3400 EXAM 2 Self Assessments

A patient with borderline personality disorder has been making steady progress but one day gets a phone call from her boyfriend, who breaks off their relationship. Although she has not self-injured in over 2 months, she makes repeated lacerations on her forearm. Which statement about this and most maladaptive behaviors seen in personality disorders is most accurate?-People with personality disorders rarely achieve lasting improvement.-However dysfunctional, most behavior is the person's best effort to cope.-People with personality disorders are at the mercy of others' actions.-What appears to be improvement can be manipulation instead.

-However dysfunctional, most behavior is the person's best effort to cope.

T/F: The patient with Schizotypal personality disorder is more likely to have a first degree relative with schizophrenia

True

The patient with borderline personality disorder has been admitted with increased self mutilating behavior and dissociation. She has been attending what type of group specifically designed for patients with this disorder?-Psychoeducational-Insight oriented psychotherapy group-Dialectical behavioral therapy group-Reminisence group

-Dialectical behavioral therapy group

A nurse has a 14 year old son, she feels an that a patient on the floor; she finds herself spending more time with him and begins to share more details about herself than is typical for her.The nurse may be experiencing:-Unprofessional behavior-Transference-Countertransference-Her own issues

-Countertransference

There is a difficult client who many staff find arrogant and manipulative. To help maintain a therapeutic milieu environment on the floor, the charge nurse does one of the following:-Agree on a consistent approach among the staff assigned to the client.-Suggest that the client take a leading role in the social activities.-Provide the client with extra time for one on one sessions.-Allow the client to negotiate the plan of care.

-Agree on a consistent approach among the staff assigned to the client.

A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have?-Narcissistic-Paranoid-Histrionic-Antisocial

-Antisocial

An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?-Eating disorder not otherwise specified-Anorexia nervosa-Bulimia nervosa-Binge eating

-Anorexia nervosa

A patient referred to the eating disorders clinic lost 35 pounds over 3 months. To assess eating patterns, the nurse should ask:-"Do you often feel fat?"-"Who plans the family meals?"-"What do you eat in a typical day?"-"What do you think about your present weight?

-"What do you eat in a typical day?

A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa?-"I'm fat and ugly."-"What I think about myself is my business."-"I'm grossly underweight, but I cover it well."-"I'm a few pounds overweight, but I can live with it.

-"I'm fat and ugly.

A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:-gain 1 to 2 pounds.-exercise 1 hour daily.-take a laxative every 3 days.-weigh self accurately using balanced scales.

-gain 1 to 2 pounds.

A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:-appropriately express angry feelings.-verbalize two positive things about self.-verbalize the importance of eating a balanced diet.-identify two alternative methods of coping with loneliness and isolation.

-identify two alternative methods of coping with loneliness and isolation.

Which nursing intervention has highest priority for a patient with bulimia nervosa?-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.

-Assist the patient to identify triggers to binge eating.

A patient has recently been under significant stress and worked long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. A desired outcome for the patient is to recognize anxiety that precedes binge eating and reduce it. Which intervention addresses the outcome?-Teach stress-reduction techniques such as relaxation and imagery.-Encourage the patient to design and implement an exercise program.-Explore ways in which the patient may feel more in control of the environment.-Encourage the patient to attend a support group such as Overeaters Anonymous.

-Teach stress-reduction techniques such as relaxation and imagery.

A nurse conducts group therapy on the eating disorders unit. Sessions are scheduled immediately after meals. What is the rationale?-Provide a forum for journaling about foods eaten.-Shift the patients' focus from food to psychotherapy.-Promote processing of anxiety associated with eating.-Focus on weight control mechanisms and food preparation.

-Promote processing of anxiety associated with eating.

A nurse is assisting a patient with moderate stage AD at mealtime. Which statement should the nurse use?-Would you like beans or potatoes?-Why aren't you eating your dinner, honey?-Your food will get cold. Eat your dinner now.-If you don't eat, you will get dehydrated.

-Would you like beans or potatoes?Giving the patient choices allows for independence but sets clear boundaries from which to choose

A client presents to the emergency department with an acute decrease in cognitive ability. The nurse's assessment should include which of the following? Select all that apply.-Slow progression of symptoms-Impaired attention and concentration-Diminished appetite-Symptoms diminish as the day progresses-Oriented to time and place with no wandering

-Impaired attention and concentration-Oriented to time and place with no wandering

An 80 year old client admitted to the ED is experiencing fever, urinary frequency, and dysuria. The client is combative and seeing things that others do not see. Which nursing diagnosis reflects this client's problem?-Disturbed sensory perception R/T infection AEB visual hallucinations-Risk for violence: self directed R/T disorientation-Self care deficit R/T decreased perceived need AEB disheveled appearance-Social isolation R/T decreased self esteem

-Disturbed sensory perception R/T infection AEB visual hallucinations

A client who is delirious yells out to the nurse: You are an idiot. Get me your supervisor" Which is the best nursing response in this situation?-You need to calm down and listen to what I am saying-You're very upset, I'll call my supervisor-You're going through a difficult time. I'll stay with you.-Why do you feel that my calling my supervisor will help anything?

-You're going through a difficult time. I'll stay with you.

In working with clients with late stage AD, which is a priority intervention?-Assist the client to consume fluids and food to prevent electrolyte imbalance-Reorient the client to place and time frequently to reduce confusion and fear-Encourage the client to participate in own ADLs to promote self esteem-Assist with ambulation to prevent injury from falls

-Assist the client to consume fluids and food to prevent electrolyte imbalance

On discharge, a client diagnosed with dementia is prescribed donepezil hydrochloride (Aricept). Which of the following would the nurse include in the teaching plan for the client's family?-Aricept is a sedative/hypnotic used for short term insomnia-Aricept is an Alzheimer's treatment used for mild to moderate dementia-Aricept is an antipsychotic used for clients diagnosed with dementia-Aricept is an Antianxiety agent used to help with the anxiety of early stage dementia

-Aricept is an Alzheimer's treatment used for mild to moderate dementia

A client is admitted to an acute care facility with delirium caused by a serious urinary tract infection. Which of the following assessment data should the nurse expect to find? Select all that apply.-Disorientation to time, place, person-Ability to perform most self-care activities-Normal and stable vital signs-Wandering attention-Perceptual disturbances-Change in level of consciousness

-Wandering attention-Perceptual disturbances-Change in level of consciousness

Which of the following interventions is appropriate for the nurse to use on clients with either delirium or dementia?-For safety, use physical restraints with an aggressive client-Approach quietly and touch the client before speaking-Speak in a loud, firm voice to the client-Reorient the client to the nurse with each contact

-Reorient the client to the nurse with each contact

A young female member in a therapy group relates to an older female patient as one might to a mother, accusing her of trying to control her whenever the older member offers observations or suggestions to her. Which therapeutic factor of a group is represented by this behavior?-Instillation of hope-Existential resolution-Development of socializing techniques-Corrective recapitulation of the primary family

-Corrective recapitulation of the primary family

A patient in a group therapy session listens for a time and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This is an example of:-ventilation.-altruism.-universality.-group cohesiveness.

-universality.

A patient, Mary, has talked constantly throughout the group therapy session. She has repeated the same material several times. Other members were initially attentive then became bored, inattentive, and finally sullen. Which intervention would be most effective for the nurse leader to take?-"Most of you have become quiet. I'm wondering if it might be related to concerns you may have about how the group is progressing today."-"Mary has been doing most of the talking. I think it would be helpful for everyone to tell Mary how that has affected your experience of the group."-"I noticed that as the group went on, most members became quiet, then disinterested, and now seem almost angry. What is going on?"-"Mary, you have been doing most of the talking, and others have not had much chance to speak as a result. Could you please yield to others now?

-"Most of you have become quiet. I'm wondering if it might be related to concerns you may have about how the group is progressing today.

Which remark would the nurse expect to hear during the working stage of group therapy?-"My problems are very personal and private; how do I know you people will not tell others what you hear in group?"-"I have enjoyed this group; hard to believe that only a few weeks ago I couldn't even bring myself to talk here."-"One thing everyone seems to have in common is that sometimes it's hard to be truly honest with those you love most."-"I don't think I agree with that; it might help you, but it seems like it would upset your family.

-"I don't think I agree with that; it might help you, but it seems like it would upset your family."The group has developed trust enough in each other to be able to tell their opinion.

The nurse is running a psychoeducational group on anger management . The form of leadership style for this type of group is:-lasseiz-faire-democratic-authoritative-universal

-authoritative

The nurse therapist assessing a family system perceives the family to be poorly differentiated and determines that family members have little sense of individuality. A desirable outcome is that members will:-distinguish who is at fault for the family's dysfunction.-develop their own values and beliefs instead of simply adopting those of others.-become comfortable adhering to family norms and rules.-integrate more effectively with other social systems.

-develop their own values and beliefs instead of simply adopting those of others.

T/F: A young man presents to the university health services complaining of symptoms of depression with anxiety. He reveals that his family has disowned him because he has decided to go to school in another town. The nurse's assessment would be that the family is most likely enmeshed and reacting to the patient's independence.

True

The school nurse learns that since the death of their youngest son, Mr. and Mrs. Jones have been missing work enough to face disciplinary action. The surviving children, aged 8 and 10 years, are having to make their own dinners as best they can. The school nurse notices that the children are wearing dirty clothes and sometimes are inadequately clothed. Which nursing diagnosis would be a priority in this situation?-Caregiver role strain-Interrupted family processes-Compromised resilience-Dysfunctional family processes

-Dysfunctional family processesThe parental unit is unable to deal with the stress of the loss and care for their remaining children. The nurses role would be to help the family identify constructive ways of dealing with the loss.

T/F: A woman presents to an ED after having been the victim of a violent rape. The nurse immediately moves to establish a therapeutic relationship with the patient.

A woman presents to an ED after having been the victim of a violent rape. The nurse immediately moves to establish a therapeutic relationship with the patient.

A university student presents to the ED after having a panic attack at school during an exam. Which of the following identifies the type of crisis that the patient is experiencing?-situational-anticipated life transition-psychiatric emergency-life stress event

-anticipated life transition

A patient asks, "What are neurotransmitters? The doctor said mine are imbalanced." Select the nurse's best response.-"How do you feel about having imbalanced neurotransmitters?"-"You must feel relieved to know that your problem has a physical basis."-"Neurotransmitters are substances we eat daily that influence memory and mood."-"Neurotransmitters are natural chemicals that pass messages between brain cells.

-"Neurotransmitters are natural chemicals that pass messages between brain cells.

A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain?-Hippocampus-Frontal lobe-Cerebellum-Brainstem

-Frontal lobe

The therapeutic action of neurotransmitter inhibitors that block reuptake cause:-decreased concentration of the neurotransmitter in the central nervous system.-increased concentration of neurotransmitter in the synaptic gap.-destruction of receptor sites.-limbic system stimulation.

-increased concentration of neurotransmitter in the synaptic gap.

A patient is hospitalized for severe depression. Of the medications listed below, the nurse can expect to provide the patient with teaching about:-chlordiazepoxide (Librium).-clozapine (Clozaril).-sertraline (Zoloft).-tacrine (Cognex).

-sertraline (Zoloft).Zoloft is a serotonin reuptake inhibitor and the results of its use is elevated mood and resolution of other symptoms of depression.

A patient with bipolar disorder has an unstable mood, aggressiveness, agitation, talkativeness, and irritability. The nurse begins care planning based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n):-anticholinergic.-mood stabilizer.-psychostimulant.-antidepressant.

-mood stabilizer.

Which instruction has priority when teaching a patient taking clozapine (Clozaril)?-"Avoid unprotected sex."-"Report sore throat and fever immediately."-"Reduce foods high in polyunsaturated fats."-"Use over-the-counter preparations for rashes.

-"Report sore throat and fever immediately."The major side effect of note and caution with Clozaril is Agranulocytosis or the depletion of white blood cells. Any symptoms of physical illness may indicate an imbalance in the WBC count.

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:-cardiac dysrhythmia.-hypotensive shock.-hypertensive crisis.-cardiogenic shock.

-hypertensive crisis.MAO breaks down the metabolites of fermented foods (cheese, red wine, etc). When MAO is inhibited by certain medications, the amines rise and a hypertensive crisis can result.

SSRIs improve depression by which action? SSRIs:-destroy increased amounts of serotonin.-block muscarinic and ?1 norepinephrine receptors.-make more serotonin available at the synaptic gap.-increase production of acetylcholine and dopamine.

-make more serotonin available at the synaptic gap.

A patient admitted for injuries suffered while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here". Select the most accurate assessment of the situation. The patient:-Is attempting to gain attention from staff-May have sustained a head injury before admission-Has symptoms of alcohol-withdrawal delirium-Is having an acute psychosis

-Has symptoms of alcohol-withdrawal delirium

An alcohol-dependent patient admitted yesterday believes that the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a:-Benzodiazepine, such as Ativan or Librium-Antipsychotic, such as Zyprexa or haldol-Monoamine oxidase inhibitor-Narcotic analgesic, such as codeine

-Benzodiazepine, such as Ativan or Librium

A hospitalized, alcohol-dependent patient believes that spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?-Check the patient every 15 minutes-One-on-one supervision-Keep the room dimly lit-Force fluids

-Force fluidsDehydration may be a cause of delirium i.e. auditory/visual hallucinations

Which medication to maintain abstinence would most likely be prescribed for patients with either alcoholism or opiod addiction?-Bromocriptine (Parlodel)-Methodone (dolophine)-Disulfiram (Antabuse)-Naltrexone (ReVia)

-Naltrexone (ReVia)Naltrexone is used to prevent cravings for substances and can be used for both Alcohol and opiod addiction

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred?-The alcohol is less potent-Tolerance has developed-Hypomagnesemia has occurred-Antagonistic effects are evident

-Tolerance has developed

Which of the following are part of the CAGE questionnaire screening tool? Select all that apply.-Have you ever felt that you should cut down on your drinking?-Have people annoyed you by criticizing your drinking?-Have you ever felt guilty about your drinking?-Have you ever had a drink in the morning to steady your nerves?-Have you ever attempted suicide while intoxicated?

-Have you ever felt that you should cut down on your drinking?-Have people annoyed you by criticizing your drinking?-Have you ever felt guilty about your drinking?-Have you ever had a drink in the morning to steady your nerves?

What is the priority nursing diagnosis for a patient experiencing cocaine intoxication?-Risk for altered cardiac perfusion-Chronic low self esteem-Ineffective denial-Dysfunctional grieving

-Risk for altered cardiac perfusion

When the nurse is planning relapse prevention strategies for clients diagnosed with substance dependence, which of the following should be the initial nursing approach?-Address previously successful coping skills-Encourage rehearsing stressful situations that may lead to relapse-Keep the interventions simple-Provide community resources such as AA

-Keep the interventions simple

What classification of drugs shares similar features with alcohol overdose and alcohol withdrawal?-Anxiolytics-Amphetamines-Cocaine-PCP

-Anxiolytics

A child with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?-Monoamine oxidase inhibitors-Antipsychotic medications-Anxiolytic medications-Psychostimulant drugs

-Psychostimulant drugs

A nurse works with an adolescent who is moody and withdrawn because the teen's parents are divorcing. Establishing a therapeutic alliance is a priority because:-focusing on the strengths of an individual increases the individual's self-esteem.-the adolescent should express feelings and not keep them internalized.-acceptance and trust convey feelings of security to the adolescent.-therapeutic activities provide an outlet for tension

-acceptance and trust convey feelings of security to the adolescent.

When assessing a 2-year-old with suspected autistic disorder, a nurse would expect:-hyperactivity and attention deficits.-failure to develop interpersonal skills.-a history of disobedience and destructive acts.-high levels of anxiety when separated from the parent

-failure to develop interpersonal skills.

A 15-year-old is referred to the mental health clinic by juvenile court after an arrest for vandalism and running away from home six times. The teen has been physically abusive to the mother and defiant to the father. The adolescent's problem is most consistent with criteria for:-attention-deficit hyperactivity disorder.-adolescent depression.-conduct disorder.-autistic disorder.

-conduct disorder.

Which child shows behaviors indicative of mental illness?-Age 3 months: cries after feeding until burped; sucks thumb-Age 9 months: does not eat vegetables; likes to be rocked-Age 3 years: mute; passive toward adults; twirls when walking-Age 6 years: developed enuresis after the birth of a sibling

-Age 3 years: mute; passive toward adults; twirls when walking

Parents of a child with ADHD tell the nurse, "We try to teach our child how to behave, but it doesn't help. We feel as though we are terrible parents." Select the nurse's most helpful response.-Refer the parents for pastoral counseling.-Discuss how traumatic life events precipitate ADHD.-Explain the correlation between ADHD and parental conflict.-Provide information about the relationship between ADHD and biochemical abnormalities.

-Provide information about the relationship between ADHD and biochemical abnormalities.

A parent with schizophrenia and 10-year-old child live in a homeless shelter. The child has adapted to shelter life and formed a relationship with a supportive volunteer. The child says, "My three best friends and I got an A on our school science project." Which assessment applies?-The child displays resilience.-Risk factors for substance abuse are evident.-The child is at risk for posttraumatic stress disorder.-The child uses intellectualization to deal with problems.

-The child displays resilience.

An 11-year-old has Asperger's disorder. Which assessment finding supports this diagnosis?-Mutism-Tics and twitching-Severe developmental delays-Restricted and repetitive patterns of behavior

-Restricted and repetitive patterns of behavior