the client is not indicated, and is usually the treatment for Tourette’s
syndrome.
The most appropriate intervention for head banging is to hold the client’s head
steady and apply a helmet. The helmet is the least restrictive intervention and will
serve to protect the client’s head from injury.
Distraction with games would be ineffective.
CON: Cognition
12.
ANS: 1
Chapter: Chapter 0, Children and Adolescents
Objective: Describe treatment modalities relevant to selected disorders of infancy, childhood,
and adolescence.
Page: 648
Heading: Neurodevelopmental Disorders > Tourette’s Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should recognize that neuroleptic (antipsychotic) medications are
effective in the treatment of Tourette’s syndrome. These medications are used to
reduce the severity of tics and are most effective when combined with
psychosocial therapy.
Antimanic medications are not an appropriate treatment choice.
Tricyclic antidepressant medications are not an appropriate treatment choice.
Monoamine oxidase inhibitor medications are not an appropriate treatment choice.
CON: Cognition
13.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Describe treatment modalities relevant to selected disorders of infancy, childhood,
and adolescence.
Page: 661–662
Heading: General Therapeutic Approaches > Behavior Therapy
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Involving parents is important but not a behavioral approach.
The nurse should reinforce positive actions to encourage repetition of desirable
behaviors when caring for children diagnosed with disruptive behavior disorder.
Behavior therapy is based on the concepts of classical conditioning and operant
conditioning.
Providing opportunities to learn is not a behavioral approach.
Administering medications is not a behavioral approach.
CON: Cognition
14.
ANS: 1
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 634–635
Heading: Table 24-3 Care Plan for the Child with Autism Spectrum Disorder
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
An appropriate outcome for this client is to name own body parts as separate from
others. The nurse should assist the client in the recognition of separateness during
self-care activities, such as dressing and feeding. The long-term goal for disturbed
personal identity is for the client to develop an ego identity.
The client will establish a means of communicating personal needs by discharge
does not address the diagnosis.
The client will initiate social interactions with caregivers by day four does not
address the diagnosis.
The client will not harm self or others by discharge does not address the diagnosis.
CON: Cognition
15.
ANS: 1
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 627
Heading: Introduction
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The student’s evaluation of the situation is appropriate when indicating a need for
the client to be evaluated according to developmental norms. The DSM-5 indicates
that emotional problems exist if the behavioral manifestations are not ageappropriate, deviate from cultural norms, or create deficits or impairments in
adaptive functioning.
Stating “This child has symptoms of attention deficit-hyperactivity disorder” does
not indicate appropriate evaluation.
Stating “This child has symptoms of the early stages of autistic disorder” does not
indicate appropriate evaluation.
Stating “This child’s behavior indicates possible symptoms of oppositional defiant
disorder” does not indicate appropriate evaluation.
CON: Cognition
16.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 629
Heading: Table 24-1 Developmental Characteristics of Intellectual Developmental Disorder by
Degree of Severity
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
Risk for injury R/T self-mutilation is not the best nursing diagnosis.
The appropriate nursing diagnosis associated with this degree of IDD is altered
social interaction R/T nonadherence to social convention. A client with an IQ of 47
would be diagnosed with moderate intellectual developmental disorder and may
also experience some limitations in speech communications.
Altered verbal communication R/T delusional thinking is not the best nursing
diagnosis.
Social isolation R/T severely decreased gross motor skills is not the best nursing
diagnosis.
1
2
3
4
PTS: 1
Risk for injury R/T self-mutilation is not the best nursing diagnosis.
The appropriate nursing diagnosis associated with this degree of IDD is altered
social interaction R/T nonadherence to social convention. A client with an IQ of 47
would be diagnosed with moderate intellectual developmental disorder and may
also experience some limitations in speech communications.
Altered verbal communication R/T delusional thinking is not the best nursing
diagnosis.
Social isolation R/T severely decreased gross motor skills is not the best nursing
diagnosis.
CON: Cognition
17.
ANS: 2
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 637
Heading: Figure 24-1 Neurobiology of Attention Deficit/Hyperactivity Disorder
Integrated Process: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The Ritalin dosage should not be doubled.
The nurse should instruct the parents to administer Ritalin to the child after
breakfast. Ritalin is a central nervous system stimulant and can cause decreased
appetite. Central nervous system stimulants can also temporarily interrupt growth
and development.
Ritalin can cause weight loss and should be given after breakfast.
Ritalin increases ability to concentrate and learn.
CON: Cognition
18.
ANS: 3
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 656–657
Heading: Table 24-8 Care Plan for Child/Adolescent with Conduct Disorder
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
After safety has been established, the nurse can modify environment to decrease
stimulation and provide opportunities for quiet reflection.
After safety has been established, the nurse can convey unconditional acceptance
and positive regard.
The priority nursing intervention when caring for a child diagnosed with conduct
disorder should be to recognize escalating aggressive behavior and to intervene
before violence occurs. This intervention serves to keep the client and others safe,
which is the priority nursing concern.
After safety has been established, the nurse can provide immediate positive
feedback for appropriate behaviors.
CON: Cognition
19.
ANS: 3
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 637–638
Heading: Figure 24-21 Neurobiology of Attention Deficit/Hyperactivity Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Ritalin is a nervous system stimulant, this statement provides false information.
Antihistamines would not improve the effectiveness of Ritalin; this statement
provides false information.
The nurse should explain to the mother that the child has probably developed a
tolerance to Ritalin and may need a higher dosage. Methylphenidate is a central
nervous system stimulant, and tolerance can develop rapidly. Physical and
psychological dependence can also occur.
These are not signs of an allergic reaction to Ritalin.
CON: Cognition
20.
ANS: 4
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 650
Heading: Box 24-5 Diagnostic Criteria for Oppositional Defiant Disorder
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The DSM-5 rules out the diagnosis of ODD when only siblings are involved in
argumentative interactions.
Angry and resentful behavior over more than 6 months, not 3 months, would be
considered a symptom of ODD.
Initiating physical fights is a symptom of conduct disorder, not ODD.
Arguing with authority figures for more than 6 months is listed by the DSM-5 as a
symptom for the diagnosis of ODD.
CON: Cognition
MULTIPLE RESPONSE
21.
ANS: 1, 2, 3
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 627–628
Heading: Neurodevelopmental Disorders > Intellectual Disability (Intellectual Developmental
Disorder)
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
Feedback
The nurse should recognize a family history of Tay-Sachs disease as risk factors
that would predispose a child to IDD.
The nurse should recognize a family history of childhood meningococcal
infections as risk factors that would predispose a child to IDD.
The nurse should recognize a family history of deprivation of nurturance and
social contact as risk factors that would predispose a child to IDD.
A diagnosis of maternal major depressive disorder would not predispose a child to
IDD.
that would predispose a child to IDD.
The nurse should recognize a family history of childhood meningococcal
infections as risk factors that would predispose a child to IDD.
The nurse should recognize a family history of deprivation of nurturance and
social contact as risk factors that would predispose a child to IDD.
A diagnosis of maternal major depressive disorder would not predispose a child to
IDD.
2.
3.
4.
PTS: 1
CON: Cognition
22.
ANS: 2, 4
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 636–638
Heading: Neurodevelopmental Disorders > Attention Deficit/Hyperactivity Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback
Smoking does not lead to the development of ADHD.
The nurse should identify that a low birth weight would predispose a client to the
development of ADHD.
Lactose intolerance does not lead to the development of ADHD.
The nurse should identify that having a sibling diagnosed with ADHD would
predispose a client to the development of ADHD.
A diagnosis of dyslexia does not lead to the development of ADHD.
1.
2.
3.
4.
5.
PTS: 1
CON: Cognition
COMPLETION
23.
ANS:
6
Chapter: Chapter 0, Children and Adolescents
Objective: Identify nursing diagnoses common to clients with these disorders and select and
appropriate nursing interventions for each.
Page: 650
Heading: Box 24-5 Diagnostic Criteria for Oppositional Defiant Disorder
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
Feedback: A persistent pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness must be evident and last at least 6 months according to the DSM-5 criteria for the
diagnosis of ODD.
PTS: 1
CON: Cognition
Chapter 33. The Aging Individual
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A client has recently been placed in a long-term care facility, because of marked
confusion and inability to perform most activities of daily living. Which nursing intervention is
most appropriate to maintain the client’s self-esteem?
1.
Leave the client alone in the bathroom to test ability to perform self-care.
2.
Assign a variety of caregivers to increase potential for socialization.
3.
Allow client to choose between two different outfits when dressing for the day.
4.
Modify the daily schedule often to maintain variety and decrease boredom.
____ 2.
A son, who recently brought his extremely confused parent to a nursing home for
admission, reports feelings of guilt. Which is the appropriate nursing response?
1.
“Support groups are held here on Mondays for children of residents in similar
situations.”
2.
“You did what you had to do. I wouldn’t feel guilty if I were you.”
3.
“Support groups are available to low-income families.”
4.
“Your parent is doing just fine. We’ll take very good care of him.”
____ 3.
A family asks why their father is attending activity groups at the long-term care
facility. The son states, “My father worked hard all of his life. He just needs some rest at this
point.” Which is the appropriate nursing response?
1.
“I’m glad we discussed this. We’ll excuse him from the activity groups.”
2.
“The groups benefit your father by providing social interaction, sensory stimulation,
and reality orientation.”
3.
“The groups are optional. Only clients at high functioning levels would benefit.”
4.
“If your father doesn’t go to these activity groups, he will be at high risk for
developing cognitive problems.”
____ 4.
A nursing instructor is teaching about reminiscence therapy. What student
statement indicates that learning has occurred?
1.
“Reminiscence therapy is a group in which participants create collages representing
significant aspects of their lives.”
2.
“Reminiscence therapy encourages members to share both positive and negative
significant life memories to promote resolution.”
3.
“Reminiscence therapy is a social group where members chat about past events and
future plans.”
4.
“Reminiscence therapy encourages members to share positive memories of
significant life transitions.”
____ 5.
A couple resides in a long-term care facility. The husband is admitted to the
psychiatric unit after physically abusing his wife. He states, “My wife is having an affair with a
young man, and I want it investigated.” Which is the appropriate nursing response?
1.
“Your wife is not having an affair. What makes you think that?”
2.
“Why do you think that your wife is having an affair?”
3.
“Your wife has told us that these thoughts have no basis in fact.”
4.
“I understand that you are upset. We will talk about it.”
____ 6.
A student nurse asks the instructor, “Which psychiatric disorder is most likely
initially diagnosed in the elderly?” Which instructor response gives the student accurate
information?
1.
“Schizophrenia is most likely diagnosed later in life.”
2.
“Major depressive disorder is most likely diagnosed later in life.”
3.
“Phobic disorder is most likely diagnosed later in life.”
4.
“Dependent personality disorder is most likely diagnosed later in life.”
____ 7.
An older client attending an adult day care program suddenly begins reporting
dizziness, weakness, and confusion. What should be the initial nursing intervention?
1.
Implement complete bedrest.
2.
Advocate for a complete physical exam.
3.
Address self-esteem needs.
4.
Advocate for individual psychotherapy.
____ 8.
An older client who lives with a caregiver is admitted to an emergency
department with a fractured arm. The client is soaked in urine and has dried fecal matter on
lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the
nurse suspect?
1.
2.
3.
4.
Inability for the client to meet self-care needs
Alzheimer’s disease
Abuse and/or neglect
Caregiver role strain
____ 9.
An older, emaciated client is brought to an emergency department by the client’s
caregiver. The client has bruises and abrasions on shoulders and back in multiple stages of
healing. When directly asked about these symptoms, which type of client response should a
nurse anticipate?
1.
The client will honestly reveal the nature of the injuries.
2.
The client may deny or minimize the injuries.
3.
The client may have forgotten what caused the injuries.
4.
The client will ask to be placed in a nursing home.
____ 10.
A client in the middle stage of Alzheimer’s disease has difficulty communicating
because of cognitive deterioration. Which nursing intervention is appropriate to improve
communication?
1.
Discourage attempts at verbal communication owing to increased client frustration.
2.
Increase the volume of the nurse’s communication responses.
3.
Verbalize the nurse’s perception of the implied communication.
4.
Encourage the client to communicate by writing.
____ 11.
An older client is exhibiting symptoms of major depressive disorder. A physician
is considering prescribing an antidepressant. Which physiological problem should make a nurse
question this medication regime?
1.
Altered cortical and intellectual functioning
2.
Altered respiratory and gastrointestinal functioning
3.
Altered liver and kidney functioning
4.
Altered endocrine and immune system functioning
____ 12.
An older client has met the criteria for a diagnosis of major depressive disorder.
The client does not respond to antidepressant medications. Which therapeutic intervention should
a nurse anticipate will be ordered for this client?
1.
Electroconvulsive therapy (ECT)
2.
Neuroleptic therapy
3.
An antiparkinsonian agent
4.
An anxiolytic agent
____ 13.
A nurse is charting assessment information about a 70-year-old client. According
to the U.S. Census Bureau, what term would the nurse use to describe this client?
1.
The nurse should document using the term older.
2.
The nurse should document using the term elderly.
3.
The nurse should document using the term aged.
4.
The nurse should document using the term very old.
____ 14.
Which individual is most likely to be below the poverty level in the United
States?
1.
A 70-year-old Hispanic woman living alone
2.
A 72-year-old African American man living alone
3.
A 68-year-old Asian American woman living with family
4.
A 75-year-old Latino American man living with family
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 15.
A nurse is listening to a lecture on the environmental theory. Which statement(s)
by the nurse indicates that teaching has been effective?(Select all that apply.)
1.
“Personality characteristics in old age are correlated with early life characteristics.”
2.
“Carcinogens can affect aging.”
3.
“Trauma can affect the aging process.”
4.
“The effects of sunlight can have an effect on the aging process.”
5.
“Decline in the immune system can affect the aging process.”
Completion
Complete each statement.
16.
The discipline of _______________________ is the branch of clinical medicine
specializing in psychopathology of the elderly population.
Chapter 0: The Aging Individual
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Chapter: Chapter 0, The Aging Individual
Objective: Apply the steps of the nursing process to the care of aging individuals.
Page: 689–692
Heading: Table 25-2 Care Plan for the Elderly Client
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should also provide appropriate supervision to keep the client safe.
The nurse should also maintain consistency of caregivers.
The most appropriate nursing intervention to maintain this client’s self-esteem is to
allow the client to choose between two different outfits when dressing for the day.
The nurse should also maintain a structured daily routine to minimize confusion.
CON: Cognition
2.
ANS: 1
Chapter: Chapter 0, The Aging Individual
Objective: Apply the steps of the nursing process to the care of aging individuals.
Page: 689–692
Heading: Table 25-2 Care Plan for the Elderly Client
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The most appropriate response by the nurse is to offer support to the son by
presenting available support groups. Caregivers can often experience negative
emotions and guilt. Release of these emotions can serve to prevent caregivers from
developing psychopathology such a depression.
This statement does not offer solutions to the son’s feelings.
This statement may degrade what the son is feeling.
This statement does not validate the son’s feelings.
CON: Cognition
3.
ANS: 2
Chapter: Chapter 0, The Aging Individual
Objective: Apply the steps of the nursing process to the care of aging individuals.
Page: 689–692
Heading: Table 25-2 Care Plan for the Elderly Client
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Group activities help better the life of the client.
The most appropriate nursing response is to educate the family that the purpose of
activity groups is to provide social interaction, sensory stimulation, and reality
orientation. Groups can also serve to increase self-esteem and reduce depression.
All clients would benefit in some manner from group activities.
This statement does not provide education to the family.
CON: Cognition
4.
ANS: 2
Chapter: Chapter 0, The Aging Individual
Objective: Apply the steps of the nursing process to the care of aging individuals.
Page: 693
Heading: Box 25-3 Reminiscence Therapy and Life Review With the Elderly
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement indicates that learning has not occurred.
Reminiscence therapy encourages members to share both positive and negative
significant life memories to promote resolution. Stimulation of life memories serve
to help older clients work through their losses and maintain self-esteem.
Reminiscence therapy can take place in one-on-one or group settings.
This statement indicates that further education is necessary.
This statement indicates that teaching has not been effective.
CON: Cognition
5.
ANS: 4
Chapter: Chapter 0, The Aging Individual
Objective: Apply the steps of the nursing process to the care of aging individuals.
Page: 689–692
Heading: Table 25-2 Care Plan for the Elderly Client
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement degrades what the client is experiencing.
This statement may not be therapeutic to the client.
This statement does not validate the client’s feelings.
The most appropriate response by the nurse is to empathize with the client and
encourage the client to talk about the situation. The nurse should remain
nonjudgmental and help maintain client’s orientation, memory, and recognition.
CON: Cognition
6.
ANS: 2
Chapter: Chapter 0, The Aging Individual
Objective: Describe biological, psychological, sociocultural, and sexual aspects of the normal
aging process.
Page: 671
Heading: Epidemiological Statistics > Health Status
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Schizophrenia is not most likely diagnosed later in life.
Major depressive disorder is most likely to be identified later in life. Depression
among older adults can be increased by physical illness, functional disability,
cognitive impairment, and loss of a spouse.
Phobic disorder is not most likely diagnosed later in life.
Dependent personality disorder is not most likely diagnosed later in life.
CON: Cognition
7.
ANS: 2
Chapter: Chapter 0, The Aging Individual
Objective: Describe biological, psychological, sociocultural, and sexual aspects of the normal
aging process.
Page: 686–687
Heading: Application of the Nursing Process > Assessment
Integrated Process: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Implementing complete bedrest should not be the initial nursing intervention.
The initial nursing intervention should be to advocate for a complete physical
exam. Sudden onset of dizziness, weakness, and confusion could indicate a
problem with the client’s cardiovascular or respiratory symptoms. Physical
symptoms should be thoroughly assessed prior to attributing symptoms to
psychological causes.
Addressing self-esteem needs should not be the initial nursing intervention.
Advocating for individual psychotherapy should not be the initial nursing
intervention.
CON: Perfusion
8.
ANS: 3
Chapter: Chapter 0, The Aging Individual
Objective: Describe the problem of elder abuse as it exists in today’s society.
Page: 684–685
Heading: Special Concerns of the Elderly Population > Elder Abuse
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not expect that the client is unable to complete self-care.
The nurse would not expect Alzheimer’s disease.
The nurse should expect that this client is a victim of elder abuse or neglect.
Indicators of elder physical abuse include bruises, fractures, burns, and other
physical injury. Neglect may be manifested as hunger, poor hygiene, unattended
physical problems, or abandonment.
The nurse would not expect caregiver role strain.
CON: Patient-Centered Care
9.
ANS: 2
Chapter: Chapter 0, The Aging Individual
Objective: Describe the problem of elder abuse as it exists in today’s society.
Page: 685–686
Heading: Special Concerns of the Elderly Population > Elder Abuse
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not expect the client to reveal the nature of the injuries.
The nurse should anticipate that the client may deny or minimize the injuries. The
older client may be unwilling to disclose information, because of fear of
retaliation, embarrassment about the existence of abuse in the family,
protectiveness toward a family member, or unwillingness to bring about legal
action.
The nurse would not anticipate that the client may have forgotten the cause of the
injuries.
The nurse would not anticipate that the client will ask to be placed in a nursing
home.
CON: Patient-Centered Care
10.
ANS: 3
Chapter: Chapter 0, The Aging Individual
Objective: Describe biological, psychological, sociocultural, and sexual aspects of the normal
aging process.
Page: 686–687
Heading: Application of the Nursing Process > Assessment
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should also keep explanations simple.
The nurse should use face-to-face interaction.
The most appropriate nursing intervention is to verbalize the nurse’s perception of
the implied communication.
The nurse should speak slowly without shouting.
1
2
3
4
PTS: 1
Feedback
The nurse should also keep explanations simple.
The nurse should use face-to-face interaction.
The most appropriate nursing intervention is to verbalize the nurse’s perception of
the implied communication.
The nurse should speak slowly without shouting.
CON: Cognition
11.
ANS: 3
Chapter: Chapter 0, The Aging Individual
Objective: Describe biological, psychological, sociocultural, and sexual aspects of the normal
aging process.
Page: 674
Heading: The Normal Aging Process > Biological Aspects of Aging
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not need to consider altered cortical and intellectual functioning.
The nurse would not need to consider altered respiratory and gastrointestinal
functioning.
The nurse should question the use of antidepressant medication in a client with
altered liver and kidney function. Antidepressant medication should be
administered with consideration for age-related physiological changes in
absorption, distribution, elimination, and brain receptor sensitivity. Because of
these changes, medications can reach high levels despite moderate oral dosage.
The nurse would not need to consider altered endocrine and immune system
functioning.
CON: Cognition
12.
ANS: 1
Chapter: Chapter 0, The Aging Individual
Objective: Describe biological, psychological, sociocultural, and sexual aspects of the normal
aging process.
Page: 678
Heading: Psychological Aspects of Aging > Psychiatric Disorders Later in Life
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should anticipate that ECT will be ordered to treat this client’s
symptoms of depression. ECT remains one of the safest and most effective
treatments for major depression in older adults. The response to ECT may be
slower in older clients, and the effects may be of limited duration.
Neuroleptic therapy is not a therapeutic intervention for the client with major
depressive disorder.
An antiparkinsonian agent is not a therapeutic intervention for the client with
major depressive disorder.
An anxiolytic agent is not a therapeutic intervention for the client with major
depressive disorder.
CON: Patient-Centered Care
13.
ANS: 2
Chapter: Chapter 0, The Aging Individual
Objective: Describe an epidemiological profile of aging in the United States.
Page: 669
Heading: How Old is Old?
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The U.S. Census Bureau has developed a system for classification of older
Americans. In it, “older” refers to persons aged 55–64 years old.
The U.S. Census Bureau classifies a 70-year-old individual as elderly.
The U.S. Census Bureau has developed a system for classification of older
Americans. In it, “aged” refers to persons aged 75–84 years old.
The U.S. Census Bureau has developed a system for classification of older
Americans. In it, “very old” refers to persons aged 85 years old and older.
CON: Patient-Centered Care
14.
ANS: 1
Chapter: Chapter 0, The Aging Individual
Objective: Describe an epidemiological profile of aging in the United States.
Page: 670–671
Heading: Epidemiological Statistics > Economic Status
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1
2
3
4
Feedback
Approximately 3.5 million persons aged 65 years or older were below the poverty
level in 2010. Older women had a higher poverty rate than older men, and older
Hispanic women living alone had the highest poverty rate.
A 72-year-old African American man living alone is not the most likely to be
below the poverty level in the United States.
A 68-year-old Asian American woman living with family is not the most likely to
be below the poverty level in the United States.
A 75-year-old Latino American man living with family is not the most likely to be
below the poverty level in the United States.
PTS: 1
CON: Patient-Centered Care
MULTIPLE RESPONSE
15.
ANS: 2, 3, 4
Chapter: Chapter 0, The Aging Individual
Objective: Discuss various theories of aging.
Page: 671
Heading: Theories of Aging > Genetic Theory
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity Cognitive
Level: Application [Applying] Concept:
Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
This statement is reflective of the personality theory.
The environmental theory states that carcinogens can affect aging process.
The environmental theory states that trauma can affect the aging process.
The effects of sunlight can affect the aging process.
A decline in the immune system can affect the aging process, according to the
autoimmune theory.
PTS: 1
COMPLETION
CON: Patient-Centered Care
16.
geropsychiatry
ANS:
Chapter: Chapter 0, The Aging Individual
Objective: Discuss various theories of aging.
Page: 669
Heading: Introduction
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback: The discipline of geropsychiatry is the branch of clinical medicine specializing in
psychopathology of the elderly population.
PTS: 1
CON: Patient-Centered Care
Chapter 34. Survivors of Abuse or Neglect
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A kindergarten student is frequently violent toward other children. A school nurse
notices bruises and burns on the child’s face and arms. What other symptom should indicate to
the nurse that the child may have been physically abused?
1.
The child shrinks at the approach of adults.
2.
The child begs or steals food or money.
3.
The child is frequently absent from school.
4.
The child is delayed in physical and emotional development.
____ 2.
A woman presents with a history of physical and emotional abuse in her intimate
relationships. What should this information lead a nurse to suspect?
1.
The woman may be exhibiting a controlled response pattern.
2.
The woman may have a history of childhood neglect.
3.
The woman may be exhibiting codependent characteristics.
4.
The woman may be a victim of incest.
____ 3.
A nursing instructor is developing a lesson plan to teach about domestic violence.
Which information should be included?
1.
Power and control are central to the dynamic of domestic violence.
2.
Poor communication and social isolation are central to the dynamic of domestic
violence.
3.
Erratic relationships and vulnerability are central to the dynamic of domestic
violence.
4.
Emotional injury and learned helplessness are central to the dynamic of domestic
1.
2.
3.
4.
Power and control are central to the dynamic of domestic violence.
Poor communication and social isolation are central to the dynamic of domestic
violence.
Erratic relationships and vulnerability are central to the dynamic of domestic
violence.
Emotional injury and learned helplessness are central to the dynamic of domestic
violence.
____ 4.
A client is brought to an emergency department after being violently raped. Which
nursing action is appropriate?
1.
Discourage the client from discussing the rape, because this may lead to further
emotional trauma.
2.
Remain nonjudgmental while actively listening to the client’s description of the
violent rape event.
3.
Meet the client’s self-care needs by assisting with showering and perineal care.
4.
Probe for further, detailed description of the rape event.
____ 5.
A raped client answers a nurse’s questions in a monotone voice with single words,
appears calm, and exhibits a blunt affect. How should the nurse interpret this client’s responses?
1.
The client may be lying about the incident.
2.
The client may be experiencing a silent rape reaction.
3.
The client may be demonstrating a controlled response pattern.
4.
The client may be having a compounded rape reaction.
____ 6.
A client who is in a severely abusive relationship is admitted to a psychiatric
inpatient unit. The client fears for her life. A staff nurse asks, “Why doesn’t she just leave him?”
Which is the nursing supervisor’s most appropriate response?
1.
“These clients don’t know life any other way, and change is not an option until they
have improved insight.”
2.
“These clients have limited cognitive skills and few vocational abilities to be able to
make it on their own.”
3.
“These clients often have a lack of financial independence to support themselves
and their children, and most have religious beliefs prohibiting divorce and
separation.”
4.
“These clients are paralyzed into inaction by a combination of physical threats and a
sense of powerlessness.”
____ 7.
A woman comes to an emergency department with a broken nose and multiple
bruises after being beaten by her husband. She states, “The beatings have been getting worse,
and I’m afraid next time he will kill me.” Which is the appropriate nursing response?
1.
“Leopards don’t change their spots, and neither will he.”
2.
“There are things you can do to prevent him from losing control.”
3.
“Let’s talk about your options so that you don’t have to go home.”
4.
“Why don’t we call the police so that they can confront your husband with his
behavior?”
1.
2.
3.
4.
“Leopards don’t change their spots, and neither will he.”
“There are things you can do to prevent him from losing control.”
“Let’s talk about your options so that you don’t have to go home.”
“Why don’t we call the police so that they can confront your husband with his
behavior?”
____ 8.
A college student was sexually assaulted when out on a date. After several weeks
of crisis intervention therapy, which client statement should indicate to a nurse that the student is
handling this situation in a healthy manner?
1.
“I know that it was not my fault.”
2.
“My boyfriend has trouble controlling his sexual urges.”
3.
“If I don’t put myself in a dating situation, I won’t be at risk.”
4.
“Next time I will think twice about wearing a sexy dress.”
____ 9.
A client asks, “Why does a rapist use a weapon during the act of rape?” Which is
the most appropriate nursing response?
1.
“To decrease the victimizer’s insecurity”
2.
“To inflict physical harm with the weapon”
3.
“To terrorize and subdue the victim”
4.
“To mirror learned family behavior patterns related to weapons”
____ 10.
When questioned about bruises, a woman states, “It was an accident. My husband
just had a bad day at work. He’s being so gentle now and even brought me flowers. He’s going to
get a new job, so it won’t happen again.” This client is in which phase of the cycle of battering?
1.
Phase I: The tension-building phase
2.
Phase II: The acute battering incident phase
3.
Phase III: The honeymoon phase
4.
Phase IV: The resolution and reorganization phase
____ 11.
Which information should the nurse in an employee assistance program provide
to an employee who exhibits symptoms of domestic physical abuse?
1.
Have ready access to a gun and learn how to use it.
2.
Research lawyers that can aid in divorce proceedings.
3.
File charges of assault and battery.
4.
Have ready access to the number of a safe house for battered women.
____ 12.
A survivor of rape presents in an emergency department crying, pacing, and
cursing her attacker. A nurse should recognize these client actions as which behavioral defense?
1.
Controlled response pattern
2.
Compounded rape reaction
3.
Expressed response pattern
4.
Silent rape reaction
1.
2.
3.
4.
Controlled response pattern
Compounded rape reaction
Expressed response pattern
Silent rape reaction
____ 13.
Which assessment data should a school nurse recognize as a sign of physical
neglect?
1.
The child is often absent from school and seems apathetic and tired.
2.
The child is very insecure and has poor self-esteem.
3.
The child has multiple bruises on various body parts.
4.
The child has sophisticated knowledge of sexual behaviors.
____ 14.
A client diagnosed with an eating disorder experiences insomnia, nightmares, and
panic attacks that occur before bedtime. She has never married or dated, and she lives alone. She
states to a nurse, “My father has recently moved back to town.” What should the nurse suspect?
1.
Possible major depressive disorder
2.
Possible history of childhood incest
3.
Possible histrionic personality disorder
4.
Possible history of childhood physical abuse
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 15.
In planning care for a woman who presents as a survivor of domestic abuse, a
nurse should be aware of which of the following data? (Select all that apply.)
1.
It often takes several attempts before a woman leaves an abusive situation.
2.
Substance abuse is a common factor in abusive relationships.
3.
Until children reach school age, they are usually not affected by abuse between their
parents.
4.
Women in abusive relationships usually feel isolated and unsupported.
5.
Economic factors rarely play a role in the decision to stay.
____ 16.
Which of the following nursing diagnoses are typically appropriate for an adult
survivor of incest? (Select all that apply.)
1.
Low self-esteem
2.
Powerlessness
3.
Disturbed personal identity
4.
Knowledge deficit
5.
Nonadherence
____ 17.
A nursing instructor is teaching about intimate partner violence. Which of the
following student statements indicate that learning has occurred? (Select all that apply.)
1.
“Intimate partner violence is a pattern of abusive behavior that is used by an
intimate partner.”
2.
“Intimate partner violence is used to gain power and control over the other intimate
partner.”
3.
“Fifty-one percent of victims of intimate violence are women.”
4.
“Women ages 25 to 34 experience the highest per capita rates of intimate violence.”
5.
“Victims are typically young married women who are dependent housewives.”
Other
18.
Order the description of the progressive phases of Walker’s model of the “cycle of
battering.”
________ This phase is the most violent and the shortest, usually lasting up to 24 hours.
________ In this phase, the man’s tolerance for frustration is declining.
________ In this phase, the batterer becomes extremely loving, kind, and contrite.
Completion
Complete each statement.
19.
A pattern of coercive control founded on and supported by physical and/or sexual
violence or threat of violence of an intimate partner is termed ______________________.
20.
Physical ________________ of a child includes refusal of or delay in seeking
health care, abandonment, expulsion from the home or refusal to allow a runaway to return
home, and inadequate supervision.
Chapter 0: Survivors of Abuse or Neglect
Answer Section
MULTIPLE CHOICE
1.
ANS: 1
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 706–707
Heading: Application of the Nursing Process > Background Assessment Data > Physical Abuse
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should determine that a child who shrinks at the approach of adults in
addition to having bruises and burns may be a victim of abuse. Maltreatment is
considered, whether or not the adult intended to harm the child.
Stealing money or food does not indicate physical abuse.
Frequently missing school does not indicate physical abuse.
Developmental delays do not indicate physical abuse.
CON: Violence
2.
ANS: 4
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 708–709
Integrated Process: Application of the Nursing Process > Background Assessment Data
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not expect that the client is exhibiting a controlled response
pattern.
The nurse would not expect a history of childhood neglect.
The nurse would not expect codependency.
The nurse should suspect that this client may be a victim of incest. Many women
who are battered have low self-esteem and have feelings of guilt, anger, fear, and
shame. Women in abusive relationships often grew up in an abusive home.
CON: Violence
3.
ANS: 1
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 704–706
Heading: Application of the Nursing Process > Background Assessment Data
Integrated Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nursing instructor should include the concept that power and control are
central to the dynamic of domestic violence. Battering is defined as a pattern of
coercive control founded on physical and/or sexual violence or threat of violence.
The typical abuser is very possessive and perceives the victim as a possession.
Poor communication and social isolation are not central to the dynamic of
domestic violence.
Erratic relationships and vulnerability are not central to the dynamic of domestic
violence.
Emotional injury and learned helplessness are not central to the dynamic of
domestic violence.
CON: Violence
4.
ANS: 2
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 712–714
Heading: Table 26-1 Care Plan for Survivors of Abuse
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client should be encouraged to discuss the rape.
The most appropriate nursing action is to remain nonjudgmental and actively listen
to the client’s description of the event. It is important to also communicate to the
victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening
provides an avenue for catharsis, which contributes to the healing process.
Showering would not be an appropriate nursing intervention and may destroy
evidence.
Probing for further detail would not be appropriate.
CON: Violence
5.
ANS: 3
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 711
Heading: Application of the Nursing Process > Background Assessment Data
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client is not likely lying about the incident.
The client is not likely to be experiencing a silent rape reaction.
This client is most likely demonstrating a controlled response pattern. In the
controlled response pattern, the client’s feelings are masked or hidden, and a calm,
composed, or subdued affect is seen. In the expressed response pattern, feelings of
fear, anger, and anxiety are expressed through crying sobbing, smiling,
restlessness, and tension.
The client is not likely having a compounded rape reaction.
CON: Violence
6.
ANS: 4
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 706
Heading: Application of the Nursing Process > Background Assessment Data > Why Does She
Stay?
Integrated Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
Feedback
Stating “These clients don’t know life any other way, and change is not an option
until they have improved insight” is not the most appropriate response.
Stating “These clients have limited cognitive skills and few vocational abilities to
be able to make it on their own” is not the most appropriate response.
Stating “These clients often have a lack of financial independence to support
themselves and their children, and most have religious beliefs prohibiting divorce
and separation” is not the most appropriate response.
The nursing supervisor is accurate when stating that clients who are in abuse
relationships are paralyzed into inaction by a combination of physical threats and a
sense of powerlessness. Women often choose to stay with an abusive partner: for
the children, for financial reasons, for fear of retaliation, for lack of a support
network, for religious reasons, or because of hopefulness.
2
3
4
PTS: 1
Stating “These clients have limited cognitive skills and few vocational abilities to
be able to make it on their own” is not the most appropriate response.
Stating “These clients often have a lack of financial independence to support
themselves and their children, and most have religious beliefs prohibiting divorce
and separation” is not the most appropriate response.
The nursing supervisor is accurate when stating that clients who are in abuse
relationships are paralyzed into inaction by a combination of physical threats and a
sense of powerlessness. Women often choose to stay with an abusive partner: for
the children, for financial reasons, for fear of retaliation, for lack of a support
network, for religious reasons, or because of hopefulness.
CON: Violence
7.
ANS: 3
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 712–714
Heading: Table 26-1 Care Plan for Survivors of Abuse
Integrated Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Imposing judgments is nontherapeutic.
Giving advice to the client is nontherapeutic.
The most appropriate response by the nurse is to talk with the client about options
so that the client does not have to return to the abusive environment. It is essential
that clients make decisions on their own without the nurse being the “rescuer.”
This statement is nontherapeutic to the client.
CON: Violence
8.
ANS: 1
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 712–714
Heading: Table 26-1 Care Plan for Survivors of Abuse
Integrated Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The client who realizes that sexual assault was not her fault is handling the
situation in a healthy manner. The nurse should provide nonjudgmental listening
and communicate statements that instill trust and validate self-worth.
Stating “My boyfriend has trouble controlling his sexual urges” does not indicate
that the client is handling the situation in a healthy manner.
Stating “If I don’t put myself in a dating situation, I won’t be at risk” does not
indicate that the client is handling the situation in a healthy manner.
Stating “Next time I will think twice about wearing a sexy dress” does not indicate
that the client is handling the situation in a healthy manner.
CON: Violence
9.
ANS: 3
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 710
Heading: Application of the Nursing Process > Background Assessment Data > Profile of the
Victimizer
Integrated Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Rapists do not use weapons to decrease their own insecurities.
Rapists do not use weapons to inflict physical harm.
The nurse should explain that a rapist uses weapons to terrorize and subdue the
victim. Rape is the expression of power and dominance by means of sexual
violence. Rape can occur over a broad spectrum of experience, from violent attack
to insistence on sexual intercourse by an acquaintance or spouse.
Rapists do not use weapons to mirror learned family behavior patterns related to
weapons.
CON: Violence
10.
ANS: 3
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 705–706
Heading: Application of the Nursing Process > Background Assessment Data > The Cycle of
Battering
Integrated Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
Feedback
This scenario is not an example of Phase I: The tension-building phase.
This scenario is not an example of Phase II: The acute battering incident phase.
The client is in the honeymoon phase of the cycle of battering. In this phase, the
batterer becomes extremely loving, kind, and contrite. Promises are often made
that the abuse will not happen again.
This scenario is not an example of Phase IV: The resolution and reorganization
phase.
1
2
3
4
PTS: 1
CON: Violence
11.
ANS: 4
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 712–714
Heading: Table 26-1 Care Plan for Survivors of Abuse
Integrated Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
Feedback
The nurse would not provide information on keeping a gun to the client.
The nurse would not provide information on divorce attorneys.
The nurse would not provide information on filing charges of assault and battery.
The nurse should provide information about the accessibility of safe houses for
battered women when working with a client who has symptoms of domestic
physical abuse. Many women feel powerless within the abusive relationship and
may be staying in the abusive relationship out of fear.
1
2
3
4
PTS: 1
12.
CON: Violence
ANS: 3
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 711
Heading: Application of the Nursing Process > Background Assessment Data > The Victim
Integrated Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
In the controlled response pattern, the client’s feelings are masked or hidden, and a
calm, composed, or subdued affect is seen.
The client is not experiencing a compounded rape reaction.
The nurse should recognize that this client is exhibiting an expressed response
pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are
expressed through crying, sobbing, smiling, restlessness, and tension.
The client is not experiencing a silent rape reaction.
CON: Violence
13.
ANS: 1
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 706–707
Heading: Application of the Nursing Process > Background Assessment Data > Child Abuse
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse should recognize that a child who is often absent from school and seems
apathetic and tired may be a victim of neglect. Other indicators of neglect are
stealing food or money, lacking medical or dental care, being consistently dirty,
lacking sufficient clothing, or stating that there is no one home to provide care.
Insecurity and poor self-esteem are not signs of physical neglect.
Bruising is a sign of physical abuse.
Sophisticated sexual behaviors is a sign of sexual abuse.
CON: Violence
14.
ANS: 2
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 709
Heading: Application of the Nursing Process > Background Assessment Data > The Adult
Survivor of Incest
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not expect a possible major depressive disorder.
The nurse should suspect that this client may have a history of childhood incest.
Adult survivors of incest are at risk for developing posttraumatic stress disorder,
sexual dysfunction, somatization disorders, compulsive sexual behavior disorders,
depression, anxiety, eating disorders, and substance abuse disorders.
The nurse would not expect a possible histrionic personality disorder.
The nurse would not expect a possible history of childhood physical abuse.
CON: Violence
MULTIPLE RESPONSE
15.
ANS: 1, 2, 4
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Discuss characteristics of victims and victimizers.
Page: 704–706
Heading: Application of the Nursing Process > Background Assessment Data > Intimate Partner
Violence
Integrated Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
Feedback
When planning care for a woman who is a survivor of domestic abuse, the nurse
should be aware that it often takes several attempts before a woman leaves an
abusive situation.
When planning care for a woman who is a survivor of domestic abuse, the nurse
should be aware that substance abuse is a common factor in abusive relationships.
Children can be affected by domestic violence from infancy.
When planning care for a woman who is a survivor of domestic abuse, the nurse
should be aware that women in abusive relationships usually feel isolated and
unsupported.
1.
2.
3.
4.
5.
PTS: 1
Feedback
When planning care for a woman who is a survivor of domestic abuse, the nurse
should be aware that it often takes several attempts before a woman leaves an
abusive situation.
When planning care for a woman who is a survivor of domestic abuse, the nurse
should be aware that substance abuse is a common factor in abusive relationships.
Children can be affected by domestic violence from infancy.
When planning care for a woman who is a survivor of domestic abuse, the nurse
should be aware that women in abusive relationships usually feel isolated and
unsupported.
Economic factors often play a role in the victim’s decision to stay.
CON: Violence
16.
ANS: 1, 2
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 709
Heading: Application of the Nursing Process > Background Assessment Data > The Adult
Survivor of Incest
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
An adult survivor of incest would most likely have low self-esteem.
An adult survivor of incest would most likely have a sense of powerlessness.
An adult survivor of incest would not likely have disturbed personal identity.
An adult survivor of incest would not likely have a knowledge deficit.
An adult survivor of incest would not likely have nonadherence.
CON: Violence
17.
ANS: 1, 2, 4
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 704–706
Heading: Application of the Nursing Process > Background Assessment Data > Intimate Partner
Violence
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
Intimate partner violence is a pattern of abusive behavior that is used by an
intimate partner.
It is used to gain power and control over the other intimate partner.
Eighty-five percent of victims of intimate violence are women.
Women ages 25 to 34 experience the highest per capita rates of intimate violence.
Battered women represent all age, racial, religious, cultural, educational, and
socioeconomic groups. They may be married or single, housewives or business
executives.
PTS: 1
CON: Violence
ORDERED RESPONSE
18.
ANS:
The correct order is 2, 1, 3.
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 705–706
Heading: Application of the Nursing Process > Background Assessment Data > Intimate Partner
Violence
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis
Concept: Violence
Difficulty: Moderate
Feedback: In her classic studies of battered women and their relationships, Walker identified a
cycle of predictable behaviors that are repeated over time. The behaviors can be divided into
three distinct phases that vary in time and intensity both within the same relationship and among
different couples.
1. Tension-building phase: In this phase, the man’s tolerance for frustration is declining.
2. Acute-battering incident phase: This phase is the most violent and the shortest, usually lasting
up to 24 hours.
3. Honeymoon phase: In this phase, the batterer becomes extremely loving, kind, and contrite.
PTS: 1
COMPLETION
CON: Violence
19.
ANS:
battering
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 704
Heading: Core Concept > Battering
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
Feedback: Battering is a pattern of behavior used to establish power and control over another
person with whom an intimate relationship is or has been shared through fear and intimidation,
often including the threat or use of violence. Battering happens when one person believes they
are entitled to control another.
PTS: 1
CON: Violence
20.
ANS:
neglect
Chapter: Chapter 0, Survivors of Abuse or Neglect
Objective: Identify nursing diagnoses, goals of care, and appropriate nursing interventions for
care of survivors of intimate partner violence, child abuse, and sexual assault.
Page: 707
Heading: Core Concept > Neglect
Integrated Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application
Concept: Violence
Difficulty: Moderate
Feedback: Physical neglect of a child includes refusal of or delay in seeking health care,
abandonment, expulsion from the home or refusal to allow a runaway to return home, and
inadequate supervision. Children are vulnerable and relatively powerless, and the effects of
maltreatment are infinitely deep and long lasting.
PTS: 1
CON: Violence
Chapter 35 Community Mental Health Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A nursing instructor is teaching about the Community Health Centers Act of 1963.
What was a deterring factor to the proper implementation of this act?
1.
Many prospective clients did not meet criteria for mental illness diagnostic-related
groups.
2.
Zoning laws discouraged the development of community mental health centers.
3.
States could not match federal funds to establish community mental health centers.
4.
There was not a sufficient employment pool to staff community mental health
centers.
____ 2.
A nurse is implementing care within the parameters of tertiary prevention. Which
nursing action is an example of this type of care?
1.
Teaching an adolescent about pregnancy prevention
2.
Teaching a client the reportable side effects of a newly prescribed neuroleptic
medication
3.
Teaching a client to cook meals, make a grocery list, and establish a budget
4.
Teaching a client about his or her new diagnosis of bipolar disorder
____ 3.
A nursing instructor is teaching about case management. What student statement
indicates that learning has occurred?
1.
“Case management is a method used to achieve independent client care.”
2.
“Case management provides coordination of services required to meet client
needs.”
3.
“Case management exists mainly to facilitate client admission to needed inpatient
services.”
4.
“Case management is a method to facilitate physician reimbursement.”
____ 4.
A client at the mental health clinic tells the case manager, “I can’t think about
living another day, but don’t tell anyone about the way I feel. I know you are obligated to protect
my confidentiality.” Which case manager response is most appropriate?
1.
“The treatment team is composed of many specialists who are working to improve
your ability to function. Sharing this information with the team is critical to your
care.”
2.
“Let’s discuss steps that will resolve negative lifestyle choices that may have
increased your suicidal risk.”
3.
“You seem to be preoccupied with self. You should concentrate on hope for the
future.”
4.
“This information is secure with me because of client confidentiality.”
____ 5.
When intervening with a married couple experiencing relationship discord, which
nursing action reflects an intervention at the secondary level of prevention?
1.
Teaching assertiveness skills in order to meet assessed needs
2.
Supplying the couple with guidelines related to marital seminar leadership
3.
Teaching the couple about various methods of birth control
4.
Counseling the couple related to open and honest communication skills
____ 6.
A school nurse provides education on drug abuse to a high school class. This
nursing action is an example of which level of preventive care?
1.
Primary prevention
2.
Secondary prevention
3.
Tertiary prevention
4.
Primary intervention
____ 7.
A newly admitted homeless client diagnosed with schizophrenia states, “I have
been living in a cardboard box for two weeks. Why did the government let me down?” Which is
an appropriate nursing response?
1.
“Your discharge from the state hospital was done prematurely. Had you remained in
the state hospital longer, you would not be homeless.”
2.
“Your premature discharge from the state hospital was not intended for patients
diagnosed with chronic schizophrenia.”
3.
“Your discharge from the state hospital was based on firm principles; however, the
resources were not available to make the transition a success.”
4.
“Your discharge from the state hospital was based on presumed family support, and
this was not forthcoming.”
____ 8.
An instructor is teaching nursing students about the difference between partial and
inpatient hospitalization. In what way does partial hospitalization differ from traditional inpatient
hospitalization?
1.
Partial hospitalization does not provide medication administration and monitoring.
2.
Partial hospitalization does not use an interdisciplinary team.
3.
Partial hospitalization does not offer a comprehensive treatment plan.
4.
Partial hospitalization does not provide supervision 24 hours a day.
____ 9.
When a home health nurse administers an outpatient’s injection of haloperidol
decanoate (Haldol decanoate), which level of care is the nurse providing?
1.
Primary prevention level of care
2.
Secondary prevention level of care
3.
Tertiary prevention level of care
4.
Case management level of care
1.
2.
3.
4.
Primary prevention level of care
Secondary prevention level of care
Tertiary prevention level of care
Case management level of care
____ 10.
A client diagnosed with schizophrenia is hospitalized owing to an exacerbation of
psychosis related to nonadherence with antipsychotic medications. Which level of care does the
client’s hospitalization reflect?
1.
Primary prevention level of care
2.
Secondary prevention level of care
3.
Tertiary prevention level of care
4.
Case management level of care
____ 11.
When attempting to provide health-care services to the homeless, what should be
a realistic concern for a nurse?
1.
Most individuals that are homeless reject help.
2.
Most individuals that are homeless are suspicious of anyone who offers help.
3.
Most individuals that are homeless are proud and will often refuse charity.
4.
Most individuals that are homeless relocate frequently.
____ 12.
A homeless client comes to an emergency department reporting cough, night
sweats, weight loss, and blood-tinged sputum. Which disease, which has recently become more
prevalent among the homeless community, should a nurse suspect?
1.
Meningitis
2.
Tuberculosis
3.
Encephalopathy
4.
Mononucleosis
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 13.
Which of the following clients should a nurse recommend for a structured day
program? (Select all that apply.)
1.
An acutely suicidal teenager
2.
A chronically mentally ill woman who has a history of medication nonadherence
3.
A socially isolated older individual
4.
A depressed individual who is able to contract for safety
5.
A client who is hearing voices that tell the client to harm others
____ 14.
Which of the following are characteristics of a Program of Assertive Community
Treatment (PACT), as described by the National Alliance on Mental Illness (NAMI)? (Select all
that apply.)
1.
PACT offers nationally based treatment to people with serious and persistent mental
illnesses.
2.
PACT is a type of case-management program.
3.
The PACT team provides services 24 hours a day, 7 days a week, 365 days a year.
4.
The PACT team provides highly individualized services directly to consumers.
5.
PACT is a multidisciplinary team approach.
____ 15.
Which of the following have been assessed as the most common types of mental
illness identified among homeless individuals? (Select all that apply.)
1.
Schizophrenia
2.
Body dysmorphic disorder
3.
Antisocial personality disorder
4.
Neurocognitive disorder
5.
Conversion disorder
Other
16.
Order the goals of the levels of prevention as they progress through the public
health model set forth by Gerald Caplan.
________ Interventions aimed at minimizing early symptoms of psychiatric illness and directed
toward reducing the prevalence and duration of the illness
________ Services aimed at reducing the residual defects that are associated with severe and
persistent mental illness
________ Services aimed at reducing the incidence of mental disorders within the population
Completion
Complete each statement.
17.
The ________________________ movement closed state mental hospitals and
caused the discharge of individuals with mental illness.
Chapter 0: Community Mental Health Nursing
Answer Section
MULTIPLE CHOICE
1.
ANS: 3
Chapter: Chapter 0, Community Mental Health Nursing
Objective Discuss the changing focus of care in the field of mental health.
Page: 723
Heading: The Changing Focus of Care
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
A client who did not meet criteria for mental illness was not a deterring factor.
Zoning laws were not a deterring factor.
A deterring factor to the proper implementation of the Community Mental Health
Centers Act of 1963 was that states could not match federal funds to establish
community mental health centers. This act called for the construction of
comprehensive community mental health centers to offset the effect of
deinstitutionalization, the closing of state mental health hospitals.
Insufficient staffing was not a deterring factor.
CON: Mood
2.
ANS: 3
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Discuss tertiary prevention of mental illness within the community as it relates to the
seriously mentally ill and homeless mentally ill.
Page: 725
Heading: The Public Health Model
Integrated Process: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
Feedback
Teaching about pregnancy prevention is primary prevention.
Teaching about side effects of a new medication and bipolar disorder is secondary
prevention.
The nurse who teaches a client to cook meals, make a grocery list, and establish a
budget is implementing care within the parameters of tertiary prevention. Tertiary
prevention consists of services aimed at reducing the residual effects that are
associated with severe and persistent mental illness. It is accomplished by
preventing complications of the illness and promoting rehabilitation that is
directed toward achievement of maximum functioning.
Teaching about bipolar disorder to a newly diagnosed client is secondary
prevention.
PTS: 1
CON: Mood
3.
ANS: 2
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Apply steps of the nursing process to care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 739
Heading: The Community as Client > Tertiary Prevention
Integrated Process: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This statement indicates that further education is needed.
The instructor evaluates that learning has occurred when a student defines case
management as providing coordination of services required to meet client needs.
Case management strives to organize client care so that specific outcomes are
achieved within allotted time frames.
This statement indicates that learning has not occurred.
This statement indicates that further teaching is required.
CON: Mood
4.
ANS: 1
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Apply steps of the nursing process to care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 739
Heading: The Public Health Model
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1
2
3
4
Feedback
The most appropriate response by the case manager is to explain that sharing the
information with the treatment team is critical to the client’s care. This case
manager’s priority is to ensure client safety and to inform others on the treatment
team of the client’s suicidal ideation.
Stating “Let’s discuss steps that will resolve negative lifestyle choices that may
have increased your suicidal risk” does not protect the client’s safety, which is the
priority.
Stating “You seem to be preoccupied with self. You should concentrate on hope
for the future” does not protect the client’s safety, which is the priority.
Stating “This information is secure with me because of client confidentiality” does
1
2
3
4
PTS: 1
Feedback
The most appropriate response by the case manager is to explain that sharing the
information with the treatment team is critical to the client’s care. This case
manager’s priority is to ensure client safety and to inform others on the treatment
team of the client’s suicidal ideation.
Stating “Let’s discuss steps that will resolve negative lifestyle choices that may
have increased your suicidal risk” does not protect the client’s safety, which is the
priority.
Stating “You seem to be preoccupied with self. You should concentrate on hope
for the future” does not protect the client’s safety, which is the priority.
Stating “This information is secure with me because of client confidentiality” does
not protect the client’s safety, which is the priority.
CON: Mood
5.
ANS: 4
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Discuss secondary prevention of mental illness within the community
Page: 726–727
Heading: The Community as Client > Primary Prevention > Maturational Crises
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Teaching assertiveness skills in order to meet assessed needs is tertiary prevention.
Supplying the couple with guidelines related to marital seminar leadership is
primary prevention.
Teaching the couple about various methods of birth control is primary prevention.
Counseling the couple related to open and honest communication skills is a
reflection of a nursing intervention at the secondary level of prevention. Secondary
prevention aims at minimizing symptoms and is accomplished through early
identification of problems and prompt initiation of effective treatment.
CON: Health Promotion
6.
ANS: 1
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Discuss nursing intervention in primary prevention of mental illness within the
community.
Page: 726
Heading: The Community as Client > Primary Prevention
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Providing nursing education on drug abuse to a high school class is an example of
primary prevention. Primary prevention services are aimed at reducing the
incidence of mental health disorders within the population.
Secondary prevention is aimed at early detection and prompt intervention.
Tertiary prevention is aimed at reduction of symptoms.
Primary intervention is not a term associated with the public health model.
CON: Health Promotion
7.
ANS: 3
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 745–750
Heading: The Community as Client > Tertiary Prevention > The Homeless Population
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This is inaccurate because the client was not discharged prematurely.
This is inaccurate because the client was not discharged prematurely due to
schizophrenia.
The most accurate nursing response is to explain to the client that the resources
were not available to make transitioning out of a state hospital a success. There are
several factors that are thought to contribute to homelessness among the mentally
ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable
health care, domestic violence, and addiction disorders.
This statement is not accurate based on the client’s situation.
CON: Health Promotion
8.
ANS: 4
Chapter: Chapter 0: Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 740–741
Heading: The Community as Client > Tertiary Prevention
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Partial hospitalization provides medication administration and monitoring.
Partial hospitalization uses an interdisciplinary team.
Partial hospitalization offers a comprehensive treatment plan.
The instructor should explain that partial hospitalization does not provide
supervision 24 hours a day. Partial hospitalization programs generally offer a
comprehensive treatment plan formulated by an interdisciplinary team, including
medication administration. They have proved to be an effective method of
preventing hospitalization.
CON: Health Promotion
9.
ANS: 3
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Discuss tertiary prevention of mental illness within the community as it relates to the
seriously mentally ill and homeless mentally ill.
Page: 739
Heading: The Community as Client > Tertiary Prevention
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
Primary prevention is aimed at preventing services before they are needed.
Secondary prevention is aimed at early detection and fast intervention.
When administering medication in an outpatient setting, the nurse is providing a
tertiary prevention level of care. Tertiary prevention services are aimed at reducing
the residual effects that are associated with severe and persistent mental illness. It
is accomplished by preventing complications of the illness and promoting
rehabilitation that is directed toward achievement of maximum functioning.
Case management level of care is not a term associated with the public health
model.
PTS: 1
CON: Health Promotion
10.
ANS: 2
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Discuss secondary prevention of mental illness within the community
Page: 731
Heading: The Community as Client > Secondary Prevention
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Primary prevention aims are preventing the need of services.
The client’s hospitalization reflects the secondary prevention level of care.
Secondary prevention aims at minimizing symptoms and is accomplished through
early identification of problems and prompt initiation of effective treatment.
Tertiary prevention aims at reducing the symptoms of a disease or illness.
Case management level of care is not a term associated with the public health
model.
CON: Health Promotion
11.
ANS: 4
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 745–750
Heading: The Community as Client > Tertiary Prevention > The Homeless Population
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
1
2
3
4
Feedback
It is inaccurate to state that most homeless reject help.
It is inaccurate to state that most homeless are suspicious of those who offer help.
It is inaccurate to state that most homeless refuse charity.
A realistic concern in the provision of health-care services to the homeless is that
individuals who are homeless relocate frequently. Frequent relocation confounds
service delivery and interferes with providers’ efforts to ensure appropriate care.
1
2
3
4
PTS: 1
Feedback
It is inaccurate to state that most homeless reject help.
It is inaccurate to state that most homeless are suspicious of those who offer help.
It is inaccurate to state that most homeless refuse charity.
A realistic concern in the provision of health-care services to the homeless is that
individuals who are homeless relocate frequently. Frequent relocation confounds
service delivery and interferes with providers’ efforts to ensure appropriate care.
CON: Health Promotion
12.
ANS: 2
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 745–750
Heading: The Community as Client > Tertiary Prevention > The Homeless Population
Heading: The Homeless Population
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
Meningitis has not recently become more prevalent.
The nurse should suspect that the homeless client has contracted tuberculosis.
Tuberculosis is a growing problem among individuals who are homeless, owing to
being in crowded shelters, which are ideal conditions for the spread of respiratory
tuberculosis. Prevalence of alcoholism, drug addiction, HIV infection, and poor
nutrition also impact the increase of contracted cases of tuberculosis.
Encephalopathy has not recently become more prevalent.
Mononucleosis has not recently become more prevalent.
CON: Perfusion
MULTIPLE RESPONSE
13.
ANS: 2, 4
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 740–741
Heading: The Community as Client > Tertiary Prevention
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
A suicidal teenager is not an appropriate candidate for a structured day program.
The nurse should recommend a structured day program for a chronically mental ill
woman who has a history of medication nonadherence.
A socially isolated older adult is not an appropriate candidate for a structured day
program.
The nurse should recommend a structured day program for a depressed individual
who is able to contract for safety.
A client hearing voices is not an appropriate candidate for a structured day
program.
CON: Patient-Centered Care
14.
ANS: 2, 3, 4, 5
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 739–740
Heading: The Community as Client > Tertiary Prevention
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
NAMI defines PACT as a service-delivery model that provides comprehensive,
locally, not nationally, based treatment to people with serious and persistent mental
illnesses.
PACT is a type of case-management program.
The PACT team provides these services 24 hours a day, 7 days a week, 365 days a
year.
PACT is a type of case-management program that provides highly individualized
services directly to consumers.
It is a team approach and includes members from psychiatry, social work, nursing,
substance abuse, and vocational rehabilitation.
PTS: 1
CON: Patient-Centered Care
15.
ANS: 1, 3, 4
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Identify treatment alternatives for care of the seriously mentally ill and homeless
mentally ill within the community.
Page: 745–750
Heading: The Community as Client > Tertiary Prevention > The Homeless Population
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Mood
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
A number of studies have been conducted, primarily in large, urban areas, which
have addressed the most common types of mental illness identified among
homeless individuals. Schizophrenia is frequently described as the most common
diagnosis.
Body dysmorphic disorder is not among the most common types of mental
illnesses among homeless individuals.
Other prevalent disorders include personality disorders, such as antisocial
personality disorder.
Other prevalent disorders include neurocognitive disorders.
Conversion disorder is not among the most common types of mental illnesses
among homeless individuals.
CON: Mood
ORDERED RESPONSE
16.
ANS:
The correct order is 2, 3, 1.
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Define the concepts of care associated with the public health model.
Page: 724–725
Heading: The Public Health Model
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Health Promotion
Difficulty: Moderate
Feedback: The premise of the model of public health is based largely on the concepts set forth by
Gerald Caplan (1964) during the initial community mental health movement. They include
primary prevention, secondary prevention, and tertiary prevention.
1. Primary prevention is aimed at reducing the incidence of mental disorders within the
population.
2. Secondary prevention is aimed at minimizing early symptoms of psychiatric illness and
directed toward reducing the prevalence and duration of the illness.
3. Tertiary prevention is aimed at providing services that reduce the residual defects that are
associated with severe and persistent mental illness.
PTS: 1
CON: Health Promotion
COMPLETION
17.
ANS:
deinstitutionalization
Chapter: Chapter 0, Community Mental Health Nursing
Objective: Relate historical and epidemiological factors associated with caring for the seriously
mentally ill and homeless mentally ill within the community.
Page: 723
Heading: The Changing Focus of Care
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
Feedback: The deinstitutionalization movement closed state mental hospitals and caused the
discharge of individuals with mental illness. Congress passed the Mental Retardation Facilities
and Community Mental Health Centers Construction Act (often called the Community Mental
Health Centers Act) in 1963. This act called for the construction of comprehensive community
health centers, the cost of which would be shared by federal and state governments.
Unfortunately, many state governments did not have the capability to match the federal funds
required for the establishment of these mental health centers.
PTS: 1
CON: Health Promotion
Chapter 36. The Bereaved Individual
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
A client is diagnosed with terminal cancer. Which situation represents KüblerRoss’s grief stage of “anger”?
1.
2.
3.
4.
The client registers for an Ironman marathon to be held in 9 months.
The client is a devout Catholic but refuses to attend church and states that his faith
has failed him.
The client promises God to give up smoking if allowed to live long enough to
witness a grandchild’s birth.
The client gathers family in order to plan a funeral and make last wishes known.
____ 2.
A nurse is caring for an Irish client who has recently lost his wife. The client tells
the nurse that he is planning an elaborate wake and funeral. According to George Engel, what
purpose would these rituals serve?
1.
To delay the recovery process initiated by the loss of the client’s wife
2.
To facilitate the acceptance of the loss of the client’s wife
3.
To avoid dealing with grief associated with the loss of the client’s wife
4.
To eliminate emotional pain related to the loss of the client’s wife
____ 3.
A nurse discharges a female client to home after delivering a stillborn infant. The
client finds that neighbors have dismantled the nursery that she and her husband planned.
According to Worden, how could this intervention affect the woman’s grieving task completion?
1.
This intervention may hamper the woman from continuing a relationship with her
infant.
2.
This intervention would help the woman forget the sorrow and move on with life.
3.
This intervention communicates full support from her neighbors.
4.
This intervention would motivate the woman to look to the future and not the past.
____ 4.
A teenager has recently lost a parent. Which grieving behavior should a school
nurse expect when assessing this client?
1.
Denial of personal mortality
2.
Preoccupation with the loss
3.
Clinging behaviors and personal insecurity
4.
Acting-out behaviors, exhibited in aggression and defiance
____ 5.
What term should a nurse use when assessing a response to grieving that includes
a sudden physical collapse and paralysis, and which cultural group would be associated with this
behavior?
1.
“Falling out” in the African American culture
2.
“Body rocking” in the Vietnamese American culture
3.
“Conversion disorder” in the Jewish American culture
4.
“Spirit possession” in the Native American culture
____ 6.
Which grieving behaviors should a nurse anticipate when caring for a Navajo
client who recently lost a child?
1.
Celebrating the life of a deceased person with festivities and revelry
2.
Not expressing grief openly and reluctance to touch the dead body
3.
Holding a prayerful vigil for a week following the person’s death
4.
Expressing grief openly and publicly and erecting an altar in the home to honor the
dead
____ 7.
A nursing instructor is teaching about the typical grieving behaviors of Chinese
Americans. Which student statement would indicate that more instruction is necessary?
1.
“In this culture, the color red is associated with death and is considered bad luck.”
2.
“In this culture, there is an innate fear of death.”
3.
“In this culture, emotions are not expressed openly.”
4.
“In this culture, death and bereavement are centered on ancestor worship.”
____ 8.
A nurse assigns a client the nursing diagnosis of complicated grieving. According
to Bowlby, which long-term outcome would be most appropriate for this nursing diagnosis?
1.
The client will accomplish the recovery stage of grief by year one.
2.
The client will accomplish the acceptance stage of grief by year one.
3.
The client will accomplish the reorganization stage of grief by year one.
4.
The client will accomplish the emotional relocation stage of grief by year one.
____ 9.
A nurse assesses a woman whose husband died 13 months ago. She isolates
herself, screams at her deceased spouse, and is increasingly restless. According to Bowlby, this
widow is in which stage of the grieving process?
1.
Stage I: Numbness or protest
2.
Stage II: Disequilibrium
3.
Stage III: Disorganization and despair
4.
Stage IV: Reorganization
____ 10.
Which is the most accurate description of the nursing diagnosis of dysfunctional
grieving?
1.
Inability to form a valid appraisal of a loss and to use available resources
2.
The experience of distress, with accompanying sadness, which fails to follow norms
3.
A perceived lack of control over a current loss situation
4.
Aloneness perceived as imposed by others and as a negative or threatening state
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 11.
A nurse is leading a bereavement group. Which of following members of the
group should the nurse identify as being at high risk for complicated grieving? (Select all that
apply.)
1.
A widower who has recently experienced the death of two good friends
2.
A man whose wife died suddenly after a cerebrovascular accident
3.
A widow who removed life support after her husband was in a vegetative state for a
year
4.
A woman who had a competitive relationship with her recently deceased brother
5.
A young couple whose child recently died of a genetic disorder
____ 12.
An instructor is teaching nursing students about Worden’s grief process.
According to Worden, which of the following client behaviors would delay or prolong the
grieving process? (Select all that apply.)
1.
Refusing to allow oneself to think painful thoughts
2.
Indulging in the pain of loss
3.
Using alcohol and drugs
4.
Idealizing the object of loss
5.
Recognizing that time will heal
____ 13.
Which of the following types of care should the interdisciplinary team of hospice
provide? (Select all that apply.)
1.
Physical care available on a 24/7 basis
2.
Counseling on the addictive properties of pain-management medications
3.
Discussions related to death and dying
4.
Explorations of new aggressive treatments
5.
Assistance with obtaining spiritual support and guidance
Other
14.
Order the stages of normal grief, according to John Bowlby.
________ Reorganization
________ Disequilibrium
________ Disorganization and despair
________ Numbness/protest
15.
Order the stages of normal grief, according to J. William Worden.
________ Finding an enduring connection with the lost entity in the mist of embarking on a new
life
________ Accepting the reality of the loss
________ Adjusting to a world without the lost entity
________ Processing the pain of grief
Completion
Complete each statement.
16.
______________________ grieving is the experiencing of the feelings and
emotions associated with the normal grief response before the loss actually occurs. Chapter
0: The Bereaved Individual
Answer Section
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler-Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 759
Heading: Theoretical Perspectives on Loss and Bereavement > Elisabeth Kübler-Ross
Integrated Processes: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
This is stage one, or denial.
The nurse should assess that the client is in the “anger” stage of grieving when the
client refuses to attend church and states that his faith has failed him. Anger is the
second stage of Kübler-Ross’s grief process, in which the reality of the situation is
realized, and the individual has feelings of sadness, guilt, shame, helplessness, and
hopelessness.
This is the bargaining stage.
This is stage five, or acceptance.
CON: Grief and Loss
2.
ANS: 2
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 760
Heading: Theoretical Perspectives on Loss and Bereavement > George Engel
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
These rituals do not serve to delay the recovery process initiated by the loss of the
client’s wife.
The nurse should anticipate that the purpose of these rituals is to facilitate the
acceptance of the loss of the client’s wife. Resolution of the loss is the fourth stage
in Engel’s grief process, in which the bereaved experiences a preoccupation with
the loss, which gradually decreases over time.
These rituals do not serve to avoid dealing with grief associated with the loss of
the client’s wife.
These rituals do not serve to eliminate emotional pain related to the loss of the
client’s wife.
CON: Grief and Loss
3.
ANS: 1
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 760
Heading: Theoretical Perspectives on Loss and Bereavement > J. William Worden
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should anticipate that this intervention could hinder the woman from
continuing a relationship with her infant. The first task in Worden’s grief process is
to accept the reality of the loss. It is common for individuals to refuse to believe
that the loss has occurred.
This intervention could complicate the grieving process.
The intervention could isolate the women from others.
This intervention could prevent the women from grieving the loss and moving
forward.
PTS: 1
CON: Grief and Loss
4.
ANS: 4
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss grieving behaviors common to individuals at various stages across the life
span.
Page: 764–765
Heading: Application of the Nursing Process > Adolescents
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not expect denial of personal mortality.
The nurse would not expect preoccupation with the loss.
The nurse would not expect clinging behaviors and personal insecurity.
The school nurse should anticipate that the teenager will exhibit aggression and
acting out. Adolescents have the ability to understand death on an adult level yet
have difficulty tolerating the intense feelings associated with the death of a loved
one. It is often easier for adolescents to talk with peers about feelings than with
other adults.
CON: Grief and Loss
5.
ANS: 1
Chapter: Chapter 0: The Bereaved Individual
Objective: Describe customs associated with grief in individuals of various cultures.
Page: 765–766
Heading: Application of the Nursing Process > African Americans
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
Feedback
The nurse should use the term falling out to describe a sudden physical collapse
and paralysis in the African American culture. The individuals may also
experience an inability to see or speak yet maintain hearing and understanding.
“Body rocking” in the Vietnamese American culture does not include a sudden
physical collapse and paralysis.
“Conversion disorder” in the Jewish American culture does not include a sudden
physical collapse and paralysis.
“Spirit possession” in the Native American culture does not include a sudden
physical collapse and paralysis.
1
2
3
4
PTS: 1
Feedback
The nurse should use the term falling out to describe a sudden physical collapse
and paralysis in the African American culture. The individuals may also
experience an inability to see or speak yet maintain hearing and understanding.
“Body rocking” in the Vietnamese American culture does not include a sudden
physical collapse and paralysis.
“Conversion disorder” in the Jewish American culture does not include a sudden
physical collapse and paralysis.
“Spirit possession” in the Native American culture does not include a sudden
physical collapse and paralysis.
CON: Grief and Loss
6.
ANS: 2
Chapter: Chapter 0, The Bereaved Individual
Objective: Describe customs associated with grief in individuals of various cultures.
Page: 767
Heading: Application of the Nursing Process > Native Americans
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nurse would not anticipate that the client will celebrate the life of a deceased
person with festivities and revelry.
The nurse should identify that a Navajo client who recently lost a child would not
express grief openly and would be reluctant to touch the dead body. Navajo
Indians do not bury the body of a deceased person for four days after death, and
they conduct a cleaning ceremony prior to burial. The dead are buried with their
shoes on the wrong feet and rings on their index fingers.
The nurse would not anticipate that the client will hold a prayerful vigil for a week
following the person’s death.
The nurse would not anticipate that the client will express grief openly and
publicly and erecting an altar in the home to honor the dead.
CON: Grief and Loss
7.
ANS: 1
Chapter: Chapter 0, The Bereaved Individual
Objective: Describe customs associated with grief in individuals of various cultures.
Page: 766
Heading: Application of the Nursing Process > Chinese Americans
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The nursing instructor should evaluate that more instruction is needed if a student
states that the color red is associated with death and bad luck in the Chinese
culture. Chinese Americans consider the color white as associated with death and
is considered bad luck. Red is the ultimate color of luck in this culture.
Stating “In this culture, there is an innate fear of death” is not accurate regarding
the Chinese American.
Stating “In this culture, emotions are not expressed openly” is not accurate
regarding the Chinese American.
Stating “In this culture, death and bereavement are centered on ancestor worship”
is not accurate regarding the Chinese American.
CON: Grief and Loss
8.
ANS: 3
Chapter: Chapter 0 The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 759
Heading: Theoretical Perspectives on Loss and Bereavement > John Bowlby
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
Feedback
Accomplishing the recovery stage of grief by year one may not be appropriate for
this client.
The reorganization stage of grieving is the final stage in which the individual
accepts the loss and new goals and patterns are established.
The nurse should identify that, according to Bowlby, an appropriate long-term
outcome for this client is to accomplish the reorganization stage of grief by year
one. Until the client can recognize and accept personal feelings regarding the loss,
grief work cannot progress.
Accomplishing the emotional relocation stage of grief by year one may not be
realistic for this client.
PTS: 1
CON: Grief and Loss
9.
ANS: 3
Chapter: Chapter 0: The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 759
Heading: Theoretical Perspectives on Loss and Bereavement > John Bowlby
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
The widow is not in Stage I: Numbness or protest.
The widow is not in Stage II: Disequilibrium.
The nurse should identify that this client is in the third stage of Bowlby’s grief
process, called disorganization and despair. This stage is characterized by feelings
of despair in response to the realization that the loss has occurred. The individual
experiences helplessness, fear, and hopelessness. Perceptions of visualizing or
being in the presence of the lost one may occur.
The widow is not in Stage IV: Reorganization.
CON: Grief and Loss
10.
ANS: 2
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 762–763
Heading: Maladaptive Responses to Loss> Distorted (Exaggerated) Grief Response
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1
2
3
Feedback
Inability to form a valid appraisal of a loss and to use available resources is not the
most accurate description of the nursing diagnosis of dysfunctional grieving.
The nurse should define dysfunctional grieving as the experience of distress, with
accompanying sadness, which fails to follow norms. Three types of pathological
grief reactions are delayed or inhibited grief, distorted (exaggerated) grief
response, and chronic or prolonged grieving. One crucial difference between
normal and dysfunctional grieving is the loss of self-esteem marked my feelings of
guilt or worthlessness that may precipitate depression.
A perceived lack of control over a current loss situation is not the most accurate
1
2
3
4
PTS: 1
Feedback
Inability to form a valid appraisal of a loss and to use available resources is not the
most accurate description of the nursing diagnosis of dysfunctional grieving.
The nurse should define dysfunctional grieving as the experience of distress, with
accompanying sadness, which fails to follow norms. Three types of pathological
grief reactions are delayed or inhibited grief, distorted (exaggerated) grief
response, and chronic or prolonged grieving. One crucial difference between
normal and dysfunctional grieving is the loss of self-esteem marked my feelings of
guilt or worthlessness that may precipitate depression.
A perceived lack of control over a current loss situation is not the most accurate
description of the nursing diagnosis of dysfunctional grieving.
Aloneness perceived as imposed by others and as a negative or threatening state is
not the most accurate description of the nursing diagnosis of dysfunctional
grieving.
CON: Grief and Loss
MULTIPLE RESPONSE
11.
ANS: 1, 2, 4, 5
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 762–763
Heading: Maladaptive Responses to Loss
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should identify that individuals are at a high risk for complicated
grieving when the individual experienced a number of recent losses.
The nurse should identify that individuals are at a high risk for complicated
grieving when the bereaved person was strongly dependent on the lost entity.
Having a year to process grief while her husband was in a vegetative state would
reduce the widow’s risk for the problem of complicated grieving.
The nurse should identify that individuals are at a high risk for complicated
grieving when, the relationship with the lost entity was highly ambivalent.
The nurse should identify that individuals are at a high risk for complicated
grieving when the loss is that of a young person.
CON: Grief and Loss
12.
ANS: 1, 3, 4
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 760–761
Heading: Theoretical Perspectives on Loss and Bereavement > J. William Worden
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should identify that refusing to allow oneself to think painful thoughts
will delay or prolong the grieving process.
Indulging in the pain of loss will not delay the grieving process.
The nurse should identify that using alcohol and drugs will delay or prolong the
grieving process.
The nurse should identify that idealizing the object of loss will delay or prolong
the grieving process.
Recognizing that time will heal does not delay the grieving process.
CON: Grief and Loss
13.
ANS: 1, 3, 5
Chapter: Chapter 0, The Bereaved Individual
Objective: Describe the concept of hospice care for people who are dying and their families
Page: 770
Heading: Additional Assistance > Hospice
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The nurse should identify that the interdisciplinary team of hospice provides
physical care available on a 24/7 basis.
The interdisciplinary team of hospice does not provide counseling on the addictive
properties of pain-management medications.
The nurse should identify that the interdisciplinary team of hospice provides
discussions related to death and dying.
The interdisciplinary team of hospice does not provide explorations of new
aggressive treatments.
The nurse should identify that the interdisciplinary team of hospice provides
assistance with obtaining spiritual support and guidance.
1.
2.
3.
4.
5.
PTS: 1
Feedback
The nurse should identify that the interdisciplinary team of hospice provides
physical care available on a 24/7 basis.
The interdisciplinary team of hospice does not provide counseling on the addictive
properties of pain-management medications.
The nurse should identify that the interdisciplinary team of hospice provides
discussions related to death and dying.
The interdisciplinary team of hospice does not provide explorations of new
aggressive treatments.
The nurse should identify that the interdisciplinary team of hospice provides
assistance with obtaining spiritual support and guidance.
CON: Grief and Loss
ORDERED RESPONSE
14.
ANS:
The correct order is 4, 2, 3, 1
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 759
Heading: Theoretical Perspectives on Loss and Bereavement > John Bowlby
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Moderate
Feedback: John Bowlby hypothesized four stages in the grief process. He implies that these
behaviors can be observed in all individuals who have experienced the loss of something or
someone of value, even in babies as young as 6 months of age.
1. Numbness/protest
2. Disequilibrium
3. Disorganization and despair
4. Reorganization
PTS: 1
CON: Grief and Loss
15.
ANS:
The correct order is 4, 1, 3, 2.
Chapter: Chapter 0, The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 760–761
Heading: Theoretical Perspectives on Loss and Bereavement > J. William Worden
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Moderate
Feedback: Worden views the bereaved person as active and self-determining rather than a
passive participant in the grief process. He proposes that bereavement includes a set of tasks that
must be reconciled in order to complete the grief process.
1. Accepting the reality of the loss
2. Processing the pain of grief
3. Adjusting to a world without the lost entity
4. Finding an enduring connection with the lost entity in the mist of embarking on a new life
PTS: 1
CON: Grief and Loss
COMPLETION
16.
ANS:
Anticipatory
Chapter: Chapter 0 The Bereaved Individual
Objective: Discuss theoretical perspectives of grieving as proposed by Elisabeth Kübler- Ross,
John Bowlby, George Engel, and J. William Worden.
Page: 762
Heading: Anticipatory Grief
Integrated Process: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
Feedback: Anticipatory grieving is the experiencing of the feelings and emotions associated with
the normal grief response before the loss actually occurs. Anticipatory grieving may serve as a
defense for some individuals to ease the burden of loss when it actually occurs.
PTS: 1
CON: Grief and Loss
Chapter 37. Military Families
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
Approximately two million American children have experienced the deployment
of a parent to Iraq or Afghanistan. How many of these children either lost a parent or have a
parent who was wounded in these conflicts?
1.
48,000
2.
26,000
3.
11,000
4.
8,000
1.
2.
3.
4.
48,000
26,000
11,000
8,000
____ 2.
Research has shown that an adolescent (13 to 18 years) would typically exhibit
which behavior as a reaction to parental military deployment?
1.
May exhibit regressive behaviors and assume blame for parent’s departure
2.
May become sullen, tearful, throw temper tantrums, or develop sleep problems
3.
May participate in high-risk behaviors, sexual acting out, and drug or alcohol abuse
4.
May respond to schedule disruptions with irritability and/or apathy and weight loss
____ 3.
What is the expected feeling and/or behavior experienced by military families
during the “sustainment” cycle of deployment, as described by Pincus and associates?
1.
Feelings alternate between denial and anticipation of loss
2.
Feelings alternate between excitement and apprehension associated with
homecoming
3.
Feelings focus on the establishment of new support systems and new family
routines
4.
Feelings focus on the struggle to take charge of the details of the new family
structure
____ 4.
A nursing instructor is teaching about suicide among active duty military. Which
fact should the instructor include in the lesson plan?
1.
On average, two suicides per day occur in the U.S. military.
2.
From 2005 to 2009, relationship distress factored in more than 25 percent of Army
suicides.
3.
Statistically, in 2012, suicide rates of service members surpassed the number killed
in combat.
4.
Military suicides are associated with a narcissistic personality disorder diagnosis.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 5.
A nursing instructor is preparing a lesson plan related to the history of the
diagnosis of PTSD. Which of the following facts would be appropriate to include? (Select all
that apply.)
1.
Between 1950 and 1970, little was written about PTSD.
2.
During the 1970s and 1980s, there was a major increase in research on PTSD.
3.
During the 1970s and 1980s, much research was related to World War II veterans.
4.
PTSD did not appear until the third edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-III).
5.
PTSD did not appear until the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV).
1.
2.
3.
4.
5.
Between 1950 and 1970, little was written about PTSD.
During the 1970s and 1980s, there was a major increase in research on PTSD.
During the 1970s and 1980s, much research was related to World War II veterans.
PTSD did not appear until the third edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-III).
PTSD did not appear until the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV).
____ 6.
Which of the following should a nurse identify as stressors in the lives of military
spouses and children? (Select all that apply.)
1.
Frequent moves
2.
School credit transfer issues
3.
Complications of spousal employment
4.
Spousal loneliness
5.
Loss of military privileges during spousal deployment
____ 7.
Owing to the unique challenges experienced by children of active duty military,
which of the following fears would a nurse most likely identify? (Select all that apply.)
1.
Fear of not being accepted in new schools
2.
Fear of being behind academically
3.
Fear of not making friends in new schools
4.
Fear of losing athletic standing
5.
Fear of discrimination from new school faculty
____ 8.
After reporting a sexual assault, a female soldier is diagnosed with a personality
disorder. Which of the following consequences may result? (Select all that apply.)
1.
Court-martial proceedings
2.
Loss of health-care benefits
3.
Loss of service-related disability compensation
4.
Stigma of a psychiatric diagnosis
5.
Service discharge
Completion
Complete each statement.
9.
Members of various components of the National Guard and U.S. Military
Reserves are classified as the _________________________ _______________________.
10.
An association between Parkinson’s disease and combat-related TBI has been
established. This disorder may develop years after TBI as a result of damage to the
_________________________ _______________________.
Chapter 0: Military Families
Answer Section
MULTIPLE CHOICE
1.
ANS: 1
Chapter: Chapter 0, Military Families
Objective: Discuss historical aspects and epidemiological statistics related to members of the U.S
military.
Page: 780
Heading: Application of the Nursing Process>Assessment>The Impact of Deployment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
More than 48,000 children have either lost a parent or have a parent who was
wounded in Iraq or Afghanistan.
The number 26,000 does not indicate how many children either lost a parent or
have a parent who was wounded in these conflicts.
The number 11,000 does not indicate how many children either lost a parent or
have a parent who was wounded in these conflicts.
The number 8,000 does not indicate how many children either lost a parent or have
a parent who was wounded in these conflicts.
CON: Family Dynamics
2.
ANS: 3
Chapter: Chapter 0, Military Families
Objective: Discuss historical aspects and epidemiological statistics related to members of the U.S
military.
Page: 780
Heading: Application of the Nursing Process>Assessment>The Impact of Deployment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1
2
3
Feedback
Preschoolers (3 to 6 years) may regress in areas such as toilet training, sleep,
separation fears, physical complaints, or thumb sucking and may assume blame for
parent’s departure. School age children (6 to 12 years) are more aware of potential
dangers to parent, and may exhibit irritable behavior, aggression, or whininess,
and become more regressed and fearful about parent’s safety.
Toddlers (1 to 3 years) may become sullen, tearful, throw temper tantrums, or
develop sleep problems.
Adolescents (13 to 18 years) may be rebellious, irritable, or more challenging of
1
2
3
4
PTS: 1
Feedback
Preschoolers (3 to 6 years) may regress in areas such as toilet training, sleep,
separation fears, physical complaints, or thumb sucking and may assume blame for
parent’s departure. School age children (6 to 12 years) are more aware of potential
dangers to parent, and may exhibit irritable behavior, aggression, or whininess,
and become more regressed and fearful about parent’s safety.
Toddlers (1 to 3 years) may become sullen, tearful, throw temper tantrums, or
develop sleep problems.
Adolescents (13 to 18 years) may be rebellious, irritable, or more challenging of
authority. Parents need to be alert to high-risk behaviors, such as problems with
the law, sexual acting out, and drug or alcohol abuse.
Infants (birth to 12 months) may respond to schedule disruptions with irritability
and/or apathy and weight loss.
CON: Family Dynamics
3.
ANS: 3
Chapter: Chapter 0, Military Families
Objective: Discuss the impact of deployment on families of service members.
Page: 780
Heading: Application of the Nursing Process > The Military Family>The Impact of Deployment
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
In the predeployment cycle, feelings alternate between denial and anticipation of
loss.
In the redeployment cycle, feelings alternate between excitement and
apprehension associated with homecoming.
In the sustainment cycle, families establish new support systems and new family
routines.
In the deployment cycle, the spouse struggles to take charge of the details of living
without his or her partner.
CON: Family Dynamics
4.
ANS: 3
Chapter: Chapter 0 Military Families
Objective: Discuss the impact of deployment on families of service members.
Page: 785
Heading: Veterans > Depression and Suicide
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1
2
3
4
PTS: 1
Feedback
On average, one—not two—suicides a day occur in the U.S. military.
From 2005 to 2009, relationship distress factored in more than 50 percent—not 25
percent—of Army suicides.
Statistically, in 2012, suicide rates of service members surpassed the number killed
in combat.
Military suicides are associated with the diagnoses of substance use disorder,
major depressive disorder, posttraumatic stress disorder (PTSD), and traumatic
brain injury (TBI), not narcissistic personality disorder.
CON: Family Dynamics
MULTIPLE RESPONSE
5.
ANS: 1, 2, 4
Chapter: Chapter 0 Military Families
Objective: Describe combat related illnesses common in members and veterans of the U.S.
military.
Page: 784–785
Heading: Application of the Nursing Process>Veterans > Posttraumatic Stress Disorder
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
Very little was written about PTSD during the years between 1950 and 1970.
This absence was followed in the 1970s and 1980s with an explosion in the
amount of research and writing on the subject.
During this time, much research was related to Vietnam, not World War II
veterans.
PTSD did not appear until the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III).
PTSD appeared in the third edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-III).
PTS: 1
CON: Family Dynamics
6.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Military Families
Objective: Discuss the impact of deployment on families of service members.
Page: 779
Heading: Application of the Nursing Process > The Military Family
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
5.
PTS: 1
Feedback
The lives of military spouses and children are clearly affected when the servicemember’s active duty assignments require frequent family moves.
The lives of military spouses and children are clearly affected when the servicemember’s active duty assignments require frequent family moves. These include
school credit transfer issues.
The lives of military spouses and children are clearly affected when the servicemember’s active duty assignments require frequent family moves. These include
complications of spousal employment.
The lives of military spouses and children are clearly affected when the servicemember’s active duty assignments require frequent family moves. These include
spousal loneliness.
Military privileges are not lost during spousal deployment.
CON: Family Dynamics
7.
ANS: 1, 2, 3, 4
Chapter: Chapter 0, Military Families
Objective: Discuss the impact of deployment on families of service members.
Page: 780
Heading: Application of the Nursing Process > The Military Family
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
Feedback
Military children face unique challenges. They fear not being accepted.
Military children face unique challenges. They fear being behind academically.
Military children face unique challenges. They fear not making friends.
Military children face unique challenges. They fear losing athletic standing as
they move from one school to another.
1.
2.
3.
4.
5.
Feedback
Military children face unique challenges. They fear not being accepted.
Military children face unique challenges. They fear being behind academically.
Military children face unique challenges. They fear not making friends.
Military children face unique challenges. They fear losing athletic standing as
they move from one school to another.
Fear of discrimination from new school faculty has not been shown as a realistic
fear in this population.
PTS: 1
CON: Family Dynamics
8.
ANS: 2, 3, 4, 5
Chapter: Chapter 0, Military Families
Objective: Discuss concerns of women in the military.
Page: 781
Heading: Application of the Nursing Process > Women in the Military
Integrated Process: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
The report of a sexual assault would not lead to court-martial proceedings for the
victim.
Some military women who report their sexual assaults are discharged with a
psychiatric diagnosis of personality disorder or adjustment disorder. Some of the
consequences of this diagnosis are loss of health-care benefits.
Some military women who report their sexual assaults are discharged with a
psychiatric diagnosis of personality disorder or adjustment disorder. Some of the
consequences of this diagnosis are loss of service-related disability compensation.
Some military women who report their sexual assaults are discharged with a
psychiatric diagnosis of personality disorder or adjustment disorder. Some of the
consequences of this diagnosis are the stigma of a psychiatric diagnosis.
Some military women who report their sexual assaults are discharged with a
psychiatric diagnosis of personality disorder or adjustment disorder.
PTS: 1
CON: Family Dynamics
COMPLETION
9.
Ready Reserve
ANS:
Chapter: Chapter 0, Military Families
Objective: Describe the lifestyle of career military families.
Page: 778
Heading: Epidemiological Statistics
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
Feedback: More than 1 million men and women make up the U.S. Military “Ready Reserve,”
who are members of various components of the National Guard and U.S. Military Reserves.
PTS: 1
CON: Family Dynamics
10.
ANS:
basal ganglia
Chapter: Chapter 0, Military Families
Objective: Discuss various modalities relevant to treatment of traumatic brain injury and
posttraumatic stress disorder.
Page: 783
Heading: Treatment Modalities > Traumatic Brain Injury
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
Feedback: Neurocognitive disorders, such as Parkinson’s disease are related to TBI.
PTS: 1
CON: Family Dynamics
Chapter 38. Theoretical Models of Personality Development
1. During an assessment interview, a client diagnosed with antisocial personality
disorder spits, curses, and refuses to answer questions. Which is the appropriate
nursing response to this behavior?
•
You are very disrespectful. You need to learn to control yourself.
•
I understand that you are angry, but this behavior will not be tolerated.
•
What behaviors could you modify to improve this situation?
•
What anti-personality disorder medications have helped you in the past?
ANS: 2
Rationale: The appropriate nursing response is to reflect the clients feeling while setting
firm limits on behavior. Clients diagnosed with antisocial personality disorder have a
low tolerance for frustration, see themselves as victims, and use projection as a primary
ego defense mechanism.
Cognitive Level:
Application Integrated
Process: Implementation
2. At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to
phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted
after 10:00 p.m. Which nursing response is most appropriate?
•
Go ahead and use the phone. I know this pending divorce is stressful.
•
You know better than to break the rules. Im surprised at you.
•
It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow.
•
A divorce shouldnt be considered until you have had a good nights sleep.
ANS: 3
Rationale: The most appropriate response by the staff is to restate the unit rules in a
calm, assertive manner. The nurse can encourage the client to verbalize frustration while
maintaining an accepting attitude. The nurse may also help the client to identify the true
source of frustration.
Cognitive Level:
Application Integrated
Process: Implementation
3. A client diagnosed with paranoid personality disorder becomes violent on a unit.
Which nursing intervention is most appropriate?
•
Provide objective evidence that reasons for violence are unwarranted.
•
Initially restrain the client to maintain safety.
•
Use clear, calm statements and a confident physical stance.
•
Empathize with the clients paranoid perceptions.
ANS: 3
Rationale: The most appropriate nursing intervention is to use clear, calm statements and
to assume a confident physical stance. A calm attitude provides the client with a feeling
of safety and security. It may also be beneficial to have sufficient staff on hand to
present a show of strength.
Cognitive Level:
Application Integrated
Process: Implementation
4. A client diagnosed with borderline personality disorder brings up a conflict with the
staff in a community meeting and develops a following of clients who unreasonably
demand modification of unit rules. How can the nursing staff best handle this situation?
•
Allow the clients to apply the democratic process when developing unit rules.
•
Maintain consistency of care by open communication to avoid staff manipulation.
•
Allow the client spokesman to verbalize concerns during a unit staff meeting.
•
Maintain unit order by the application of autocratic leadership.
ANS: 2
Rationale: The nursing staff can best handle this situation by maintaining consistency
of care by open communication to avoid staff manipulation. Clients with borderline
personality disorder can exhibit negative patterns of interaction, such as clinging and
distancing, splitting, manipulation, and self-destructive behaviors.
Cognitive Level:
Application Integrated
Process: Implementation
•
•
Which nursing approach should be used to maintain a therapeutic
relationship with a client diagnosed with borderline personality disorder?
Being firm, consistent, and empathic, while addressing specific client behaviors
•
Promoting client self-expression by implementing laissez-faire leadership
•
Using authoritative leadership to help clients learn to conform to society norms
•
Overlooking inappropriate behaviors to avoid providing secondary gains
ANS: 1
Rationale: The best nursing approach when working with a client diagnosed with
borderline personality disorder is to be firm, consistent, and empathetic while addressing
specific client behaviors. Individuals with borderline personality disorder always seem
to be in a state of crisis and can often have negative patterns of interaction, such as
manipulation and splitting.
Cognitive Level:
Application Integrated
Process: Implementation
6. Which adult client should a nurse identify as exhibiting the characteristics of a
dependent personality disorder?
•
A physically healthy client who is dependent on meeting social needs by contact with 15
cat
•
A physically healthy client who has a history of depending on intense
relationships to meet basic needs
A physically healthy client who lives with parents and depends on public transportation
•
•
A physically healthy client who is serious, inflexible, perfectionistic, lacks
spontaneity, and depends on rules to provide security
ANS: 3
Rationale: A physically healthy adult client who lives with parents and depends on public
transportation exhibits signs of dependent personality disorder. Dependent personality disorder is
characterized by a pervasive and excessive need to be taken care of that leads to submissive and
clinging behaviors.
Cognitive Level:
Application Integrated
Process: Assessment
7. A client expresses low self-worth, has much difficulty making decisions, avoids positions of
responsibility, and has a behavioral pattern of suffering in silence. Which statement best explains
the etiology of this clients personality disorder?
•
Childhood nurturance was provided from many sources, and independent
behaviors were encouraged.
•
•
•
Childhood nurturance was provided exclusively from one source, and
independent behaviors were discouraged.
Childhood nurturance was provided exclusively from one source, and
independent behaviors were encouraged.
Childhood nurturance was provided from many sources, and independent
behaviors were discouraged.
Ans: 2
Rationale: The behaviors presented in the question represent symptoms of dependent
personality disorder. Nurturance provided from one source and discouragement of
independent behaviors can contribute to the development of this personality disorder.
Dependent behaviors may be rewarded by a parent who is overprotective and
discourages autonomy.
Cognitive Level:
Analysis Nursing
Process: Assessment
8. Family members of a client ask the nurse to explain the difference between schizoid
and avoidant personality disorders. Which is the appropriate nursing response?
•
Clients diagnosed with avoidant personality disorder desire intimacy but fear
it, and clients diagnosed with schizoid personality disorder prefer to be alone.
•
Clients diagnosed with schizoid personality disorder exhibit delusions and
hallucinations, while clients diagnosed with avoidant personality disorder
do not.
•
Clients diagnosed with avoidant personality disorder are eccentric, and clients
diagnosed with schizoid personality disorder are dull and vacant.
•
Clients diagnosed with schizoid personality disorder have a history of psychosis,
while clients diagnosed with avoidant personality disorder remain based in
reality.
Ans: 1
Rationale: The nurse should educate the family that clients diagnosed with avoidant
personality disorder desire intimacy but fear it, while clients diagnosed with schizoid
personality disorder prefer to be alone. Schizoid personality disorder is characterized
by a profound deficit in the ability to form personal relationships. Clients diagnosed
with schizoid personality disorder may exhibit odd and eccentric behaviors but not to
the extent of psychosis.
Cognitive Level:
Analysis Nursing
Process: Assessment
9. Which nursing diagnosis should a nurse identify as appropriate when working with a
client diagnosed with schizoid personality disorder?
•
Altered thought processes R/T increased stress
•
Risk for suicide R/T loneliness
•
Risk for violence: directed toward others R/T paranoid thinking
•
Social isolation R/T inability to relate to others
ANS: 4
Rationale: An appropriate nursing diagnosis when working with a client diagnosed with
schizoid personality disorder is social isolation R/T inability to relate to others. Clients
diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to
others. They prefer to work in isolation and are not sociable.
Cognitive Level:
Analysis Integrated
Process: Diagnosis
10. Looking at a slightly bleeding paper cut, the client screams, Somebody help me
quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of
which personality disorder?
•
Schizoid personality disorder
•
Obsessive-compulsive personality disorder
•
Histrionic personality disorder
•
Paranoid personality disorder
ANS: 3
Rationale: The nurse should identify this behavior as characteristic of histrionic
personality disorder. Individuals with this disorder tend to be self-dramatizing, attention
seeking, over gregarious, and seductive.
Cognitive Level:
Analysis Integrated
Process: Evaluation
11. When planning care for a client diagnosed with borderline personality disorder,
which self- harm behavior should a nurse expect the client to exhibit?
•
The use of highly lethal methods to commit suicide
•
The use of suicidal gestures to elicit a rescue response from others
•
The use of isolation and starvation as suicidal methods
•
The use of self-mutilation to decrease endorphins in the body
ANS: 2
Rationale: The nurse should expect that a client diagnosed with borderline personality
disorder may use suicidal gestures to elicit a rescue response from others. Repetitive,
self-mutilating behaviors are common in borderline personality disorders that result
from feelings of abandonment following separation from significant others.
Cognitive Level:
Application
Integrated Process:
Planning
12. A nurse tells a client that the nursing staff will start alternating weekend shifts.
Which response should a nurse identify as characteristic of clients diagnosed with
obsessive-compulsive personality disorder?
•
You really dont have to go by that schedule. Id just stay home sick.
•
There has got to be a hidden agenda behind this schedule change.
•
Who do you think you are? I expect to interact with the same nurse every Saturday.
•
You cant make these kinds of changes! Isnt there a rule that governs this decision?
ANS: 4
Rationale: The nurse should identify that a client with obsessive-compulsive personality disorder
would have a difficult time accepting changes. This disorder is characterized by inflexibility and
lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined,
perfectionistic, and preoccupied with rules.
Cognitive Level:
Application Integrated
Process: Assessment
13. Which reaction to a compliment from another client should a nurse identify as a
typical response from a client diagnosed with avoidant personality disorder?
•
Interpreting the compliment as a secret code used to increase personal power
•
Feeling the compliment was well deserved
•
Being grateful for the compliment but fearing later rejection and humiliation
•
Wondering what deep meaning and purpose is attached to the compliment
ANS: 3
Rationale: The nurse should identify that a client diagnosed with avoidant personality
disorder would be grateful for the compliment but would fear later rejection and
humiliation. Individuals diagnosed with avoidant personality disorder are extremely
sensitive to rejection and are often awkward and uncomfortable in social situations.
Cognitive Level:
Application
Integrated Process:
Evaluation
14. Which factors differentiate a client diagnosed with social phobia from a client
diagnosed with schizoid personality disorder?
•
Clients diagnosed with social phobia are treated with cognitive behavioral
therapy, whereas clients diagnosed with schizoid personality disorder need
medications.
•
Clients diagnosed with schizoid personality disorder experience anxiety only in
social settings, whereas clients diagnosed with social phobia experience
generalized anxiety.
•
Clients diagnosed with social phobia avoid attending birthday parties,
whereas clients diagnosed with schizoid personality disorder would
isolate self on a continual basis.
•
Clients diagnosed with schizoid personality disorder avoid attending birthday
parties, whereas clients diagnosed with social phobia would isolate self on a
continual basis.
ANS: 3
Rationale: A client diagnosed with schizoid personality disorder exhibits a profound
deficit in the ability to form personal relationships. Clients diagnosed with schizoid
personality disorder prefer being alone to being with others and avoid social situations,
social contacts, and activities.
Cognitive Level: Analysis
Integrated Process:
Assessment
15. Which client symptoms should lead a nurse to suspect a diagnosis of obsessivecompulsive personality disorder?
•
The client experiences unwanted, intrusive, and persistent thoughts.
•
The client experiences unwanted, repetitive behavior patterns.
•
The client experiences inflexibility and lack of spontaneity when dealing with others.
•
The client experiences obsessive thoughts that are externally imposed.
ANS: 3
Rationale: The nurse should suspect a diagnosis of obsessive-compulsive personality
disorder when a client experiences inflexibility and lack of spontaneity. Individuals
with this disorder are very serious, formal, and have difficulty expressing emotions.
They are perfectionistic and preoccupied with rules.
Cognitive Level:
Application Integrated
Process: Assessment
16. Which client is a nurse most likely to admit to an inpatient facility for selfdestructive behaviors?
•
A client diagnosed with antisocial personality disorder
•
A client diagnosed with borderline personality disorder
•
A client diagnosed with schizoid personality disorder
•
A client diagnosed with paranoid personality disorder
ANS: 2
Rationale: The nurse should expect that a client diagnosed with borderline personality
disorder would be most likely to be admitted to an inpatient facility for self-destructive
behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilating
behaviors. Most gestures are designed to elicit a rescue response.
Cognitive Level:
Application Integrated
Process: Assessment
17. When planning care for clients diagnosed with personality disorders, what should be
the goal of treatment?
•
To stabilize the clients pathology by using the correct combination of
psychotropic medications
•
To change the characteristics of the dysfunctional personality
•
To reduce personality trait inflexibility that interferes with functioning and relationships
•
To decrease the prevalence of neurotransmitters at receptor sites
ANS: 3
Rationale: The goal of treatment for clients diagnosed with personality disorders should
be to reduce inflexibility of personality traits that interfere with functioning and
relationships.
Personality disorders are often difficult and, in some cases, seem impossible to treat.
There are no psychotropic medications approved specifically for the treatment of
personality disorders.
Cognitive Level:
Application
Integrated Process:
Planning
18. Which client situation would reflect the impulsive behavior that is commonly associated with
borderline personality disorder?
•
As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm
and whispers, The night nurse is evil. You have to stay.
•
As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm
and states, I will be up all night if you dont stay with me.
•
As the day-shift nurse leaves the unit, the client suddenly hugs the nurses arm,
yelling, Please dont go! I cant sleep without you being here.
•
As the day-shift nurse leaves the unit, the client suddenly shows the nurse a
bloody arm and states, I cut myself because you are leaving me.
Ans: 4
Rationale: The client who states, I cut myself because you are leaving me reflects
impulsive behavior that is commonly associated with borderline personality disorder.
Repetitive, self- mutilating behaviors are common in clients diagnosed with borderline
personality disorders that result from feelings of abandonment following separation
from significant others.
Cognitive Level:
Application Nursing
Process: Evaluation
19. Which nursing diagnosis should be prioritized when providing nursing care
to a client diagnosed with paranoid personality disorder?
•
Risk for violence: directed toward others R/T paranoid thinking
•
Risk for suicide R/T altered thought
•
Altered sensory perception R/T increased levels of anxiety
•
Social isolation R/T inability to relate to others
Ans: 1
Rationale: The priority nursing diagnosis for a client diagnosed with paranoid
personality disorder should be risk for violence: directed toward others R/T
paranoid thinking. Clients diagnosed with paranoid personality disorder have a
pervasive distrust and suspiciousness of others that result in a constant threat
readiness. They are often tense and irritable, which increases the likelihood of
violent behavior.
Cognitive Level:
Analysis Nursing
Process: Diagnosis
20. From a behavioral perspective, which nursing intervention is appropriate when
caring for a client diagnosed with borderline personality disorder?
•
Seclude the client when inappropriate behaviors are exhibited.
•
Contract with the client to reinforce positive behaviors with unit privileges.
•
Teach the purpose of anti-anxiety medications to improve medication compliance.
•
Encourage the client to journal feelings to improve awareness of abandonment issues.
Ans: 2
Rationale: The most appropriate nursing intervention from a behavioral perspective is to
contract with the client to reinforce positive behaviors with unit privileges. Behavioral
strategies offer reinforcement for positive change.
Cognitive Level:
Application Nursing
Process: Implementation
21. A highly emotional client presents at an outpatient clinic appointment and states, My
dead husband returned to me during a sance. Which personality disorder should a nurse
associate with this behavior?
•
Obsessive-compulsive personality disorder
•
Schizotypal personality disorder
•
Narcissistic personality disorder
•
Borderline personality disorder
ANS: 2
Rationale: The nurse should associate schizotypal personality disorder with this
behavior. The behaviors of people diagnosed with schizotypal personality disorder are
odd and eccentric but do not decompensate to the level of schizophrenia.
Cognitive Level:
Application Integrated
Process: Assessment
22. A nursing instructor is teaching students about clients diagnosed with histrionic
personality disorder and the quality of their relationships. Which student statement
indicates that learning has occurred?
•
Their dramatic style tends to make their interpersonal relationships quite
interesting and fulfilling.
•
Their interpersonal relationships tend to be shallow and fleeting, serving
their dependency needs.
•
They tend to develop few relationships because they are strongly independent
but generally maintain deep affection.
•
They pay particular attention to details, which can interfere with the
development of relationships.
ANS: 2
Rationale: The instructor should evaluate that learning has occurred when the student describes
clients diagnosed with histrionic personality disorder as having relationships that are shallow and
fleeting. These types of relationships tend to serve their dependency needs.
Cognitive Level:
Application
Integrated Process:
Evaluation
23. During an interview, which client statement should indicate to a nurse a potential
diagnosis of schizotypal personality disorder?
•
I dont have a problem. My family is inflexible, and relatives are out to get me.
•
I am so excited about working with you. Have you noticed my new nail polish, Ruby Red
Roses?
•
I spend all my time tending my bees. I know a whole lot of information about bees.
•
I am getting a message from the beyond that we have been involved with
each other in a previous life.
ANS: 4
Rationale: The nurse should assess that a client who states that he or she is getting a
message from beyond indicates a potential diagnosis of schizotypal personality
disorder. Individuals with schizotypal personality disorder are aloof and isolated and
behave in a bland and apathetic manner. The person experiences magical thinking,
ideas of reference, illusions, and depersonalization as part of daily life.
Cognitive Level:
Application Integrated
Process: Assessment
24. Which nursing diagnosis should be prioritized when providing nursing care to a
client diagnosed with avoidant personality disorder?
•
Risk for violence: directed toward others R/T paranoid thinking
•
Risk for suicide R/T altered thought
•
Altered sensory perception R/T increased levels of anxiety
•
Social isolation R/T inability to relate to others
ANS: 4
Rationale: The priority nursing diagnosis for a client diagnosed with avoidant
personality disorder should be social isolation R/T inability to relate to others. These
clients avoid close or romantic relationships, interpersonal attachments, and intimate
sexual relationships.
Cognitive Level: Analysis
Integrated Process:
Diagnosis
Multiple Response
25. A nurse is admitting a client with a new diagnosis of a personality disorder. Which of
the following would make the nurse question this diagnosis? (Select all that apply.)
•
The client has been diagnosed with sickle cell anemia.
•
The client has an inflated self-appraisal and feels a sense of entitlement.
•
The client has a history of a substance use disorder.
•
The client is odd and eccentric but not delusional.
•
The client has an intellectual developmental disorder.
ANS: 1, 3, 5
Rationale: The DSM-5 states that impairments in personality functioning and the
individuals personality trait expression are not better understood as normative for the
individuals developmental stage or sociocultural environment. The impairments in
personality functioning and the individuals personality trait expression are not solely
due to the direct physiological effects of a substance (e.g., a drug of abuse, medication)
or a general medical condition (e.g., severe head trauma). The nurse would question the
diagnosis of a personality disorder in a client with sickle cell anemia, substance use
disorder, or an intellectual developmental disorder.
Cognitive Level:
Application
Integrated Process:
Evaluation
26. Which statements represent positive outcomes for clients diagnosed with narcissistic
personality disorder? (Select all that apply.)
•
The client will relate one empathetic statement to another client in group by day two.
•
The client will identify one personal limitation by day one.
•
The client will acknowledge one strength that another client possesses by day two.
•
The client will list four personal strengths by day three.
•
The client will list two lifetime achievements by discharge.
ANS: 1, 2, 3
Rationale: The nurse should determine that appropriate outcomes for a client diagnosed
with narcissistic personality disorder include relating empathetic statements to other
clients, identifying one personal limitation, and acknowledging one strength in another
client.
Narcissistic personality disorder is characterized by an exaggerated sense of self-worth,
a lack of empathy, and exploitation of others.
Cognitive Level:
Application
Integrated Process:
Planning
27. A nurse is caring for a client diagnosed with antisocial personality disorder. Which
factors should the nurse consider when planning this clients care? (Select all that apply.)
•
This client has personality traits that are deeply ingrained and difficult to modify.
•
This client needs medication to treat the underlying physiological pathology.
•
This client uses manipulation, making the implementation of treatment problematic.
•
This client has poor impulse control that hinders compliance with a plan of care.
•
This client is likely to have secondary diagnoses of substance abuse and depression.
ANS: 1, 3, 4, 5
Rationale: The nurse should consider that individuals diagnosed with antisocial
personality disorders have deeply ingrained personality traits, use manipulation, have
poor impulse control, and often have secondary diagnoses of substance abuse or
depression.
Cognitive Level:
Application
Integrated Process:
Planning
28. A client is being assessed for antisocial personality disorder. According to the
DSM-5, which of the following symptoms must the client meet in order to be assigned
this diagnosis? (Select all that apply.)
•
Ego-centrism and goal setting based on personal gratification.
•
Incapacity for mutually intimate relationships.
•
Frequent feelings of being down miserable and/or hopeless.
•
Disregard for and failure to honor financial and
other obligations. 5, Intense feelings of
nervousness, tenseness, or panic.
ANS: 1, 2, 4
Rationale: The essential features of a personality disorder are impairments in
personality (self and interpersonal) functioning and the presence of pathological
personality traits. Pathological personality traits of antagonism and disinhibition must
occur in order to meet the criteria for the diagnosis of antisocial personality disorder.
Frequent feelings of being down, miserable, and/or hopeless and intense feelings of
nervousness, tenseness, or panic are characteristics of the pathological personality trait
domain of negative affectivity. This domain is listed by the DSM-5 for the diagnosis of
borderline personality disorder, not antisocial personality disorder.
Cognitive Level:
Application Integrated
Process: Assessment
Fill-in-the-Blank
•
personality disorder is characterized by a profound defect in the ability to
form personal relationships or to respond to others in any meaningful emotional
way.
ANS: Schizoid
Rationale: Persons diagnosed with schizoid personality disorder have a profound defect
in the ability to form personal relationships or to respond to others in any meaningful
emotional way. These individuals display a life-long pattern of social withdrawal, and
their discomfort with human interaction is apparent.
Cognitive Level:
Application Integrated
Process: Assessment
•
personality disorder is characterized by colorful, dramatic, and
extraverted behavior in excitable, emotional people.
ANS: Histrionic
Rationale: Histrionic personality disorder is characterized by colorful, dramatic, and extraverted
behavior in excitable, emotional people. They have difficulty maintaining long-lasting
relationships, although they require constant affirmation of approval and acceptance from others.
Cognitive Level:
Application Integrated
Process: Assessment
•
personality disorder is characterized by a pervasive and excessive need
to be taken care of that leads to submissive and clinging behavior and fears of
separation.
ANS: Dependent
Rationale: Dependent personality disorder is characterized by a pervasive and excessive
need to be taken care of that leads to submissive and clinging behavior and fears of
separation. These characteristics are evident in the tendency to allow others to make
decisions, to feel helpless
when alone, to act submissively, to subordinate needs to others, to tolerate mistreatment
by others, to demean oneself to gain acceptance, and to fail to function adequately in
situations that require assertive or dominant behavior.
Cognitive Level:
Application Integrated
Process: Assessment
•
personality disorder is a pervasive distrust and suspiciousness of
others, such that their motives are interpreted as malevolent.
ANS: Paranoid
Rationale: Paranoid personality disorder is a pervasive distrust and suspiciousness of
others such that their motives are interpreted as malevolent. This disorder begins in early
adulthood and presents in a variety of contexts.
Chapter 39. Cultural and Spiritual Concepts Relevant to Psychiatric Mental Health Nursing
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1.
An African American youth, growing up in an impoverished neighborhood, seeks
affiliation with a black gang. Soon he is engaging in theft and assault. What cultural
consideration should a nurse identify as playing a role in this youth’s choices?
1.
Most African American homes are headed by strong, dominant father figures.
2.
Most African Americans choose to remain within their own social organization.
3.
Most African Americans are uncomfortable expressing emotions and seek out
belonging.
4.
Most African Americans have few religious beliefs, which contributes to criminal
activity.
____ 2.
Northern European Americans value punctuality, hard work, and the acquisition
of material possessions and status. A nurse should recognize that these values may contribute to
which form of psychopathology?
1.
Dissociative disorders
2.
Alzheimer’s dementia
3.
Stress-related disorders
4.
Schizophrenia-spectrum disorders
____ 3.
A community health nurse is planning a health fair at a local shopping mall.
Which middle-class socioeconomic cultural group should the nurse anticipate would most value
preventive medicine and primary health care?
1.
2.
3.
4.
Northern European Americans
Native Americans
Latino Americans
African Americans
____ 4.
Which rationale by a nursing instructor best explains why it is challenging to
globally classify the Asian American culture?
1.
Extremes of emotional expression prevent accurate assessment of this culture.
2.
Suspicion of Western civilization has understandably resulted in minimal
participation in cultural research.
3.
The small size of this subpopulation makes research virtually impossible.
4.
The Asian American culture includes individuals from Japan, China, Vietnam,
Korea, and other countries.
____ 5.
A Latin American woman refuses to participate in an assertiveness training group.
Which cultural belief should a nurse identify as most likely to affect this client’s decision?
1.
Future orientation causes the client to devalue assertiveness skills.
2.
Decreased emotional expression makes it difficult to be assertive.
3.
Assertiveness techniques may not be aligned with the client’s definition of the
female role.
4.
Religious prohibitions prevent the client’s participation in assertiveness training.
____ 6.
A Latin American man refuses to acknowledge responsibility for hitting his wife,
stating instead, “It’s the man’s job to keep his wife in line.” Which cultural belief should a nurse
associate with this client’s behavior?
1.
That families are male-dominated, with clear male–female role distinctions
2.
That religious tenets support the use of violence in a marital context
3.
That the nuclear family is female-dominated and the mother has ultimate authority
4.
That marriage dynamics are controlled by dominant females in the family
____
avoid?
1.
2.
3.
4.
7.
____
8.
When working with clients of a particular culture, which action should a nurse
Making direct eye contact
Assuming that all individuals who share a culture or ethnic group are similar
Supporting the client in participating in cultural and spiritual rituals
Using an interpreter to clarify communication
To effectively plan care for Asian American clients, a nurse should be aware of
which cultural factor?
1.
Obesity and alcoholism are common problems.
2.
Older people maintain positions of authority within the culture.
3.
“Tai” and “chi” are the fundamental concepts of Asian health practices.
4.
Asian Americans are likely to seek psychiatric help.
____ 9.
A Native American client is admitted to an emergency department (ED) with an
ulcerated toe, secondary to uncontrolled diabetes mellitus. The client refuses to talk to a
physician unless a shaman is present. Which nursing intervention is most appropriate?
1.
Try to locate a shaman who will agree to come to the ED.
2.
Explain to the client that “voodoo” medicine will not heal the ulcerated toe.
3.
Ask the client to explain what the shaman can do that the physician cannot.
4.
Inform the client that refusing treatment is a client’s right.
____ 10.
When planning client care, which folk belief that may affect health-care practices
should a nurse identify as characteristic of the Latino American culture?
1.
The root doctor is often the first contact made when illness is encountered.
2.
The yin and yang practitioner is often the first contact made when illness is
encountered.
3.
The shaman is often the first contact made when illness is encountered.
4.
The curandero is often the first contact made when illness is encountered.
____ 11.
In what probable way should a nurse expect an Asian American client to view
mental illness?
1.
Mental illness relates to uncontrolled behaviors that bring shame to the family.
2.
Mental illness is a curse from God related to immoral behaviors.
3.
Mental illness is cured by home remedies based on superstitions.
4.
Mental illness is cured by “hot and cold” herbal remedies.
____ 12.
Which cultural considerations should a nurse identify as reflective of Western
European Americans?
1.
They are present-time oriented and perceive the future as God’s will.
2.
They value youth, and older adults are commonly placed in nursing homes.
3.
They are at high risk for alcoholism, because of a genetic predisposition.
4.
They are future oriented and practice preventive health care.
____ 13.
A nurse should recognize that clients who have a history of missed or late medical
appointments are most likely to come from which cultural group?
1.
2.
3.
4.
African Americans
Asian Americans
Native Americans
Jewish Americans
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 14.
When interviewing a client of a different culture, which of the following questions
should a nurse consider? (Select all that apply.)
1.
Would using perfume products be acceptable?
2.
Who may be expected to be present during the client interview?
3.
Should communication patterns be modified to accommodate this client?
4.
How much eye contact should be made with the client?
5.
Would hand shaking be acceptable?
____ 15.
A female nurse is caring for an Arab American male client. When planning
effective care for this client, the nurse should be aware of which of the following cultural
considerations? (Select all that apply.)
1.
Limited touch is acceptable only between members of the same sex.
2.
Conversing individuals of this culture stand far apart and do not make eye contact.
3.
Devout Muslim men may not shake hands with women.
4.
The man is the head of the household, and women take on a subordinate role.
5.
Men of this culture are responsible for the education of their children.
____ 16.
In which of the following cultural groups should a nurse expect to find assessment
of mood and affect most challenging, owing to the characteristics of the groups? (Select all that
apply.)
1.
Arab Americans
2.
Native Americans
3.
Latino Americans
4.
Western European Americans
5.
Asian Americans
____ 17.
A nursing instructor is developing a lesson plan to teach about the Northern
European American culture. Which of the following information should be included? (Select all
that apply.)
1.
About half of first marriages end in divorce in this cultural group.
2.
This cultural group does not use preventive medicine and primary health care.
3.
Punctuality and efficiency are highly valued in this cultural group.
4.
This cultural group tends to be future oriented.
5.
A typical diet of this cultural group includes rice, vegetables, and fish.
1.
2.
3.
4.
5.
About half of first marriages end in divorce in this cultural group.
This cultural group does not use preventive medicine and primary health care.
Punctuality and efficiency are highly valued in this cultural group.
This cultural group tends to be future oriented.
A typical diet of this cultural group includes rice, vegetables, and fish.
____ 18.
The United States, viewed as a “melting pot” of multiple worldwide ethnic
groups, has its own unique culture that impacts the health and care of individuals. Which of the
following are characteristics common to U.S. culture? (Select all that apply.)
1.
The culture values independence, self-reliance, and determining one’s life.
2.
There is a strong emphasis on achievement in jobs, sports, and physical beauty.
3.
Constructive criticism is considered personally offensive.
4.
The culture favors structured and formal behaviors, speech, and relationships with
others.
5.
Overconsumption of food in this culture leads to increased obesity and decreased
health.
Completion
Complete each statement.
19.
___________________ exists within each individual, regardless of belief system,
and serves as a force for interconnectedness between the self and others, the environment, and a
higher power.
MULTIPLE CHOICE
1.
ANS: 2
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Describe cultural variances, based on the six phenomena, for African Americans.
Page: 100
Heading: Application of the Nursing Process > African Americans
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
Feedback
Most African American homes are headed by strong, dominant maternal figures.
The nurse should identify that a tendency to remain within one’s own social
organization may have played a role in the youth’s choice to join a black gang.
It is incorrect that most African Americans are uncomfortable expressing
emotions.
It is incorrect that most African Americans have few religious beliefs.
1
2
3
4
PTS: 1
Feedback
Most African American homes are headed by strong, dominant maternal figures.
The nurse should identify that a tendency to remain within one’s own social
organization may have played a role in the youth’s choice to join a black gang.
It is incorrect that most African Americans are uncomfortable expressing
emotions.
It is incorrect that most African Americans have few religious beliefs.
CON: Culture
2.
ANS: 3
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Identify cultural differences based on six characteristic phenomena.
Page: 97
Heading: Application of the Nursing Process > Northern European American Values
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Dissociative disorders are not indicative of Northern European American values.
Alzheimer’s dementia is not indicative of Northern European American values.
The nurse should correlate many Northern European American values, such as
punctuality, hard work, and acquisition of material possessions, with stress-related
disorders. Psychopathology may occur when individuals fail to meet the
expectations of the culture.
Schizophrenia-spectrum disorders are not indicative of Northern European
American values.
CON: Culture
3.
ANS: 1
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Identify cultural differences based on six characteristic phenomena.
Page: 97
Heading: Application of the Nursing Process > Northern European Americans Integrated
Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The community health nurse should anticipate that Northern European Americans,
especially those who achieve middle-class socioeconomic status, place the most
value on preventative medicine and primary health care. This value is most likely
related to this group’s educational level and financial capability.
Many members of the Native American subgroups value folk medicine practices.
Many members of the Latino American subgroups value folk medicine practices.
Many members of the African American subgroups value folk medicine practices.
CON: Culture
4.
ANS: 4
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Identify cultural differences based on six characteristic phenomena.
Page: 101–102
Heading: Application of the Nursing Process > Asian/Pacific Islander Americans
Integrated Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
This statement is not accurate regarding the Asian American culture.
Minimal participation in research is not a factor that has made classifying Asian
American culture difficult.
The Asian American subculture is large.
The nursing instructor’s best explanation is that the Asian American culture is
difficult to classify globally because of the number of countries that identify with
this culture. The Asian American culture includes peoples and descendants from
Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India,
and the Pacific Islands. Within this culture there are vast differences in values,
religious practices, languages, and attitudes.
CON: Culture
5.
ANS: 3
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental
Health Nursing
Objective: Identify cultural differences based on six characteristic phenomena.
Page: 102–103
Heading: Application of the Nursing Process > Latino Americans
Integrated Processes: Nursing Process
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
Feedback
It is not likely that the Latin American woman devalues assertiveness skills.
It is not likely that the Latin American woman has decreased emotional
expression.
The nurse should identify that the Latin American woman’s refusal to participate
in an assertiveness training group may be affected by the Latin American cultural
definition of the female role. Latin Americans place a high value on the family,
which is male dominated. The father usually possesses the ultimate authority.
It is not likely that the Latin American woman has religious prohibitions.
1
2
3
4
PTS: 1
CON: Culture
6.
ANS: 1
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Apply the nursing process in the care of individuals from various cultural groups.
Page: 102–103
Heading: Application of the Nursing Process > Latino Americans
Integrated Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
Feedback
The nurse should associate the cultural belief that families are male-dominated,
with clear male–female role distinctions with the client’s abusive behavior. The
father in the Latin American family usually has the ultimate authority.
Religious tenets do not support the use of violence.
The Latin American family is male-dominated.
This statement is untrue, because Latin American families are male-dominated.
1
2
3
4
PTS: 1
7.
CON: Culture
ANS: 2
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Apply the nursing process in the care of individuals from various cultural groups.
Page: 95
Heading: Cultural Concepts
Integrated Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Avoiding eye contact is not necessary in all cultures.
The nurse should avoid assuming that all individuals who share a culture or ethnic
group are similar.
The nurse should always strive to support the client in cultural and spiritual rituals.
The nurse should assess whether or not an interpreter is needed.
CON: Culture
8.
ANS: 2
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Apply the nursing process in the care of individuals from various cultural groups.
Page: 101–102
Heading: Application of the Nursing Process > Asian/Pacific Islander Americans Integrated
Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
Obesity and alcoholism are low among Asian Americans.
To effectively care for Asian American clients, the nurse should be aware that
older people in this culture maintain positions of authority.
The balance of yin and yang is the fundamental concept of Asian health practices.
Psychiatric illness is often believed to be out-of-control behavior and would be
considered shameful to individuals and families.
CON: Culture
9.
ANS: 1
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Apply the nursing process in the care of individuals from various cultural groups.
Page: 100–101
Heading: Application of the Nursing Process > Native American
Integrated Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The most appropriate nursing intervention would be to try to locate a shaman that
will agree to come to the ED.
The nurse should understand that in the Native American culture, religion, and
health-care practices are often intertwined.
The shaman, a medicine man, may confer with physicians regarding the care of a
client.
The client is not refusing treatment at this time.
CON: Culture
10.
ANS: 4
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Apply the nursing process in the care of individuals from various cultural groups.
Page: 102–103
Heading: Application of the Nursing Process > Latino Americans
Integrated Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application (Application)
Concept: Culture
Difficulty: Easy
1
2
3
4
Feedback
This is not true of Latin American culture.
Yin and yang is present in Asian American culture.
The shaman is a healer in the Native American culture.
The nurse should understand that it is characteristic of Latin American culture for
a client to contact a curandero when illness is initially encountered.
PTS: 1
CON: Culture
11.
ANS: 1
Chapter: Chapter 0 Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Apply the nursing process in the care of individuals from various cultural groups.
Page: 101–102
Heading: Application of the Nursing Process > Asian/Pacific Islander Americans Integrated
Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application [Applying]
Concept: Culture
Difficulty: Easy
1
2
3
4
PTS: 1
Feedback
The nurse should expect that many Asian Americans are most likely to view
mental illness as uncontrolled behavior that brings shame to the family.
Asian Americans do not view mental illness as a curse from God.
Asian Americans do not view mental illness as curable by home remedies.
Asian Americans do not view mental illness as curable by hot and cold herbal
remedies.
CON: Culture
12.
ANS: 1
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Describe cultural variances, based on the six phenomena, for Western
European Americans.
Page: 97
Heading: Application of the Nursing Process
Integrated Processes: Teaching and Learning
Client Need: Psychosocial integrity
Cognitive Level: Application (Application)
Concept: Culture
Difficulty: Easy
1
2
3
4
Feedback
The nurse should identify that most Western European Americans are present
oriented and perceive the future as God’s will.
Older adults are held in positions of respect and are often cared for in the home
instead of in nursing homes.
Western European Americans are not at high risk for alcoholism.
The nurse should identify that most Western European Americans are present
oriented.
1
2
3
4
PTS: 1
The nurse should identify that most Western European Americans are present
oriented and perceive the future as God’s will.
Older adults are held in positions of respect and are often cared for in the home
instead of in nursing homes.
Western European Americans are not at high risk for alcoholism.
The nurse should identify that most Western European Americans are present
oriented.
CON: Culture
13.
ANS: 3
Chapter: Chapter 0, Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health
Nursing
Objective: Describe cultural variances, based on the six phenomena, for Native Americans.
Page: 100–101
Heading: Application of the Nursing Process > Native Americans
Integrated Processes: