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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS
Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach  8th Edition By 
Margaret Jordan Halter -Test Bank
Sample  Questions

 

Chapter 01: Mental Health and Mental Illness

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

 

MULTIPLE CHOICE

 

  1. A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention?
a. Conduct mental health assessments.
b. Prescribe psychotropic medication.
c. Establish therapeutic relationships.
d. Individualize nursing care plans.

 

 

ANS:  B

In most states, prescriptive privileges are granted to master’s-prepared nurse practitioners and clinical nurse specialists who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-23       TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A nursing student expresses concerns that mental health nurses “lose all their clinical nursing skills.” Select the best response by the mental health nurse.
a. “Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of the patients’ problems.”
b. “Psychiatric nurses use complex communication skills as well as critical thinking to solve multidimensional problems. I am challenged by those situations.”
c. “That’s a misconception. Psychiatric nurses frequently use high technology monitoring equipment and manage complex intravenous therapies.”
d. “Psychiatric nurses do not have to deal with as much pain and suffering as medical–surgical nurses do. That appeals to me.”

 

 

ANS:  B

The practice of psychiatric nursing requires a different set of skills than medical–surgical nursing, though there is substantial overlap. Psychiatric nurses must be able to help patients with medical as well as mental health problems, reflecting the holistic perspective these nurses must have. Nurse–patient ratios and workloads in psychiatric settings have increased, just like other specialties. Psychiatric nursing involves clinical practice, not just documentation. Psychosocial pain and suffering are as real as physical pain and suffering.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-2, 21                                  TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. When a new bill introduced in Congress reduces funding for care of persons diagnosed with mental illness, a group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled?
a. Recovery
b. Attending
c. Advocacy
d. Evidence-based practice

 

 

ANS:  C

An advocate defends or asserts another’s cause, particularly when the other person lacks the ability to do that for self. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the human condition. Since funding is necessary to deliver quality programming for persons with mental illness, the letter-writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-26       TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A family has a long history of conflicted relationships among the members. Which family member’s comment best reflects a mentally healthy perspective?
a. “I’ve made mistakes but everyone else in this family has also.”
b. “I remember joy and mutual respect from our early years together.”
c. “I will make some changes in my behavior for the good of the family.”
d. “It’s best for me to move away from my family. Things will never change.”

 

 

ANS:  C

The correct response demonstrates the best evidence of a healthy recognition of the importance of relationships. Mental health includes rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem. Recalling joy from earlier in life may be healthy, but the correct response shows a higher level of mental health. The other incorrect responses show blaming and avoidance.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Pages 1-2, 3, 32 (Figure 1-1)          TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? The patient
a. reports occasional sleeplessness and anxiety.
b. reports a consistently sad, discouraged, and hopeless mood.
c. is able to describe the difference between “as if” and “for real.”
d. perceives difficulty making a decision about whether to change jobs.

 

 

ANS:  B

The correct response describes a mood alteration, which reflects mental illness. The distracters describe behaviors that are mentally healthy or within the usual scope of human experience.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-2 to 4                                           TOP:              Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which finding best indicates that the goal “Demonstrate mentally healthy behavior” was achieved for an adult patient? The patient
a. sees self as capable of achieving ideals and meeting demands.
b. behaves without considering the consequences of personal actions.
c. aggressively meets own needs without considering the rights of others.
d. seeks help from others when assuming responsibility for major areas of own life.

 

 

ANS:  A

The correct response describes an adaptive, healthy behavior. The distracters describe maladaptive behaviors.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-2 to 4                                           TOP:              Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse encounters an unfamiliar psychiatric disorder on a new patient’s admission form. Which resource should the nurse consult to determine criteria used to establish this diagnosis?
a. International Statistical Classification of Diseases and Related Health Problems (ICD-10)
b. The ANA’s Psychiatric-Mental Health Nursing Scope and Standards of Practice
c. Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
d. A behavioral health reference manual

 

 

ANS:  C

The DSM-V gives the criteria used to diagnose each mental disorder. It is the official guideline for diagnosing psychiatric disorders. The distracters may not contain diagnostic criteria for a psychiatric illness.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-18, 19                                          TOP:              Nursing Process: Assessment

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A nurse wants to find a description of diagnostic criteria for anxiety disorders. Which resource would have the most complete information?
a. Nursing Outcomes Classification (NOC)
b. DSM-V
c. The ANA’s Psychiatric-Mental Health Nursing Scope and Standards of Practice
d. ICD-10

 

 

ANS:  B

The DSM-V details the diagnostic criteria for psychiatric clinical conditions. It is the official guideline for diagnosing psychiatric disorders. The other references are good resources but do not define the diagnostic criteria.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 1-18, 19                                          TOP:              Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which individual is demonstrating the highest level of resilience? One who
a. is able to repress stressors.
b. becomes depressed after the death of a spouse.
c. lives in a shelter for 2 years after the home is destroyed by fire.
d. takes a temporary job to maintain financial stability after loss of a permanent job.

 

 

ANS:  D

Resilience is closely associated with the process of adapting and helps people facing tragedies, loss, trauma, and severe stress. It is the ability and capacity for people to secure the resources they need to support their well-being. Repression and depression are unhealthy. Living in a shelter for 2 years shows a failure to move forward after a tragedy. See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-5, 6   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Complete this analogy. NANDA: clinical judgment: NIC: _________________
a. patient outcomes.
b. nursing actions.
c. diagnosis.
d. symptoms.

 

 

ANS:  B

Analogies show parallel relationships. NANDA, the North American Nursing Diagnosis Association, identifies diagnostic statements regarding human responses to actual or potential health problems. These statements represent clinical judgments. NIC (Nursing Interventions Classification) identifies actions provided by nurses that enhance patient outcomes. Nursing care activities may be direct or indirect.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Pages 1-21, 22                                          TOP:              Nursing Process: Evaluation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. An adult says, “Most of the time I’m happy and feel good about myself. I have learned that what I get out of something is proportional to the effort I put into it.” Which number on this mental health continuum should the nurse select?

 

Mental Illness Mental Health
1 2 3 4 5

 

a. 1
b. 2
c. 3
d. 4
e. 5

 

 

ANS:  E

The adult is generally happy and has an adequate self-concept. The statement indicates the adult is reality-oriented, works effectively, and has control over own behavior. Mental health does not mean that a person is always happy.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-2, 3, 32 (Figure 1-1)          TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which disorder is an example of a culture-bound syndrome?
a. Epilepsy
b. Schizophrenia
c. Running amok
d. Major depressive disorder

 

 

ANS:  C

Culture-bound syndromes occur in specific sociocultural contexts and are easily recognized by people in those cultures. A syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in furious, almost indiscriminate violent behavior.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-7         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. The DSM-V classifies:
a. deviant behaviors.
b. present disability or distress.
c. people with mental disorders.
d. mental disorders people have.

 

 

ANS:  D

The DSM-V classifies disorders people have rather than people themselves. The terminology of the tool reflects this distinction by referring to individuals with a disorder rather than as a “schizophrenic” or “alcoholic,” for example. Deviant behavior is not generally considered a mental disorder. Present disability or distress is only one aspect of the diagnosis.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 1-18, 19                                          TOP:              Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A citizen at a community health fair asks the nurse, “What is the most prevalent mental disorder in the United States?” Select the nurse’s correct response.
a. Schizophrenia
b. Bipolar disorder
c. Dissociative fugue
d. Alzheimer’s disease

 

 

ANS:  D

The 12-month prevalence for Alzheimer’s disease is 10% for persons older than 65% and 50% for persons older than 85. The prevalence of schizophrenia is 1.1% per year. The prevalence of bipolar disorder is 2.6%. Dissociative fugue is a rare disorder.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-33 (Table 1-1)                               TOP:              Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. In the majority culture of the United States, which individual has the greatest risk to be labeled mentally ill? One who
a. describes hearing God’s voice speaking.
b. is usually pessimistic but strives to meet personal goals.
c. is wealthy and gives away $20 bills to needy individuals.
d. always has an optimistic viewpoint about life and having own needs met.

 

 

ANS:  A

The question asks about risk. Hearing voices is generally associated with mental illness, but in charismatic religious groups, hearing the voice of God or a prophet is a desirable event. Cultural norms vary, which makes it more difficult to make an accurate diagnosis. The individuals described in the other options are less likely to be labeled mentally ill.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Pages 1-3, 4   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient’s relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health?
a. Effectiveness in work
b. Communication skills
c. Productive activities
d. Fulfilling relationships

 

 

ANS:  D

The information given centers on relationships with others that are described as intense and unstable. The relationships of mentally healthy individuals are stable, satisfying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-32 (Figure 1-1)                    TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which belief will best support a nurse’s efforts to provide patient advocacy during a multidisciplinary patient care planning session?
a. All mental illnesses are culturally determined.
b. Schizophrenia and bipolar disorder are cross-cultural disorders.
c. Symptoms of mental disorders are unchanged from culture to culture.
d. Assessment findings in mental illness reflect a person’s cultural patterns.

 

 

ANS:  D

Symptoms must be understood in terms of a person’s cultural background. A nurse who understands that a patient’s symptoms are influenced by culture will be able to advocate for the patient to a greater degree than a nurse who believes that culture is of little relevance. The distracters are untrue statements.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-27       TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse is part of a multidisciplinary team working with groups of depressed patients. One group of patients receives supportive interventions and antidepressant medication. The other group receives only medication. The team measures outcomes for each group. Which type of study is evident?
a. Incidence
b. Prevalence
c. Comorbidity
d. Clinical epidemiology

 

 

ANS:  D

Clinical epidemiology is a broad field that addresses studies of the natural history (or what happens if there is no treatment and the problem is left to run its course) of an illness, studies of diagnostic screening tests, and observational and experimental studies of interventions used to treat people with the illness or symptoms. Prevalence refers to numbers of new cases. Comorbidity refers to having more than one mental disorder at a time. Incidence refers to the number of new cases of mental disorders in a healthy population within a given period. See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-17       TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. The spouse of a patient diagnosed with schizophrenia says, “I don’t understand how events from childhood have anything to do with this disabling illness.” Which response by the nurse will best help the spouse understand the cause of this disorder?
a. “Psychological stress is the basis of most mental disorders.”
b. “This illness results from developmental factors rather than stress.”
c. “Research shows that this condition more likely has a biological basis.”
d. “It must be frustrating for you that your spouse is sick so much of the time.”

 

 

ANS:  C

Many of the most prevalent and disabling mental disorders have strong biological influences. Genetics are only one part of biological factors. Empathy does not address increasing the spouse’s level of knowledge about the cause of the disorder. The other distracters are not established facts.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-5, 6   TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A category 5 tornado occurred in a community of 400 people. Many homes and businesses were destroyed. In the 2 years following the disaster, 140 individuals were diagnosed with posttraumatic stress disorder (PTSD). Which term best applies to these newly diagnosed cases?
a. Prevalence
b. Comorbidity
c. Incidence
d. Parity

 

 

ANS:  C

Incidence refers to the number of new cases of mental disorders in a healthy population within a given period of time. Prevalence describes the total number of cases, new and existing, in a given population during a specific period of time, regardless of when they became ill. Parity refers to equivalence, and legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical–surgical coverage. Comorbidity refers to having more than one mental disorder at a time.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-16       TOP:   Nursing Process: Planning/Outcomes Identification

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which component of treatment of mental illness is specifically recognized by Quality and Safety Education for Nurses (QSEN)?
a. All genomes are unique.
b. Care is centered on the patient.
c. Healthy development is vital to mental health.
d. Recovery occurs on a continuum from illness to health.

 

 

ANS:  B

The key areas of care promoted by QSEN are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 1-14       TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Select the best response for the nurse to a question from another health professional regarding the difference between a diagnosis in DSM-V and a nursing diagnosis.
a. “There is no functional difference between the two. Both identify human disorders.”
b. “The DSM-V diagnosis disregards culture, whereas the nursing diagnosis takes culture into account.”
c. “The DSM-V diagnosis describes causes of disorders whereas a nursing diagnosis does not explore etiology.”
d. “The DSM-V diagnosis guides medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing.”

 

 

ANS:  D

The medical diagnosis is concerned with the patient’s disease state, causes, and cures, whereas the nursing diagnosis focuses on the patient’s response to stress and possible caring interventions. Both tools consider culture. The DSM-V is multiaxial. Nursing diagnoses also consider potential problems.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 1-21       TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which nursing intervention below is part of the scope of an advanced practice psychiatric/mental health nurse rather than a basic level registered nurse?
a. Coordination of care
b. Health teaching
c. Milieu therapy
d. Psychotherapy

 

 

ANS:  D

Psychotherapy is part of the scope of practice of an advanced practice nurse. The distracters are within a basic level registered nurse’s scope of practice.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 1-23, 35 (Table 1-2)             TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. An experienced nurse says to a new graduate, “When you’ve practiced as long as I have, you automatically know how to take care of patients experiencing psychosis.” Which factors should the new graduate consider when analyzing this comment? (Select all that apply.)
a. The experienced nurse may have lost sight of patients’ individuality, which may compromise the integrity of practice.
b. New research findings should be integrated continuously into a nurse’s practice to provide the most effective care.
c. Experience provides mental health nurses with the essential tools and skills needed for effective professional practice.
d. Experienced psychiatric nurses have learned the best ways to care for mentally ill patients through trial and error.
e. An intuitive sense of patients’ needs guides effective psychiatric nurses.

 

 

ANS:  A, B

Evidence-based practice involves using research findings and standards of care to provide the most effective nursing care. Evidence is continuously emerging, so nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 1-14       TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which findings are signs of a person who is mentally healthy? (Select all that apply.)
a. Says, “I have some weaknesses, but I feel I’m important to my family and friends.”
b. Adheres strictly to religious beliefs of parents and family of origin.
c. Spends all holidays alone watching old movies on television.
d. Considers past experiences when deciding about the future.
e. Experiences feelings of conflict related to changing jobs.

 

 

ANS:  A, D, E

Mental health is a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-2, 3, 32 (Figure 1-1)          TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient in the emergency department says, “Voices say someone is stalking me. They want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat.” Which aspects of the patient’s mental health have the greatest and most immediate concern to the nurse? (Select all that apply.)
a. Happiness
b. Appraisal of reality
c. Control over behavior
d. Effectiveness in work
e. Healthy self-concept

 

 

ANS:  B, C, E

The aspects of mental health of greatest concern are the patient’s appraisal of and control over behavior. The appraisal of reality is inaccurate. There are auditory hallucinations, delusions of persecution, and delusions of grandeur. In addition, the patient’s control over behavior is tenuous, as evidenced by the plan to stab anyone who seems threatening. A healthy self-concept is lacking, as evidenced by the delusion of grandeur. Data are not present to suggest that the other aspects of mental health (happiness and effectiveness in work) are of immediate concern.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 1-3, 4   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

Chapter 03: Psychobiology and Psychopharmacology

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

 

MULTIPLE CHOICE

 

  1. A patient asks, “What are neurotransmitters? My doctor said mine are imbalanced.” Select the nurse’s best response.
a. “How do you feel about having imbalanced neurotransmitters?”
b. “Neurotransmitters protect us from harmful effects of free radicals.”
c. “Neurotransmitters are substances we consume that influence memory and mood.”
d. “Neurotransmitters are natural chemicals that pass messages between brain cells.”

 

 

ANS:   D

The patient asked for information, and the correct response is most accurate. Neurotransmitters are chemical substances that function as messengers in the central nervous system. They are released from the axon terminal, diffuse across the synapse, and attach to specialized receptors on the postsynaptic neuron. The distracters either do not answer the patient’s question or provide untrue, misleading information.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 3-9          TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. The parent of an adolescent diagnosed with schizophrenia asks the nurse, “My child’s doctor ordered a PET. What kind of test is that?” Select the nurse’s best reply.
a. “This test uses a magnetic field and gamma waves to identify problem areas in the brain. Does your teenager have any metal implants?”
b. “PET means positron-emission tomography. It is a special type of scan that shows blood flow and activity in the brain.”
c. “A PET scan passes an electrical current through the brain and shows brain-wave activity. It can help diagnose seizures.”
d. “It’s a special x-ray that shows structures of the brain and whether there has ever been a brain injury.”

 

 

ANS:   B

The parent is seeking information about PET scans. It is important to use terms the parent can understand, so the nurse should identify what the initials mean. The correct response is the only option that provides information relevant to PET scans. The distracters describe magnetic resonance image (MRI), computed tomography (CT) scans, and EEG. See relationship to audience response question.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-13, 58 (Table 3-2)                 TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A patient with a long history of hypertension and diabetes now develops confusion. The health care provider wants to make a differential diagnosis between Alzheimer’s disease and multiple infarcts. Which diagnostic procedure should the nurse expect to prepare the patient for first?
a. Skull x-rays
b. CT scan
c. PET
d. Single photon emission computed tomography (SPECT)

 

 

ANS:   B

A CT scan shows the presence or absence of structural changes, including cortical atrophy, ventricular enlargement, and areas of infarct, information that would be helpful to the health care provider. PET and SPECT show brain activity rather than structure and may occur later. See relationship to audience response question.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-13, 58 (Table 3-2)                 TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A patient’s history shows drinking 4 to 6 L of fluid and eating more than 6,000 calories per day. Which part of the central nervous system is most likely dysfunctional for this patient?
a. Amygdala
b. Parietal lobe
c. Hippocampus
d. Hypothalamus

 

 

ANS:   D

The hypothalamus, a small area in the ventral superior portion of the brainstem, plays a vital role in such basic drives as hunger, thirst, and sex. See relationship to audience response question.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-10, 11                                    TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. The nurse prepares to assess a patient diagnosed with major depressive disorder for disturbances in circadian rhythms. Which question should the nurse ask this patient?
a. “Have you ever seen or heard things that others do not?”
b. “What are your worst and best times of the day?”
c. “How would you describe your thinking?”
d. “Do you think your memory is failing?”

 

 

ANS:   B

Mood changes throughout the day may be related to circadian rhythm disturbances. Questions about sleep pattern are also relevant to circadian rhythms. The distracters apply to assessment for illusions and hallucinations, thought processes, and memory.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Page 3-7          TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

  1. The nurse administers a medication that potentiates the action of ã-aminobutyric acid (GABA). Which effect would be expected?
a. Reduced anxiety
b. Improved memory
c. More organized thinking
d. Fewer sensory perceptual alterations

 

 

ANS:   A

Increased levels of GABA reduce anxiety. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations. See relationship to audience response question.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-15, 16, 20, 53 (Table 3-1)     TOP:    Nursing Process: Evaluation

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse would anticipate that treatment for a patient with memory difficulties might include medications designed to
a. inhibit GABA.
b. prevent destruction of acetylcholine.
c. reduce serotonin metabolism.
d. increase dopamine activity.

 

 

ANS:   B

Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA affects anxiety rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson’s disease rather than improving memory.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-37, 43, 53 (Table 3-1)           TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A patient has disorganized thinking associated with schizophrenia. Neuroimaging would likely show dysfunction in which part of the brain?
a. Hippocampus
b. Frontal lobe
c. Cerebellum
d. Brainstem

 

 

ANS:   B

The frontal lobe is responsible for intellectual functioning. The hippocampus is involved in emotions and learning. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-13, 50 (Figure 3-5)                TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. The nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the
a. parasympathetic nervous system.
b. sympathetic nervous system.
c. reticular activating system.
d. medulla oblongata.

 

 

ANS:   A

Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When anticholinergic drugs inhibit acetylcholine action, blurred vision, dry mouth, constipation, and urinary retention commonly occur.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 3-50 (Figure 3-1) | Page 3-53 (Table 3-1)

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. The therapeutic action of neurotransmitter inhibitors that block reuptake cause
a. decreased concentration of the blocked neurotransmitter in the central nervous system.
b. increased concentration of the blocked neurotransmitter in the synaptic gap.
c. destruction of receptor sites specific to the blocked neurotransmitter.
d. limbic system stimulation.

 

 

ANS:   B

If the reuptake of a substance is inhibited, it accumulates in the synaptic gap, and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-10, 24, 64 (Box 3-2)             TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. Which drug action causes these symptoms to develop?
a. Anticholinergic effects
b. Dopamine-blocking effects
c. Endocrine-stimulating effects
d. Ability to stimulate spinal nerves

 

 

ANS:   B

Medication that blocks dopamine often produces disturbances of movement, such as akathisia, because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-28, 36, 52 (Figure 3-20)        TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. A fearful patient has an increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter?
a. GABA
b. Norepinephrine
c. Acetylcholine
d. Histamine

 

 

ANS:   B

Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for “fight or flight.” GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 3-30 (Figure 3-1) | Page 3-53 (Table 3-1)

TOP:    Nursing Process: Assessment             MSC:   Client Needs: Physiological Integrity

 

  1. A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group?
a. Tricyclic antidepressants
b. Antipsychotic drugs
c. Mood stabilizers
d. Benzodiazepines

 

 

ANS:   D

Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Mood stabilizers are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-20, 21, 51 (Figure 3-12)        TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A patient is hospitalized for severe major depressive disorder. Of the medications listed below, the nurse can expect to provide the patient with teaching about
a. chlordiazepoxide.
b. clozapine.
c. sertraline.
d. tacrine.

 

 

ANS:   C

Sertraline (Zoloft) is an selective serotonin reuptake inhibitor (SSRI). This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimer’s disease.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 3-25        TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A patient diagnosed with bipolar disorder displays aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group?
a. Psychostimulants
b. Mood stabilizers
c. Anticholinergics
d. Antidepressants

 

 

ANS:   B

The symptoms describe mania, which is effectively treated by mood stabilizers, such as lithium, and selected anticonvulsants (carbamazepine, valproic acid, and lamotrigine). Drugs from the other classifications listed are not effective in the treatment of mania.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-32, 33                                    TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A drug causes muscarinic receptor blockade. The nurse will assess the patient for
a. dry mouth.
b. gynecomastia.
c. pseudoparkinsonism.
d. orthostatic hypotension.

 

 

ANS:   A

Muscarinic receptor blockade includes atropine-like side effects, such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with á1 antagonism.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-25, 30, 35 to 37                     TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. A patient begins therapy with a phenothiazine medication. What teaching should the nurse provide related to the drug’s strong dopaminergic effect?
a. Chew sugarless gum.
b. Increase dietary fiber.
c. Arise slowly from bed.
d. Report changes in muscle movement.

 

 

ANS:   D

Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Movement disorders and motor abnormalities (extrapyramidal side effects), such as parkinsonism, akinesia, akathisia, dyskinesia, and tardive dyskinesia, are likely to occur early in the course of treatment. They are often heralded by sensations of muscle stiffness. Early intervention with antiparkinsonism medication can increase the patient’s comfort and prevent dystonic reactions. The distracters are related to anticholinergic effects.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-28, 36, 37, 52 (Figure 3-20)

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

  1. A patient tells the nurse, “My doctor prescribed paroxetine for my depression. I assume I’ll have side effects like I had when I was taking imipramine.” The nurse’s reply should be based on the knowledge that paroxetine is a(n)
a. selective norepinephrine reuptake inhibitor.
b. tricyclic antidepressant.
c. monoamine oxidase (MAO) inhibitor.
d. SSRI.

 

 

ANS:   D

Paroxetine is an SSRI and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 3-25        TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse can anticipate anticholinergic side effects are likely when a patient takes
a. lithium.
b. buspirone.
c. imipramine.
d. risperidone.

 

 

ANS:   C

Imipramine (Tofranil) is a tricyclic antidepressant with strong anticholinergic properties, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid-balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-29, 30, 52 (Figure 3-17)        TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. Which instruction has priority when teaching a patient about clozapine?
a. “Avoid unprotected sex.”
b. “Report sore throat and fever immediately.”
c. “Reduce foods high in polyunsaturated fats.”
d. “Use over-the-counter preparations for rashes.”

 

 

ANS:   B

Clozapine therapy may produce agranulocytosis; therefore, signs of infection should be immediately reported to the health care provider. In addition, the patient should have white blood cell levels measured weekly. The other options are not relevant to clozapine.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-38, 39                                    TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse cares for a group of patients receiving various medications, including haloperidol, carbamazepine, trazodone, and phenalgine. The nurse will order a special diet for the patient who takes
a. carbamazepine.
b. haloperidol.
c. phenelzine.
d. trazodone.

 

 

ANS:   C

Patients taking phenelzine, an MAO inhibitor, must be on a low tyramine diet to prevent hypertensive crisis. There are no specific dietary precautions associated with the distracters.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Page 3-31        TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse instructs a patient taking a drug that inhibits MAO to avoid certain foods and drugs because of the risk of
a. cardiac dysrhythmia.
b. hypotensive shock.
c. hypertensive crisis.
d. hypoglycemia.

 

 

ANS:   C

Patients taking MAO-inhibiting drugs must be on a low tyramine diet to prevent hypertensive crisis. In the presence of MAO inhibitors, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 3-31        TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse caring for a patient taking a SSRI will develop outcome criteria related to
a. coherent thought processes.
b. improvement in depression.
c. reduced levels of motor activity.
d. decreased extrapyramidal symptoms.

 

 

ANS:   B

SSRIs affect mood, relieving depression in many cases. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-24, 25                                    TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. By which mechanism do SSRI medications improve depression?
a. Destroying increased amounts of serotonin
b. Making more serotonin available at the synaptic gap
c. Increasing production of acetylcholine and dopamine
d. Blocking muscarinic and á1 norepinephrine receptors

 

 

ANS:   B

Depression is thought to be related to lowered availability of the neurotransmitter serotonin. SSRIs act by blocking reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. SSRIs prevent destruction of serotonin. SSRIs have little or no effect on acetylcholine and dopamine production. SSRIs do not produce muscarinic or á1 norepinephrine blockade.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-24, 25                                    TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3. Select the nurse’s best action.
a. Report the results to the health care provider immediately.
b. Administer the next dose as prescribed.
c. Give aspirin and force fluids.
d. Repeat the laboratory test.

 

 

ANS:   A

These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider, and the drug should be withheld. The health care provider may repeat the test, but in the meantime, the drug should be withheld. (Note: This question requires students to apply previous learning regarding normal and abnormal values of white blood cell counts.)

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 3-38, 39                                    TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A drug blocks the attachment of norepinephrine to a1 receptors. The patient may experience
a. hypertensive crisis.
b. orthostatic hypotension.
c. severe appetite disturbance.
d. an increase in psychotic symptoms.

 

 

ANS:   B

Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of  a1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Teach patients ways of minimizing this phenomenon.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-28, 41, 42                              TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

 

  1. A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving
a. lithium.
b. clozapine.
c. fluoxetine.
d. venlafaxine.

 

 

ANS:   A

Lithium is a salt and known to alter fluid and electrolyte balance, producing polyuria, edema, and other symptoms of imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block. Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-33, 62 (Table 3-3)                 TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. An obese patient has a diagnosis of schizophrenia. Medications that block which receptors would contribute to further weight gain?
a. H1
b. 5 HT2
c. Acetylcholine
d. GABA

 

 

ANS:   A

H1 receptor blockade results in weight gain, which is undesirable for an obese patient. Blocking of the other receptors would have little or no effect on the patient’s weight.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-37, 38, 40                              TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. An individual hiking in the forest encounters a large poisonous snake on the path. Which change in this individual’s vital signs is most likely?
a. Pulse rate changes from 90 to 72.
b. Respiratory rate changes from 22 to 18.
c. Complaints of intestinal cramping begin.
d. Blood pressure changes from 114/62 to 136/78.

 

 

ANS:   D

This frightening experience would stimulate the sympathetic nervous system, causing a release of norepinephrine, an excitatory neurotransmitter. It prepares the body for fight or flight. Increased blood pressure, pupil size, respiratory rate, and pulse rate signify release of norepinephrine. Intestinal cramping would be associated with stimulation of the parasympathetic nervous system.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-5, 50 (Figure 3-1)                  TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. Consider these medications: carbamazepine, lamotrigine, gabapentin. Which medication below also belongs to this group?
a. Galantamine
b. Valproate
c. Buspirone
d. Tacrine

 

 

ANS:   B

The medications listed in the stem are mood stabilizers, anticonvulsant types. Valproate (Depakote) is also a member of this group. The distracters are drugs for treatment of Alzheimer’s disease and anxiety.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-33, 34                                    TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. A professional football player is seen in the emergency department after losing consciousness from an illegal block. Prior to discharge, the nurse assists the patient to schedule an outpatient computed tomography (CT) scan for the next day. Which strategy should the nurse use to ensure the patient remembers the appointment?
a. Write the appointment day, time, and location on a piece of paper and give it to the player.
b. Log the appointment day, time, and location into the player’s cell phone calendar feature.
c. Ask the health care provider to admit the patient to the hospital overnight.
d. Verbally inform the patient of the appointment day, time, and location.

 

 

ANS:   B

This player may have suffered repeated head injuries with damage to the hippocampus. The hippocampus has significant role in maintaining memory. Logging the appointment into the player’s cell phone calendar will remind him of the appointment the next day. Paper will be lost, and the patient is unlikely to remember verbal instruction. Hospitalization is unnecessary. See relationship to audience response question. Caution: This question requires students to apply previous learning regarding central nervous system anatomy and physiology.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Page 3-12        TOP:    Nursing Process: Implementation

MSC:   Client Needs: Safe, Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. A nurse prepares to administer a second-generation antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring for adverse effects will be most important if the patient has which co-morbid health problems? (Select all that apply.)
a. Parkinson’s disease
b. Grave’s disease
c. Hyperlipidemia
d. Osteoarthritis
e. Diabetes

 

 

ANS:   A, C, E

Antipsychotic medications may produce weight gain, which would complicate care of a patient with diabetes, and increase serum triglycerides, which would complicate care of a patient with hyperlipidemia. Parkinson’s disease involves changes in transmission of dopamine and acetylcholine, so these drugs would also complicate care of this patient. Osteoarthritis and Grave’s disease should have no synergistic effect with this medication.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 3-37, 38, 40                              TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. Questions the nurse could ask that would be nonjudgmental when obtaining information about a patient’s use of complementary and herbal remedies include (Select all that apply)
a. “You don’t regularly take herbal remedies, do you?”
b. “What herbal medicines have you used to relieve your symptoms?”
c. “What over-the-counter medicines, vitamins, and nutritional supplements do you use?”
d. “What differences in your symptoms do you notice when you take herbal supplements?”
e. “Have you experienced problems from using herbal and prescription drugs at the same time?”

 

 

ANS:   B, C, D, E

The correct responses are neutral in tone and do not express bias for or against the use of complementary or herbal medicines. The distracter, worded in a negative way, makes the nurse’s bias evident.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Page 3-45        TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

  1. An individual is experiencing problems with memory. Which of these structures are most likely to be involved in this deficit? (Select all that apply.)
a. Amygdala
b. Hippocampus
c. Occipital lobe
d. Temporal lobe
e. Basal ganglia

 

 

ANS:   A, B, D

The frontal and temporal lobes of the cerebrum play a key role in the storage and processing of memories. The amygdala and hippocampus also play roles in memory. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement, as well as some thoughts and emotions.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 3-7, 12, 16, 50 (Figure 3-5)      TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A patient’s sibling says, “My brother has a mental illness, but the doctor ordered a functional magnetic resonance image (fMRI) test. That test is too expensive and will just increase the hospital bill.” Select the nurse’s best responses. (Select all that apply.)
a. “Sometimes there are physical causes for psychiatric symptoms. This test will help us understand whether that is the situation.”
b. “Some mental illnesses are evident on fMRIs. This test will give information to help us plan the best care for your brother.”
c. “This test will indicate whether your brother has been taking his psychotropic medications as prescribed.”
d. “It sounds like you do not truly believe your brother had a mental illness.”
e. “It would be better for you to discuss your concerns with the health care provider.”

 

 

ANS:   A, B

The correct responses provide information to the sibling. Modern imaging techniques are important tools in assessing molecular changes in mental disease and marking the receptor sites of drug action, which can help in treatment planning. Psychiatric symptoms can be caused by anatomical or physiologic abnormalities. There is no evidence of denial in the sibling’s comment. The nurse can answer this question rather than referring it to the physician/health care provider. An fMRI does not demonstrate adherence to the medication regime.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 3-13, 58 (Table 3-2)                 TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity

Chapter 11: Childhood and Neurodevelopmental Disorders

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

 

MULTIPLE CHOICE

 

  1. Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders?
a. Impaired social interaction related to difficulty maintaining relationships
b. Chronic low self-esteem related to excessive negative feedback
c. Deficient fluid volume related to abnormal eating habits
d. Anxiety related to nightmares and repetitive activities

 

 

ANS:   A

Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-29, 30, 54 (Table 11-1)       TOP:    Nursing Process: Analysis/Diagnosis

MSC:   Client Needs: Psychosocial Integrity

 

  1. Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child
a. plays with one toy for 30 minutes.
b. repeats words spoken by a parent.
c. holds the parent’s hand while walking.
d. spins around and claps hands while walking.

 

 

ANS:   C

Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone’s hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-33 to 35                               TOP:    Nursing Process: Evaluation

MSC:   Client Needs: Psychosocial Integrity

 

  1. A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to
a. promote integration of self-concept.
b. provide inpatient treatment for the child.
c. reduce loneliness and increase self-esteem.
d. improve language and communication skills.

 

 

ANS:   C

Because of their disruptive behaviors, children diagnosed with attention deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 11-36, 40                                  TOP:    Nursing Process: Planning

MSC:   Client Needs: Psychosocial Integrity

 

  1. A nurse will prepare teaching materials for the parents of a child newly diagnosed with ADHD. Information will focus on which medication likely to be prescribed?
a. Paroxetine
b. Imipramine
c. Methylphenidate
d. Carbamazepine

 

 

ANS:   C

Central nervous system (CNS) stimulants are the drugs of choice for treating children diagnosed with ADHD. Methylphenidate and mixed amphetamine salts are most commonly used. None of the other drugs are psychostimulants used to treat ADHD.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 11-41, 56 (Table 11-2)             TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. What is the nurse’s priority focused assessment for side effects in a child taking methylphenidate for ADHD?
a. Dystonia, akinesia, and extrapyramidal symptoms
b. Bradycardia and hypotensive episodes
c. Sleep disturbances and weight loss
d. Neuroleptic malignant syndrome

 

 

ANS:   C

The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child’s growth and development. The distracters relate to side effects of conventional antipsychotic medications.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-41 to 43, 56 (Table 11-2)    TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

 

  1. A desired outcome for a 12-year-old diagnosed with ADHD is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care?
a. Reality therapy
b. Simple restitution
c. Social skills group
d. Insight-oriented group therapy

 

 

ANS:   C

Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Page 11-43      TOP:    Nursing Process: Planning

MSC:   Client Needs: Psychosocial Integrity

 

  1. The parent of a 6-year-old says, “My child is in constant motion and talks all the time. My child isn’t interested in toys but is out of bed every morning before me.” The child’s behavior is most consistent with diagnostic criteria for
a. communication disorder.
b. stereotypic movement disorder.
c. intellectual development disorder.
d. ADHD.

 

 

ANS:   D

Excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 11-35 to 38                               TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

  1. A child diagnosed with ADHD had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? The child
a. has an improved ability to identify anxiety and use self-control strategies.
b. has increased expressiveness in communication with others.
c. shows increased responsiveness to authority figures.
d. engages in cooperative play with other children.

 

 

ANS:   D

The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child’s aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-39, 40, 43, 44                      TOP:    Nursing Process: Evaluation

MSC:   Client Needs: Psychosocial Integrity

 

  1. When a 5-year-old diagnosed with ADHD bounces out of a chair and runs over and slaps another child, what is the nurse’s best action?
a. Instruct the parents to take the aggressive child home.
b. Direct the aggressive child to stop immediately.
c. Call for emergency assistance from other staff.
d. Take the aggressive child to another room.

 

 

ANS:   D

The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-40, 41, 62 (Box 11-3)         TOP:    Nursing Process: Implementation

MSC:   Client Needs: Safe, Effective Care Environment

 

  1. A child diagnosed with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?
a. CNS stimulants c. Antipsychotics
b. Tricyclic antidepressants d. Anxiolytics

 

 

ANS:   A

CNS stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 11-41, 56 (Table 11-2)             TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, “If my parents loved me, they would work out their problems.” Which nursing diagnosis has the highest priority?
a. Social isolation
b. Decisional conflict
c. Chronic low self-esteem
d. Disturbed personal identity

 

 

ANS:   A

This child shows difficulty coping with problems associated with the family. Social isolation refers to aloneness that the patient perceives negatively, even when self-imposed. The other options are not supported by data in the scenario.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-54 (Table 11-1), 61(Box 11-2)

TOP:    Nursing Process: Analysis/Diagnosis

MSC:   Client Needs: Psychosocial Integrity

 

  1. A nurse works with a child who is sad and irritable because the child’s parents are divorcing. Why is establishing a therapeutic alliance with this child a priority?
a. Therapeutic relationships provide an outlet for tension.
b. Focusing on the strengths increases a person’s self-esteem.
c. Acceptance and trust convey feelings of security to the child.
d. The child should express feelings rather than internalize them.

 

 

ANS:   C

Trust is frequently an issue because the child may question their trusting relationship with the parents. In this situation, the trust the child once had in parents has been disrupted, reducing feelings of security. The correct answer is the most global response.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 11-12, 16, 61 (Box 11-2)         TOP:    Nursing Process: Planning

MSC:   Client Needs: Psychosocial Integrity

 

  1. A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child’s disorder? The child
a. has occasional toileting accidents.
b. interrupts or intrudes on others.
c. cries when separated from a parent.
d. continuously rocks in place for 30 minutes.

 

 

ANS:   D

Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 11-30, 31                                  TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

  1. A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, “What should we do?” Select the nurse’s best response.
a. “Ask the teacher to let the child call you at play time.”
b. “Withdraw the child from preschool until maturity increases.”
c. “Remain with your child for the first hour of preschool time.”
d. “Give your child a kiss before you leave the preschool program.”

 

 

ANS:   D

The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-12, 13, 61 (Box 11-2)         TOP:    Nursing Process: Implementation

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness?
a. The child has been raised by a parent with recurring major depressive disorder.
b. The child’s best friend was absent from the child’s birthday party.
c. The child was not promoted to the next grade one year.
d. The child moved to three new homes over a 2-year period.

 

 

ANS:   A

Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent’s depression means it has been a consistent stressor. The other factors are not as risk-enhancing.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-6, 7                                      TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

  1. The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with
a. ADHD.
b. posttraumatic stress disorder (PTSD).
c. communication disorder.
d. an anxiety disorder.

 

 

ANS:   A

Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 11-43      TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity

 

  1. A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse’s best first action?
a. Give notice to the chief administrator at the school regarding the events.
b. Encourage the victimized child to share feelings about the experience.
c. Encourage the victimized child to ignore the bullying behavior.
d. Discuss the events with the aggressive classmate.

 

 

ANS:   B

The behaviors by the bullying child create emotional pain and present the risk for physical pain. Encouraging the victimized child to share feelings about the experience provides the nurse an opportunity to further assess the situation as well as provide support to the child. The nurse should validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 11-8, 12                                    TOP:    Nursing Process: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others’ conversations. How should the nurse document these behaviors?
a. Disobedience
b. Hyperactivity
c. Impulsivity
d. Anxiety

 

 

ANS:   C

These behaviors are most directly related to impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is demonstrated by failure to listen. Defiance is demonstrated by willfully doing what an authority figure has said not to do.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 11-37      TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

  1. A child diagnosed with ADHD shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior?
a. Increased expressiveness in communication with others
b. Abilities to identify anxiety and implement self-control strategies
c. Improved abilities to participate in cooperative play with other children
d. Tolerates social interactions for short periods without disruption or frustration

 

 

ANS:   C

The goal is improvement in the child’s hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-41 to 43

TOP:    Nursing Process: Outcomes Identification

MSC:   Client Needs: Psychosocial Integrity

 

  1. When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses
a. guided imagery.
b. talk focused on a specific issue.
c. play and talk about a play activity.
d. group discussion about selected topics.

 

 

ANS:   C

Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-13, 14, 19                            TOP:    Nursing Process: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. Which child demonstrates behaviors indicative of a neurodevelopmental disorder?
a. A 4-year-old who stuttered for 3 weeks after the birth of a sibling
b. A 9-month-old who does not eat vegetables and likes to be rocked
c. A 3-month-old who cries after feeding until burped and sucks a thumb
d. A 3-year-old who is mute, passive toward adults, and twirls while walking

 

 

ANS:   D

Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. ASD is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 11-32, 33, 61 (Box 11-2)         TOP:    Nursing Process: Assessment

MSC:   Client Needs: Health Promotion and Maintenance

 

  1. The parent of a child diagnosed with Tourette’s disorder says to the nurse, “I think my child is faking the tics because they come and go.” Which response by the nurse is accurate?
a. “Perhaps your child was misdiagnosed.”
b. “Your observation indicates the medication is effective.”
c. “Tics often change frequency or severity. That doesn’t mean they aren’t real.”
d. “This finding is unexpected. How have you been administering your child’s medication?”

 

 

ANS:   C

Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette’s disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-22, 23                                  TOP:    Nursing Process: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. When a 5-year-old is disruptive, the nurse says, “You must take a time-out.” The expectation is that the child will
a. go to a quiet room until called for the next activity.
b. slowly count to 20 before returning to the group activity.
c. sit on the edge of the activity until able to regain self-control.
d. sit quietly on the lap of a staff member until able to apologize for the behavior.

 

 

ANS:   C

Time-out is designed so that staff can be consistent in their interventions. Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self-control and reviews the episode with a staff member. Time-out may not require going to a designated room and does not involve special attention such as holding. Counting to 10 or 20 is not sufficient.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Page 11-18      TOP:    Nursing Process: Implementation

MSC:   Client Needs: Safe, Effective Care Environment

 

  1. A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, “My three friends and I got an A on our school science project.” The nurse can assess that the child
a. displays resiliency.
b. has a passive temperament.
c. is at risk for PTSD.
d. uses intellectualization to deal with problems.

 

 

ANS:   A

Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-6, 7                                      TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A nurse prepares to lead a discussion at a community health center regarding children’s health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? (Select all that apply.)
a. Autism
b. Bullying
c. Mental retardation
d. Autism spectrum disorder
e. Intellectual development disorder

 

 

ANS:   B, D, E

Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It is important for the nurse to use current terminology.

 

PTS:    1                      DIF:    Cognitive Level: Understand (Comprehension)

REF:    Pages 11-8, 25, 29                              TOP:    Nursing Process: Implementation

MSC:   Client Needs: Psychosocial Integrity

 

  1. A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will (Select all that apply)
a. graduate from high school.
b. live independently in an apartment.
c. independently perform own personal hygiene.
d. obtain employment in a local sheltered workshop.
e. correctly use public buses to travel in the community.

 

 

ANS:   C, D, E

Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 11-25 to 28

TOP:    Nursing Process: Outcomes Identification

MSC:   Client Needs: Psychosocial Integrity

 

  1. At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? (Select all that apply.)
a. Report the finding to the official child protection social services agency.
b. Educate all members of the family about potential safety risks in online environments.
c. Talk with the parents about parental controls on the children’s communication devices.
d. Encourage the family to schedule daily time together without communication devices.
e. Obtain the family’s network password and examine online sites family members have visited.

 

 

ANS:   B, C, D

The nurse’s focus is safety, including online environments. Education and awareness-based approaches are indicated to reduce the risks of potentially harmful behavior, including risks associated with cyberbullying. Parental controls on the children’s devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family’s network password and an invasion of privacy to inspect sites family members have visited.

 

PTS:    1                      DIF:    Cognitive Level: Analyze (Analysis)

REF:    Pages 11-8, 45, 61 (Box 11-2)           TOP:    Nursing Process: Assessment

MSC:   Client Needs: Safe, Effective Care Environment

 

  1. Which assessment findings present familial risks for a child to develop a psychiatric disorder? (Select all that apply.)
a. Having a mother diagnosed with schizophrenia
b. Being the oldest child in a family
c. Living with an alcoholic parent
d. Being an only child
e. Living in an urban community

 

 

ANS:   A, C

Familial risk factors that correlate with child psychiatric disorders include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. Having a parent with a substance abuse problem increases the risk of marital discord. A family history of schizophrenia presents a genetic risk. Being in a middle-income family, living in an urban community, and being an only or oldest child do not represent adversity.

 

PTS:    1                      DIF:    Cognitive Level: Apply (Application)

REF:    Pages 11-6, 7                                      TOP:    Nursing Process: Assessment

MSC:   Client Needs: Psychosocial Integrity

Chapter 17: Somatic Symptom Disorders

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

 

MULTIPLE CHOICE

 

  1. Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)?
a. Voluntary control of symptoms
b. Patient’s style of presentation
c. Results of diagnostic testing
d. The role of secondary gains

 

 

ANS:  B

Patients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their concerns and display more obsessive attention to detail, whereas the patients with conversion (functional neurological) disorder often exhibit less concern with the symptom they are presenting than would be expected. Neither disorder involves voluntary control of the symptoms. Results of diagnostic testing for both would be negative (i.e., no physiological basis would be found for the symptoms). Secondary gains can occur in both disorders but are not necessary to either. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-6 to 9                               TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder?
a. Narcotic analgesics for use as needed for acute pain
b. Antidepressant medications to treat co-morbid depression
c. Long-term use of benzodiazepines to support coping with anxiety
d. Conventional antipsychotic medications to correct cognitive distortions

 

 

ANS:  B

Various types of antidepressants may be helpful in somatic disorders not only directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood but also fatigue, pain perception, GI distress, and other somatic symptoms. Patients may benefit from short-term use of antianxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-18, 24                              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably
a. readily seek psychiatric counseling.
b. be resistant to accepting psychiatric help.
c. attend psychotherapy sessions without encouragement.
d. be eager to discover the true reasons for physical symptoms.

 

 

ANS:  B

Patients with somatic symptom disorders go from one health care provider to another trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling offered, these patients reject both.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-29, 30                              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse’s planning for this patient?
a. The patient is suppressing accurate feelings regarding the problem.
b. The patient’s anxiety is relieved through the physical symptom.
c. The patient’s optic nerve transmission has been impaired.
d. The patient will not disclose genuine fears.

 

 

ANS:  B

Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. While some MRI studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation, there is no actual alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously).

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-8, 9                                  TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should
a. establish a “buddy” system with other patients who can feed the patient at each meal.
b. expect the patient to feed self after explaining arrangement of the food on the tray.
c. direct the patient to locate items on the tray independently and feed self.
d. address needs of other patients in the dining room, then feed this patient.

 

 

ANS:  B

The patient is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-27, 28                              TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient with blindness related to conversion (functional neurological) disorder says, “All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don’t find me as interesting.” Which nursing diagnosis is most relevant?
a. Social isolation
b. Chronic low self-esteem
c. Interrupted family processes
d. Ineffective health maintenance

 

 

ANS:  B

The patient mentions that the symptoms make people more interested. This indicates that the patient feels uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in the scenario.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-23, 28, 58 (Table 17-3)   TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority
a. explain the pathophysiology of symptoms.
b. help these patients suppress feelings of anger.
c. shift focus from somatic symptoms to feelings.
d. investigate each physical symptom as it is reported.

 

 

ANS:  C

Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome would be that the patient would express feelings, including anger if it is present. Once physical symptoms are investigated, they do not need to be reinvestigated each time the patient reports them.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-28, 60 (Table 17-4)         TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, “My chest is tight, and my heart misses beats. I’m often absent from work. I don’t go out much because I need to rest.” Which health problem is most likely?
a. Dysthymic disorder
b. Somatic symptom disorder
c. Antisocial personality disorder
d. Illness anxiety disorder (hypochondriasis)

 

 

ANS:  D

Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-6, 7                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient
a. sees a relationship between symptoms and interpersonal conflicts.
b. has little difficulty communicating emotional needs to others.
c. rarely derives personal benefit from the symptoms.
d. has altered comfort and activity needs.

 

 

ANS:  D

The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic symptom disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-18, 19, 36 (Case Study and Nursing Care Plan)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms
a. are generally chronic.
b. have a physiological basis.
c. can be voluntarily controlled.
d. provide relief from health anxiety.

 

 

ANS:  D

At the unconscious level, the patient’s primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide secondary gain, patients frequently fiercely cling to the symptoms. The symptoms tend to be chronic, but that does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-18, 19, 36 (Case Study and Nursing Care Plan)          TOP:    Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient’s disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will
a. assume roles and functions of other family members.
b. demonstrate performance of former roles and tasks.
c. focus energy on problems occurring in the family.
d. rely on family members to meet personal needs.

 

 

ANS:  B

The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-23, 24, 36 (Case Study and Nursing Care Plan)

TOP:   Nursing Process: Outcomes Identification

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies?
a. “My employer should have paid for a health club membership for me.”
b. “My family will see me through this. It won’t be easy, but I will never be alone.”
c. “My heart attack was no fun, but it showed me up the importance of a good diet and more exercise.”
d. “I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily.”

 

 

ANS:  A

Blaming someone else and rationalizing one’s failure to exercise are not adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one’s situation are seen as more effective strategies. The distracters demonstrate effective coping associated with a serious medical condition.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-9 to 12                             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient?
a. “Since my father died, I’ve been short of breath and had sharp pains that go down my left arm, but I think it’s just indigestion.”
b. “I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I’m getting seriously dehydrated.”
c. “Sexual intercourse is painful. I pretend as if I’m asleep so I can avoid it. I think it’s starting to cause problems with my marriage.”
d. “I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus.”

 

 

ANS:  A

Patients with conversion (functional neurological) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed la belle indifférence. There is also a specific, identifiable cause for the development of the symptoms; in this instance, the death of a parent would precipitate stress. The distracters relate to sexual dysfunction and illness anxiety disorder.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-8, 9                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient’s needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic?
a. “I’m wondering if you are feeling anxious about your illness and being left alone.”
b. “The staff are concerned that you are not satisfied with the care you are receiving.”
c. “Let’s talk about why you use your call light so frequently. It is a problem.”
d. “You frustrate the staff by calling them so often. Why are you doing that?”

 

 

ANS:  A

This patient is experiencing anxiety associated with a serious medical condition. Verbalization is an effective outlet for anxiety. “I’m wondering if you are anxious …” focuses on the emotions underlying the behavior rather than the behavior itself. This opening conveys the nurse’s willingness to listen to the patient’s feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. The other options focus on the behavior or its impact on nursing and do not help the patient with her emotional needs.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-9 to 12                             TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient reports fears of having cervical cancer and says to the nurse, “I’ve had Pap smears by six different doctors. The results were normal, but I’m sure that’s because of errors in the laboratory.” Which disorder would the nurse suspect?
a. Conversion (functional neurological) disorder
b. Illness anxiety disorder (hypochondriasis)
c. Somatic symptom disorder
d. Factitious disorder

 

 

ANS:  B

Patients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease. These fears persist despite medical evaluations and interfere with daily functioning. There are no complaints of pain. There is no evidence of factitious or conversion disorder.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-6, 7                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with a somatic symptom disorder says, “My pain is from an undiagnosed injury. I can’t take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much.” It is important for the nurse to assess
a. mood.
b. cognitive style.
c. secondary gains.
d. identity and memory.

 

 

ANS:  C

Secondary gains should be assessed. The patient’s dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient’s diagnosis has been established.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-21, 58 (Table 17-3) | Pages 17-28, 60 (Table 17-4)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What is an essential difference between somatic symptom disorders and factitious disorders?
a. Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic.
b. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress.
c. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound.
d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.

 

 

ANS:  D

The key is the only fully accurate statement. Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound. Factitious disorders are under voluntary control. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-19, 31, 32                        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says, “I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day.” Which response by the nurse fosters cognitive reframing?
a. “You do not have a brain tumor. The more you talk about it, the more it reinforces your belief.”
b. “Let’s see if there are any other possible explanations for your vomiting.”
c. “You seem so worried. Let’s talk about how you’re feeling.”
d. “We need to talk about something else.”

 

 

ANS:  B

Questioning the evidence is a cognitive reframing technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-25, 30                              TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively?
a. Flooding
b. Response prevention
c. Relaxation techniques
d. Systematic desensitization

 

 

ANS:  C

Somatic symptom disorders are commonly associated with complicated reactions to stress. These reactions are accompanied by muscle tension and pain. Relaxation can diminish the patient’s perceptions of pain and reduce muscle tension. The distracters are modalities useful in treating selected anxiety disorders.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-25 to 27, 60 (Table 17-4)           TOP:              Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder?
a. “What are you unable to do now but were previously able to do?”
b. “How many doctors have you seen in the last year?”
c. “Who do you talk to when you’re upset?”
d. “Did you experience abuse as a child?”

 

 

ANS:  A

Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The patient’s dependency needs may be evident through losses of abilities. When secondary gains are prominent, the patient is more resistant to giving up the symptom. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 17-21     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, “Although I’m still having pain, I notice it less and am able to perform more activities.” The nurse should evaluate the treatment plan as
a. marginally successful.
b. minimally successful.
c. partially successful.
d. totally achieved.

 

 

ANS:  C

Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-23, 24, 31                        TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder imposed on another is suspected. Which nursing interventions are appropriate? (Select all that apply.)
a. Increase private visiting time for the parents to improve bonding.
b. Keep careful, detailed records of visitation and untoward events.
c. Place mittens on the child to reduce access to ports and incisions.
d. Encourage family members to visit in groups of two or three.
e. Interact with the patient frequently during visiting hours.

 

 

ANS:  B, D, E

Factitious disorder imposed on another is a condition wherein a person intentionally causes or perpetuates the illness of a loved one (e.g., by periodically contaminating IV solutions with fecal material). When this disorder is suspected, the child’s life could be at risk. Depending on the evidence supporting this suspicion, interventions could range from minimizing unsupervised visitation to blocking visitation altogether. Frequently checking on the child during visitation and minimizing unobserved access to the child (by encouraging small group visits) reduces the opportunity to take harmful action and increases the collection of data that can help determine whether this disorder is at the root of the child’s illness. Detailed tracking of visitation and untoward events helps identify any patterns there might be between select visitors and the course of the child’s illness. Increasing private visitation provides more opportunity for harm. Educating visitors about aseptic techniques would not be of help if the infections are intentional, and preventing inadvertent contamination by the child himself would not affect factitious disorder by proxy.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-34, 35                              TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which assessment findings suggest the possibility of a factitious disorder, imposed on self-type? (Select all that apply.)
a. History of multiple hospitalizations without findings of physical illness
b. History of multiple medical procedures or exploratory surgeries
c. Going from one doctor to another seeking the desired response
d. Claims illness to obtain financial benefit or other incentive
e. Difficulty describing symptoms

 

 

ANS:  A, B

Persons with factitious disorders, imposed on self-type, typically have a history of multiple hospitalizations and medical workups, with negative findings from workups. Sometimes they have even had multiple surgeries seeking the origin of the physical complaints. If they do not receive the desired response from a hospitalization, they may elope or accuse staff of incompetence. Such persons usually seek treatment through a consistent health care provider rather than doctor shopping, are not motivated by financial gain or other external incentives, and present symptoms in a very detailed, plausible manner indicating considerable understanding of the disorder or presentation they are mimicking. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 17-32     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with a somatic symptom disorder says, “Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear.” Which nursing diagnoses apply to this patient? (Select all that apply.)
a. Spiritual distress
b. Decisional conflict
c. Adult failure to thrive
d. Impaired social interaction
e. Ineffective role performance

 

 

ANS:  A, E

The patient’s verbalization is consistent with spiritual distress. The patient’s description of being unable to provide for and burdening the family indicates ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-23, 24, 58 (Table 17-3)   TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? (Select all that apply.)
a. Female
b. Reports frequent syncope
c. Rates pain as “1” on a scale of “10”
d. First diagnosed with psoriasis at age 12
e. Reports insomnia often results from back pain

 

 

ANS:  A, B, E

There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 17-2 to 4                               TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse’s neighbor says, “I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?” The nurse should respond by noting that some serious medical conditions may be complicated by emotional stress, including (Select all that apply)
a. cancer.
b. hip fractures.
c. hypertension.
d. immune disorders.
e. cardiovascular disease.

 

 

ANS:  A, C, D, E

A number of diseases can be worsened or brought to awareness by intense emotional stress. Immune disorders can be complicated associated with detrimental effects of stress on the immune system. Others can be brought about indirectly, such as cardiovascular disease due to acute or chronic hypertension. Hip fractures are not in this group.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 17-9 to 12, 51 (Table 17-1)  TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

Chapter 26: Crisis and Disaster

Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

 

MULTIPLE CHOICE

 

  1. A patient comes to the crisis clinic after an unexpected job termination. The patient paces, sobs, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse’s best initial comment to this patient.
a. “Everything is going to be all right. You are here at the clinic and the staff will keep you safe.”
b. “I see you are feeling upset. I’m going to stay and talk with you to help you feel better.”
c. “You need to try to stop crying and pacing so we can talk about your problems.”
d. “Let’s set some guidelines and goals for your visit here.”

 

 

ANS:  B

A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient’s safety, and interpersonal reassurance.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-18, 19, 45 (Box 26-2) | Page 26-24 (Case Study and Nursing Care Plan)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient is seen in the clinic for superficial cuts on both wrists. Initially the patient paces and sobs but after a few minutes, the patient is calmer. The nurse attempts to determine the patient’s perception of the precipitating event by asking:
a. “Tell me why you were crying.”
b. “How did your wrists get injured?”
c. “How can I help you feel more comfortable?”
d. “What was happening when you started feeling this way?”

 

 

ANS:  D

A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events facilitates assessment of the precipitating event. The patient is unlikely to be able to articulate what interventions will increase feelings of comfort. “Why” questions are nontherapeutic.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-10, 11                              TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient comes to the crisis center saying, “I’m in a terrible situation. I don’t know what to do.” The triage nurse can initially assume that the patient is
a. suicidal.
b. anxious and fearful.
c. misperceiving reality.
d. potentially homicidal.

 

 

ANS:  B

Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-15, 42 (Table 26-3)         TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle’s behavior, but the parents did not believe the adolescent. What type of crisis exists?
a. Maturational
b. Tertiary
c. Situational
d. Organic

 

 

ANS:  C

A situational crisis arises from events that are extraordinary, external rather than internal, and often unanticipated. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. “Organic” and “Tertiary” are not types of crisis.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-7, 8                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. While conducting the initial interview with a patient in crisis, the nurse should
a. speak in short, concise sentences.
b. convey a sense of urgency to the patient.
c. be forthright about time limits of the interview.
d. let the patient know the nurse controls the interview.

 

 

ANS:  A

Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient’s anxiety. Letting the patient know who controls the interview or stating that time is limited is nontherapeutic.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-15, 19, 42 (Table 26-3), 45 (Box 26-2) | Page 26-24 (Case Study and Nursing Care Plan)     TOP:           Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. An adult seeks counseling after the spouse was murdered. The adult angrily says, “I hate the beast that did this. It has ruined my life. During the trial, I don’t know what I’ll do if the jury doesn’t return a guilty verdict.” What is the nurse’s highest priority response?
a. “Would you like to talk to a psychiatrist about some medication to help you cope during the trial?”
b. “What resources do you need to help you cope with this situation?”
c. “Do you have enough support from your family and friends?”
d. “Are you having thoughts of hurting yourself or others?”

 

 

ANS:  D

The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Pages 26-10, 42 (Table 26-3)         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, “What else can happen?” What type of crisis is this person experiencing?
a. Maturational
b. Mitigation
c. Situational
d. Recurring

 

 

ANS:  C

Severe physical or mental illness is a potential cause of a situational crisis. The potential loss of a loved one also serves as a potential cause of a situational crisis. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. Mitigation refers to attempts to limit a disaster’s impact on human health and community function.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-7, 8                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A woman said, “I can’t take anymore! Last year my husband had an affair and now we don’t communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college.” What is the nurse’s priority assessment?
a. Identify measures useful to help improve the couple’s communication.
b. The patient’s feelings about the possibility of having a mastectomy
c. Whether the husband is still engaged in an extramarital affair
d. Clarify what the patient means by “I can’t take anymore.”

 

 

ANS:  D

During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-10, 42 (Table 26-3)         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman says tearfully, “What else can happen?” If the woman’s immediate family is unable to provide sufficient support, the nurse should
a. suggest hospitalization for a short period.
b. ask what other relatives or friends are available for support.
c. tell the patient, “You are a strong person. You can get through this crisis.”
d. foster insight by relating the present situation to earlier situations involving loss.

 

 

ANS:  B

The assessment of situational supports should continue. Even though the patient’s nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-11, 12, 42 (Table 26-3), 45 (Box 26-2)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. A woman says, “I can’t take anymore. Last year my husband had an affair and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she’s quitting college and moving in with her boyfriend.” Which issue should the nurse focus on during crisis intervention?
a. The possible mastectomy
b. The disordered family communication
c. The effects of the husband’s extramarital affair
d. Coping with the reaction to the daughter’s events

 

 

ANS:  D

The focus of crisis intervention is on the most recent problem: “the straw that broke the camel’s back.” The patient had coped with the breast lesion, the husband’s infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-10, 11, 14, 44 (Box 26-1)          TOP:              Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient who is visiting the crisis clinic for the first time asks, “How long will I be coming here?” The nurse’s reply should consider that the usual duration of crisis intervention is
a. 1 to 2 weeks.
b. 3 to 4 weeks.
c. 4 to 6 weeks.
d. 8 to 12 weeks.

 

 

ANS:  C

The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 26-44 (Box 26-1)                   TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A student falsely accused a college professor of sexual intimidation. The professor tells the nurse, “I cannot teach nor do any research. My mind is totally preoccupied with these false accusations.” What is the priority nursing diagnosis?
a. Ineffective denial related to threats to professional identity
b. Deficient knowledge related to sexual harassment protocols
c. Impaired social interaction related to loss of teaching abilities
d. Ineffective coping related to distress from false accusations

 

 

ANS:  D

Ineffective coping may be evidenced by inability to meet basic needs, inability to meet role expectations. This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor’s crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-14, 15, 39 (Table 26-2)   TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which communication technique will the nurse use more in crisis intervention than traditional counseling?
a. Role modeling
b. Giving direction
c. Information giving
d. Empathic listening

 

 

ANS:  B

The nurse working in crisis intervention must be creative and flexible in looking at the patient’s situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 26-44 (Box 26-1) | Page 26-42 (Table 26-3)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which situation demonstrates use of primary intervention related to crisis?
a. Implementation of suicide precautions for a depressed patient
b. Teaching stress-reduction techniques to a first-year college student
c. Assessing coping strategies used by a patient who attempted suicide
d. Referring a patient diagnosed with schizophrenia to a partial hospitalization program

 

 

ANS:  B

Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 26-14     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A victim of intimate partner violence comes to the crisis center seeking help. Crisis intervention strategies the nurse applies will focus on
a. supporting emotional security and reestablishing equilibrium.
b. long-term resolution of issues precipitating the crisis.
c. promoting growth of the individual.
d. providing legal assistance.

 

 

ANS:  A

Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the precrisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-16, 17, 44 (Box 26-1)      TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred?
a. Reactive
b. Situational
c. Maturational
d. Body image

 

 

ANS:  C

Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual.  “Reactive” and “body image” are not types of crisis.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-6, 7                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which scenario is an example of a situational crisis?
a. The death of a child from sudden infant death syndrome
b. Development of a heroin addiction
c. Retirement of a 55-year-old person
d. A riot at a rock concert

 

 

ANS:  D

The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of maturational crises.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-6, 7                                  TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which agency provides coordination in the event of a terrorist attack?
a. Food and Drug Administration (FDA)
b. Environmental Protection Agency (EPA)
c. National Incident Management System (NIMS)
d. Federal Emergency Management Agency (FEMA)

 

 

ANS:  C

The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-22, 23                              TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. During the initial interview at the crisis center, a patient says, “I’ve been served with divorce papers. I’m so upset and anxious that I can’t think clearly.” Which comment should the nurse use to assess personal coping skills?
a. “In the past, how have you handled difficult or stressful situations?”
b. “What would you like us to do to help you feel more relaxed?”
c. “Tell me more about how it feels to be anxious and upset.”
d. “Can you describe your role in the marital relationship?”

 

 

ANS:  A

The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she “cannot think clearly,” and seek to explore issues tangential to the crisis.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-12, 13, 42 (Table 26-3), 45 (Box 26-2)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. An adult has cared for a debilitated parent for 10 years. The health care provider recently recommended transfer of the parent to a skilled nursing facility. The adult says, “I’ve always been able to care for my parents. Nursing home placement goes against everything I believe.” Successful resolution of this adult’s crisis will most closely relate to
a. resolving the feelings associated with the threat to the person’s self-concept.
b. ability of the person to identify situational supports in the community.
c. reliance on assistance from role models within the person’s culture.
d. mobilization of automatic relief behaviors by the person.

 

 

ANS:  A

The adult’s crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the parent’s condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors include withdrawal or flight and will not be helpful. Automatic relief behaviors are part of the third phase of crisis.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-8, 44 (Box 26-1)              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. The principle most useful to a nurse planning crisis intervention for any patient is that the patient
a. is experiencing a state of disequilibrium.
b. is experiencing a type of mental illness.
c. poses a threat of violence to others.
d. has high potential for self-injury.

 

 

ANS:  A

Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Pages 26-4, 5, 44 (Box 26-1)          TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient’s situational support.
a. “Has anything upsetting occurred in the past few days?”
b. “Who can be helpful to you during this time?”
c. “How does this problem affect your life?”
d. “What led you to seek help at this time?”

 

 

ANS:  B

Only the answer focuses on situational support. The incorrect options focus on the patient’s perception of the precipitating event.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-11, 12                              TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, “I don’t know what to do. How can I get another job? Who will pay the bills? How will I feed my family?” Which nursing diagnosis applies?
a. Hopelessness
b. Powerlessness
c. Chronic low self-esteem
d. Interrupted family processes

 

 

ANS:  B

The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient’s family processes are not interrupted at this point.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 26-39 (Table 26-2)                 TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

 

  1. A troubled adolescent pulled out a gun in a school cafeteria, fatally shot three people and injured many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next?
a. Ask police to encircle the school campus with yellow tape to prevent parents from entering.
b. Announce over the loudspeakers, “The campus is now secure. Please return to your classrooms.”
c. Require parents to pass through metal detectors and then allow them to look for their children in the school.
d. Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

 

 

ANS:  D

Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-17, 18, 44 (Box 26-1) | Page 26-42 (Table 26-3)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Safe, Effective Care Environment

 

  1. At the last contracted visit in the crisis intervention clinic, an adult says, “I’ve emerged from this a stronger person. You helped me get my life back in balance.” The nurse responds, “I think we should have two more sessions to explore why your reactions were so intense.” Which analysis applies?
a. The patient is experiencing transference.
b. The patient demonstrates need for continuing support.
c. The nurse is having difficulty terminating the relationship.
d. The nurse is empathizing with the patient’s feelings of dependency.

 

 

ANS:  C

Termination is indicated; however, the nurse’s remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient shows no need for continuing support. The scenario does not describe dependency needs.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 26-36 (Table 26-1)                 TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Emergency response workers arrive in a community after a large-scale natural disaster. What is the workers’ first action?
a. Report to the incident command system (ICS) center.
b. Determine whether the community is safe.
c. Establish teams of workers with varied skills.
d. Evaluate actions completed by local law enforcement.

 

 

ANS:  A

An ICS provides a common organizational structure facilitating an immediate response. It establishes a clear chain of command that supports the coordination of personnel and equipment at an event site. The incorrect responses describe actions that may or may not be taken by the ICS.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-22, 23                              TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? (Select all that apply.)
a. Difficulty using a cell phone
b. Long-term memory losses
c. Fecal incontinence
d. Rapid speech
e. Trembling

 

 

ANS:  A, D, E

Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Pages 26-15, 39 (Table 26-2)         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer patients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? (Select all that apply.)
a. Preparedness
b. Mitigation
c. Response
d. Recovery
e. Evaluation

 

 

ANS:  B, C

This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses’ activities applied to mitigation (attempts to limit a disaster’s impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Pages 26-21, 22                              TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment