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MH Exam Questions and Answers • Question 1 A patient with a history of cocaine use reports a concurrent history of using other drugs in order to counteract the effects of cocaine. Which drug is... this patient likely to have abused? Selected Answer: Alcohol Answers: PCP Alcohol Methylpheni date Caffeine Response Feedback: Alcohol is a depressant which can neutralize the effects of cocaine, which is a stimulant. Caffeine, methylphenidate (used to treat ADHD) and the illegal drug PCP are also stimulating and would only exacerbate the effects of cocaine. • Question 2 A patient is admitted with a heart rate of 53 bpm, respirations 6/min, temp 96.8 and pinpoint pupils. Based on these clinical manifestations, what substance did this patient most likely overdose on? Selected Answer: Marijuana Answers: Opioids Alcohol Marijuana Amphetam ine Response Feedback: Opioids include prescribed medications such as oxycodone and morphine, and the illegal substance heroin. The above symptoms are typical of opioid overdose, but are not typically seen with marijuana, alcohol or amphetamines. • Question 3 An elderly client with cognitive impairment is combative and pulled out a nasogastric tube, intravenous line, and indwelling urinary catheter. What can the nurse anticipate that the health care provider will most likely prescribe? Selected Answer: A small dose of a selective serotonin reuptake inhibitor Answers: A small dose of a selective serotonin reuptake inhibitor A large dose of a benzodiazepine A maintenance dose of buspirone A small dose of an atypical antipsychotic Response Feedback : Aggressive behavior can be safely managed by antipsychotic medication. Initial dosing should be small and raised cautiously until behavior is controlled. Selective serotonin reuptake inhibitors are not indicated for aggressive behavior. If a benzodiazepine is used, the initial dose should be low. Buspirone is not effective if given on an as-needed basis. It is administered in small divided doses daily to control agitation. • Question 4 A nursing care plan contains the intervention “monitor for complications of refeeding syndrome.” Which body system should a nurse most closely monitor for clinical manifestations of dysfunction? Selected Answer: Central nervous Answers: Renal Central nervous Endocrine Cardiovascu lar Response Feedback: Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse; thus focused assessment becomes a necessity to ensure patient physiological integrity. The other body systems are not initially involved in the refeeding syndrome. • Question 5 Which of the following is the best example of all-or-nothing thinking, a common cognitive distortion of patients with an eating disorder? Selected Answer: “If I gain any weight, I’ll keep going until I’m huge.” Answers: “If I gain any weight, I’ll keep going until I’m huge.” “When people tell me I’m looking better, they really mean I’m fatter.” “No one likes me because I’m fat.” “When I’m thin, I’m perfect.” Response Feedback: In all-or-nothing thinking, the person cannot see any middle ground between extremes; a person with an eating disorder will see themselves as either thin or immense. The other comments are common in eating disorders but are not examples of all-or- nothing thinking. • Question 6 A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient with Alzheimer’s disease, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? Selected Answer: Flattering the nurse Answers: Lying to other patients Flattering the nurse Verbal abuse of another patient Detached superficiality during counseling Response Feedback: Limits must be set in areas in which the patient’s behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters. • Question 7 Which of the following are primary characteristics of a person with borderline personality disorder? Selected Answer: Demonstrated a self-defeating cycle of behavior Answers: Demonstrates flexibility and compromise Response Feedback : Demonstrates socially appropriate behaviors Demonstrates eagerness to learn new coping skills Demonstrated a self-defeating cycle of behavior A self-defeating cycle of behavior is a hallmark of borderline personality disorder, creating difficulties is work, social and family relationships. Individuals with a borderline personality are inflexible and do not compromise easily. Socially inappropriate behavior is common in borderline personality, as is an unwillingness to change and learn new coping skills • Question 8 A nurse is working with a patient with a histrionic personality disorder. Which of the following nursing interventions must be implemented throughout the inpatient stay? Selected Answer: Setting appropriate limits on maladaptive behaviors Answers: Setting appropriate limits on maladaptive behaviors Offering relationship advice Providing multiple options when the patient makes frequent requests Having the patient approach different staff members for interpretation of unit rules Response Feedback : Setting firm limits and maintaining consistency are essential elements in working with people with personality disorders. Flexibility and providing too many choices does not help the individual with boundaries and limits. Offering relationship advice is not professional behavior and can have a negative effect on the nurse-client relationship. Encouraging the patient to attend daily activities may be a part of the care plan, but is not as high of a priority as setting limits • Question 9 A patient has blindness related to conversion disorder. In order to assist the patient with eating, which of the following interventions should the nurse implement? Selected Answer: Expect the patient to feed himself after explaining arrangement of the food on the tray. Answers: Establish a “buddy” system with other patients who can feed Response Feedback: this patient at each meal. Expect the patient to feed himself after explaining arrangement of the food on the tray. Address the needs of other patients in the dining room, then feed this patient. Direct the patient to locate items on the tray independently and feed himself unassisted. The patient is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support. • Question 10 A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of a former girlfriend who had refused to see him. His history reveals childhood abuse by a punitive father, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority in the plan of care? Selected Answer: Post-trauma syndrome Answers: Risk for injury Post-trauma syndrome Disturbed thought processes Risk for other-directed violence Response Feedback: 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 the scenario • Question 11 A patient is referred to the mental health center by the family health care provider. Over the past year, the patient has cooked gourmet meals for family members, but eats only tiny portions of the food. The patient wears layers of loose clothing, saying, “It’s just my style.” The patient’s weight has dropped from 130 to 95 pounds. The patient has amenorrhea. Which medical diagnosis are the history and symptoms are most consistent with? Selected Answer: Anorexia nervosa Answers: Anorexia nervosa Bulimia nervosa Binge eating Eating disorder not otherwise specified Response Feedback : Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese. • Question 12 A patient sat in silence for 20 minutes after a therapy appointment. The patient appeared tense and vigilant. The patient abruptly stood up and paced back and forth across the day room, clenching and unclenching his fists. Next, he stopped and stared intently into the face of a psychiatric technician. Which of the following best explains the nurse’s observations of this patient? Selected Answer: The patient is exhibiting clues to potential aggression. Answers: The patient is demonstrating withdrawal The patient is working off angry feelings. The patient is using relaxation strategies effectively. The patient is exhibiting clues to potential aggression. Response Feedback: The description of the patient’s behavior shows the classic signs of someone whose potential for aggression is increasing. • Question 13 A patient referred to the eating disorders clinic has lost 35 pounds during one summer. Which of the following questions would be best if the nurse wished to assess the patient’s eating patterns? Selected Answer: “What do you think about your present weight?” Answers: “Do you often feel fat?” Response Feedback : “Who plans the family meals?” “What do you eat in a typical day?” “What do you think about your present weight?” Although all the questions might be appropriate to ask, only “What do you eat in a typical day?” focuses on the patient’s eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient’s thoughts on present weight explores the patient’s feelings about weight. • Question 14 When a victim of sexual assault is discharged from the emergency department, which of the following interventions should the nurse perform? Selected Answer: Provide referral information verbally and in writing Answers: Notify the patient’s family of the event to seek support for the patient Provide referral information verbally and in writing Offer to stay with the patient until stability is regained Advise the patient to try not to think about the assault Response Feedback : Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The remaining options violate the patient’s right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective. • Question 15 A patient admitted for a heroin overdose received naloxone, which improved her breathing pattern. Two hours later the patient reports muscle aches, abdominal cramps, and gooseflesh, and says, “I feel terrible.” Which is the correct analysis of this assessment? Selected Answer: The patient should be monitored closely for seizures Answers: A peculiar reaction to naloxone is occurring The patient should be monitored closely for seizures Response Feedback: The patient is experiencing a relapse Symptoms are present due to abrupt cessation of narcotic The symptoms given in the question are consistent with narcotic withdrawal. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly seen in alcohol withdrawal syndrome. • Question 16 A health care provider writes these new prescriptions for a nursing home resident: 2-g sodium diet; restraints as needed for behavioral problems; limit fluids to 2000 mL daily; continue antihypertensive medication; milk of magnesia 30 mL orally one time as needed if no bowel movement for 3 days. Which of the following is most appropriate for the nurse to do first? Selected Answer: Clarify the order for restraints Answers: Clarify the order for fluid restriction Clarify the order for restraints Transcribe all orders as written Clarify the order for milk of magnesia Response Feedback : Restraints may be imposed only on the written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other orders would be considered appropriate for implementation. • Question 17 The son of an elderly client with dementia is talking to the nurse about discharge. He indicates that his father’s physician has given him 48 hours to decide on a living situation. The nurse discusses possible living arrangements and provides contact information. The nurse knows that the son requires further teaching when he says: Selected Answer: I want the social worker to decide if he should stay home or go to assisted living so he doesn’t blame me. Answers: I have quite a decision to make. I want the social worker to decide if he should stay home or go Response Feedback : to assisted living so he doesn’t blame me. Well I guess we can try him at home and if it doesn’t work out, I can move him to assisted living later. I think Dad would rather be at home and I think my sister and I can do it. We’ll talk to this home care agency. The son is avoiding making a decision and taking responsibility if he states that he wants the social worker to make the decision. Admitting that he has a difficult decision to make, realizing that he can change the living situation when needed, and making a decision to try home care are all healthy comments in this situation and show that he is accepting responsibility and is willing to make a decision. • Question 18 A child with ADHD will begin medication therapy. Which of the following classifications of medications should the nurse prepare to teach the patient and family about? Selected Answer: Central nervous system stimulants Answers: Central nervous system stimulants Monoamine oxidase inhibitors (MAOIs) Antipsychotic medications Anxiolytic medications Response Feedback: Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate • Question 19 Which of the following nursing interventions is the highest priority while working with a patient who has a somatoform disorder for the first time? Selected Answer: Assess for objective data to support the patient’s report of each physical symptom. Answers: Help the patient shift focus from somatic symptoms to feelings. Imply that somatic symptoms are not real. Response Feedback : Help the patient suppress feelings of anger. Assess for objective data to support the patient’s report of each physical symptom. Physical symptoms need to be investigated with the first patient encounter to rule out an underlying medical condition as cause of the reported symptoms; however, they do not need to be re- investigated each time the patient reports them. Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient as a person rather than as a condition, but this is accomplished after ruling out a serious medical condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome would be that patient would express feelings, including anger if it is present. Once physical symptoms have been investigated, they do not need to be reinvestigated each time the patient reports them. • Question 20 The nurse is assessing a patient who has been diagnosed with hypochondriasis. Which clinical manifestation would the nurse most likely assess in this patient? Selected Answer: Misinterpretation of physical sensations as evidence of serious illness Answers: Loss of interest in formerly pleasurable activities Repetitive, time-consuming rituals Deliberate fabrication of symptoms for an obvious benefit Misinterpretation of physical sensations as evidence of serious illness Response Feedback : People with hypochondriasis experience severe distress, and their ability to function in personal, social, and occupational roles often is impaired. Most patients with hypochondriasis present with somatic symptoms as well as total preoccupation with the belief of having a devastating sickness or disease. These individuals are thought to have prominent health anxiety (hypochondriasis), another form of hypochondriasis. They have minimal or no somatic symptoms but reveal a disproportionate or excessive preoccupation with having a serious illness. • Question 21 While providing health teaching for a patient with binge-purge bulimia, what information is most important for the nurse to prioritize? Selected Answer: self-esteem maintenance Answers: self-monitoring of daily food and fluid intake establishing the desired daily weight gain symptoms of hypokalemia self-esteem maintenance Response Feedback : Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia. • Question 22 An 11-year-old is absent from school to stay at home and care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, “I don’t think my parents like me very much. They call me stupid and say I never do anything right.” Which type of abuse is most likely? Selected Answer: Emotion al Answers: Physical Sexual Emotion al Econom ic Response Feedback: Examples of emotional abuse include having an adult demean a child’s worth or frequently criticize or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse. • Question 23 The student nurse is asked to provide a general and concise description of persons with personality disorders. Which of the following would be the best description? Selected Answer: “They have difficulties in social, family and work relationships.” Answers: “They can tolerate high levels of stress.” “They have difficulties in social, family and work relationships.” “They are good at compromise and often function as mediators.” “They often seek instructions to learn better coping behaviors.” Response Feedback : The defining characteristic of personality disorders is difficulty in social relationships. Most people with personality disorders do not respond well to stress and are generally inflexible and poor compromisers. People with personality disorders tend not to seek help on their own due to a variety of factors; for example, their adaptations make them feel that they are functioning well, they have little desire to change, and possess an overall distrust of others. • Question 24 A nurse in the emergency department tells the daughter of an older adult woman, “Your mother had a severe stroke.” The daughter tearfully says, “Who will take care of me now? My mother always tells me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious.” This behavior could best be assessed as: Selected Answer: Depende nt. Answers: Histrionic . Depende nt. Narcissist ic. Borderlin e. Response Feedback: Clients with a dependent personality have an inability to complete anything on their own; they are unable to make decisions without excessive advice and reassurance as described by the client above. • Question 25 Which behavior best describes physical aggression? Selected Answer: Stomping away from the nurses’ station, going to the day room, and grabbing a pool cue from a patient standing at the pool table Answers: Stomping away from the nurses’ station, going to the day room, and grabbing a pool cue from a patient standing at the pool table Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing Telling the primary nurse, “When you told me that I could not have a second helping at lunch, I felt angry.” Telling the medication nurse, “I am not going to take that, or any other, medication.” Response Feedback: Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The remaining options do not feature violation of another’s rights • Question 26 Which nursing intervention(s) would be most likely included in a plan of care for a patient with bulimia nervosa? Select all that apply. Selected Answers: Assist the patient to identify triggers to binge eating. Explore needs for health teaching. Answers: Assist the patient to identify triggers to binge eating. Provide remedial consequences for weight loss Assess for signs of impulsive eating. Explore needs for health teaching. Response Feedback : For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority. • Question 27 An older adult patient with Alzheimer’s disease lives with family and goes to day care on weekdays. The nurse at the center observed poor hygiene and discussed this observation with the caregiver, the patient’s adult child. The caregiver became defensive and said, “It takes all my time and energy to care for my mother. She’s awake all night. Last night she fell down the stairs.” Which nursing intervention takes highest priority in this case? Selected Answer: Secure additional safety measures for the mother’s evening and night care Answers: Teach the caregiver more about the effects of Alzheimer’s disease Secure additional safety measures for the mother’s evening and night care Support the caregiver to grieve the loss of the mother’s ability to function Teach the family how to give physical care more effectively and efficiently Response Feedback : The patient’s child and her family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished. • Question 28 Which patient statement would be best documented as a subjective assessment finding supporting a psychiatric diagnosis of dissociative fugue? Selected Answer: “I cannot recall why I’m living in this town.” Answers: “I cannot recall why I’m living in this town.” “I hear a male voice telling me to drink this poison.” “I feel very anxious and worried about my problems.” “I feel like I am on top of the world and want to tell everyone about it.” Response Feedback: The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with paranoid schizophrenia, generalized anxiety disorder, or bipolar disorder. • Question 29 A patient admitted yesterday for injuries sustained in a fall while intoxicated believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? Selected Answer: A phenothiazine, such as chlorpromazine or thioridazine Answers: A benzodiazepine, such as lorazepam or chlordiazepoxide A phenothiazine, such as chlorpromazine or thioridazine A monoamine oxidase inhibitor, such as phenelzine A narcotic analgesic, such as codeine Response Feedback: Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. • Question 30 A patient is pacing the hall near the nurses’ station, swearing loudly. Which of the following best describes how the nurse should address this situation in a therapeutic manner? Selected Answer: “You seem upset. Will you tell me more about it?” Answers: “Please quiet down.” “Hey, you’re too loud. It’s bothering people” “You seem upset. Will you tell me more about it?” “You need to go to your room to get control of yourself.” Response Feedback: Intervention should begin with analysis of the patient and the situation. With this response the nurse is attempting to hear the patient’s feelings and concerns. This leads to the next step of planning an intervention. • Question 31 Which of the following nursing interventions are necessary after administration of naloxone (Narcan)? Selected Answer: Monitor airway. Vital signs every 15 minutes. Answers: Monitor airway. Vital signs every 15 minutes. Response Feedback : Insert an indwelling urinary catheter. Insert a nasogastric tube and test gastric pH. Treat hyperpyrexia with cooling measures Narcotic antagonists such as naloxone quickly reverse CNS depression, but because the narcotics have a longer span of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The remaining options are measures unrelated to naloxone use. • Question 32 What is a nurse’s legal responsibility if child abuse or neglect is suspected? Selected Answer: Report the suspected abuse or neglect according to state regulations Answers: Discuss the findings with the child’s teacher, principal, and school psychologist Report the suspected abuse or neglect according to state regulations Document the observations and speculations in the medical record Continue the assessment. Response Feedback: Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be absolutely sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. • Question 33 What is the priority nursing diagnosis for a patient who is experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? Selected Answer: Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait Answers: Bathing/hygiene self-care deficit related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks Risk for injury related to altered cerebral function, Response Feedback : misperception of the environment, and unsteady gait Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations Fear related to sensory perceptual alterations, as evidenced by hiding from hallucinated dog and asking nurse to remove hallucinated bugs from legs The physical safety of the patient is of 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 are concerns, but are lower priorities. • Question 34 Nurses working in a family planning clinic for women routinely ask clients about whether they have experienced domestic violence. The purpose of having this question in the assessment tool is that: Selected Answer: A woman experiencing domestic violence may not seek out help Answers: Identifies women who should be taking birth control. A woman experiencing domestic violence may not seek out help It assists law enforcement in identifying perpetrators of violence It ensures compliance with the health care plan Response Feedback : A woman may not speak about the domestic abuse unless the health care provider asks about it specifically; identifying the problem is the first step in obtaining help and ensuring the family's safety and also helps to reduce stigma by making this a routine question. Assisting law enforcement is not an appropriate reason to include a question in the nursing assessment. Identifying the problem may allow the patient the freedom to comply with any medical orders, but is not the purpose of the question. The question is meant to identify victims of domestic violence, not to suggest that those women should start birth control. • Question 35 An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? Selected Answer: Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) Answers: Between 0800 and 1000 today (6 to 8 hours after drinking stopped) Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) About 0200 on hospital day 3 (72 hours after drinking stopped) About 0200 on hospital day 4 (96 hours after drinking stopped) Response Feedback: Alcohol withdrawal usually begins 6 to 8 hours after cessation or marked reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium • Question 36 Which is an important nursing intervention when giving care to a patient withdrawing from a CNS stimulant? Selected Answer: Observe for depression and suicidal ideation. Answers: Make physical contact by frequently touching the patient. Offer intellectual activities requiring concentration. Observe for depression and suicidal ideation. Avoid manipulation by ignoring patient requests Response Feedback : CNS stimulants produce an imbalance of neurotransmitters (dopa-mine and norepinephrine) that are most likely responsible for many of the physical withdrawal symptoms reported by heavy chronic cocaine users: depression, paranoia, lethargy, anxiety, insomnia, nausea and vomiting, and sweating and chills — all signs of the body struggling to regain its normal chemical balance. This question is looking for safety first. • Question 37 Which of the following clinical manifestations should the nurse expect to assess in a 2-year-old with suspected autistic disorder? Selected Answer: Failure to display affection toward others, such as hugging or touching a parent Answers: Hyperactivity and attention deficits Response Feedback : Failure to display affection toward others, such as hugging or touching a parent A history of disobedience and destructive acts High levels of anxiety when separated from the parent Autistic disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers nearly always mention the child’s failure to develop interpersonal skills. The remaining options are more relevant to ADHD, separation anxiety, and conduct disorder • Question 38 The nurse working on a memory care unit hears her client in a group of his peers reminiscing about his past. How might this behavior affect the client’s daily functioning on the unit? Selected Answer: The client could become depressed about his losses. Answers: Reminiscing will increase his confusion by dwelling on the past. The client may feel less isolated and lonely. The client could become depressed about his losses. Thinking about the past will keep the client from participating in other activities. Response Feedback : Reminiscing with people of the same generation can reduce feelings of loneliness and isolation. Reminiscing has been shown to help with orientation and does not create confusion, nor does it contribute to depression. Thinking about the past should not affect other activities, and may actually improve the client’s mood so that he has more interest in participating. • Question 39 Which child shows behaviors that are most indicative of a potential mental illness? Selected Answer: A 3-year-old who is mute, passive toward adults, and twirls while walking Answers: A 3-month-old who cries after feeding until burped and sucks a thumb A 6-month-old who does not eat vegetables well and likes to be rocked A 3-year-old who is mute, passive toward adults, and twirls Response Feedback: while walking A 4-year-old who lisps and wets the bed after the birth of a sibling Symptoms consistent with pervasive developmental disorder are evident in the answer. The behaviors of the other children are within normal ranges. • Question 40 A patient being assessed for somatoform pain disorder says, “My pain is from an undiagnosed injury. I can’t perform my own activities of daily living or walk 20 minutes. I have to take pain medicine six or seven times a day. I feel like a baby because my family has to provide so much care for me.” Which of the following does the nurse understand is most important to include as part of this assessment? Selected Answer: mood. Answers: mood. cognitive style. secondary gain. identity and memory Response Feedback : Secondary gain should be assessed. The patient’s dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient’s diagnosis has been established. • Question 41 A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!” The most therapeutic response by the nurse would be: Selected Answer: "You need to come and take a shower before you can go get your hair cut." Answers: "You need to come and take a shower before you can go get your hair cut." "Please stop banging on the door. Your room is right over there. " Response Feedback : "The door is locked so that you don’t leave and get hurt." "It's Monday and you’re in the hospital. I'm your nurse." The best response is to orient the client to the day, place and the people around him. Telling him to stop banging on the door and to go to his room is a non-therapeutic response. Explaining why the door is locked does not provide orientation and is irrelevant to his concern about needing to get to the barber. Promising that he can go to the barber after a shower does not present reality. • Question 42 Which intervention is most effective in managing excessive demands from a client with borderline personality disorder? Selected Answer: Be consistent in responses to client demands. Answers: Assign two staff members per shift to this client. Hold a quick staff meeting whenever the client has a complaint Be consistent in responses to client demands. Be flexible and willing to change your mind Response Feedback : Because people with borderline personality disorder have emotional lability and inconsistency in behavior, it’s important for the nurse to be consistent in responses and limits. The person with borderline personality will often test boundaries and rules; being consistent and not changing one’s mind frequently will help the individual feel safe in the environment. Assigning two people per shift can contribute to the tendency to pit two people against each other in order to create conflict. Holding a quick staff meeting in response to client complaints does not keep firm boundaries and allows staff to be manipulated. • Question 43 A client is admitted for acute alcohol withdrawal. Which of the following clinical manifestations indicate the need for treatment of acute alcohol withdrawal? Selected Answer: Tachycardia, paranoid delusions, and elevated blood pressure Answers: Myopia, hypothermia, and elevated mood. Bradycardia, hypotension and drowsiness. Decreased reflexes, somnolence and Response Feedback: hypothermia. Tachycardia, paranoid delusions, and elevated blood pressure Tachycardia, delusions, hallucinations, and elevated blood pressure are symptoms of alcohol withdrawal. • Question 44 A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food, but doesn’t pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try first? Selected Answer: Hand the fork to the client and say, “Use this fork to eat your meat loaf.” Answers: Send the food back to the kitchen and try something else. Help the client by feeding her. Hand the fork to the client and say, “Use this fork to eat your meat loaf.” Tell the client, “It's time to start eating. Those potatoes look good” Response Feedback : A client with agnosia does not recognize objects or understand what they’re used for, so the nurse should give the client concrete directions. It should not be assumed that the client doesn’t like the food without attempting other interventions first. Feeding the client does not provide independence and dignity; if she is able to feed herself with reminders, she should do so. The client doesn’t remember the steps involved in eating, so telling her it’s time to eat and suggesting the food will taste good doesn’t address the problem of not remembering how to eat. • Question 45 A nurse is preparing a care plan for a newly admitted patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be highest priority for the plan of care? Selected Answer: Disturbed body image Answers: Anxiety Risk for suicide Ineffective role performance Response Feedback: Disturbed body image There is a high risk of completed suicide in patients with body dysmorphic disorder. Safety is always a high priority for the nurse; in this instance the plan of care should include an awareness of the risk for self inflicted harm. • Question 46 Which of the following statements best indicates a client is utilizing an individualized relapse prevention plan as part of recovery from alcohol dependence? Selected Answer: “I need to identify what situations I have difficulty handling”. Answers: “I can stay sober on my own, without a support system because I am strong-willed.” “I have to work on my own recovery once a week”. “I need to identify what situations I have difficulty handling”. “I limit myself. I only go to the bars to socialize with other people.” Response Feedback : The goal of relapse prevention is to help individuals learn from “trigger situations” so that periods of sobriety can be lengthened over time and so that lapses and relapses are not viewed as total failure. General strategies for relapse prevention are cognitive and behavioral: recognizing and learning how to avoid or cope with threats to recovery; changing lifestyle; learning how to participate fully in society without drugs; and securing help from other people, or social support. • Question 47 Which of the following interventions are included as part of milieu management in the plan of care for a patient with anorexia who is admitted for inpatient treatment? Select all that apply. Adherence to a selected menu Observation during and after meals Monitoring during bathroom trips Answer Meals delivered to patient in room to allow for eating s: without observation Adherence to a selected menu Observation during and after meals Unscheduled weight checks Monitoring during bathroom trips Response Priority milieu interventions support restoration of weight and Feedback : normalization of eating patterns. This requires close supervision of the patient’s eating and prevention of exercise, purging, and so forth. Menus are strictly adhered to. Observation is maintained during and after meals to prevent throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are precisely observed, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance. • Question 48 The nurse is caring for a client who is receiving treatment for an overdose of phencyclidine piperidine (PCP). Which of the following interventions would the nurse expect to see as part of a collaborative plan of care? Selected Answer: Administer a benzodiazepine Answers: Monitor vital signs once daily Administer epinephrine Administer a benzodiazepine Wrap the patient in warm blankets Response Feedback : Administering a benzodiazepine, usually diazepam, reduces agitation, psychotic symptoms and tachycardia. Administering epinephrine would further increase the heart rate and blood pressure, which are elevated with PCP use. The patient using PCP is probably hyperthermic and therefore wrapping the patient in warm blankets would be counterproductive, as well as difficult due to agitation. Approaching the patient and attempting to calm him verbally would not be effective; in this condition, the patient is combative and not likely to respond to verbal interventions and could be dangerous due to agitation and psychosis. • Question 49 Which scenario bet predicts the highest risk for a patient who may direct violent behavior toward others? Selected Answer: Paranoid delusions of being followed by members of the mafia Answers: Obsessive-compulsive disorder; performs many rituals Paranoid delusions of being followed by members of the mafia Severe depression with delusions of worthlessness. Response Feedback: Completed alcohol withdrawal; beginning a rehabilitation program. The key has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability. • Question 50 An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful to the patient in managing these illusions? Selected Answer: Placing large clocks and calendars on the wall Answers: Placing large clocks and calendars on the wall Placing personally meaningful objects in view Wearing glasses and hearing aids Keeping the room dimly lit constantly Response Feedback: Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects may not be noticed. Round-the- clock lighting promotes sensory overload and sensory perceptual alterations. [Show More]

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