Mental Health Exam 2 with Accurate Questions and Answers A+ rated., Exams of Nursing

Download Mental Health Exam 2 with Accurate Questions and Answers A+ rated. and more Exams Nursing in PDF only on Docsity! Mental Health Exam 2 with Accurate Questions and Answers A+ rated. A person has had difficulty keeping a job because of arguing with co- workers and accusing them of conspiracy. Today the person shouts, They're all plotting to destroy me. Isn't that true? Select the nurses most therapeutic response. a. Everyone here is trying to help you. No one wants to harm you. b. Feeling that people want to destroy you must be very frightening. c. That is not true. People here are trying to help you if you will let them. d. Staff members are health care professionals who are qualified to help you. - Correct Ans: ✔✔ANS: B (Feeling that people want to destroy you must be very frightening.) 2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination. - Correct Ans: ✔✔ANS: B (An idea of reference) 3. A patient diagnosed with schizophrenia says, My co-workers are out to get me. I also saw two doctors plotting to kill me. How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre - Correct Ans: ✔✔ANS: B (Dangerous) 4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose - Correct Ans: ✔✔ANS: A (Sedation and muscle stiffness) 5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a. I hear angels playing harps. b. The voices say everyone is trying to kill me. a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2. - Correct Ans: ✔✔ANS: B (Perform self-care activities with coaching by the end of day 3) 11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal - Correct Ans: ✔✔ANS: B (Wavy flexibility) 12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition - Correct Ans: ✔✔ANS: A (Allowing the patient supervised access to food vending machines) 13. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurses best plan. a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurses identity; encourage the patient to talk while the nurse works on reports. - Correct Ans: ✔✔ANS: A (Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return) 14. Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness. - Correct Ans: ✔✔ANS: D (Avoid relationships because they become anxious with emotional closeness) 15. A newly admitted patient diagnosed with schizophrenia says, The voices are bothering me. They yell and tell me I am bad. I have got to get away from them. Select the nurses most helpful reply. a. Do you hear the voices often? b. Do you have a plan for getting away from the voices? c. I'll stay with you. Focus on what we are talking about, not the voices. d. Forget the voices and ask some other patients to play cards with you. - Correct Ans: ✔✔ANS: C (I'll stay with you. Focus on what we are talking about, not the voices.) 16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a.Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia - Correct Ans: ✔✔ANS: C (Pseudoparkinsonism) 21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation - Correct Ans: ✔✔ANS: C (Poor personal hygiene) 22. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms - Correct Ans: ✔✔ANS: A (Withdrawal, misinterpreting, poor concentration, and preoccupation with religion) 23. A patient diagnosed with schizophrenia says, Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people. Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia - Correct Ans: ✔✔ANS: D (Paranoia) 24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 56 and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures - Correct Ans: ✔✔ANS: B (Weight management strategies) 25. A patient diagnosed with schizophrenia says, Its beat. Time to eat. No room for the cat. What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness - Correct Ans: ✔✔ANS: D (Associative looseness) 26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl) - Correct Ans: ✔✔ANS: B (Olanzapine (Zyprexa)) 27. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and familys role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family - Correct Ans: ✔✔ANS: A (Psychoeducational) 28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, My 33. A nurse asks a patient diagnosed with schizophrenia, What is meant by the old saying You cant judge a book by looking at the cover.? Which response by the patient indicates concrete thinking? a. The table of contents tells what a book is about. b. You cant judge a book by looking at the cover. c. Things are not always as they first appear. d. Why are you asking me about books? - Correct Ans: ✔✔ANS: A (The table of contents tells what a book is about.) 34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills. - Correct Ans: ✔✔ANS: D (demonstrate improved social skills) 35. A client says, Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist. Select the nurses best initial action. a. Tell the client, Facebook is a safe website. You don't need to worry about Homeland Security. b. Tell the client, You are in a safe place where you will be helped. c. Administer a PRN dose of an antipsychotic medication. d. Tell the client, You don;t need to worry about that. - Correct Ans: ✔✔ANS: B (Tell the client, you are in a safe place where you will be helped.) 36. Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations - Correct Ans: ✔✔ANS: C (Poverty of thought) 37. A patient insistently states, I can decipher codes of DNA just by looking at someone. Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion - Correct Ans: ✔✔ANS: B (Magical thinking) 38. A newly hospitalized patient experiencing psychosis says, Red chair out town board. Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia - Correct Ans: ✔✔ANS: A (Word salad) 1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a. The importance of taking your medication correctly b. How to complete an application for employment c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking - Correct Ans: ✔✔ANS: A, E (The importance of taking your medication correctly, ways to quit smoking) 2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, Two staff members I saw talking were (Risk for injury) 5. A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. Stop that! No one did anything to provoke an attack by you. b. If you do that one more time, you will be secluded immediately. c. Do not hit anyone. If you are unable to control yourself, we will help you. d. You know we will not let you hit anyone. Why do you continue this behavior? - Correct Ans: ✔✔ANS: C (Do not hit anyone. If you are unable to control yourself, we will help you.) 6. This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days.Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit. - Correct Ans: ✔✔ANS: B (drink six servings of high-calorie, high-protein drink each day) 7. A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity. - Correct Ans: ✔✔ANS: B (bring hyperactivity under rapid control) 8. A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) c. risperidone (Risperdal) b. clonidine (Catapres) d. carbamazepine (Tegretol) - Correct Ans: ✔✔ANS: D (carbamazepine (Tegretol)) 9. The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms. - Correct Ans: ✔✔ANS: A (several factors, including genetics, are implicated) 10. The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. A high proportion of patients with bipolar disorders are found among creative writers. b. A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder. c. Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress. d. More individuals with bipolar disorder come from high socioeconomic and educational backgrounds. - Correct Ans: ✔✔ANS: B (A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder) 11. A patient diagnosed with bipolar disorder commands other patients, Get me a book. Take this stuff out of here, and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable. - Correct Ans: ✔✔ANS: B (Hold staff meeting to discuss consistency and limit-setting approaches) 17. A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, Why dont you put your clothes on? b. firmly telling the patient, Stop dancing and put on your clothing. c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area. - Correct Ans: ✔✔ANS: C (putting a blanket around the patient and walking with the patient to a quiet room) 18. A patient waves a newspaper and says, I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes. Select the nurses appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases. - Correct Ans: ✔✔ANS: B (invites the patient to sit together and look at new fashion magazines) 19. An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice. - Correct Ans: ✔✔ANS: A (meals) 20. A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine. - Correct Ans: ✔✔ANS: A (maintain normal salt and fluids in the diet) 21. Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping - Correct Ans: ✔✔ANS: B (Disturbed sleep pattern) 22. Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream - Correct Ans: ✔✔ANS: C (Broiled chicken breast on a roll, an ear of corn, and an apple) 27. A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision. - Correct Ans: ✔✔ANS: D (arrange for one-on-one supervision) 28. A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, Ill throw the pool balls if anyone comes near me. To best assure safety, the nurses first intervention is to: a. tell the patient, You need to be secluded. b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force. - Correct Ans: ✔✔ANS: B (clear the room of all other patients) 29. A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patients family during this phase of treatment? a. Attending psychoeducation sessions c. Increasing food and fluids b. Decreasing physical activity d. Meeting self-care needs - Correct Ans: ✔✔ANS: A (Attending psychoeducation sessions) 30. A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema - Correct Ans: ✔✔ANS: C (Diaphoresis, weakness, and nausea) 31. A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, Do I have to keep taking this lithium even though my mood is stable now? Select the nurses appropriate response. a. You will be able to stop the medication in about 1 month. b. Taking the medication every day helps reduce the risk of a relapse. c. Usually patients take medication for approximately 6 months after discharge. d. It's unusual that the health care provider hasn't already stopped your medication. - Correct Ans: ✔✔ANS: B (Taking medication every day helps reduce the risk of a relapse) 32. An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, Ive had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do? The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now. - Correct Ans: ✔✔ANS: B (have someone bring the patient to the clinic immediately) 33. A newly diagnosed patient is prescribed lithium. Which information from the patients history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure - Correct Ans: ✔✔ANS: D (Heart failure) 34. Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: (Provide a structured environment for the patient, ensure that the patients nutritional needs are met) 1. A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, No one cares about me. I'm not worth anything. Which response by the nurse would be the most helpful? a. Things will look brighter soon. Everyone feels down once in a while. b. Our staff members care about you and want to try to help you get better. c. It is difficult for others to care about you when you repeatedly say the same negative things. d. I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you. - Correct Ans: ✔✔ANS: D (I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you.) 2. A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date). - Correct Ans: ✔✔ANS: A (verbalize realistic positive characteristics about self by (date)) 3. A patient diagnosed with major depression says, No one cares about me anymore. I'm not worth anything. Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. You look nice this morning. b. You're wearing a new shirt. c. I like the shirt you are wearing. d. You must be feeling better today. - Correct Ans: ✔✔ANS: B (You're wearing a new shirt) 4. An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy - Correct Ans: ✔✔ANS: A (Social skills training) 5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu. - Correct Ans: ✔✔ANS: B (careful unobtrusive observation around the clock) 6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies. - Correct Ans: ✔✔ANS: C (cognitive behavioral therapy) 7. A patient says to the nurse, My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day. The nurse documents this report as an example of: a. dysthymia. c. euphoria. b. anhedonia. 12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet. - Correct Ans: ✔✔ANS: C (reporting increased suicidal thoughts) 13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls - Correct Ans: ✔✔ANS: B (Mashed potatoes, ground beef patty, corn, green beans, apple pie) 14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts - Correct Ans: ✔✔ANS: B Supporting physiological stability 15. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications. - Correct Ans: ✔✔ANS: D (confers with a pharmacist when selecting over-the-counter medications 16. Major depression resulted after a patients employment was terminated. The patient now says to the nurse, Im not worth the time you spend with me. I am the most useless person in the world. Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity - Correct Ans: ✔✔ANS: C (situational low self-esteem) 17. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings. - Correct Ans: ✔✔ANS: A (Make observations) 18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares. The nurse will advise the patient to: a. Go to the nearest emergency department immediately. b. Do not to be alarmed. Take two aspirin and drink plenty of fluids. to me. Ive been feeling sad for several months. How will the nurse document the patients affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent. - Correct Ans: ✔✔ANS: B (Affect flat; mood depressed) 24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, You must bathe daily. c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering. - Correct Ans: ✔✔ANS: D (firmly and neutrally assist the patient with showering) 25. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, This medicine isnt working. The nurses best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement. - Correct Ans: ✔✔ANS: C (explain the time lag before antidepressants relieve symptoms) 26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward - Correct Ans: ✔✔ANS: D (Eyes pointed downward) 27. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule. - Correct Ans: ✔✔ANS: C (Temporary memory impairments and confusion may occur with electroconvulsive therapy.) 28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock. - Correct Ans: ✔✔ANS: B (hypertensive crisis) 29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a. They will put me to sleep during the procedure so I wont know what is happening. b. I might be a little dizzy or have a mild headache after each procedure. c. I will be unable to care for my children for about 2 months. d. I will avoid eating foods that contain tyramine. - Correct Ans: ✔✔ANS: B (Vital signs, presence of abdominal pain and diarrhea, hyperactivity of feelings of restlessness) 1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first? a. Verify the patients learning style. b. Lower the patients current anxiety. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms. - Correct Ans: ✔✔ANS: B (Lower the patient's current anxiety) 2. A woman is 57, 160 lbs, and wears a size 8 shoe. She says, My feet are huge. Ive asked three orthopedists to surgically reduce my feet. This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a. Social anxiety disorder b. Body dysmorphic disorder c. Separation anxiety disorder d. Obsessive-compulsive disorder due to a medical condition - Correct Ans: ✔✔ANS: B (Body dysmorphic disorder) 3. A patient experiencing moderate anxiety says, I feel undone. An appropriate response for the nurse would be: a. What would you like me to do to help you? b. Why do you suppose you are feeling anxious? c. Im not sure I understand. Give me an example. d. You must get your feelings under control before we can continue. - Correct Ans: ✔✔ANS: C (I'm not sure I understand. Give me an example.) 4. A patient fearfully runs from chair to chair crying, Theyre coming! They're coming! The patient does not follow the staffs directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for the patients safety. b. encourage clarification of feelings. c. respect the patients personal space. d. offer an outlet for the patients energy. - Correct Ans: ✔✔ANS: A (provide for the patient's safety) 5. A patient fearfully runs from chair to chair crying, Theyre coming! Theyre coming! The patient does not follow the staffs directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Fear b. Risk for injury c. Self-care deficit d. Disturbed thought processes - Correct Ans: ✔✔ANS: B (Risk for injury) 6. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of: a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring. - Correct Ans: ✔✔ANS: D (cognitive restructuring) 7. A patient undergoing diagnostic tests says, Nothing is wrong with me except a stubborn chest cold. The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial - Correct Ans: ✔✔ANS: D 12. A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurses office, furnished with chairs, files, magazines, and bookcases - Correct Ans: ✔✔ANS: A (An interview room furnished with a desk and two chairs) 13. A person has minor physical injuries after an auto accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is the persons level of anxiety? a. Mild b. Moderate c. Severe d. Panic - Correct Ans: ✔✔ANS: C (Severe) 14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, The nurse manager had a headache the day I was interviewed. Which defense mechanism is evident? a. Introjection c. Projection b. Conversion d. Splitting - Correct Ans: ✔✔ANS: C (Projection) 15. A patient tells a nurse, My new friend is the most perfect person one could imagine: kind, considerate, and good-looking. I cant find a single flaw. This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation. - Correct Ans: ✔✔ANS: C (idealization) 16. A patient experiences a sudden episode of severe anxiety. Of these medications in the patients medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin) - Correct Ans: ✔✔ANS: B (lorazepam (Ativan)) 17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurses response? a. Altruism b. Suppression c. Intellectualization d. Reaction formation - Correct Ans: ✔✔ANS: A (Altruism) 18. A person who feels unattractive repeatedly says, Although Im not beautiful, I am smart. This is an example of: a. repression. b. devaluation. c. identification. d. compensation. - Correct Ans: ✔✔ANS: D (compensation) (That person should not have provoked me.) 24. A patient experiencing panic suddenly began running and shouting, Im going to explode! Select the nurses best action. a. Ask, Im not sure what you mean. Give me an example. b. Capture the patient in a basket-hold to increase feelings of control. c. Tell the patient, Stop running and take a deep breath. I will help you. d. Assemble several staff members and say, We will take you to seclusion to help you regain control. - Correct Ans: ✔✔ANS: C (Tell the patient, stop running and take a deep breath. I will help you.) 25. A person who has been unable to leave home for more than a week because of severe anxiety says, I know it does not make sense, but I just cant bring myself to leave my apartment alone. Which nursing intervention is appropriate? a. Help the person use online video calls to provide interaction with others. b. Advise the person to accept the situation and use a companion. c. Ask the person to explain why the fear is so disabling. d. Teach the person to use positive self-talk techniques. - Correct Ans: ✔✔ANS: D (Teach the person to use positive self-talk techniques) 26. A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive- compulsive disorder? a. I check where my car keys are eight times. b. My legs often feel weak and spastic. c. Im embarrassed to go out in public. d. I keep reliving a car accident. - Correct Ans: ✔✔ANS: A (I check where my car keys are eight times.) 27. When alprazolam (Xanax) is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to: a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level. - Correct Ans: ✔✔ANS: C (avoid alcoholic beverages) 28. The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia? a. Im sure I will get over not wanting to leave home soon. It takes time. b. Being afraid to go out seems ridiculous, but I cant go out the door. c. My family says they like it now that I stay home most of the time. d. When I have a good incentive to go out, I can do it. - Correct Ans: ✔✔ANS: B (Being afraid to go out seems ridiculous, but I can't go out the door.) 29. A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis? a. feelings of responsibility for the health of family members b. approval-seeking behavior from friends and family c. persistent thoughts about bacteria, germs, and dirt d. needs to avoid interactions with others - Correct Ans: ✔✔ANS: C (persistent thoughts about bacteria, germs, and dirt) 30. A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patients symptoms rather than on the patient. - Correct Ans: ✔✔ANS: B (Encourage the patient to participate in social activities.) (Are there others in your family who must do things in a certain way to feel comfortable?; Is it difficult to keep certain thoughts out of your awareness?; Do you do certain things over and over again?) 4. The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? Select all that apply. a. Ineffective home maintenance b. Situational low self-esteem c. Chronic low self-esteem d. Disturbed body image e. Risk for injury - Correct Ans: ✔✔ANS: A, C, E (Ineffective home maintenance, chronic low self-esteem, risk for injury) 1. A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support numbing as a temporary way to manage intolerable feelings. - Correct Ans: ✔✔ANS: B (Explain that the physical symptoms are related to the psychological state.) 2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenagers grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their childs high school. - Correct Ans: ✔✔ANS: D (create a scholarship fund at their child's high school) 3. After the sudden death of his wife, a man says, I cant live without her she was my whole life. Select the nurses most therapeutic reply. a. Each day will get a little better. b. Her death is a terrible loss for you. c. Its important to recognize that she is no longer suffering. d. Your friends will help you cope with this change in your life. - Correct Ans: ✔✔ANS: B (Her death is a terrible loss for you) 4. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, If you had given him your undivided attention, he would still be alive. How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband. - Correct Ans: ✔✔ANS: C (Anger is an expected emotion in an adjustment disorder) 5. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, He would still be alive if you had given him your undivided attention. Select the nurses best intervention. a. Say to the wife, I understand you are feeling upset. I will stay with you until your family comes. b. Say to the wife, Your husbands heart was so severely damaged that it could no longer pump. c. Say to the wife, I will call the health care provider to discuss this matter with you. d. Hold the wifes hand in silence until the family arrives. - Correct Ans: ✔✔ANS: A (Say to the wife, I understand you are feeling upset. I will stay with you until your family comes.) 10. A patient states, I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school. This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder - Correct Ans: ✔✔ANS: C (Depersonalization disorder) 11. The unlicensed assistive personnel (UAP) says to the nurse, That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her? Select the nurses best reply. a. Spend as much time with her as you can and ask questions about her life. b. Use short, simple sentences and keep the environment calm and protective. c. Provide more information about her past to reduce the mysteries that are causing anxiety. d. Structure her time with activities to keep her busy, stimulated, and regaining concentration. - Correct Ans: ✔✔ANS: B (Use short, simple sentences and keep the environment calm and protective) 12. A patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patients behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication. - Correct Ans: ✔✔ANS: B (Engage the patient in a physical activity such as exercise) 13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system - Correct Ans: ✔✔ANS: C (Sympathetic NS) 14. The gas pedal on a persons car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this persons cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis - Correct Ans: ✔✔ANS: B (Flashbacks) 15. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurses highest priority is to screen this soldier for: a. bipolar disorder. b. schizophrenia. c. depression. d. dementia. - Correct Ans: ✔✔ANS: C (depression) 16. Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention? a. Its good to be home. I missed my home, family, and friends. b. I saw my best friend get killed by a roadside bomb. I dont understand why it wasnt me. c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown. family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis - Correct Ans: ✔✔ANS: C (Avoidance) 22. A soldier returned home last year after deployment to a war zone. The soldiers spouse complains, We were going to start a family, but now he wont talk about it. He will not look at children. I wonder if were going to make it as a couple. Select the nurses best response. a. Posttraumatic stress disorder often changes a persons sexual functioning. b. I encourage you to continue to participate in social activities where children are present. c. Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior. d. Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support. - Correct Ans: ✔✔ANS: D (PTSD often strains relationships. Here are some community resources for help and support.) 23. Which assessment finding best supports dissociative fugue? The patient states: a. I cannot recall why Im living in this town. b. I feel as if Im living in a fuzzy dream state. c. I feel like different parts of my body are at war. d. I feel very anxious and worried about my problems. - Correct Ans: ✔✔ANS: A (I cannot recall why I'm living in this town.) 24. After major reconstructive surgery, a patients wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus. - Correct Ans: ✔✔ANS: C (hippocampus) 25. Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones. - Correct Ans: ✔✔ANS: A (engage the parasympathetic NS) 26. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues. - Correct Ans: ✔✔ANS: D (cognitive distortions associated with unresolved childhood abuse issues) 1. A young adult says, I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I dont remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them. Which disorders should the nurse suspect based on this history? Select all that apply. a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder (An adolescent was kidnapped and held for 2 years in the home of a sexual predator, a passenger was in a bus that overturned on a sharp curve and tumbled down an embankment, an adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks) 1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified - Correct Ans: ✔✔ANS: C (Anorexia nervosa) 2. Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance - Correct Ans: ✔✔ANS: D (Patient expresses satisfaction with body appearance) 3. A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: a. Do you often feel fat? b. Who plans the family meals? c. What do you eat in a typical day? d. What do you think about your present weight? - Correct Ans: ✔✔ANS: C (What do you eat in a typical day?) 4. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, Describe what you think about your present weight and how you look. Which response by the patient is most consistent with the diagnosis? a. I am fat and ugly. b. What I think about myself is my business. c. Im grossly underweight, but thats what I want. d. Im a few pounds overweight, but I can live with it. - Correct Ans: ✔✔ANS: A (I am fat and ugly) 5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia - Correct Ans: ✔✔ANS: D (Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia) 6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds. - Correct Ans: ✔✔ANS: D (gain 1 to 2 pounds) a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others. - Correct Ans: ✔✔ANS: B (not to skip meals or restrict food) 12. A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurses comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders. - Correct Ans: ✔✔ANS: A (The nurse interacts with the patient in a protective fashion) 13. A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness. - Correct Ans: ✔✔ANS: D (Identify two alternative methods of coping with loneliness) 14. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching. - Correct Ans: ✔✔ANS: A (Assist the patient to identify triggers to binge eating) 15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36 C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5 C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7 C; pulse, 62 beats/min; blood pressure 74/48 mm Hg - Correct Ans: ✔✔ANS: A (150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg) 16. A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance. - Correct Ans: ✔✔ANS: C (how to recognize hypokalemia) 17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor - Correct Ans: ✔✔ANS: C (Lanugo) 23. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. You and I will have to sit down and discuss this problem. b. It bothers me to see you exercising. I am afraid you will lose more weight. c. Lets discuss the relationship between exercise, weight loss, and the effects on your body. d. According to our agreement, no exercising is permitted until you have gained a specific amount of weight. - Correct Ans: ✔✔ANS: D (According to our agreement, no exercising is permitted until you have gained a specific amount of weight) 24. Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements - Correct Ans: ✔✔ANS: D (Imbalanced nutrition: less than body requirements) 25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week. - Correct Ans: ✔✔ANS: A (Assess lung sounds and extremities) 26. Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, I am using contraceptives. c. says, I feel full after eating a small meal. d. reports problems with dry mouth and constipation. - Correct Ans: ✔✔ANS: A (now weighs 196 pounds) 27. A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center. - Correct Ans: ✔✔ANS: C (has accidents of defecation at kindergarten three times a week) 1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo - Correct Ans: ✔✔ANS: A, C, D, F (peripheral edema, constipation, hypotension, lanugo) 2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately. - Correct Ans: ✔✔ANS: C (acknowledge manipulative behavior when it is called to his or her attention) 5. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, Another nurse said you dont do your job right. Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt-producing. - Correct Ans: ✔✔ANS: C (manipulative) 6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling - Correct Ans: ✔✔ANS: C (Verbal abuse of another patient) 7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI) - Correct Ans: ✔✔ANS: B (Mood stabilizing medication) 8. A patients spouse filed charges after repeatedly being battered. The patient sarcastically says, Im sorry for what I did. I need psychiatric help. Which statement by the patient supports an antisocial personality disorder? a. I have a quick temper, but I can usually keep it under control. b. Ive done some stupid things in my life, but Ive learned a lesson. c. Im feeling terrible about the way my behavior has hurt my family. d. I hit because I am tired of being nagged. My spouse deserves the beating. - Correct Ans: ✔✔ANS: D (I hit because I am tired of being nagged. My spouse deserves the beating.) 9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial - Correct Ans: ✔✔ANS: A (Risk for other-directed violence) 10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patients wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patients behavior. - Correct Ans: ✔✔ANS: C (External controls are necessary due to failure of internal control) 11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior