Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practic, Exams of Nursing

Download Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practic and more Exams Nursing in PDF only on Docsity! lOM oA R c P S D | 79 06 8 27 :::: Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice 8th edition Morgan, Townsend Test Bank Chapter 1. Mental Health and Mental Illness Multiple Choice 1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The clients appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the clients behaviors? 1. The clients behaviors demonstrate mental illness in the form of depression. 2. The clients behaviors are extensive, which indicates the presence of mental illness. 3. The clients behaviors are not congruent with cultural norms. 4. The clients behaviors demonstrate no functional impairment, indicating no mental illness. ANS: 4 Rationale: The nurse should assess that the clients daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the clients distress does not indicate a mental illness. Cognitive Level: Analysis Integrated Process: Assessment 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. ANS: 2 Rationale: 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 clients ability to communicate distress would be considered a positive attribute. Cognitive Level: Application Integrated Process: Assessment 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. lOM oAR c P S D | 790 68 27 ANS: 1 Rationale: The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. Mental health is a state of being that is relative to the individual client. Environmental influences and temperament can affect stress reactions. Cognitive Level: Application Integrated Process: Implementation 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. ANS: 1 Rationale: 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 as physical health. Women are also more likely to seek treatment for mental health problems than men. Cognitive Level: Application Integrated Process: Planning 5. A psychiatric nurse intern states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses 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. ANS: 1 Rationale: The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills. Cognitive Level: Application Integrated Process: Evaluation 6. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response? 1. Its 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 isnt imperative that we complete this section. Downloaded by Abdellah Saad ([email protected]) lOM oAR c P S D | 790 68 27 Cognitive Level: Analysis Integrated Process: Evaluation 13. A nurse is performing a mental health assessment on an adult client. According to Maslows 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. ANS: 3 Rationale: 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 Maslows hierarchy of needs. Cognitive Level: Application Integrated Process: Assessment 14. According to Maslows hierarchy of needs, which situation on an in-patient 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. ANS: 2 Rationale: The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslows hierarchy of needs and must be fulfilled before other higher-level needs can be met. Clients who complain, have feelings of failure, or 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. Cognitive Level: Analysis Integrated Process: Evaluation 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 individuals cognitions, or behaviors that reflects a disturbance in the 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. ANS: 3 Rationale: A health condition characterized by significant dysfunction in an individuals cognitions, or behaviors that reflects a disturbance in the psychological, biological, or developmental process underlying mental functioning, is the new DSM 5 definition of a mental disorder. Cognitive Level: Application Integrated Process: Assessment Multiple Response lOM oAR c P S D | 790 68 27 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 ANS: 1, 2, 4 Rationale: The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance. Cognitive Level: Application Integrated Process: Assessment Fill-in-the-Blank 17. is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. ANS: Anxiety Rationale: 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. Cognitive Level: Application Integrated Process: Assessment 18. is a subjective state of emotional, physical, and social responses to the loss of a valued entity. ANS: Grief Rationale: 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. Chapter 2. Biological Implications Multiple Choice 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 lOM oAR c P S D | 790 68 27 a link between nature (biology and genetics) and nurture (environment). ANS: 1 Rationale: 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. Cognitive Level: Analysis Integrated Process: Implementation 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 ones emotional state. ANS: 4 Rationale: The nurse should explain to the client that the limbic system is largely responsible for ones emotional state. This system if often called the emotional brain and is associated with feelings, sexuality, and social behavior. 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. Cognitive Level: Application Integrated Process: Implementation 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 ANS: 3 Rationale: 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. Cognitive Level: Comprehension Integrated Process: Assessment 4. Which client statement reflects an understanding of circadian rhythms in psychopathology?1. When I dream about my mothers horrible train accident, I become hysterical. 2. I get really irritable during my menstrual cycle.3. Im a morning person. I get my best work done before noon. 4. Every February, I tend to experience periods of sadness. ANS: 3 Rationale: 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. Cognitive Level: Analysis Integrated Process: Evaluation lOM oAR c P S D | 790 68 27 Cognitive Level: Application Integrated Process: Evaluation 13. Which cerebral structure should a nursing instructor describe to students as the emotional brain?1. The cerebellum2. The limbic system3. The cortex4. The left temporal lobe ANS: 2 Rationale: The limbic system is often referred to as the emotional brain. The limbic system is largely responsible for ones emotional state and is associated with feelings, sexuality, and social behavior. Cognitive Level: Comprehension Integrated Process: Implementation 14. A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?1. Acute mania2. Schizophrenia3. Anorexia nervosa4. Alzheimers disease ANS: 3 Rationale: 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. Cognitive Level: Comprehension Integrated Process: Assessment 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 serotonin2. Decreased levels of dopamine3. Increased levels of norepinephrine 4. Decreased levels of acetylcholine ANS: 4 Rationale: The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine. Acetylcholine is a major effector chemical of the autonomic nervous system. Functions of acetylcholine include sleep regulation, pain perception, the modulation and coordination of movement, and memory. Cognitive Level: Application Integrated Process: Assessment 16. A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness?1. Bipolar disorder: mania2. Schizophrenia spectrum disorder3. Generalized anxiety disorder4. Major depressive episode ANS: 4 Rationale: 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. Cognitive Level: Application Integrated Process: Evaluation 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 disorder2. Major depressive disorder3. Body dysmorphic disorder4. Parkinsons disease lOM oAR c P S D | 790 68 27 ANS: 1 Rationale: 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 decision-making ability. Increased dopamine activity is also associated with mania. Cognitive Level: Application Integrated Process: Evaluation Multiple Response 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. ANS: 1, 3 Rationale: The nurse should explain to the client that there is a possible correlation between anorexia nervosa and decreased levels of growth hormones and gonadotropin. Anorexia nervosa has also been correlated with increased cortisol levels. Cognitive Level: Application Integrated Process: Implementation 19. Which of the following symptoms should a nurse associate with the development of increased levels of thyroid-stimulating hormone (TSH) in a newly admitted client? (Select all that apply.)1. Depression2. Fatigue3. Increased libido4. Mania5. Hyperexcitability ANS: 1, 2 Rationale: The nurse should associate depression and fatigue with increased levels of TSH. TSH is only increased when thyroid levels are low, as in the diagnosis of hypothyroidism. In addition to depression and fatigue, other symptoms, such as decreased libido, memory impairment, and suicidal ideation are associated with chronic hypothyroidism. Cognitive Level: Application Integrated Process: Assessment Fill-in-the-Blank 20. is the study of the biological foundations of cognitive, emotional, and behavioral processes. ANS: Psychobiology Rationale: 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. lOM oAR c P S D | 790 68 27 Chapter 3. Ethical and Legal Issues Multiple Choice 1. In response to a students question regarding choosing a psychiatric specialty, a charge nurse states, Mentally ill clients need special care. If I were in that position, Id want a caring nurse also. From which ethical framework is the charge nurse operating? 1. Kantianism 2. Christian ethics 3. Ethical egoism 4. Utilitarianism ANS: 2 Rationale: 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. Kantianism states that decisions should be made based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made focusing on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual. Cognitive Level: Analysis Integrated Process: Assessment 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. ANS: 2 Rationale: The applicants 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. Cognitive Level: Analysis Integrated Process: Evaluation 3. Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurses coworker observes this action but does nothing for fear of retaliation. What is the ethical interpretation of the coworkers 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. ANS: 1 Rationale: The coworkers lack of involvement can be interpreted as an unethical action. The lOM oAR c P S D | 790 68 27 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 clients therapist. ANS: 1 Rationale: The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent. Cognitive Level: Application Integrated Process: Implementation 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 ANS: 1 Rationale: The nurse should provide the information to support the clients 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. Cognitive Level: Application Integrated Process: Implementation 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 ANS: 4 Rationale: The nurse should determine that the ethical principle of justice has been violated by the physicians 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. Cognitive Level: Application Integrated Process: Evaluation lOM oAR c P S D | 790 68 27 13. Which situation reflects violation of the ethical principle of veracity? 1. A nurse discusses with a client another clients impending discharge. 2. A nurse refuses to give information to a physician who is not responsible for the clients care. 3. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. 4. A nurse does not treat all of the clients equally, regardless of illness severity. ANS: 3 Rationale: The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to ones duty to always be truthful and not intentionally deceive or mislead clients. Cognitive Level: Application Integrated Process: Implementation 14. A client who will be receiving electroconvulsive therapy (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 spouses name, date, and time of day. 4. The client relies on his or her spouse to interpret the information. ANS: 3 Rationale: The nurse should question the validity of informed consent when the client incorrectly reports the spouses name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices. Cognitive Level: Application Integrated Process: Assessment 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 clients morning orange juice. 4. Call for help to hold the client down while the injection is administered. ANS: 1 Rationale: It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The clients right to refuse treatment should be upheld, unless the refusal puts the client or others in harms way. Cognitive Level: Analysis Integrated Process: Implementation 16. Which situation exemplifies both assault and battery? 1. The nurse becomes angry, calls the client offensive names, and withholds treatment. 2. The nurse threatens to tie down the client and then does so, against the clients wishes. 3. The nurse hides the clients clothes and medicates the client to prevent elopement. 4. The nurse restrains the client without just cause and communicates this to family. lOM oAR c P S D | 790 68 27 ANS: 2 Rationale: 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. Cognitive Level: Analysis Integrated Process: Implementation 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. ANS: 4 Rationale: The least-restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified. Cognitive Level: Application Integrated Process: Implementation 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 clients 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 ANS: 3 Rationale: The nurse has violated the Health Insurance Portability and Accountability Act (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. Cognitive Level: Application Integrated Process: Implementation Multiple Response 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 lOM oAR c P S D | 790 68 27 4. Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)? a. Grimacing and lip smacking b. Falling asleep in the chair and refusing to eat lunch c. Experiencing muscle rigidity and tremors d. Having excessive salivation and drooling ANS: A TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine. 5. When the nurse realizes that a patient diagnosed with schizophrenia is not taking the prescribed oral haloperidol (Haldol), which intervention would promote medication compliance? a. Instructing the patient to have friends monitor his medications b. Beginning administration of haloperidol (Haldol) decanoate c. Writing instructions in detail for the patient to follow d. Changing haloperidol to an atypical antipsychotic ANS: B Haloperidol decanoate is a depot medication, given intramuscularly every 2 to 4 weeks. It is unknown whether the patient has a support system. The patient probably received education, including written instructions prior to discharge. Changing to another classification of medication would not necessarily improve compliance. 6. When asked how tricyclic antidepressants affect neurotransmitter activity, the nurse should respond that they: lOM oAR c P S D | 790 68 27 a. Decrease available dopamine. b. Increase availability of norepinephrine and serotonin. c. Make available increased amounts of monoamine oxidase. d. Increase the effects of the chemical gamma-aminobutyric acid. ANS: B Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of norepinephrine and serotonin available. Decreasing dopamine is the action of typical antipsychotic medication. Increasing monoamine oxidase is not the action of tricyclics. Benzodiazepines, not tricyclics, increase the effects of GABA. 7. A severely depressed patient has been prescribed clomipramine (Anafranil). For which medication side effects should the patient be monitored? a. Excess salivation and drooling b. Muscle rigidity and restlessness c. Polyuria and coarse hand tremors d. Orthostatic hypotension and constipation ANS: D Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces constipation. Mild tremors and urinary retention may occur. Drooling and excessive salvation may occur with SSRIs. Muscle rigidity and restlessness may occur with antipsychotics. 8. Which of these statements made by a patient taking the MAOI phenelzine (Nardil) would warrant further instruction? a. I often forget to wear sunscreen when I go outside. b. I need to restrict the amount of sodium in my diet. c. I should not use over-the-counter cold medications. d. I usually order liver and onions when my wife and I eat out. lOM oAR c P S D | 790 68 27 ANS: D MAOIs require patients to observe a tyramine-free diet to prevent hypertensive crisis. Liver is a food that contains large amounts of tyramine. The remaining options have no relevance for MAOI therapy. 9. Which patient complaint should receive priority from a patient who is taking the MAOI tranylcypromine (Parnate)? a. I havent had a bowel movement in 2 days. b. Will you take my temperature? I feel too warm. c. I get a headache when I drank several cups of coffee. d. My legs get stiff when I sit in the chair for any length of time. ANS: C Hypertensive crisis may occur if a patient taking a MAOI ingests certain food containing tyramine or drugs that cause blood pressure (BP) elevation. Headache is a warning sign of hypertensive crisis. The nurse should assess BP and inquire about other symptoms of hypertensive crisis. Stiffness is not related to MAOI therapy. Elevated temperature is not an initial sign of hypertensive crisis. Constipation is not a sign of hypertensive crisis. 10. Sertraline (Zoloft) has been prescribed for a patient with symptoms of a major depression. Which factor was probably most important in the physicians decision to use an SSRI? a. Good side-effect profile b. Less expense for the patient c. Increase in medication compliance d. Rapid rate of absorption from the GI tract ANS: A lOM oAR c P S D | 790 68 27 b. Recovering from a hysterectomy c. Taking hormone replacement therapy d. Displaying symptoms of postpartum depression ANS: A Lithium is contraindicated during pregnancy because of teratogenic effects. The remaining options would not be contraindicative to lithium therapy. 16. An individual with poststroke depression is receiving an SSRI. What is the rationale for giving the medication at breakfast and again at midday? a. Prevent insomnia b. Prevent toxic reactions c. Decrease afternoon sleepiness d. Give an opportunity to monitor behavior closely ANS: A CNS stimulants may cause insomnia if given late in the day. Toxicity is a result of excessive medication in the system, not when it is administered. The drowsiness resulting from SSRI use would not be minimized if taken as described. There is no expectation that resulting behaviors will need to be so closely monitored. 17. A patient who has received lithium for 3 weeks to control acute mania has the following symptoms: coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion. The priority nursing action should be to: a. Administer prn Cogentin to relieve the symptoms. b. Provide reassurance that the symptoms are transient. c. Obtain a stat lithium level; hold lithium pending results. d. Assist the patient to decrease the sodium in their daily diet. ANS: C lOM oAR c P S D | 790 68 27 The symptoms the patient is experiencing are consistent with moderate lithium toxicity. The nurse should hold lithium, obtain a stat lithium level, and notify the physician. Cogentin is inappropriate; the symptoms are not EPS. The nurse may reassure the patient but cannot suggest that the symptoms will resolve over time. Minimizing salt would worsen lithium toxicity. 18. A patient with rapid cycling bipolar disorder is not responding well to lithium. The patient tells the nurse, It feels as though Ill never get well. I get better, and then I get worse. The reply that is based on knowledge of current therapy would be: a. Youre feeling very discouraged arent you? b. Its not all bad, is it? Sometimes you like being high. c. Another drug, valproic acid, is proving effective for rapid cycling. d. If your kidneys hold out, the lithium will eventually control the symptoms. ANS: C Valproic acid is a first-line agent for the treatment of bipolar disorder. It is particularly effective with rapid cycling. The other options are not responsive to the question stem, which asks for knowledge of current therapy. 19. Which statement by a patient with generalized anxiety disorder for whom lorazepam (Ativan) is prescribed as needed (prn) suggests the patient understands the purpose of the medication? a. I can talk with my therapist more easily after my medication takes effect. b. I wonder if I will have to take this medication for the rest of my entire life. c. Im embarrassed and dont want anyone to know Im on this kind of medication. d. Im going to ask for my prn dose so I can sleep instead of worrying about my kids. ANS: A The patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist. The remaining options show questions and inappropriate use of the medication. lOM oAR c P S D | 790 68 27 20. A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks. He drools, has hand tremors, and walks with a shuffling gait. The nurse would correctly attribute these behaviors to: a. Akinesia b. Tardive dyskinesia c. Pseudoparkinsonism d. Neuroleptic malignant syndrome ANS: C These are symptoms of pseudoparkinsonism associated with dopamine blockade. Tardive dyskinesia occurs after long-term therapy. The remaining options are not associated with the symptoms mentioned. 21. What intervention will the nurse request for a patient reporting gastrointestinal side effects related to valproate therapy? a. Mild laxative b. Low-fat diet c. Oral antacid d. Histamine-2 antagonist ANS: D Indigestion, heartburn, and nausea are common side effects of valproate therapy. The administration of a histamine-2 antagonist such as famotidine (Pepcid) is sometimes helpful. The other options would have no impact on the complaint. 22. A patients serum lithium level is reported as 1.9 mEq/L. The nurse should immediately: a. Restrict sodium and fluid intake. b. Assess for signs and symptoms of toxicity. c. Seek to have the patient transferred to ICU. lOM oAR c P S D | 790 68 27 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. ANS: 4 Rationale: The nurse should respond to a clients 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. The nurse should assist the client in separating the past from the present. Cognitive Level: Application Integrated Process: Implementation 3. What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? 1. Acknowledge the clients 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. ANS: 2 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 4. Which client action should a nurse expect during the working phase of the nurse-client 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. ANS: 1 Rationale: The nurse should expect that that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals. Cognitive Level: Application Integrated Process: Planning 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 cant 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. lOM oAR c P S D | 790 68 27 3. I really dont want to talk any more about my childhood abuse. 4. Im not sure that I can count on you to protect my confidentiality. ANS: 3 Rationale: The nurse should identify that the client statement, I really dont 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. Cognitive Level: Analysis Integrated Process: Evaluation 6. A mother who is notified that her child was killed in a tragic car accident states, I cant 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 Ill stay with you until your husband arrives. ANS: 4 Rationale: The nurses response, It must be horrible to lose a child, and Ill stay with you until your husband arrives, conveys empathy to the client. Empathy is the ability to see the situation from the clients point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship. Cognitive Level: Application Integrated Process: Implementation 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 ANS: 2 Rationale: 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 nurses 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. Cognitive Level: Application Integrated Process: Assessment 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 lOM oAR c P S D | 790 68 27 3. Establishing a plan for continuing aftercare 4. Promoting the clients insight and perception of reality ANS: 4 Rationale: The nurse should place priority on promoting the clients insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the pre-interaction phase. Establishing a plan for aftercare would occur in the termination phase. Cognitive Level: Application Integrated Process: Implementation 9. Which therapeutic communication technique is being used in the following nurse-client interaction? Client: My father spanked me often. Nurse: Your father was a harsh disciplinarian. 1. Restatement 2. Offering general leads 3. Focusing 4. Accepting ANS: 1 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 10. Which therapeutic communication technique is being used in the following nurse-client 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 ANS: 3 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 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? lOM oAR c P S D | 790 68 27 ANS: 3 Rationale: The most appropriate response by the nurse is, Lets 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. Cognitive Level: Application Integrated Process: Implementation 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 nurses best response? 1. The smoke was too thick. You couldnt have gone back in. 2. Youre experiencing feelings of guilt, because you werent able to save your children. 3. Focus on the fact that you could have lost all four of your children. 4. Its best if you try not to think about what happened. Try to move on. ANS: 2 Rationale: The best response by the nurse is, Youre experiencing feelings of guilt, because you werent 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. Cognitive Level: Application Integrated Process: Implementation 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 wont participate in unit therapy? 4. Lets figure out a way for you to attend unit activities and still wash your hands. ANS: 4 Rationale: The most appropriate statement by the nurse is, Lets 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. Cognitive Level: Application Integrated Process: Planning Multiple Response 20. Which of the following characteristics should be included in a therapeutic nurse-client 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 lOM oAR c P S D | 790 68 27 4. Collaborating to set appropriate goals 5. Meeting both the physical and psychological needs of the client ANS: 2, 3, 4, 5 Rationale: The nurse-client therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. Meeting the nurses psychological needs should never be addressed within the nurse-client relationship. Cognitive Level: Application Integrated Process: Assessment 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 e-mail on a regular basis ANS: 1, 2, 3, 4 Rationale: The nurse should determine that spanking, isolating, getting tattoos, and writing are all ways in which people communicate messages to others. It is estimated that about 70% to80% of communication is nonverbal. Cognitive Level: Application Integrated Process: Evaluation Fill-in-the-Blank 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. ANS: rapport Rationale: 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. Cognitive Level: Application Integrated Process: Assessment 23. refers to a nurses behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurses past. ANS: Countertransference Rationale: Countertransference refers to a nurses behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurses past or they may be generated in response to transference feelings on the part of the client. lOM oAR c P S D | 790 68 27 Chapter 6. The Nursing Process in Psychiatric/Mental Health Nursing Multiple Choice 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. ANS: 2 Rationale: The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers, which may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle. Cognitive Level: Application Integrated Process: Assessment 2. Which statement regarding nursing interventions should a nurse identify as accurate? 1. Nursing interventions are independent from the treatment teams 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. ANS: 3 Rationale: The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the clients care. Cognitive Level: Application Integrated Process: Implementation 3. Within the nurses scope of practice, which function is exclusive to the advanced practice psychiatric nurse? 1. Teaching about the side effects of neuroleptic medications 2. Using psychotherapy to improve mental health status 3. Using milieu therapy to structure a therapeutic environment 4. Providing case management to coordinate continuity of health services ANS: 2 Rationale: The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. Education, case management, and milieu therapy can be provided by registered psychiatric mental health nurses. lOM oAR c P S D | 790 68 27 Cognitive Level: Application Integrated Process: Diagnosis 10. How should a nurse prioritize nursing diagnoses? 1. By the established goal of care 2. By the life-threatening potential 3. By the physicians priority of care 4. By the clients preference ANS: 2 Rationale: The nurse should prioritize nursing diagnoses related to their life-threatening potential. Safety is always the nurses first priority. Cognitive Level: Analysis Integrated Process: Diagnosis 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 clients sleep habits will improve during hospitalization. ANS: 3 Rationale: 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. Nursing outcomes should be derived from the diagnosis, measurable, and include a time estimate for attainment. The outcome must also be realistic for the clients capabilities. Cognitive Level: Analysis Integrated Process: Planning 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. ANS: 1 Rationale: 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. Cognitive Level: Application Integrated Process: Assessment 13. A student nurse asks an instructor how best to develop nursing outcomes for clients. Which response by the instructor most accurately answers the students question? lOM oAR c P S D | 790 68 27 1. You can use NIC, a standardized reference for nursing outcomes. 2. Look at your clients 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. ANS: 3 Rationale: Client outcomes are most realistic and achievable when there is collaboration among the interdisciplinary team members, the client, and significant others. Cognitive Level: Application Integrated Process: Planning 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 clients problem? 1. Disturbed thought processes 2. Disturbed sensory perception 3. Anxiety 4. Chronic confusion ANS: 2 Rationale: The nursing diagnosis disturbed sensory perception accurately reflects the clients symptoms of hearing things that others do not. The nursing diagnosis describes the clients condition and facilitates the prescription of interventions. Cognitive Level: Application Integrated Process: Diagnosis Multiple Response 15. Which of the following nursing interventions fall within the standards of psychiatricmental health clinical nursing practice for a nurse generalist? (Select all that apply.) 1. Assist the client to perform activities of daily living. 2. Consult with other clinicians to provide services for clients and effect system change. 3. Encourage the client to discuss triggers for relapse. 4. Use prescriptive authority in accordance with state and federal laws. 5. Educate the family about signs and symptoms of alcohol dependence and withdrawal. ANS: 1, 3, 5 Rationale: Assisting the client to perform daily living activities, encouraging the client to discuss triggers, and educating the family are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatricmental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority. Cognitive Level: Application Integrated Process: Implementation 16. 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. lOM oAR c P S D | 790 68 27 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. ANS: 3, 4 Rationale: The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others. Cognitive Level: Application Integrated Process: Planning Ordered Response 17. Number the following nursing interventions as they would proceed through the steps of the nursing process. Determine if an antianxiety medication is decreasing a clients stress. Measure a clients vital signs and review past history. Encourage deep breathing and teach relaxation techniques. Aim, with client collaboration, for a seven-hour nights sleep. Recognize and document the clients problem. ANS: The correct order is 5, 1, 4, 3, 2 Rationale: 1. Measuring a clients vital signs and reviewing past history is a nursing intervention that occurs in the assessment step of the nursing process. 2. Recognizing and documenting the clients problem occurs in the nursing diagnosis step. 3. Setting a goal with client collaboration, for a seven-hour nights sleep occurs in the planning step. 4. Encouraging deep breathing and teaching relaxation techniques occur in the implementation step. 5. Determining if an antianxiety medication is decreasing a clients stress occurs in the evaluation step. Cognitive Level: Analysis Integrated Process: Implementation Fill-in-the-Blank 18. A provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. ANS: nursing diagnosis Rationale: 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. lOM oAR c P S D | 790 68 27 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? 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 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? 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 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? 1. The psychiatrist 2. The psychiatric social worker 3. The clinical psychologist 4. 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. lOM oAR c P S D | 790 68 27 Cognitive Level: Application Integrated Process: Planning 10. In the role of milieu manager, which activity should the nurse prioritize? 1. Setting the schedule for the daily unit activities 2. Evaluating clients for medication effectiveness 3. Conducting therapeutic group sessions 4. 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.) 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 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.) 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. 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 lOM oAR c P S D | 790 68 27 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 8. Intervention in Groups Multiple Choice 1. During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style? 1. The nurse mandates that all group members reveal an embarrassing personal situation. 2. The nurse asks for a show of hands to determine group topic preference. 3. The nurse sits silently as the group members stray from the assigned topic. 4. 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? 1. Democratic 2. Autocratic 3. Laissez-faire 4. 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 lOM oAR c P S D | 790 68 27 9. During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development? 1. Its hard for me to tell my story when Im not sure about the reactions of others. 2. I think Joes Antabuse suggestion is a good one and might work for me. 3. My situation is very complex, and I need professional, not peer, advice. 4. 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? 1. The group leader establishes the rules that will govern the group after discharge. 2. The group leader encourages members to rely on each other for problem solving. 3. The group leader presents and discusses the concept of group termination. 4. 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? 1. There is little research to support AAs effectiveness. 2. Self-help groups used to be the treatment of choice, but their popularity is waning. 3. These groups have no external regulation, so clients need to be cautious. 4. 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? lOM oAR c P S D | 790 68 27 1. Open-ended membership; circle of chairs; group size of 5 to 10 members 2. Open-ended membership; chairs around a table; group size of 10 to 15 members 3. Closed membership; circle of chairs; group size of 5 to 10 members 4. 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? 1. The leader should referee the debate. 2. The leader should adamantly oppose physical disciplining measures. 3. The leader should redirect the group to a less-controversial topic. 4. 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? 1. They are experiencing problems with termination, leading to feelings of abandonment. 2. They did not think any new material would be covered at the last session. 3. They were angry with the leader for not extending the length of the group. 4. 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? 1. A psychodrama group lOM oAR c P S D | 790 68 27 2. A psychotherapy group 3. A parenting group 4. 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? 1. Psychodrama provides a safe setting in which to discuss painful issues. 2. In psychodrama, the client is the protagonist. 3. In psychodrama, the client observes actor interactions from the audience. 4. 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.) 1. Encourage members to provide feedback to each other about individual progress. 2. Ensure that group rules do not interfere with goal fulfillment. 3. Work with group members to establish rules that will govern the group. 4. Emphasize the need for and importance of confidentiality within the group. 5. 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 lOM oAR c P S D | 790 68 27 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 ANS: 3 Rationale: 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. Cognitive Level: Analysis Integrated Process: Diagnosis 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? ANS: 1 Rationale: 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 in which the crisis team should assess for client safety as a priority. Cognitive Level: Analysis Integrated Process: Assessment 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. ANS: 4 Rationale: The most appropriate nursing intervention is to set firm limits on the behavior. 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. Cognitive Level: Application Integrated Process: Implementation 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? lOM oAR c P S D | 790 68 27 1. Youve really been helpful. Can I count on your for continued support? 2. I work out in the college gym rather than jogging outdoors. 3. Im really glad I didnt go home. It would have been hard to come back. 4. I carry mace when I jog. It makes me feel safe and secure. ANS: 4 Rationale: 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. Cognitive Level: Analysis Integrated Process: Evaluation 8. A despondent client who has recently lost her husband of 30 years tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing response is most appropriate? 1. Im confident you know whats 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. ANS: 2 Rationale: During crisis intervention, the nurse should guide the client through a problem- solving 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. The nurse should also assist the client in determining whether any changes are realistic. Cognitive Level: Application Integrated Process: Implementation 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. ANS: 2 Rationale: The nurse should assess that tense facial expressions and body language may indicate that a clients anger is escalating. The nurse should conduct a thorough assessment of the clients history of violence and develop interventions for de-escalation. Cognitive Level: Application Integrated Process: Assessment 10. What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place on an inpatient unit? 1. Reinforce unit rules with the client population. 2. Create protocols for the future release of tensions associated with anger. lOM oAR c P S D | 790 68 27 3. Process client feelings and alleviate fears of undeserved seclusion and restraint. 4. Discuss the situation that led to inappropriate expressions of anger. ANS: 4 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 11. An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation? 1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 1 hour of the initiation of the restraints. 2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 2 hours of the initiation of the restraints. 3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 3 hours of the initiation of the restraints. 4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 4 hours of the initiation of the restraints. ANS: 1 Rationale: The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) requires that an in-person evaluation by physician or other licensed independent practitioner be conducted within 1 hour of the initiation of restraint or seclusion. Cognitive Level: Application Integrated Process: Implementation 12. A combative adolescent client has been placed in seclusion after all other interventions have failed. Which protocol would apply in this situation? 1. The physician or other licensed independent practitioner must reissue a new order for restraints every 24 hours. 2. The physician or other licensed independent practitioner must reissue a new order for restraints every 8 hours. 3. The physician or other licensed independent practitioner must reissue a new order for restraints every 3 to 4 hours. 4. The physician or other licensed independent practitioner must reissue a new order for restraints every 1 to 2 hours. ANS: 4 Rationale: The physician or other licensed independent practitioner must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. Restraints should be used as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm to self or others. lOM oAR c P S D | 790 68 27 coping mechanisms cannot resolve the problem. Crises result in a disequilibrium, from which many individuals require assistance to recover. Chapter 10. The Recovery Model Multiple Choice 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. ANS: 2 Rationale: 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, live a self-directed life, and strive to reach their full potential. Change in recovery is not an expedient process. It occurs incrementally over time. Cognitive Level: Application Integrated Process: Evaluation 2. Which situation presents an example of the basic concept of a recovery model? 1. The clients family is encouraged to make decisions in order to facilitate discharge. 2. A social worker, discovering the clients income, changes the clients discharge placement. 3. A psychiatrist prescribes an antipsychotic drug based on observed symptoms. 4. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy. ANS: 4 Rationale: 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. Cognitive Level: Analysis Integrated Process: Evaluation 3. A nursing instructor is teaching about the guiding principles of the recovery model, as described by the 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. ANS: 2 Rationale: SAMHSA lists the following as guiding principles for the recovery model: recovery lOM oAR c P S D | 790 68 27 emerges from hope, recovery is person-driven, recovery occurs via many pathways, recovery is holistic, recovery is supported by peers and allies, recovery is supported through relationship and social networks, recovery is culturally based and influenced, recovery is supported by addressing trauma, recovery involves individual, family, and community strengths and responsibility, recovery is based on respect. Recovery emerges from hope but affiliation with any particular religion would have little bearing on the recovery process. Cognitive Level: Application Integrated Process: Evaluation 4. A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to the SAMHSA, which dimension of recovery is supporting this client? 1. Health 2. Home 3. Purpose 4. Community ANS: 2 Rationale: SAMHSA describes the dimension of Home as a stable and safe place to live. Cognitive Level: Application Integrated Process: Assessment 5. A client diagnosed with obsessive-compulsive disorder states, I really think my future will improve because of my successful treatment choices. Im 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. ANS: 1 Rationale: The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope, recovery is person-driven, recovery occurs via many pathways, recovery is holistic, recovery is supported by peers and allies, recovery is supported through relationship and social networks, recovery is culturally based and influenced, recovery is supported by addressing trauma, recovery involves individual, family, and community strengths and responsibility, recovery is based on respect. This client has internalized hope. This hope is the catalyst of the recovery process. Cognitive Level: Application Integrated Process: Evaluation 6. A nurse maintains a clients 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. lOM oAR c P S D | 790 68 27 3. Recovery involves individual, family, and community strengths and responsibility. 4. Recovery is person-driven. ANS: 2 Rationale: The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope, recovery is person-driven, recovery occurs via many pathways, recovery is holistic, recovery is supported by peers and allies, recovery is supported through relationship and social networks, recovery is culturally based and influenced, recovery is supported by addressing trauma, recovery involves individual, family, and community strengths and responsibility, recovery is based on respect. This nurse accepts and appreciates clients who are affected by mental health and substance use problems. This nurse protects the rights of clients and does not discriminate against them. Cognitive Level: Application Integrated Process: Implementation 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 ANS: 3 Rationale: Barker & Buchanan-Barker developed a set of essential values termed the 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. This nurse is employing the Be Transparent commitment. Cognitive Level: Application Integrated Process: Implementation 8. Which is the priority focus of recovery models? 1. Empowerment of the health-care team to bring their expertise to decision-making 2. Empowerment of the client to make decisions related to individual health care 3. Empowerment of the family system to provide supportive care 4. Empowerment of the physician to provide appropriate treatments ANS: 2 Rationale: 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. Cognitive Level: Analysis Integrated Process: Assessment 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 lOM oAR c P S D | 790 68 27 4. Religious affiliation 5. Purpose ANS: 1, 2, 3, 5 Rationale: 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. Cognitive Level: Application Integrated Process: Assessment 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 clients 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. ANS: 1, 2, 4 Rationale: Barker & Buchanan-Barker developed a set of essential values termed the 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. This nurse is employing the Develop Genuine Curiosity commitment, by expressing interest, asking for clarification, and assisting the client to unfold the story at his or her own rate. Cognitive Level: Application Integrated Process: Implementation Ordered Response 16. Order the six steps of The Wellness Recovery Action Plan(WRAP) Model as described by Copeland et al. 1. Daily Maintenance List 2. Things Are Breaking Down or Getting Worse 3. Crisis Planning 4. Develop a Wellness Toolbox 5 Early Warning Signs 6. Triggers ANS: The correct order is 2, 5, 6, 1, 4, 3 Rationale: 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. lOM oAR c P S D | 790 68 27 Cognitive Level: Analysis Integrated Process: Assessment Fill-in-the-Blank 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. ANS: Recovery Rationale: 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 Chapter 11. Suicide Prevention MULTIPLE CHOICE 1. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises. 2. A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go. 3. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety. lOM oAR c P S D | 790 68 27 ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed. 4. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options. 5. A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem. 6. A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, There must be a mistake. This could not have happened. Weve given our child everything. The parents reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings. ANS: A The parents statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario. 7. An adolescent tells the school nurse, My friend threatened to take an overdose of pills. The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents? ANS: B The nurse must assess the patients access to the means to carry out the plan and, if there is lOM oAR c P S D | 790 68 27 16. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are most important and which are less important. ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving. 17. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social support ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options. 18. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness. ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired. 19. Which statement by a patient during an assessment interview should alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I shot myself. ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide. 20. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. lOM oAR c P S D | 790 68 27 b. sadness. c. elation. d. anger. ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. 21. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. 22. Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. 23. A nurse answers a suicide crisis line. A caller says, I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. Im going to shoot myself in the heart. How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue. 24. A staff nurse tells another nurse, I evaluated a new patient using the SAD PERSONS scale and got a score of 10. Im wondering if I should send the patient home. Select the best reply by the second nurse. a. That action would seem appropriate. b. A score over 8 requires immediate hospitalization. c. I think you should strongly consider hospitalization for this patient. lOM oAR c P S D | 790 68 27 d. Give the patient a follow-up appointment. Hospitalization may be needed soon. ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization. 25. A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic. ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care. Chapter 12. Caring for Patients with Mental Illness and Substance Use Disorders in General Practice Settings MULTIPLE CHOICE 1. When asked, What causes alcoholism? the nurses response will be based on the fact that: a. The response to alcohol is a result of a brain-based disorder. b. Alcoholism is believed to be an allergic response to the alcohol. c. Every individual has the same susceptibility for developing alcoholism. d. It is a physical response to alcohol but its etiology is not fully understood. ANS: A It has been determined that alcoholism is not an allergy but rather it is recognized as a partial brain-based disorder that some brains are more susceptible to than others. 2. Which patient response would support the conclusion that the patient has moved into the dark side of a narcotic addition? a. Ive been abusing drugs for at least 10 years. lOM oAR c P S D | 790 68 27 b. Vivid illusions c. Cognitive deficits d. Auditory hallucinations ANS: C Wernicke-Korsakoffs syndrome includes a severe form of amnesia and an inability to learn new skills which reflects a cognitive impairment. The other options are not associated with the syndrome. 8. Which sociological aspect, vital to relapse prevention, is greatly affected when a patient is found to have a dual diagnosis of psychosis and alcoholism? a. Ability to afford the cost of outpatient services b. A supportive, reliable, accessible support system c. Protection from both physical and emotional abuse d. Access to reasonable housing and employment opportunities ANS: B Often individuals with this type of diagnosis have lost their support systems as a result of chronic mistreatment of their family and friends and an inability to maintain and recognize the importance of this aspect to their treatment plan. Although the remaining options impact relapse prevention, they are generally available when the patient is being supported appropriately. 9. Which nursing intervention best demonstrates an understanding of the relationship between confirmed intravenous drug abuse and specific infections? a. Screening the patient for hepatitis B virus (HBV) b. Assessing the patient for potentially infected injection sites c. Determining if the patient has ever been tested for human immunodeficiency virus (HIV) d. Evaluating the patients understanding of the increased risk for developing sexually transmitted diseases lOM oAR c P S D | 790 68 27 ANS: A Injecting drug users have one of the highest HBV rates among all risk groups and account for at least half of all new HCV cases, so screening for such infections demonstrates that the nurse understands the severity of the problem. Although the other options reflect potential infection risks, they are not as commonly seen in patients with this diagnosis. 10. Which assessment data would bring into question a patients statement that, I have only a few drinks on special occasions.? a. History of treatment for glaucoma b. Fasting serum blood glucose level of 182 mg/dL c. Patient reports numbness in hands and feet bilaterally d. Red rash observed over neck, shoulders, and upper chest ANS: C Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake. Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking causing the nurse to question the patients statement. The remaining options do not reflect symptomology generally associated with alcoholism. 11. Which intervention has priority when a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs? a. Asking the staff member to explain their suspicious behavior b. Adjust the staff members assignment to minimize patient contact c. Providing the staff member with material regarding alcohol abuse and treatment d. Reporting the staff members suspicious behavior to the nursing supervisor on duty ANS: D It is a professional obligation to report suspected impaired practice. The remaining options do not have prior in this situation since the concern is patient safety. lOM oAR c P S D | 790 68 27 12. Which nursing intervention demonstrates an understanding regarding the primary form of substance use disorder among older adults? a. Assessing the patients hands and feet for the presence of both numbness and tingling b. Having the patient, describe your relationship with you adult children, co- workers, and friends. c. Asking, Please identify for me all the medications both prescribed and over the counter you regularly take. d. Evaluate the patients understanding of the possible health risks that alcohol and medication abuse has on ones health ANS: C Misuse of prescription medications is the most common form of drug abuse among older adults. This population is especially vulnerable because of the multiple drugs that are often prescribed for medical conditions. The remaining options do not help identify the presence of multiple medications. 13. Which assessment demonstrates the nurses understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium? a. Determining the patients age and gender b. Evaluating the patients food and fluid intake over the last 48 hours c. Observing the patient for fine tremors of the hands, especially the fingers d. Determining the amount of caffeine the patient ingested in the last 24 hours ANS: D Some people who ingest large amounts of caffeine develop delirium. The remaining options are not relevant to caffeine ingestion or the abuse of any other substance. 14. Which protocol should guide the nurse responsible for administering pharmacologic interventions for a patient who is experiencing alcohol intoxication? lOM oAR c P S D | 790 68 27 c. Cultures that include alcohol as part of the ritualized behavior have a higher rate of alcoholism. d. Twin studies have indicated that the environment of a person is more important than the biologic influences of parents. ANS: A Problems with alcohol increase with the number of relatives with alcoholism. No unique personality profile is prone to addiction. Ritualized use of alcohol does not predispose to alcoholism and twin studies indicate a significant genetic contribution to susceptibility to alcoholism. 19. Which observation best supports the patients success with achieving long-term sobriety? a. Asking a family member to, get rid of all the alcohol before I come home b. Identifying all the problems alcoholism has caused the family over the years c. Being able to discuss the importance of attending a support group for alcoholics d. Promising to, stop the drinking so I can be a good parent and raise a good child ANS: B One of the most prominent factors that leads an individual to recovery is the patients recognition that substance use has caused or influenced his or her lifes problems and interrupted his or her functioning. The remaining options lack that element of self-reflection. 20. Which principle of recovery is the basis of the nurses response when a patient relapses and is hospitalized for alcohol detox treatment? a. Alcoholism requires a lifelong commitment to control. b. Most people who are serious about treatment achieve sobriety. c. Relapsing is an expected occurrence for the patient diagnosed with alcohol abuse. d. Rehabilitation generally involves several relapses before true sobriety is achieved. ANS: D lOM oAR c P S D | 790 68 27 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 13. Neurocognitive Disorders Multiple Choice 1. A geriatric nurse is teaching the clients 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. ANS: 1 Rationale: 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. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory. Cognitive Level: Application Integrated Process: Implementation 2. A husband has agreed to admit his spouse, diagnosed with Alzheimers disease (AD), to a long-term care facility. He is expressing feelings of guilt and symptoms of depression. Which appropriate nursing diagnosis and subsequent intervention would the nurse document? 1. Dysfunctional grieving; AD support group 2. Altered thought process; AD support group 3. Major depressive episode; psychiatric referral 4. Caregiver role strain; psychiatric referral ANS: 1 Rationale: The most appropriate nursing diagnosis and intervention for the husband is dysfunctional grieving; AD support group. Clients with AD are often at risk for trauma and have significant self-care deficits that require more care than a spouse may be able to provide. Cognitive Level: Analysis Integrated Process: Diagnosis/Implementation 3. 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 clients safety? lOM oAR c P S D | 790 68 27 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. ANS: 4 Rationale: The nurse should question the clients safety at home if the client smokes cigarettes. Vascular NCD is a clinical syndrome of NCD due to significant cerebrovascular disease. The cause of vascular NCD is related to an interruption of blood flow to the brain. Hypertension is a significant factor in the etiology. Cognitive Level: Application Integrated Process: Assessment 4. A client diagnosed with 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 ANS: 4 Rationale: The nurse should recognize that a client exhibiting these symptoms is in the severe cognitive decline, seventh stage, of AD. Cognitive Level: Application Integrated Process: Assessment 5. A client is diagnosed in stage seven of AD. To address the clients 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. ANS: 3 Rationale: The most appropriate intervention in the seventh stage of AD is to promote the clients dignity by providing comfort, safety, and self-care measures. Stage is characterized by severe cognitive decline in which the client is unable to recognize family members and is most commonly bedfast and aphasic. Cognitive Level: Application Integrated Process: Implementation 6. Which is the reason for the proliferation of the diagnosis of NCDs? 1. Increased numbers of neurotransmitters has been implicated in the proliferation of NCD. 2. Similar symptoms of NCD and depression lead to misdiagnoses, increasing numbers of NCD. 3. Societal stress contributes to the increase in this diagnosis. 4. More people now survive into the high-risk period for neurocognitive disorders. lOM oAR c P S D | 790 68 27 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. Cognitive Level: Analysis Integrated Process: Implementation 13. A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this clients 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. Alzheimers disease ANS: 2 Rationale: 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. Cognitive Level: Application Integrated Process: Assessment 14. 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) ANS: 4 Rationale: The nurse should expect the physician to prescribe sertraline to improve the clients social functioning and concentration levels. Sertraline is an selective serotonin reuptake inhibitor (SSRI) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as a neurocognitive disorder. Cognitive Level: Application Integrated Process: Assessment 15. A client diagnosed with NCD is disoriented and ataxic and wanders. Which is the priority nursing diagnosis? 1. Disturbed thought processes 2. Self-care deficit 3. Risk for injury 4. Altered health-care maintenance ANS: 3 Rationale: The priority nursing diagnosis for this client is risk for injury. The client who is ataxic lOM oAR c P S D | 790 68 27 suffers from motor coordination deficits and is at an increased risk for falls. Clients that wander are at a higher risk for injury. Cognitive Level: Analysis Integrated Process: Diagnosis 16. Which statement accurately differentiates mild NCD from major NCD? 1. Major NCD involves disorientation that develops suddenly, whereas mild NCD develops more slowly. 2. Major NCD involves impairment of abstract thinking and judgment, whereas mild NCD does not. 3. Major NCD criteria requires substantial cognitive decline from a previous level of performance, and mild NCD requires modest decline. 4. Major NCD criteria requires decline from a previous level of performance in three of the listed domains, and mild NCD requires only one. ANS: 3 Rationale: 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. Cognitive Level: Analysis Integrated Process: Assessment 17. 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. ANS: 2 Rationale: 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. Cognitive Level: Analysis Integrated Process: Assessment Multiple Response 18. 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 lOM oAR c P S D | 790 68 27 4. Herniated brain stem 5. Temporomandibular joint syndrome ANS: 1, 2, 3 Rationale: 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: systemic infections; febrile illness; metabolic disorders, such as hypoxia, hypercarbia, or hypoglycemia; hepatic encephalopathy; head trauma; seizures; migraine headaches; brain abscess; stroke; postoperative states; and electrolyte imbalance. 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. Cognitive Level: Application Integrated Process: Assessment 19. Which of the following medications that have been known to precipitate delirium? (Select all that apply.) 1. Antineoplastic agents 2. H2-receptor antagonists 3. Antihypertensives 4. Corticosteroids 5. Lipid-lowering agents ANS: 1, 2, 3, 4 Rationale: Medications that have been known to precipitate delirium include anticholinergics, antihypertensives, corticosteroids, anticonvulsants, cardiac glycosides, analgesics, anesthetics, antineoplastic agents, antiparkinson drugs, H2-receptor antagonists (e.g., cimetidine), and others. There have been no reports of delirium ascribed to the use of lipid-lowering agents. Cognitive Level: Application Integrated Process: Assessment Fill-in-the-Blank 20. Major NCD constitutes what was previously described as in the DSM-5-TR. ANS: dementia Rationale: 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. Chapter 14. Substance Use and Addictive Disorders Multiple Choice lOM oAR c P S D | 790 68 27 3. Substance induced disorder 4. Social induced disorder ANS: 1 Rationale: The nurse should use the term psychological addiction to best describe the clients 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. Cognitive Level: Application Integrated Process: Assessment 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 ANS: 4 Rationale: 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. Cognitive Level: Application Integrated Process: Assessment 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. lOM oAR c P S D | 790 68 27 ANS: 1 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 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 nurses 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 ANS: 2 Rationale: 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. Cognitive Level: Analysis Integrated Process: Implementation 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 (NA) when I cant 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. ANS: 4 Rationale: A client who takes responsibility for the consequences of substance use disorder or lOM oAR c P S D | 790 68 27 substance addiction is making positive progress toward recovery. This would indicate completion of the first step of a 12-step program. Cognitive Level: Application Integrated Process: Evaluation 10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses 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 ANS: 4 Rationale: 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. Cognitive Level: Analysis Integrated Process: Assessment 11. A client presents with symptoms of alcohol withdrawal and states, I havent eaten in three days. A nurses assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) 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 ANS: 3 Rationale: 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. lOM oAR c P S D | 790 68 27 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. ANS: 1 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 17. A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the clients 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) ANS: 3 Rationale: The SSRIs and clomipramine have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. Lithium, carbamazepine, and naltrexone have also been shown to be effective. The antipsychotic medications clozapine, olanzapine, and ziprasidone are not treatments of choice for this disorder. Cognitive Level: Application Integrated Process: Implementation 18. A nurse is assessing a pathological gambler. What would differentiate this clients behaviors from the behaviors of a non-pathological gambler? 1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. 2. Pathological gambling occurs more commonly among women, whereas non-pathological lOM oAR c P S D | 790 68 27 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. ANS: 1 Rationale: 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. For a pathological gambler, the preoccupation with and impulse to gamble intensifies when the individual is under stress. 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. Cognitive Level: Analysis Integrated Process: Assessment 19. 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. The state board of nursing must be notified with factual documentation of impairment. 2. All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice. 3. Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work. 4. After a return to practice, a recovering nurse may be closely monitored for several years. ANS: 2 Rationale: 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. When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings. lOM oAR c P S D | 790 68 27 Cognitive Level: Application Integrated Process: Assessment Multiple Response 20. 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 fathers 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. Ill need to set boundaries to maintain a therapeutic relationship. 5. I need to take charge when dealing with clients diagnosed with substance disorders. ANS: 1, 2, 4 Rationale: 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. Cognitive Level: Application Integrated Process: Implementation 21. 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. ANS: 1 Rationale: 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