NURS 206 Mental Health 3 Questions and Answers,100% CORRECT

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NURS 206 Mental Health 3 Questions and Answers Chapter 06: Legal and Ethical Basis for Practice 1. A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. interve... nes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice. ANS: D Autonomy is the right to self-determination, that is, to make one’s own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice. 2. Which action by a psychiatric nurse best supports a patients right to be treated with dignity and respect? a. Consistently addressing a patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient’s condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning. ANS: A A simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patient’s condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity. 3. Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery. ANS: C Patients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patient’s autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery. 4. In a team meeting a nurse says, I’m concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision. Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice ANS: D The nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one’s own decisions. Fidelity is the observance of loyalty and commitment to the patient. 5. Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient’s admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patients admission status is changed from involuntary to voluntary after the patients’ hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violence because a unit is short staffed. ANS: D A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts. 6. A nurses neighbor asks, why aren’t people with mental illness kept in state institutions anymore? What is the nurses best response? a. Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent. b. Less restrictive settings are now available to care for individuals with mental illness. c. Our nation has fewer persons with mental illness; therefore, fewer hospital beds are needed. d. Psychiatric institutions are no longer popular as a consequence of negative stories in the press. ANS: B The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness. 7. Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, I’m getting out of here and no one can stop me. The nurse restrains this patient without a health care providers order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall, saying, stay in your room or you’ll be put in seclusion. c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving. ANS: B False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distractor is not competent, and the nurse is acting beneficently. The patients in the other distractors have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team. 8. A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy. ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization. 9. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, Stop! I don’t want to take that medicine anymore. I hate the side effects. Select the nurse’s best initial action. a. Stop the medication administration procedure and say to the patient, tell me more about the side effects you’ve been having. b. Say to the patient, Since I’ve already drawn the medication in the syringe, I’m required to give it, but let’s talk to the doctor about skipping next month’s dose. c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary. ANS: A Patients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patient’s decision and should not force the medication. 10. Several nurses are concerned that agency policies related to restraint and seclusion are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted. ANS: A Nurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded. 11. A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient ANS: D Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient. 12. An example of a breach of a patients right to privacy occurs when a nurse: a. asks a family to share information about a patient’s prehospitalization behavior. b. discusses the patient’s history with other staff members during care planning. c. documents the patients’ daily behaviors during hospitalization. d. releases information to the patient’s employer without consent. ANS: D The release of information without patient authorization violates the patients right to privacy. The other options are acceptable nursing practices. 13. An adolescent hospitalized after a violent physical outburst tells the nurse, I’m going to kill my father, but you can’t tell anyone. Select the nurse’s best response. a. You’re right. Federal law requires me to keep that information private. b. Those kinds of thoughts will make your hospitalization longer. c. You really should share this thought with your psychiatrist. d. I am required to share information with the treatment team. ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for the nurse in this circumstance because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm. 14. A voluntarily hospitalized patient tells the nurse, get me the forms for discharge against medical advice so I can leave now. What are the nurses best initial response? a. I can’t give you those forms without your health care providers knowledge. b. I will get them for you, but let’s talk about your decision to leave treatment. c. Since you signed your consent for treatment, you may leave if you desire. d. I’ll get the forms for you right now and bring them to your room. ANS: B A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient’s wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care providers knowledge is not true. Facilitating discharge without consent is not in the patient’s best interest before exploring the reason for the request. 15. The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will never get any treatment. Which reply by the nurse would be most helpful? a. Under the law, treatment must be provided. Hospitalization without treatment violates patient’s rights. b. That’s a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety. c. Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable. d. All patients in public hospitals have the right to choose both a primary therapist and a primary nurse. ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964. Stating that the concern is justifiable supports the family’s erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care. 16. Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse. ANS: C Throwing a heavy plate is likely to harm the waiter and is evidence of being dangerous to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. 17. A patient being treated in an alcohol rehabilitation unit reveals to the nurse, I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted. Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, I’m glad you feel comfortable talking to me about it. c. respect the nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead. ANS: A Laws regarding reporting child abuse discovered by a professional during a suspected abuser’s alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility. Anonymously reporting the abuse by telephone to the local child abuse hotline meets federal criteria. Respecting nurse-patient confidentiality and replying I’m glad you feel comfortable talking to me about it do not accomplish reporting. Filing a written report on agency letterhead violates federal law. 18. The spouse of a patient who has delusions asks the nurse, are there any circumstances under which the treatment team is justified in violating the patients right to confidentiality? The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person. ANS: D The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patients right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations. 19. A nurse cares for an older adult patient admitted for treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider. ANS: D The dose of an antidepressant medication for older adult patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse’s duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dose is excessive. Implementing the order is negligent. Giving the usual geriatric dose would be wrong; a nurse without prescriptive privileges cannot change the dose. 20. A patient diagnosed with schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient’s confidentiality. d. avoided charges of malpractice. ANS: B The duty of a health care professional is to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional and not considered a violation of confidentiality. 21. After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, please document the administration of the medication I forgot to do. My password is alpha1. The nurse should: a. fulfill the request. b. refers the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patients’ health care provider. ANS: B At most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patients’ health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem. 22. A patient diagnosed with mental illness asks a psychiatric technician, What’s the matter with me? The technician replies, your wing nuts need tightening. The nurse who overheard the exchange should take action based on: a. violation of the patients right to be treated with dignity and respect. b. the nurse’s obligation to report caregiver negligence. c. preventing defamation of the patient’s character. d. supervisory liability. ANS: A Patients have the right to be treated with dignity and respect. Patients should never be made the butt of jokes about their illness. Patient emotional abuse has been demonstrated, not negligence. The technician’s response was not clearly defamation. Patient abuse, not supervisory liability, is the issue. 23. Which documentation of a patient’s behavior best demonstrates a nurse’s observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, I need protection from dangerous bacteria trying to penetrate my skin. ANS: D The documentation states specific observations of the patient’s appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways. Select All That Apply 1. A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5) b. States nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric Mental Health Nursing ANS: C, E Regulations regarding hospitals provide information about the minimal standard. The American Nurses Association (ANA) national standards focus on elevating practice by setting high standards for nursing practice. The DSM-5 and the states nurse practice act would not provide relevant information. A summary of common practices of several local hospitals cannot be guaranteed to be helpful because the customs may or may not comply with laws or best practices. 2. In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians’ Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider. ANS: C, D Both instances jeopardize patient safety. The nurse must practice within the Code of Ethics for Nurses. A peer being unable to write behavioral outcomes is a concern but can be informally resolved. A health care provider consulting the Physicians’ Desk Reference is acceptable practice. 3. Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patients care because of concerns about countertransference. ANS: A, B Abandonment arises when a nurse does not place a patient safely in the hands of another health professional before discontinuing treatment. Calling the police to bring a suicidal patient to the hospital after a suicide attempt and referring a patient with schizophrenia to community treatment both provide for patient safety. Asking another nurse to provide a patients care because of concerns about countertransference demonstrates self-awareness. Chapter 18: Neurocognitive Disorders 1. An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer disease. ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. 2. A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, Bugs are crawling on my legs! Get them off! Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance ANS: C The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. 3. A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, someone get these bugs off me. What is the nurses best response? a. There are no bugs on your legs. Your imagination is playing tricks on you. b. Try to relax. The crawling sensation will go away sooner if you can relax. c. Don’t worry. I will have someone stay here and brush off the bugs for you. d. I don’t see any bugs, but I know you are frightened so I will stay with you. ANS: D When hallucinations are present, the nurse should acknowledge the patients’ feelings and state the nurse’s perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patients perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions. 4. What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs ANS: B The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient’s sensorium is clouded. The other diagnoses may be concerns but are lower priorities. 5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints ANS: C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury while hospitalized. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced. 6. Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? a. Keep the patient by the nurse’s desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation. ANS: D A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. 7. Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, I see scary faces. b. states, I feel bugs crawling on my legs and biting me. c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken. ANS: B Hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli. 8. Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia ANS: B The listed health problems are all forms of dementia. 9. When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne) ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer disease. 10. An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario. 11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors’ homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late) ANS: B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late), the ability to talk and walk are eventually lost, and stupor evolves. 12. Consider these problems: apolipoprotein E (apoE) malfunction, neurotic plaques, neurofibrillary tangles, granulovacuolar degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeficiency syndrome (AIDS)related dementia ANS: A The problems are all aspects of the pathophysiologic characteristics of Alzheimer disease. 13. A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain ANS: B Memory impairment is present and expected in stage 1 Alzheimer disease. Patients diagnosed with early Alzheimer disease often have difficulty remembering names, so socialization is minimized. Data are not present to support the other diagnoses. 14. A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patients sense of humor by telling jokes. ANS: A Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless. 15. Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, move along, you’re blocking the road. The other patient turns, shakes a fist, and shouts, I know what you’re up to; you’re trying to steal my car. What is the nurses best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, Walk along in the hall. This is not a traffic intersection. c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, please quiet down. We do not allow violence here. ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired. 16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patients’ glasses and hearing aids. d. Keep the room brightly lit at all times. ANS: C Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations. 17. A patient diagnosed with stage 2 Alzheimer disease calls the police saying, an intruder is in my home. Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality. b. aphasia. c. apraxia. d. agnosia. ANS: D Agnosia is the inability to recognize familiar objects, parts of one’s body, or one’s own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress. 18. During morning care, a nursing assistant asks a patient diagnosed with dementia, how was your night? The patient replies, it was lovely. I went out to dinner and a movie with my friend. Which term applies to the patient’s response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium ANS: B Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient’s response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario. 19. A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails. ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night. Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions. ANS: A The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient experiencing delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium. 21. An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items. ANS: A Patient with moderate Alzheimer disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality. 22. A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurses best reply? a. Your family member will never again be able to identify you. b. I think that is a question the health care provider should answer. c. One never knows. Consciousness fluctuates in persons with dementia. d. It is disappointing when someone you love no longer recognizes you. ANS: D Therapeutic communication techniques can assist family members to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two of the incorrect response’s close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia. 23. A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars. ANS: B Reorientation may seem like arguing to a patient experiencing cognitive deficits and increases the patient’s anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation. 24. What does the priority need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering ANS: C In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication. 25. Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication. ANS: C Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used. 26. A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality. ANS: A Risk for injury is the nurses priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes may not be realistic. Select All That Apply 1. A patient diagnosed with Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patients plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient’s name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval. ANS:A,B,E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient’s name and the name of the item maintains patient identity and dignity (and provides information if the patient has agnosia). When a patient resists, using distraction and trying again after a short interval are appropriate because patient moods are often labile; the patient may be willing to cooperate during a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Staff members are prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication. 2. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention d. Apathy e. Agnosia ANS:A,B,C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression. 3. A nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory ANS:A,B,D The memories of patients with Alzheimer disease continue to deteriorate. These patients demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (Hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia. Memory does not improve. Chapter 19: Substance-Related and Addictive Disorders 1. A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped) ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium. 2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired. ANS: D Fetal alcohol syndrome is the result of alcohols inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors. 3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Bucks traction and screams, somebody tied me up with ropes. The patient is experiencing a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon. ANS: A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping. 4. A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. I’ve got to get out of here. What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis. ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis. 5. A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury ANS: D Clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses. 6. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine ANS: C This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patients’ symptoms. 7. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit. ANS: C This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patients’ feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority. 8. A patient with a history of daily alcohol abuse says, Drinking helps me cope with being a single parent. Which response by the nurse would help the individual conceptualize the drinking more objectively? a. Sooner or later, alcohol will kill you. Then what will happen to your children? b. I hear a lot of defensiveness in your voice. Do you really believe this? c. If you were coping so well, why were you hospitalized again? d. Tell me what happened the last time you drank. ANS: D The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient. 9. A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse’s best response? a. It is a self-help group with the goal of sobriety. b. It is a form of group therapy led by a psychiatrist. c. It is a group that learns about drinking from a group leader. d. It is a network that advocates strong punishment for drunk drivers. ANS: A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed. 10. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs. ANS: B A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient’s body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs. 11. A patient admitted to an alcoholism rehabilitation program says, I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening. The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial ANS: D Minimizing one’s drinking is a form of denial of alcoholism. The patient’s own description indicates that social drinking is not an accurate name for the behavior. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one’s own system. 12. A new patient in an alcoholism rehabilitation program says, I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening. Which response by the nurse will help the patient view the drinking more honestly? a. I see, and use interested silence. b. I think you may be drinking more than you report. c. Being a social drinker involves having a drink or two once or twice a week. d. You describe drinking steadily throughout the day and evening. Am I correct? ANS: D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment. 13. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, after discharge, I’m sure everything will be just fine. Which remark by the nurse will be most helpful to the spouse? a. It is good that you’re supportive of your spouse’s sobriety and want to help maintain it. b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. c. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection. d. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse’s behavior carefully. ANS: B During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information. 14. The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse. ANS: A Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective. 15. When working with a patient beginning treatment for alcohol abuse, what is the nurses most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses. 16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patients’ reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient; we cannot see you today because you’ve been drinking. ANS: D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary. 17. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops. ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change. 18. Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug. ANS: A Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped. 19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, I feel terrible. Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse. ANS: C The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome. 20. In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge. ANS: A Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care. 21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter. ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use. 22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse’s drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers. ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility. 23. A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management. ANS: A Enabling denies the seriousness of the patients problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate. 24. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program ANS: D Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies. 25. Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane ANS: B Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both. 26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patients requests. d. Observe for depression and suicidal ideation. ANS: D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice. 27. Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache ANS: C The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible. 28. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug ANS: B Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug. 29. Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse. 30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression. ANS: C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use. 31. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurses first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway ANS: D Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration. 32. An adult in the emergency department states, I feel restless. Everything I look at wavers. Sometimes I’m outside my body looking at myself. I hear colors. I think I’m losing my mind. Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion. ANS: D The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going crazy. Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements. 33. In what significant ways is the therapeutic environment different for a patient who has ingested D- lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high- level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented. ANS: A Patients who have ingested LSD respond well to being talked down by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs. 34. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia. ANS: D Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug. 35. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, often my friend drinks, along with taking more of the drug than is prescribed. What is the effect of the use of alcohol with this drug? a. The drugs metabolism is stimulated. b. The drugs effect is diminished. c. A synergistic effect occurs. d. There is no effect. ANS: C Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other. 36. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia) ANS: D Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving. 37. Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, I see the need for ongoing treatment. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member. ANS: B The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety. 38. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. Have you ever had blackouts? b. When did you have your last drink? c. Has drinking caused you any problems? d. When did you decide to seek treatment? ANS: B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority. 39. A patient in an alcohol treatment program says, I have been a loser all my life. I’m so ashamed of what I have put my family through. Now, I’m not even sure I can succeed at staying sober. Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance ANS: A Low self-esteem is present when a patient sees himself or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options. 40. Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, I can maintain sobriety one day at a time. Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, my problems are under control. Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are real alcoholics and says, I may be able to help some of them find jobs at my company. d. Is abstinent for 21 days and says, I know I can’t handle more than one or two drinks in a social setting. ANS: A The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse. 41. Which assessment findings support a nurse’s suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia ANS: D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid abuse. Select All That Apply 1. A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds. ANS: B, E The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol. 2. A nurse can assist a patient diagnosed with addiction and the patient’s family in which aspects of relapse prevention? Select all that apply. a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances ANS:A,C,E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations. The nurse can participate in role playing and help the patient evaluate the usefulness of new strategies. The nurse can also provide valuable information about the physiologic changes that can be expected and the ways in which to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety. 3. While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional d. Prevention of seizures e. Reduction of fever ANS: D, E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation. Chapter 23: Suicidal Thoughts and Behavior 1. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises. 2. A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go. 3. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety. ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed. 4. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options. 5. A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem. 6. A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, there must be a mistake. This could not have happened. We’ve given our child everything. The parents’ reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings. ANS: A The parents statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario. 7. An adolescent tells the school nurse, my friend threatened to take an overdose of pills. The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents? ANS: B The nurse must assess the patients access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical. 8. An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions. ANS: A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated. 9. A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not kill or harm myself in any way. d. I will not kill myself until I call my primary nurse or a member of the staff. ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, I am not going to harm myself, I am going to kill myself, or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan. 10. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determines risk factors for suicide. ANS: C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide. 11. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, I am considering suicide. a. I’m glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to get help. c. We need to talk about the good things you have to live for. d. Bringing this up is a very positive action on your part. ANS: D This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, you have a lot to live for. It uses the patient’s ambivalence and sets the stage for more realistic problem- solving strategies. 12. Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment ANS: B Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide. 13. Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act. ANS: A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy. 14. A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, my business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me. ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient’s suicide as being a way to fix everything but does not say it outright. 15. A depressed patient says, nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you began feeling depressed. ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation. 16. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Let’s make a list of all your problems and think of solutions for each one. b. I’m happy you’re taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Let’s consider which problems are most important and which are less important. ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving. 17. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patient’s insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients’ social support ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options. 18. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness. ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired. 19. Which statement by a patient during an assessment interview should alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I shot myself. ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide. 20. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger. ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. 21. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. 22. Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. 23. A nurse answers a suicide crisis line. A caller says, I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I’m going to shoot myself in the heart. How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue. 24. A staff nurse tells another nurse; I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I’m wondering if I should send the patient home. Select the best reply by the second nurse. a. That action would seem appropriate. b. A score over 8 requires immediate hospitalization. c. I think you should strongly consider hospitalization for this patient. d. Give the patient a follow-up appointment. Hospitalization may be needed soon. ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization. 25. A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic. ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care. 26. A severely depressed patient who has been on suicide precautions tells the nurse, I am feeling a lot better, so you can stop watching me. I have taken too much of your time already. Which is the nurses best response? a. I wonder what this sudden change is all about. Please tell me more. b. I am glad you are feeling better. The team will consider your request. c. You should not try to direct your care. Leave that to the treatment team. d. Because we are concerned about your safety, we will continue with our plan. ANS: D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process. 27. A new nurse says to a peer, my newest patient is diagnosed with schizophrenia. At least I won’t have to worry about suicide risk. Which response by the peer would be most helpful? a. Let’s reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia. b. Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs. c. Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide. d. Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia. ANS: A Up to 10% of patients diagnosed with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients diagnosed with schizophrenia. Patients diagnosed with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia. 28. The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? a. Genetics are associated with suicide risk. Monitoring and support are important. b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins. ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications. Select All That Apply 1. A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation ANS:C,D,E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommate’s absence from the dormitory. Terminating access to one’s social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness. 2. A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patients plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient’s possession. c. Maintain arm’s length, one-on-one nursing observation around the clock. d. Check the patients whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patients whereabouts every 15 minutes and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping. ANS:A,B,C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient’s possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions. 3. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African American man d. 29-year-old African American woman e. 22-year-old man with traumatic brain injury ANS:A,B,E Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high-risk groups include young African American men, Native-American men, older Asian Americans, and persons with traumatic brain injury. 4. A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Post-traumatic stress disorder ANS: C, E Traumatic brain injury and post-traumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population. Chapter 24: Anger, Aggression, and Violence 1. Which behavior best demonstrates aggression? a. Stomping away from the nurse’s station, going to another room, and grabbing a snack from another patient. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, I felt angry when you said I could not have a second helping at lunch. d. Telling the medication nurse, I am not going to take that or any other medication you try to give me. ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another’s rights. 2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by a military attack team d. Completion of alcohol withdrawal and beginning a rehabilitation program ANS: C The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability. 3. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario. 4. A confused older adult patient in a skilled care facility is sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patients action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care workers behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out. ANS: C Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member. 5. A patient is pacing the hall near the nurse’s station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. Hey, what’s going on? b. Please quiet down immediately. c. I’d like to talk with you about how you’re feeling right now. d. You must go to your room and try to get control of yourself. ANS: C Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patients’ feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse. 6. A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, back off! and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm’s length distance from the patient. d. sit down in a chair near the patient. ANS: A Making sure space is present between the nurse and the patient avoids invading the patient’s personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurses exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient’s aggression is abating. One arm’s length is inadequate space. 7. An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, would you like to come to your room and take some medication your doctor prescribed for you? b. accompanied by three staff members and say, please come to your room so I can give you some medication that will help you feel more comfortable. c. and place the patient in a basket-hold and then say, I am going to take you to your room to give you an injection of medication to calm you. d. accompanied by two security guards and tell the patient, you can come to your room willingly so I can give you this medication, or the aide and I will take you there. ANS: B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability. 8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, I dread facing potentially violent patients. Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distractors are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event. 9. The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets ANS: A Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion. 10. An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse’s immediate attention? a. I hate all of you! b. My fingers are tingly. c. You wait until I tell my lawyer. d. It was not my fault. The other patient started it. ANS: B The correct response indicates impaired circulation and necessitates the nurse’s immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation. 11. Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication when the patient feels angry. ANS: A Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management. 12. Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of intimate partner violence. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness. ANS: B A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co- existing anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions. 13. A patient being admitted suddenly pulls a knife from a coat pocket and threatens, I will kill anyone who tries to get near me. An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic. ANS: B The patients threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distractors are not sufficient reasons for seclusion. 14. A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression. ANS: D The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing. 15. A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, I have to go home to cook dinner before my husband arrives from work. To intervene with validation therapy, the nurse should first say: a. You must come away from the door. b. You have been a widow for many years. c. You want to go home to prepare your husbands dinner? d. Was your husband angry if you did not have dinner ready on time? ANS: C Validation therapy meets the patient where she or he is at the moment and acknowledges the patient’s wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patients’ feelings. 16. A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for not knowing enough to give me pain medicine when I need it. Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation. ANS: B Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs. 17. A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Administer lorazepam (Ativan) every 4 hours to reduce the patient’s anxiety. ANS: B Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice. 18. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, don’t touch me! You are so stupid. You will make it worse! Which intervention uses a cognitive technique to help this patient? a. Discontinue the dressing change without comments and leave the room. b. Stop the dressing change, saying, perhaps you would like to change your own dressing. c. Continue the dressing change, saying, do you know this dressing change is needed so your wound will not get infected? d. Continue the dressing change, saying, Unfortunately, you have no choice. Your doctor ordered this dressing change. ANS: C Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patients anger by belittling or escalating the patients sense of powerlessness. 19. Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene) ANS: C Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or borderline personality disorder. 20. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient’s condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient’s treatment is completed. ANS: B Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse’s presence and concerns. The incorrect options are likely to increase anger because they imply that the anxiety is inappropriate. 21. Information from a patients record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. substance abuse. ANS: D The nurse should suspect marginal coping skills in a patient with substance abuse. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence. 22. A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as a difficult person who finds fault with others. The patient verbally abuses nurses for providing poor care. The most likely explanation for this behavior lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm. ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior. 23. A patient with burn injuries has had good coping skills for several weeks. Today, a new nurse is poorly organized and does not follow the patients usual schedule is. By mid- afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse managers best response? a. Explain the reasons for the disorganization and take over the patients care for the rest of the shift. b. Acknowledge and validate the patients distress and ask, what would you like to have happen? c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members. ANS: B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patients’ feelings, validating them as understandable, apologizing if necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step. 24. When a patient’s aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient’s affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible. ANS: D Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the pre-assaultive phase but is less effective during escalation. 25. A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff. ANS: B Emergency seclusion can be affected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint. Select All That Apply 1. A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de- escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, you are behaving inappropriately. d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice. ANS:A,D,E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting. 2. A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that staff take which actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise. ANS:A,B,D Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion. 3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe ANS: A, D The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations. 4. Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another ANS: A, D, E Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other- directed violence. 5. Because an intervention is required to control a patient’s aggressive behavior, a critical incident debriefing takes place. Which topics should be the focus of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression ANS:A,C,D The patient’s behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective. Chapter 26: Children and Adolescents 1. A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this Childs most likely problem? a. Tic disorder b. Oppositional defiant disorder (ODD) c. Intellectual development disorder (IDD) d. Attention deficit hyperactivity disorder (ADHD) ANS: D The excessive motion, distractibility, and excessive talkativeness suggest ADHD. Tic disorder is associated with stereotypical, rapid, and involuntary motor movements. Developmental delays would be observed if intellectual development disorder was present. ODD includes serious violations of the rights of others. 2. A child diagnosed with attention deficit hyperactivity disorder (ADHD) has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: a. increased expressiveness in communicating with others. b. improved ability to participate in play with other children. c. ability to identify anxiety and implement self-control strategies. d. improved socialization skills with other children and authority figures. ANS: B The goal is improvement in the child’s hyperactivity, distractibility, and play. The incorrect options are more relevant for a child with a developmental or anxiety disorder. 3. A 5-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurses best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings. ANS: D The use of play to express feelings is appropriate; the cognitive and language abilities of the child may require the acting out of feelings if verbal expression is limited. The incorrect options provide no outlet for feelings or opportunity to develop coping skills. 4. A 16-year-old adolescent diagnosed with conduct disorder (CD) has been in a residential program for three months. Which outcome should occur before discharge? a. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. b. The teen completes an application to enter a military academy for continued structure and discipline. c. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. d. The teen has an absence of anger and frustration for 1 week. ANS: A The patient and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The patient will continue to experience anger and frustration. The patient and parents must continue with family therapy to work on boundary and communication issues. Separating the patient from the family to work on these issues is not necessary, and separation is detrimental to the healing process. 5. A child diagnosed with attention deficit hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications ANS: A Central nervous system stimulants increase blood flow to the brain and have proven helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate. 6. Shortly after an adolescent’s parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, if my parents loved me, then they would work out their problems. What nursing diagnosis is most applicable? a. Ineffective coping b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity ANS: A Ineffective coping is evident in the adolescents response to family stress and discord. Adolescents value peer interactions, and yet this child has eliminated that source of support. The distractors are not supported by the data in this scenario. 7. Shortly after a 15-year-olds parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, All the other kids have families. If my parents loved me, then they would stay together. Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescents’ feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent’s level of depression daily. ANS: C The patients’ perceptions that all the other kids are from two-parent households and that he or she is different are not based in reality. Assisting the patient to test the accuracy of the perceptions is helpful. 8. When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9-year-old in a group that uses: a. play activities exclusively. b. group discussion exclusively. c. talk focused on a specific issue. d. play then talk about the play activity. ANS: D 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. 9. When assessing a 2-year-old diagnosed with autism spectrum disorder, a nurse expects: a. hyperactivity and attention deficits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent. ANS: B Autism spectrum disorder involves distortions in the development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers frequently mention the child’s failure to develop interpersonal skills. The distractors are more relevant to ADHD, separation anxiety, and CD. 10. A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, what should we do? What is the nurses best recommendation? a. Send a picture of yourself to school to keep with the child. b. Arrange with the teacher to let the child call home at playtime. c. Talk with the school about withdrawing the child until maturity increases. d. Talk with your health care provider about a referral to a mental health professional. ANS: D Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. Often, the first-time separation occurs is when the child goes to kindergarten or nursery school. Separation anxiety may be based on the child’s fear that something will happen to the attachment figure. The child needs professional help. 11. A 15-year- old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, we can’t manage our teenager. The adolescent is physically abusive to the mother and defiant with the father. The adolescent’s problem is most consistent with criteria for: a. attention deficit hyperactivity disorder (ADHD). b. childhood depression. c. conduct disorder (CD). d. autism spectrum disorder (ASD). ANS: C CDs are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. The Diagnostic and Statistical Manual of Mental Disorders (5th edition) (DSM-5) identifies CDs as serious violations of rules. The patients’ clinical manifestations do not coincide with the other disorders listed. 12. A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals b. Coax to gain compliance c. Offer rewards in advance d. Establish firm limits ANS: D Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teenagers thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure. 13. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all their attention on my brother, who is perfect in their eyes. Which type of therapy might promote the greatest change in this adolescent’s behavior? a. Bibliotherapy b. Play therapy c. Family therapy d. Art therapy ANS: C Family therapy focuses on problematic family relationships and interactions. The patient has already identified problems within the family. 14. An adolescent is arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all their attention on my brother, who’s perfect in their eyes. Which nursing diagnosis is most applicable? a. Ineffective impulse control, related to seeking parental attention as evidenced by acting out b. Disturbed personal identity, related to acting out as evidenced by prostitution c. Impaired parenting, related to showing preference for one child over another d. Hopelessness, related to feeling unloved by parents ANS: A The patient demonstrates an inability to control impulses and problem solve by using adaptive behaviors to meet lifes’ demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient has never mentioned hopelessness, low self-esteem, or disturbed personal identity. 15. Which assessment finding would cause the nurse to consider an 8-year-old child to be most at risk for the development of a psychiatric disorder? a. Being raised by a parent with chronic major depressive disorder b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend ANS: A Statistics tell us that children raised by a depressed parent have a 30% to 50% chance of developing an emotional disorder. The chronicity of the parents’ depression means it has been a consistent stressor. The other factors do not create ongoing stress. 16. Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking ANS: D Symptoms consistent with an autistic spectrum disorder (ASD) are evident in the correct answer. The behaviors of the other children are within normal ranges. 17. The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: a. attention deficit hyperactivity disorder (ADHD). b. post-traumatic stress disorder (PTSD). c. autism spectrum disorder (ASD). d. separation anxiety. ANS: C Propranolol is useful for controlling aggression, deliberate self-injury, and temper tantrums of some children diagnosed with autism spectrum disorder. It is not indicated in any of the other disorders. 18. A 12-year- old child has been the neighborhood bully for several years. The parents say, we can’t believe anything our child says. Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child’s behaviors are most consistent with a. conduct disorder (CD). b. defiance of authority. c. anxiety over separation from a parent. d. attention deficit hyperactivity disorder (ADHD). ANS: A The behaviors mentioned are most consistent with the DSM-5 criteria for CD: aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. The behaviors are not consistent with ADHD and separation anxiety and are more pervasive than defiance of authority. 19. 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 does not 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 and severity and are reduced or absent during sleep. 20. An 11-year- old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. a. Assign the child to a short time-out. b. Administer an antipsychotic medication. c. Place the child in a therapeutic hold. d. Call a staff member to seclude the child. ANS: A Time-out is a useful strategy for interrupting the angry expression of feelings and allows the child an opportunity to exert self-control. This method is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures. 21. When a 5-year-old child 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 meal. 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 having the child sit on the periphery of an activity until he or she gains self-control and reviews the episode with a staff member. Time-out may not require having the child go to a designated room and does not involve special attention such as holding. Having the child count to 10 or 20 is not sufficient. 22. A child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: a. intelligence. b. impulsivity. c. inattention. d. defiance. ANS: B These behaviors demonstrate impulsivity. Intelligence refers to measurements of one’s cognitive ability. Inattention is a failure to listen. Defiance is willfully doing what an authority figure has said not to do. 23. A parent diagnosed with schizophrenia and her 13-year-old child live in a homeless shelter. The child has 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 difficult temperament. c. is at risk for post-traumatic stress disorder. 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. 24. A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, I have three good friends at school. We talk and sit together at lunch. What is the nurses best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from an intimate partner violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports. ANS: D Because the teenager shows no evidence of poor mental health, the best action would be to foster existing healthy characteristics and environmental supports. No other option is necessary or appropriate under the current circumstances. 25. Which behavior indicates that the treatment plan for a child diagnosed with 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 with autism would resist holding someone’s hand and stand or walk alone, perhaps flapping arms or moving in a stereotypical pattern. The other options reflect behaviors that are consistent with autistic disorder. Select All That Apply 1. What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with: a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others. ANS: B, E Children with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas children with CD frequently behave in ways that violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with post-traumatic stress disorder. Stereotypical language behaviors are observed in autistic children. Separation problems with resultant anxiety occur with separation anxiety disorder. 2. A nurse prepares the plan of care for a 15-year-old adolescent diagnosed with moderate intellectual developmental disorder (IDD). What are the highest outcomes that are realistic for this person? (Select all that apply.) Within 5 years, the person will: a. live unaided in an apartment. b. complete high school or earn a general equivalency diploma (GED). c. independently performs his or her own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly uses public buses to travel in the community. ANS:C,D,E Individuals with moderate intellectual developmental disorder progress academically to about a second-grade level. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, they can function in the community, but independent living is not likely. Chapter 27: Adults 1. Health maintenance and promotion efforts for patients diagnosed with severe and persistent mental illness should include education about the importance of regular: a. home safety inspections. b. monitoring of self-care abilities. c. screening for cancer, hypertension, and diabetes. d. determination of adequacy of a patients support system. ANS: C Individuals diagnosed with severe and persistent mental illness have an increased prevalence of medical disorders. Patients should be taught the importance of regular visits to a primary care physician for screening for these illnesses. Home safety inspections are more often suggested for patients with physical impairments. Caregivers and family members usually evaluate self-care abilities, rather than the patient. Assessment of a patients support system is not usually considered part of health promotion and maintenance. 2. Severe and persistent mental illness is characterized as a: a. mental illness with longer than 2 weeks duration. b. major ongoing mental illness marked by significant functional impairments. c. mental illness accompanied by physical impairment and severe social problems. d. major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities. ANS: B Severe and persistent mental illness has replaced the phrase chronic mental illness. Global impairments in function are evident, including social skills. Physical impairments may be present. Severe mental illness can be treated, but remissions and exacerbations are part of the course of the illness. 3. A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says that girl looked like she was 19 years old. Which defense mechanism is this patient using? a. Denial b. Identification c. Displacement d. Rationalization ANS: D Rationalization is used to justify upsetting behaviors by creating reasons that would allow the individual to believe that the behaviors were warranted or appropriate. The patient is rationalizing molestation of a minor. Denial is used to avoid dealing with the problems and responsibilities related to one’s behaviors. Identification is incorporating the image of an emulated person and then acting, thinking, and feeling like that person. Displacement is the discharge of pent-up feelings onto something or someone else in the environment that is less threatening than the original source of the feelings. 4. Which nursing diagnosis is likely to apply to a homeless individual diagnosed with severe and persistent mental illness? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome ANS: C Many individuals with severe mental illness do not live with their families and are homeless. Life on the street or in a shelter has a negative influence on the individuals’ self- esteem, making this nursing diagnosis one that should be considered. Insomnia may be noted in some patients but is not a universal problem. Substance abuse is not an approved North American Nursing Diagnosis Association International (NANDA-I) diagnosis. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not observed in a majority of the homeless population. 5. A patient diagnosed with schizophrenia tells the community mental health nurse, I threw away my pills because they interfere with God’s voice. The nurse identifies the cause of the patient’s ineffective management of the medication regimen as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. impaired reasoning secondary to schizophrenia. d. dislike of the side effects of antipsychotic medications. ANS: C The patients ineffective management of the medication regimen is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears God’s voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest that any of the other factors often relate to medication nonadherence. 6. A patient diagnosed with severe and persistent mental illness lives independently. This patient has command hallucinations and shouts warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says you can’t come back here. You cause too much trouble. What problem is the patient experiencing? a. Grief b. Stigma c. Recidivism d. Lack of insurance parity ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as the patient’s problem. Recidivism refers to repetition of a previous offense. Insurance parity is not relevant to this scenario. 7. A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse’s initial priority? a. Develop a relationship b. Find supported employment c. Administer prescribed medication d. Teach appropriate health care practices ANS: A Basic psychosocial needs do not change because a person is homeless. The nurse’s initial priority should be establishing rapport. Once a trusting relationship is established, then the nurse can pursue other interventions. 8. A patient diagnosed with severe and persistent mentally illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care? a. Encourage mutual goal setting. b. Verbally communicate empathy. c. Reinforce participation in activities. d. Demonstrate an accepting attitude. ANS: A Mutual goal setting is an intervention designed to promote feelings of personal autonomy and dispel feelings of powerlessness. Although it might be easier and faster for the nurse to establish a plan and outcomes, this action contributes to the patients sense of powerlessness. Involving the patient in decision making empowers the patient and reduces feelings of powerlessness. 9. A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. I am feeling safe and comfortable here. Nobody bothers me. b. They will not let me drink. They have many rules in the shelter. c. Those guys are always watching me. I think someone stole my shoes. d. That shot made my arm sore. I’m not going to take any more of them. ANS: A Evaluation of a patient’s progress is made based on patient satisfaction with the new health status and the health care teams estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being bothered by others denotes an improvement in the patient’s condition. The other options suggest that the patient is in danger of relapse. 10. For patients diagnosed with severe and persistent mental illness, what is the major advantage of case management? A case manager can: a. modify traditional psychotherapy. b. efficiently access and use resources. c. focus on social skills training and self-esteem building. d. brings groups of patients together to discuss common problems. ANS: B The case manager not only provides entrance into the system of care, but he or she also coordinates the multiple referrals that so often confuse the patient who is severely and persistently mentally ill and the patient’s family. Case management promotes the efficient use of services. The other options are lesser advantages or may be irrelevant. 11. The father of a child diagnosed with schizophrenia says, I lost my job, so we have no health insurance. The mother says, I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture. The sibling says, my parents don’t pay very much attention to me. These comments signify: a. life-cycle stressors. b. psychobiologic issues. c. family burden of mental illness. d. stigma associated with mental illness. ANS: C Family burden refers to the meaning that the experience of living with a person who is mentally ill has for families. The stressors mentioned are not related to live-cycle issues. The stressors described are psychosocial. Stigma refers to shame and ridicule associated with mental illness. 12. The parent of an adult diagnosed with severe and persistent mental illness asks the nurse, why are you making a referral to that vocational rehabilitation program? My child won’t ever be able to hold a job. Which is the nurses best reply? a. We make this referral to continue eligibility for federal funding. b. Are you concerned that were trying to make your child too independent? c. If you think the program would be detrimental, we can postpone it for a time. d. Most patients are capable of employment at some level, competitive or supported. ANS: D Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment; also, they demonstrate significant improvement in assertiveness and work behaviors, as well as decreased depression. 13. An adult says, When I was a child, I took medication because I couldn’t follow my teachers’ directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job. Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder (GAD) c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (ADHD) ANS: D Adult ADHD is usually diagnosed in early life and treated until adolescence. Treatment is often stopped because professionals think the disorder resolves itself because the hyperactive impulsive behaviors may diminish; the inattentive and disorganized behaviors tend to persist, however. Stress intolerance disorder is not found in the DSM-5. The scenario description is inconsistent with generalized anxiety disorder and borderline personality disorder. 14. A patient says, I often make careless mistakes and have trouble staying focused. Sometimes it’s hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment. Which problem should the nurse document? a. Inattention b. Impulsivity c. Hyperactivity d. Social impairment ANS: A Inattention refers to the failure to stay focused. A number of the other problems are the result of failure to pay attention, which contributes to problems with organization. Impulsivity refers to acting without thinking through the consequences. Hyperactivity refers to excessive motor activity. Social impairment refers to the failure to use appropriate social skills. 15. A nurse prepares for an initial interview with a patient with suspected adult attention deficit hyperactivity disorder (ADHD). Questions should be focused to elicit information about which problem? a. Headaches b. Inattention c. Sexual impulses d. Trichotillomania ANS: B Inattention usually persists from childhood into adult ADHD, although hyperactivity, impulsivity, and social impairments may also be present. Headaches would not be expected. Sexual impulses may be affected by adult ADHD, but this area is assessed later. Trichotillomania refers to pulling out one’s hair as a tension- relieving behavior. 16. A nurse prepares a plan of care for a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which intervention should be included? a. Remind the patient of priorities and deadlines. b. Teach work-related skills such as basic computer literacy. c. Establish penalties for failing to organize and prioritize tasks. d. Give encouragement and strategies for managing and organizing. ANS: D The nurses’ major responsibilities lie with encouraging the patient to learn and use necessary skills, assisting the patient to stay on task. The nurse is not an ever-present taskmaster or disciplinarian. The nurse does not teach work-related skills; vocational staff members assume those types of tasks. 17. The treatment team believes medication will help a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which class of medications does the nurse expect will be prescribed? a. Benzodiazepines b. Psychostimulants c. Antipsychotics d. Anxiolytics ANS: B Psychostimulants, such as methylphenidate and amphetamines, provide the basis for treatment of both adult and childhood ADHD. They are the most commonly used medications; therefore, the nurse could expect the health care provider to prescribe a drug in this class. None of the other drugs listed as options have proved useful in the treatment of ADHD. 18. An adult diagnosed with attention deficit hyperactivity disorder (ADHD) says, I’ve always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I can’t keep a job. The nurse managing care should consider a. aversive therapy to extinguish negative behaviors. b. cognitive therapy to help address internalized beliefs. c. group therapy to allow comparison of feelings with others. d. vocational counseling to identify needed occupational skills. ANS: B Cognitive therapy and knowledge of ADHD will make it possible for the patient to reframe the past and present in a more positive and realistic light and to challenge internalized false beliefs about self. Aversive therapy would not be useful for the patient. Group therapy may be valuable later to allow for the testing of new coping behaviors in a safe environment. Vocational counseling can help the patient explore suitable career options while pursuing treatment. 19. A new staff nurse tells the clinical nurse specialist, I’m unsure about my role when patients bring up sexual problems. Which information should the clinical nurse specialist provide? All nurses: a. qualify as sexual counselors. Each has knowledge about the biopsychosocial aspects of sexuality throughout the life cycle. b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality. d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples. ANS: B The basic education of nurses provides information sufficient to qualify as a generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy require additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors; additional education is necessary. The registered nurse may provide basic information about sexual function, but complex questions may require referral. 20. Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquire knowledge of the patients’ sexual roles and preferences b. Develop an understanding of human sexual responses c. Assess the patients sexual functioning d. Clarify the nurses own personal values ANS: D Before a nurse can be helpful to patients with sexual dysfunction, he or she must be aware of and comfortable with his or her own feelings about sex and sexuality. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. 21. A patient tells the nurse, my sexual functioning is normal when my partner wears lace. Without it, I’m not interested in sex. This comment evidences: a. exhibitionism. b. voyeurism. c. pedophilia. d. fetishism. ANS: D A person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality, to be sexually satisfied. Exhibitionism refers to exposing one’s genitalia publicly. Voyeurism refers to viewing others in intimate situations. Pedophilia refers to the preference for having sexual relations with a child. 22. A man tells the nurse, all my life, I have felt and acted like a woman while living in a man’s body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity. Which request is the patient likely to make to the health care provider? a. Can you refer me for psychological testing? b. Will you prescribe estrogen therapy? c. Will you alter my medical records? d. What should I tell my parents? ANS: B Before sexual reassignment surgery, the step that follows living as a member of the other sex is hormone therapy. The patient’s decision to live as a woman makes this a natural request. Psychological testing occurs before sexual reassignment surgery, often after hormone therapy has begun. The patient has likely told his parents by this point. 23. The manager of a health club put a hidden camera in the women’s locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism ANS: D Voyeurism is the viewing of others in intimate situations such as undressing, bathing, or having sexual relations. Voyeurs are often called peeping Toms. Frotteurism is touching or rubbing against a nonconsenting person to achieve sexual gratification. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with prepubescent children. 24. Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is: a. sympathy. b. assertiveness training. c. sexual self-awareness. d. effective communication. ANS: C Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distractors are not prerequisites. 25. An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior? a. Voyeurism b. Frotteurism c. Exhibitionism d. Sexual masochism ANS: C Exhibitionism is obtaining sexual pleasure from exposing one’s genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. Frotteurism is associated with obtaining sexual arousal by rubbing one’s genitals against an unsuspecting person. Sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer. 26. A nurse cares for a patient diagnosed with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic medication d. Mood stabilizer ANS: A SSRIs are reported to have a positive effect on paraphilia. The other medications are not indicated for this disorder. 27. A patient diagnosed with severe and persistent mental illness who recently moved to a homeless shelter says my life is out of control. I’m like a leaf at the mercy of the wind. The nurse formulates the diagnosis Powerlessness. Outcomes will focus on: a. instilling hope. b. controlling anxiety. c. planning social activities. d. developing personal autonomy. ANS: D Powerlessness is associated with feeling unable to control events in one’s life. It is often associated with low self-esteem. The goal is to increase one’s sense of autonomy. The scenario does not indicate hopelessness or anxiety. Socialization is not the primary need. Select All That Apply 1. Which information should a nurse include in health teaching for adults diagnosed with attention deficit hyperactivity disorder (ADHD) and their significant others? Select all that apply. a. Tendency for genetic transmission b. Prevention strategies related to substance abuse c. Negative reinforcement strategies to help modify behaviors d. Selective serotonin reuptake inhibitors (SSRIs) are usually prescribed for hyperactivity e. Cognitive therapy may help resolve internalized negative beliefs about self ANS: A, B, E Evidence suggests that ADHD has a biological basis. This fact can help adults with the disorder to cope with low self-esteem. Cognitive therapy is helpful in reframing negative beliefs about self. Adults diagnosed with ADHD have a higher incidence of substance abuse problems. Psychostimulant medications, rather than SSRIs, are usually prescribed. 2. An adult patient tells the case manager, I don’t have bipolar disorder anymore, so I don’t need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I’m bored and don’t have any friends. Which resources should the nurse suggest for the patient? Select all that apply. a. Psychoeducation classes b. Vocational rehabilitation c. Social skills training d. Homeless shelter e. Crisis intervention ANS:A,B,C The patient does not understand the illness and the need for adhering to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. Work gives meaning and purpose to life; vocational rehabilitation can assist with this aspect of care. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with severe mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking down the skill into small verbal and nonverbal components. The patient presently has a home and does not require the services of a homeless shelter. The nurse case manager functions in the role of crisis stabilizer, so no related referral is needed. 3. Which economic factors are most critical to the success of discharge planning for a patient diagnosed with severe and persistent mental illness? Select all that apply. a. Access to housing b. Individual psychotherapy c. Income to meet basic needs d. Availability of health insurance e. Ongoing interdisciplinary evaluation ANS:A,C,D The success of discharge planning requires careful attention to the patient’s economic status. Access to housing is the first priority of the seriously mentally ill, and lack of income and health insurance is a barrier to effective treatment and rehabilitation. Although important aspects of ongoing care of the seriously mentally ill patient, ongoing interdisciplinary evaluation and individual psychotherapy are not economic factors. 4. Which statements most clearly indicate that the speaker views mental illness with stigma? Select all that apply. a. We are all a little bit crazy. b. If people with mental illness would go to church, their problems would be solved. c. Many mental illnesses are genetically transmitted. It’s no one’s fault that the illness occurs. d. Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people. e. People with mental illness are lazy. They get government disability checks instead of working. ANS:A,B,E Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. [Show More]

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