Mental Health Disorders and Their Treatments | Exams Psychology | Docsity (2024)

Download Mental Health Disorders and Their Treatments and more Exams Psychology in PDF only on Docsity! NCLEX Mental Health 1 of 2 Test Bank (1220 Questions and Answers). A client is diagnosed with intermittent explosive disorder. The clinic nurse should anticipate teaching about which medication? A. Citalopram (Celexa) B. Risperidone (Risperdal) C. Fluvoxamine (Luvox) D. Isocarboxazid (Marplan) - Correct Answers ANS: B An antipsychotic like Risperdal can be prescribed for intermittent explosive disorder. An antidepressant is not the usual drug of choice for this disorder. A nurse is caring for a client who is suspected of having the diagnosis of trichotillomania. What condition must be ruled out prior to a definitive diagnosis of this disorder? A. Bipolar disorder B. Alopecia areata C. Post-traumatic stress disorder D. Body dysmorphic disorder - Correct Answers ANS: B Alopecia areata is a dermatological condition that, according to the DSM-IV diagnostic criteria for trichotillomania, must be ruled out to establish this diagnosis. A nursing instructor is teaching about the correlation between pathological gambling and abnormalities in the neurotransmitter system. What statement by the nursing student indicates that learning has occurred? A. "Pathological gamblers present with decreased serotonin, increased norepinephrine, and increased dopamine." B. "Pathological gamblers present with increased serotonin, increased norepinephrine, and increased dopamine." C. "Pathological gamblers present with decreased serotonin, decreased norepinephrine, and decreased dopamine." D. "Pathological gamblers present with increased serotonin, decreased norepinephrine, and decreased dopamine." - Correct Answers ANS: A Serotonergic function is linked to behavioral initiation, inhibition, and aggression. Noradrenergic function mediates arousal and detects novel and aversive stimuli. Dopaminergic function is associated with reward and reinforcement mechanisms. Thus, pathological gamblers present with decreased serotonin, increased norepinephrine, and increased dopamine. A 13-year-old client's father has recently been deployed to Afghanistan. Since deployment, the client has begun to participate in isolative behaviors, truancy, vandalism, and fighting. The pediatric nurse practitioner should identify this behavior with which adjustment disorder? A. An adjustment disorder with anxiety B. An adjustment disorder with disturbance of conduct C. An adjustment disorder with mixed disturbance of emotions and conduct D. An adjustment disorder unspecified - Correct Answers ANS: C The predominant features of an adjustment disorder with mixed disturbance of emotions and conduct include symptoms of anxiety or depression as well as behaviors to include violations of rights of others, truancy, vandalism, and fighting. A client, who recently delivered a stillborn baby, has a diagnosis of adjustment disorder unspecified. The nurse case manager should expect which client presentation that is characteristic of this diagnosis? A. The client worries continually and appears nervous and jittery. B. The client complains of a depressed mood, is tearful, and feels hopeless. C. The client is belligerent, violates the rights of others, and defaults on legal responsibilities. D. The client complains of many physical ailments, refuses to socialize, and quits her job. - Correct Answers ANS: D The diagnosis of adjustment disorder unspecified is assigned when the maladaptive reaction is not consistent with any of the other categories. Manifestations may include physical complaints, social withdrawal, or work or academic inhibition, without significant depressed or anxious mood. A client has been extremely nervous ever since a person died as a result of the client's drunk driving. When assessing for the diagnosis of adjustment disorder, within what timeframe should the nurse expect the client to exhibit these symptoms? diagnosis of the impulse control disorder, trichotillomania, may be assigned. After a spouse dies, a client is diagnosed with adjustment disorder with depressed mood. Client symptoms include chronic migraines, feelings of hopelessness, social isolation, and self-care deficit. Which outcome would be most appropriate to direct the focus of this client's care? A. The client will not cope with stress by impulsive behaviors by discharge. B. The client will accomplish activities of daily living independently by discharge. C. The client will be able to cope effectively by delaying gratification by discharge. D. The client will verbalize a positive body image by discharge. - Correct Answers ANS: B Impulsive behaviors and the inability to delay gratification are symptoms of impulse control, not adjustment disorders. There is no evidence presented that the client has a body image distortion. Setting an outcome of independent self-care will direct nursing interventions toward encouraging the client to meet self-care needs. Which individual would most likely be diagnosed with intermittent explosive disorder? A. A client diagnosed with antisocial personality disorder who attacks the nursing staff B. A client diagnosed with diabetes mellitus who has a history of multiple severe assaultive acts C. A client diagnosed with schizophrenia who sets fires because of command hallucinations D. A client diagnosed with alcohol dependence who severely beats wife while intoxicated - Correct Answers ANS: B The DSM-IV-TR criteria for the diagnosis of intermittent explosive disorder state that the aggressive episodes are not better accounted for by another mental disorder like antisocial personality disorder or schizophrenia. Also, the aggressive episodes are not due to the direct physiological effect of a substance such as alcohol. A client has been diagnosed with pathological gambling. The client's family inquires about their brother's behavior that led to this diagnosis. Which of the following information should the clinic nurse provide? (Select all that apply.) A. Your brother has been preoccupied with thoughts about gambling. B. Your brother has been gambling with increased amounts of money to gain excitement. C. Your brother has tried but failed to control his gambling. D. Your brother's gambling is a result of manic behavior. E. Your brother has lied to you about the extent of his gambling. - Correct Answers ANS: A, B, C, E The DSM-IV-TR criteria for the diagnosis of pathological gambling include all and more of the behaviors presented. The gambling behavior cannot be better accounted for by a manic episode. In evaluating nursing interventions, which of the following types of questions would a nurse use to gather information from a client diagnosed with an impulse control disorder? (Select all that apply.) A. Can the client demonstrate the ability to delay gratification? B. Does the client demonstrate evidence of progression along the grief response? C. Can the client accomplish activities of daily living independently? D. Does the client verbalize symptoms of tension preceding unacceptable behavior? E. Does the client verbalize the unacceptability of maladaptive behaviors? - Correct Answers ANS: A, D, E A client diagnosed with an impulse control disorder should not have difficulty accomplishing activities of daily living or progressing through the grief process. These types of questions would be appropriate for clients diagnosed with adjustment disorders, not impulse control disorders. A client diagnosed with an adjustment disorder asks the nurse, "Tell me about medications that will cure this problem." Which of the following are appropriate nursing replies? (Select all that apply.) A. "Medications can interfere with your ability to find a more permanent problem solution." B. "Medications may mask the real problem at the root of this diagnosis." C. "Adjustment disorders are not commonly treated with medications." D. "Psychoactive drugs carry the potential for physiological and psychological dependence." E. "Psychoactive drugs will be prescribed only if your problems persist for more than 3 months." - Correct Answers ANS: A, B, C, D Adjustment disorder is not commonly treated with medications because of temporary effects, masking the real problem, interfering with finding a permanent solution, and the potential for addiction. A fatherless, 11-year-old African American girl lives with her grandmother after the death of her mother. Her older stepbrother is very involved in her life. How should the community health nurse view this family constellation, and why? A. Abnormal; the grandmother should be concerned with issues other than childrearing. B. Abnormal; a two-parent household is the most advantageous arrangement for parenting. C. Normal; cultural variations exist in the family life cycle. D. Normal; because of their wisdom, older adults make better parenting figures. - Correct Answers ANS: C The nurse should be aware that cultural differences and specific events may lead to variety in family constellations. This is normal. In defiance of parental wishes, a Japanese teenager succumbs to peer pressure and gets a tattoo. According to Bowen's family systems theory, how should the community health nurse interpret the teenager's action? A. The teenager is attempting to differentiate self. B. The teenager is triangulating self. C. The teenager is cutting self off emotionally. D. The teenager is exhibiting antisocial traits. - Correct Answers ANS: A The teenager is taking on some of the cultural values of peers and is beginning to develop a unique identity. This process is called differentiation and is a normal task of adolescence. A home health nurse is visiting an Asian family. A married couple, their three children, and the maternal grandparents all live in the home. How should the nurse interpret the presence of the grandparents in the home? Functional families allow and respect differences among members. They learn to handle differences and conflict through negotiation and compromise. After hearing parents discuss divorce, a 5-year-old develops behavioral problems. Upon dealing with the child's behavioral issues, the marital relationship conflict decreases. The pediatric clinic nurse should recognize that this is an example of which family system concept? A. Differentiation of self B. Triangulation C. Fusion D. Emotional cutoff - Correct Answers ANS: B Triangulation occurs when a relationship between two people is dysfunctional so a third person is brought into the relationship to help stabilize it. The son and his behavioral problems redirect the focus from the couple's marital problems. An instructor is teaching about differentiated parent and adult child relationships. Students are instructed to give an example of a well- differentiated parent and adult child relationship. Which student example meets the instructor requirement? A. An adult child considers, but is not governed by, the advice of his or her parents. B. An adult child appears to listen, but ignores, the advice of his or her parents. C. An adult child respects and is governed by the wishes of his or her parents. D. An adult child never requests advice or feedback from his or her parents. - Correct Answers ANS: A The correct student example of a well-differentiated parent and adult child relationship is when an adult child considers, but is not governed by, the advice of his or her parent. The adult child should be differentiated enough not to be threatened by parental advice and should be able to consider the parental advice without feeling the advice must be followed. During family counseling a husband states, "Every time my wife and I discuss child discipline, we get into shouting matches." The nurse instructs the couple to shout at each other for 2 weeks on Tuesdays and Thursdays for 30 minutes. What intervention is the nurse using? A. Reframing B. Restructuring the family C. Expressive psychotherapy D. Paradoxical intervention - Correct Answers ANS: D In a paradoxical intervention, the therapist requests the family to continue the maladaptive behavior. This removes control over the behavior from the family to the therapist. Clients are made more aware of the defeating behavior and this can lead to behavioral change. During family counseling a child states, "I just want to surf like other kids. Mom says it's okay, but Dad says I'm too young." The mother allows surfing when the father is absent. In the structural model of family therapy, what family interactional pattern should the nurse recognize? A. Multigenerational transmission B. Disengagement C. Mother-child subsystem D. Emotional cutoff - Correct Answers ANS: C In this situation, the mother and child have formed a subsystem in which they have aligned themselves against the father. During family counseling, a husband tells his wife to spend more time with the family, and she responds by stating, "Okay, I'll turn in my resignation tomorrow." The husband replies, "I knew it! You've always been a quitter!" How should the nurse interpret the husband's statement? A. The husband is expressing an emotional cutoff. B. The husband is expressing double-bind communication. C. The husband is expressing indirect messages. D. The husband is expressing avoidance behaviors. - Correct Answers ANS: B Double-bind communication sets up no-win situations. The husband has created a situation in which no matter what the wife does, she is wrong. A couple has been married for 20 years. They argue constantly, belittle feelings, and continuously contradict each other. During a therapy session, the nurse documents "Marital schism." What does the nurse mean by this documentation? A. The couple has a compatible marriage relationship. B. The husband has a dominant relationship over the wife. C. The couple has an enmeshed relationship. D. The couple has an incompatible marriage relationship. - Correct Answers ANS: D A marital schism is a state of chronic disequilibrium and discord. This describes this couple's marriage. A couple is in counseling related to their dysfunctional relationship. Their daughter has recently made a suicide gesture. The nurse should recognize that this might be an example of which family system concept? A. Triangulation B. Pseudohostility C. Double-bind communication D. Pseudomutuality - Correct Answers ANS: A Triangulation occurs when a relationship between two people is dysfunctional. A third person is brought into the relationship to help stabilize it. The couple is triangulating with their daughter. The threatened daughter draws attention from her parent's interpersonal conflicts by her own dysfunctional behavior. An adolescent, his mother, and his soon-to-be stepfather have been in counseling with the nurse. Which statement by the nurse fosters positive relationships within this new family structure? A. "Your son should be consistently disciplined by only one parent." B. "You should not have any more children because your son will need your full attention." C. "You need to keep the lines of communication open between all of you." D. "Allow your son to make his own choices because this new situation will be stressful." - Correct Answers ANS: C Open lines of communication are needed for newly forming families to begin their relationship together and establish a new family structure. 4. "You must be experiencing a problem now." - Correct Answers 2. Asking, "Are you feeling anxious?" helps the client to specifically label the feeling as anxiety so that he can begin to understand and manage it. Some clients need assistance with identifying what they are feeling so they can recognize what is happening to them. Stating, "You need to sit down and relax," is not appropriate because the client needs to continue his pacing to feel better. Asking if something is bothering the client or saying that he must be experiencing a problem is vague and does not help the client identify his feelings as anxiety. A client is brought to the emergency department by his brother. The client is perspiring profusely, breathing rapidly, and complaining of dizziness and palpitations. Problems of a cardiovascular nature are ruled out, and the client's diagnosis is tentatively listed as a panic attack. After the symptoms pass, the client states, "I thought I was going to die." Which of the following responses by the nurse is best? 1. "It was very frightening for you." 2. "We would not have let you die." 3. "I would have felt the same way." 4. "But you're okay now." - Correct Answers 1. The nurse responds with the statement, "It was very frightening for you," to express empathy, thus acknowledging the client's discomfort and accepting his feelings. The nurse conveys respect and validates the client's self- worth. The other statements do not focus on the client's underlying feelings, convey active listening, or promote trust. Which of the following points should the nurse include when teaching a client about panic disorder? 1. Staying in the house will eliminate panic attacks. 2. Medication should be taken when symptoms start. 3. Symptoms of a panic attack are time limited and will abate. 4. Maintaining self-control will decrease symptoms of panic. - Correct Answers 3. It is important for the nurse to teach the client that the symptoms of a panic attack are time limited and will abate. This helps decrease the client's fear about what is occurring. Clients benefit from learning about their illness, what symptoms to expect, and the helpful use of medication. A simple biologic explanation of the disorder can convince clients to take their medication. Telling the client to stay in the house to eliminate panic attacks is not correct or helpful. Panic attacks can occur "out of the blue," and clients with panic disorder can become agoraphobic because of fear of having a panic attack where help is not available or escape is impossible. Medication should be taken on a scheduled basis to block the symptoms of panic before they start. Taking medication when symptoms start is not helpful. Telling the client to maintain self-control to decrease symptoms of panic is false information because the brain and biochemicals may account for its development. Therefore, the client cannot control when a panic attack will occur. A client with panic disorder is taking alprazolam (Xanax) 1 mg P.O. three times daily. The nurse understands that this medication is effective in blocking the symptoms of panic because of its specific action on which of the following neurotransmitters? 1. Gamma-aminobutyrate. 2. Serotonin. 3. Dopamine. 4. Norepinephrine. - Correct Answers 1. Alprazolam, a benzodiazepine used on a short-term or temporary basis to treat symptoms of anxiety, increases gamma-aminobutyrate, a major inhibitory neurotransmitter. Because gamma-aminobutyric acid is increased and the reticular activating system is depressed, incoming stimuli are muted and the effects of anxiety are blocked. Alprazolam does not directly target serotonin, dopamine, or norepinephrine. A client is diagnosed with Generalized Anxiety Disorder (GAD) and given a prescription for venlafaxine (Effexor). Which of the following information should the nurse include in a teaching plan for this client? Select all that apply. 1. Various strategies for reducing anxiety. 2. The benefits and mechanisms of actions of Effexor in treating GAD. 3. How Effexor will eliminate his anxiety at home and work. 4. The management of the common side effects of Effexor. 5. Substituting adaptive coping strategies for maladaptive ones. 6. The positive effects of Effexor being evident in 4 to 5 days. - Correct Answers 1, 2, 4, 5. It is appropriate to provide education on medication mechanisms, benefits, and managing side effects. No medication will eliminate all anxiety, so teaching about anxiety reduction and adaptive coping is needed. Effexor is a serotonin-norepinephrine reuptake inhibitor antidepressant and it will take 2 to 4 weeks to feel the effects. While a client is taking alprazolam (Xanax), which of the following should the nurse instruct the client to avoid? 1. Chocolate. 2. Cheese. 3. Alcohol. 4. Shellfish. - Correct Answers 3. Using alcohol or any central nervous system depressant while taking a benzodiazepine, such as alprazolam, is contraindicated because of additive depressant effects. Ingestion of chocolate, cheese, or shellfish is not problematic. Which of the following statements by a client who has been taking buspirone (BuSpar) as prescribed for 2 days indicates the need for further teaching? 1. "This medication will help my tight, aching muscles." 2. "I may not feel better for 7 to 10 days." 3. "The drug does not cause physical dependence." 4. "I can take the medication with food." - Correct Answers 1. Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. BuSpar is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects not occurring for 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset. A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use first? 1. Explain the effects of stress on the mind and body. 2. Reassure the client that her feelings are typical reactions to serious trauma. 3. Reassure the client that her symptoms are temporary. 4. Acknowledge the unfairness of the client's situation. - Correct Answers 2. The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful 116.A newly admitted 20-year-old client, diagnosed with Post Traumatic Stress Disorder (PTSD), reluctantly reveals that she escaped from a satanic cult 2 years ago. The mother has been in the cult since the client was 3 years old and refused to leave with the client. The client says, "Nobody will ever believe the horrible things the men did to me and my mother never stopped them." Which of the following responses is appropriate for the nurse to make? 1. "I'll believe anything you tell me. You can trust me." 2. "I can't understand why your mother didn't protect you. It's not right." 3. "Tell me about the cult. I didn't know there were any near here." 4. "It must be difficult to talk about what happened. I'm willing to listen." - Correct Answers 4. Survivors of trauma/ torture have a lot of difficulty with trust and do not readily talk about the horrible events. Therefore, empathy and a willingness to listen without pressuring the client are crucial. Option 1 may or may not be possible and does not convey the empathy. It is sometimes difficult to believe what satanic cults can do to children. Option 2 diverts attention from the client to the mother. Option 3 shows more interest in the cult than the client. A client diagnosed with Post Traumatic Stress Disorder is readmitted for suicidal thoughts and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which of the following suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply. 1. Trying relaxation techniques to help decrease her anxiety before bedtime. 2. Taking the quetiapine (Seroquel) 25 mg as needed as ordered by the physician. 3. Staying in the dayroom and trying to sleep in the recliner chair near staff. 4. Listening to calming music as she tries to fall asleep. 5. Processing the content of her flashbacks no less than hour before bedtime. 6. Leaving her door slightly open to decrease noise during the nightly checks. - Correct Answers 1, 2, 4, 6. Relaxation techniques and listening to calming music decrease anxiety and promote sleep. Seroquel is often effective in decreasing nightmare and flashbacks and has a beneficial side effect of drowsiness. Leaving her door slightly open will decrease the noise of making 15 minute checks at night. Staying in the dayroom in a recliner with all the noise and lights is not likely to help. Processing memories an hour or two before bedtime doesn't allow enough time to calm down before sleep. A client with posttraumatic stress disorder needs to find new housing and wants to wait for a month before setting another appointment to see the nurse. The nurse interprets this action as which of the following? 1. A method of avoidance. 2. A detriment to progress. 3. The end of treatment. 4. A necessary break in treatment. - Correct Answers 4. The nurse judges the client's request for an interruption in treatment as a necessary break in treatment. A "time-out" is common and necessary to enable the client to focus on pressing problems and solutions. It is not necessarily a method of avoidance, a detriment to progress, or the end of treatment. A problem like housing can be very stressful and require all of the client's energy and attention, with none left for the emotional stress of treatment. The nurse should warn a client who is taking a benzodiazepine about using which of the following medications in combination with his current medication? 1. Antacids. 2. Acetaminophen (Tylenol). 3. Vitamins. 4. Aspirin. - Correct Answers 1. Combining a benzodiazepine with an antacid impairs the absorption rate of the benzodiazepine. Acetaminophen, vitamins, and aspirin are safe to take with a benzodiazepine because no major drug interactions occur. Which of the following client statements indicates the need for additional teaching about benzodiazepines? 1. "I can't drink alcohol while taking diazepam (Valium)." 2. "I can stop taking the drug anytime I want." 3. "Valium can make me drowsy, so I shouldn't drive for a while." 4. "Valium will help my tight muscles feel better." - Correct Answers 2. Valium, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly tapered off of the medication to decrease withdrawal symptoms, which would be similar to withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased central nervous system depressant effect and therefore should be avoided. Valium can cause drowsiness, and the client should be warned about driving until tolerance develops. Valium has muscle relaxant properties and will help tight, tense muscles feel better. A client is diagnosed with agoraphobia without panic disorder. Which type of therapy is most effective for this illness? 1. Insight therapy. 2. Group therapy. 3. Behavior therapy. 4. Psychoanalysis. - Correct Answers 3. The nurse should suggest behavior therapy, which is most successful for clients with phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most therapeutic for clients with phobias. Self- exposure treatment is being increasingly used to avoid frequent therapy sessions. Insight therapy, exploration of the dynamics of the client's personality, is not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis, which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because it does not help to manage the underlying anxiety or disorder. The client diagnosed with a fear of eating in public places or in front of other people has finished eating lunch in the dining area in the nurse's presence. Which of the following statements by the nurse should reinforce the client's positive action? 1. "It wasn't so hard, now was it?" 2. "At supper, I hope to see you eat with a group of people." 3. "You must have been hungry today." 4. "It is progress for you to eat in the dining room with me." - Correct Answers 4. Saying, "It's a sign of progress to eat in the dining area with me," conveys positive reinforcement and gives the client hope and confidence, thus reinforcing the adaptive behavior. Stating, "It wasn't so hard, now was it," decreases the client's self-worth and minimizes his accomplishment. Stating, "At supper, I hope to see you eat with a group of people," will overwhelm the client and increase anxiety. Stating, "You must have been hungry today," ignores the client's positive behavior and shows the nurse's lack of understanding of the dynamics of the disorder. The client diagnosed with agoraphobia refuses to walk down the hall to the group room. Which of the following responses by the nurse is appropriate? The nurse notices that a client diagnosed with Major Depression and Social Phobia must get up and move to another area when someone sits next to her. Which of the following actions by the nurse is appropriate? 1. Ignore the client's behavior. 2. Question the client about her avoidance of others. 3. Convey awareness of the client's anxiety about being around others. 4. Tell the other clients to follow the client when she moves away. - Correct Answers 3. The nurse conveys empathy and awareness of the client's need to reduce anxiety by showing acceptance and understanding to the client, thereby promoting trust. Ignoring the behavior, questioning the client about her avoidance of others, or telling other clients to follow her when she moves are not therapeutic or appropriate. The nurse is developing a long term care plan for an outpatient client diagnosed with Dissociative Identity Disorder. Which of the following should be included in this plan? Select all that apply. 1. Learning how to manage feelings, especially anger and rage. 2. Joining several outpatient support groups that are process-oriented. 3. Identifying resources to call when there is a risk of suicide or self- mutilation. 4. Selecting a method for alter personalities to communicate with each other, such as journaling. 5. Trying different medicines to find one that eliminates the dissociative process. 6. Helping each alter accept the goal of sharing and integrating all their memories. - Correct Answers 1, 3, 4, 6. Managing suicidal thought, urges to self-mutilate and the intense anger are critical safety issues. Then the focus can switch to communication methods for each alter and the integration issues. Process groups can be overwhelming when too much is revealed or when child alters are unable to understand the group content. There are no known medicines to stop the process of dissociating. A co-manager of a convenience store was taking the daily receipts to the bank when she was robbed at gun point. She did not report the robbery and could not be found for 2 days. In a city 100 miles away, a hotel manager called the police because the woman gave a false name and address. After learning that the robbery was confirmed by the bank cameras, she was admitted to the hospital with a diagnosis of Dissociative Fugue. The nurse should include which of the following in the client's care plan? Select all that apply. 1. Develop trust and rapport to provide safety and support. 2. Rule out possible physical and neurological causes for the fugue. 3. Help the client discuss what she can remember about the trip to the bank. 4. Seclude the client from the other clients because of her lack of memory. 5. Question her repeatedly about the robbery and how she responded. 6. Encourage the client to talk about her feelings - Correct Answers 1, 2, 3, 6. A client experiencing a Dissociate Fugue needs to feel safe and supported as well as evaluated medically and neurologically. Then it is appropriate to discuss what she can remember about the trip to the bank and her feelings about all that has happened to her since then. It is not appropriate to seclude her from others or to apply pressure to get details about the crime at this time. The police and the bank will ask these questions during their investigations. A client named Jana, with a long history of experiencing Dissociative Identity Disorder, is admitted to the unit after the cuts on her legs were sutured in the Emergency Department. During the admission interview, Jana tearfully states that she does not know what happened to her legs. Then a stronger, alter personality named Jason emerges. Jason states that Jana is useless, weak, and needs to be eliminated completely. The nurse should do which of the following first? 1. Explore Jason's attitudes toward Jana more thoroughly. 2. Place Jana in restraints when Jason emerges. 3. Contract with Jason to tell the nurse when he has the urge to harm Jana and the body they both share. 4. Keep Jana in a stress-free environment so that the stronger Jason does not get a chance to emerge. - Correct Answers 3. The No Harm Contract with any destructive alters is essential along with the reminder that the alters share the same body. Later, Jason's attitudes about Jana can be explored in more depth. When alter personalities emerge, their behaviors are not predictable. Restraints could not be placed on the client soon enough. There are no behaviors to justify restraints at this point. Creating a stress-free environment is not possible. 1. A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, "He didn't really mean to hurt me, but I hate for the kids to see this. I'm so worried about them." Which of the following is the most crucial information for the nurse to determine? 1. The type and extent of abuse occurring in the family. 2. The potential of immediate danger to the client and her children. 3. The resources available to the client. 4. Whether the client wants to be separated from her husband. - Correct Answers 2. The safety of the client and her children is the most immediate concern. If there is immediate danger, action must be taken to protect them. The other options can be discussed after the client's safety is assured. A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which of the following as characteristic of abusive families? 1. Tight, impermeable boundaries. 2. Unbalanced power ratio. 3. Role stereotyping. 4. Dysfunctional feeling tone. - Correct Answers 3. The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families. When planning the care for a client who is being abused, which of the following measures is most important to include? 1. Being compassionate and empathetic. 2. Teaching the client about abuse and the cycle of violence. 3. Explaining to the client her personal and legal rights. 4. Helping the client develop a safety plan. - Correct Answers 4. The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care to ensure the client's safety. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured. A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic? Select all that apply. The mother of a school-aged child tells the nurse that, "For most of the past year my husband was unemployed and I worked a second job. Twice during the year I spanked my son repeatedly when he refused to obey. It has not happened again. Our family is back to normal." After assessing the family, the nurse decides that the child is still at risk for abuse. Which of the following observations best supports this conclusion? 1. The parents say they are taking away privileges when their son refuses to obey. 2. The child has talked about family activities with the nurse. 3. The parent's are less negative toward the nurse. 4. The child wears long sleeve shirts and long pants, even in warm weather. - Correct Answers 4. Parental use of nonviolent discipline, the child's talk about what the family is doing and the easing of the parent's negativity toward the school nurse are all signs of progress. Avoidance and wearing clothes inappropriate for the weather implies that the child has something to hide, likely signs of physical abuse. When caring for a client who was a victim of a crime, the nurse is aware that recovery from any crime can be a long and difficult process depending on the meaning it has for the client. Which of the following should the nurse establish as a victim's ultimate goal in reconstructing his or her life? 1. Getting through the shock and confusion. 2. Carrying out home and work routines. 3. Resolving grief over any losses. 4. Regaining a sense of security and safety. - Correct Answers 4. Ultimately, a victim of a crime needs to move from being a victim to being a survivor. A reasonable sense of safety and security is key to this transition. Getting through the shock and confusion, carrying out home and work routines, and resolving grief over any losses represent steps along the way to becoming a survivor. A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether to file a report, the nurse's next priority is to offer which of the following to the client? 1. Legal assistance. 2. Crisis intervention. 3. A rape support group. 4. Medication for disturbed sleep. - Correct Answers 2. The experience of rape is a crisis. Crisis intervention services, especially with a rape crisis nurse, are essential to help the client begin dealing with the aftermath of a rape. Legal assistance may be recommended if the client decides to report the rape and only after crisis intervention services have been provided. A rape support group can be helpful later in the recovery process. Medications for sleep disturbance, especially benzodiazepines, should be avoided if possible. Benzodiazepines are potentially addictive and can be used in suicide attempts, especially when consumed with alcohol. In working with a rape victim, which of the following is most important? 1. Continuing to encourage the client to report the rape to the legal authorities. 2. Recommending that the client resume sexual relations with her partner as soon as possible. 3. Periodically reminding the client that she did not deserve and did not cause the rape. 4. Telling the client that the rapist will eventually be caught, put on trial, and jailed. - Correct Answers 3. Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the rapist will be caught, tried, and jailed. Most rapists are not caught or convicted. In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client voices which of the following? 1. "I didn't fight him, but I guess I did the right thing because I'm alive." 2. "Suicide would be an easy escape from all this pain, but I couldn't do it to myself." 3. "I wish they gave the death penalty to all rapists and other sexual predators." 4. "I get so angry at times that I have to have a couple of drinks before I sleep." - Correct Answers 4. Use of alcohol reflects unhealthy coping mechanisms. A client's report of needing alcohol to calm down needs to be addressed. Survival is the most important goal during a rape. The client's acknowledging this indicates that she is aware that she made the right choice. Although suicidal thoughts are common, the statement that suicide is an easy escape but the client would be unable to do it indicates low risk. Fantasies of revenge, such as giving the death penalty to all rapists, are natural reactions and are a problem only if the client intends to carry them out directly. One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which of the following behaviors is more likely to be used by the abusers? 1. Tying the child down. 2. Bribery with money. 3. Coercion as a result of the trusting relationship. 4. Asking for the child's consent for sex. - Correct Answers 3. Coercion is the most common strategy used because the child commonly trusts the abuser. Tying the child down usually is not necessary. Typically the abusive person can control the child by his or her size and weight alone. Bribery usually is not necessary because the child wants love and affection from the abusive person, not money. Young children are not capable of giving consent for sex before they develop an adult concept of what sex is. A preadolescent child is suspected of being sexually abused because he demonstrates the self-destructive behaviors of self-mutilation and attempted suicide. Which common behavior should the nurse also expect to assess? 1. Inability to play. 2. Truancy and running away. 3. Head banging. 4. Over-control of anger. - Correct Answers 2. Truancy and running away are common symptoms for young children and adolescents. The stress of the abuse interferes with school success, leading to the avoidance of school. Running away is an effort to escape the abuse and/ or lack of support at home. Rather than an inability to play or a lack of play, play is likely to be aggressive with sexual overtones. Children tend to act out anger rather than control it. Head banging is a behavior typically seen with very young children who are abused. Adolescents and adults who were sexually abused as children commonly mutilate themselves. The nurse interprets this behavior as: 4. Difficulty with controlling aggression. - Correct Answers 4. Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information. A 3-year-old child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which of the following comments by the nurse would be most appropriate? 1. "It's okay to cry when something hurts." 2. "That really didn't hurt, did it?" 3. "We're mean to hurt you that way, aren't we?" 4. "You were very good not to cry with the needle." - Correct Answers 1. It is not normal for a preschooler to be totally passive during a painful procedure. Typically a preschooler reacts to a painful procedure by crying or pulling away because of the fear of pain. However, an abused child may become "immune" to pain and may find that crying can bring on more pain. The child needs to learn that appropriate emotional expression is acceptable. Telling the child that it really didn't hurt is inappropriate because it is untrue. Telling the child that nurses are mean does not build a trusting relationship. Praising the child will reinforce the child's response not to cry, even though it is acceptable to do so. While interviewing a 3-year-old girl who has been sexually abused about the event, which approach would be most effective? 1. Describe what happened during the abusive act. 2. Draw a picture and explain what it means. 3. "Play out" the event using anatomically correct dolls. 4. Name the perpetrator. - Correct Answers 3. A 3-year-old child has limited verbal skills and should not be asked to describe an event, explain a picture, or respond verbally or nonverbally to questions. More appropriately, the child can act out an event using dolls. The child is likely to be too fearful to name the perpetrator or will not be able to do so. Which of the following observations by the nurse should suggest that a 15- month-old toddler has been abused? 1. The child appears happy when personnel work with him. 2. The child plays alongside others contentedly. 3. The child is underdeveloped for his age. 4. The child sucks his thumb. - Correct Answers 3. An almost universal finding in descriptions of abused children is underdevelopment for age. This may be reflected in small physical size or in poor psychosocial development. The child should be evaluated further until a plausible diagnosis can be established. A child who appears happy when personnel work with him is exhibiting normal behavior. Children who are abused often are suspicious of others, especially adults. A child who plays alongside others is exhibiting normal behavior, that of parallel play. A child who sucks his thumb contentedly When planning interventions for parents who are abusive, the nurse should incorporate knowledge of which factor as a common parental indicator? 1. Lower socioeconomic group. 2. Unemployment. 3. Low self-esteem. 4. Loss of emotional family attachments. - Correct Answers 3. Parents who are abusive often suffer from low self-esteem, commonly because of the way they were parented, including not being able to develop trust in caretakers and not being encouraged or offered emotional support by parents. Therefore, the nurse works to bolster the parents' self-esteem. This can be achieved by praising the parents for appropriate parenting. Employment and socioeconomic status are not indicators of abusive parents. Abusive parents usually are attached to their children and do not want to give them up to foster care. Parents who are abusive love their children and feel close to them emotionally. According to Erikson's developmental theory, when planning care for a 47- year-old client, which developmental task should a nurse identify as appropriate for this client? A. To develop a basic trust in others B. To achieve a sense of self-confidence and recognition from others C. To reflect back on life events to derive pleasure and meaning D. To achieve established life goals and consider the welfare of future generations - Correct Answers ANS: D The nurse should identify that an appropriate developmental task for a 47- year-old client would be to achieve established life goals and consider the welfare of future generations. According to Erikson, the client would be in the generativity versus stagnation stage of development. A jilted college student is admitted to a hospital following a suicide attempt and states, "No one will ever love a loser like me." According to Erikson's theory of personality development, a nurse should recognize a deficit in which developmental stage? A. Trust versus mistrust B. Initiative versus guilt C. Intimacy versus isolation D. Ego integrity versus despair - Correct Answers ANS: C The nurse should recognize that the client who states, "No one will ever love a loser like me." has not adequately completed the intimacy versus isolation stage of development. The intimacy versus isolation stage is presumed to occur in young adulthood between the ages of 20 and 30 years. The major developmental task in this stage is to establish intense, lasting relationships or commitment to another person, cause, institution, or creative effort. A nurse observes a 3-year-old client willingly sharing candy with a sibling. According to Peplau, which psychological stage of development should the nurse determine that this child has completed? A. "Learning to count on others" B. "Learning to delay satisfaction" C. "Identifying oneself" D. "Developing skills in participation" - Correct Answers ANS: B The nurse should determine that this client has completed the "Learning to delay satisfaction" stage of development according to Peplau's interpersonal theory. This stage typically occurs in toddlerhood when one learns the satisfaction of pleasing others. When a mother brings her 9-month-old to daycare, the child smiles and reaches for the daycare caregiver. The nurse should determine that according to Mahler's developmental theory, this child's development is at which phase? A. The autistic phase B. The symbiotic phase C. The differentiation subphase of the separation-individuation phase D. The rapprochement subphase of the separation-individuation phase - Correct Answers ANS: C D. Establishing a career, personal relationships, and societal connections - Correct Answers ANS: D The nurse should assist the client in establishing a career, personal relationships, and societal connections. According to Erikson, non- achievement in the generativity versus stagnation stage results in self- absorption, including withdrawal from others and having no capacity for giving of the self to others. A 1-month-old infant is left alone for extended periods, has little physical stimulation, and is malnourished. Based on this infant's history, in which phase of development according to Mahler's theory, should a nurse expect to see a potential deficit? A. The symbiotic phase B. The autistic phase C. The consolidation phase D. The rapprochement phase - Correct Answers ANS: B The nurse should expect that a 1-month-old infant who is left alone, has little physical stimulation, and is malnourished would not meet the autistic phase of development. The autistic phase of development usually occurs from birth to 1 month, at which time the infant's focus is on basic needs and comfort. A 6-year-old boy uses his father's flashlight to explore his 3-year-old sister's genitalia. According to Freud, in which stage of psychosocial development should a nurse identify this behavior as normal? A. Oral B. Anal C. Phallic D. Latency - Correct Answers ANS: C The nurse should identify this behavior as normal because the 6-year-old client who focuses on genital organs is in the phallic stage of Freud's stages of psychosexual stages of development. Children in the phallic stage of development focus on genital organs and develop a sense of sexual identity. Identification with the same-sex parent also occurs at this stage. A married, 26-year-old client works as a schoolteacher. She and her husband have just had their first child. A nurse should recognize that this client is successfully accomplishing which stage of Erikson's developmental theory? A. Industry versus inferiority B. Identity versus role confusion C. Intimacy versus isolation D. Generativity versus stagnation - Correct Answers ANS: C The nurse should recognize that a 26-year-old client who is married and has a child has successfully accomplished the intimacy versus isolation stage of Erikson's developmental theory. The intimacy versus isolation stage of young adulthood involves forming lasting relationships. Achievement of this tasks results in the capacity for mutual love and respect. A 10-year-old child wins the science fair competition and is chosen as a cheerleader for the basketball team. A nurse should recognize that this child is in the process of successfully accomplishing which stage of Erikson's developmental theory? A. Industry versus inferiority B. Identity versus role confusion C. Intimacy versus isolation D. Generativity versus stagnation - Correct Answers ANS: A The nurse should recognize that a 10-year-old child who is successful in school both academically and socially has successfully accomplished the industry versus inferiority developmental stage of Erikson's psychosocial theory. The industry versus inferiority stage of development usually occurs between 6 to 12 years of age, at which time individuals achieve a sense of self-confidence by learning, competing, performing successfully, and receiving recognition from others. A client has flashbacks of sexual abuse by her uncle. She had not been aware of these memories until recently, when she became sexually active with her boyfriend. A nurse should identify this experience as which part of Sullivan's concept of the self-system? A. The "good me" B. The "bad me" C. The "not me" D. The "bad you" - Correct Answers ANS: C The nurse should identify a client remembering sexual abuse when becoming sexually active with her boyfriend as experiencing the "not me" part of the personality. According to Sullivan, the "not me" part of the personality develops in response to situations that produced intense anxiety in childhood. According to Freud, which statement should a nurse associate with predominance of the superego? A. "No one is looking, so I will take three cigarettes from Mom's pack." B. "I don't ever cheat on tests. It is wrong." C. "If I skip school I will get in trouble and fail my test." D. "Dad won't miss this little bit of vodka." - Correct Answers ANS: B The nurse should associate the statement "I don't ever cheat on tests. It is wrong." as indicative of the predominance of the superego. Freud described the superego as the part of the personality that internalizes the values and morals set forth by primary caregivers. The superego can be referred to as the "perfection principle." A female complains that her husband only meets his sexual needs and never her needs. According to Freud, which personality structure should a nurse identify as predominantly driving the husband's actions? A. The id B. The superid C. The ego D. The superego - Correct Answers ANS: A The nurse should identify that the husband's actions are driven by the predominance of the id. According to Freud, the id is the part of the personality that is identified as the pleasure principle. The id is the locus of instinctual drives. A father of a 5-year-old demeans and curses at his child for disobedience. In turn, when upset, the child uses swear words in kindergarten. A school nurse recognizes this behavior as unsuccessful completion of which stage of development according to Peplau? A. "Learning to count on others" B. "Learning to delay satisfaction" C. "Identifying oneself" A. Client symptoms are viewed as learned behaviors that are maintained because they are reinforced. B. Client symptoms are viewed as responses to anxiety arising from interpersonal relationships. C. Client symptoms are viewed as internal conflicts arising from early childhood trauma. D. Client symptoms are viewed as the misinterpretations of experiences. - Correct Answers ANS: B Sullivan believed that anxiety is the chief disruptive force in interpersonal relations and the main factor in the development of serious difficulty in living. A nursing instructor is teaching about the application of Peplau's theory to nursing care. Which student statement indicates that learning has occurred? A. "The nurse assumes the role of a parenting figure instructing the client in good health practices." B. "The nurse is concerned more about psychosocial functioning than physiological functioning." C. "The nurse bases the client care plan on standardized nursing approaches and physician orders." D. "The nurse applies principles of human relations to the problems that arise at all levels of experience." - Correct Answers ANS: D Peplau applied interpersonal theory to nursing practice and, most specifically, to nurse-client relationship development. According to Peplau, treatment of client symptoms should involve which nursing action? A. Establishing a therapeutic nurse-client relationship B. Using the technique of desensitization C. Challenging clients' negative thoughts D. Uncovering clients' past experiences - Correct Answers ANS: A Peplau applied interpersonal theory to nursing practice and, most specifically, to nurse-client relationship development. The nurse practitioner plans to use a psychoanalytical framework when treating a client diagnosed with an anxiety disorder. Which would be the focus of this nursing intervention? A. Correcting inappropriate learning patterns B. Changing a dysfunctional social environment C. Exploring the "here-and-now" with the client and family D. Dealing with issues of physical abuse at an early age - Correct Answers ANS: D Freud, a psychoanalytic theorist, considered the first 5 years of a child's life to be the most important, because he believed that an individual's basic character had been formed by the age of five. Which is a nursing intervention to assist a client to achieve Erikson's developmental task of ego integrity? A. Encourage a life review of triumphs and disappointments B. Provide opportunities for success experiences C. Focus on embracing the future D. Foster the development of creativity - Correct Answers ANS: A Erikson believed that between the age of 65 years and death, the goal is to review one's life and derive meaning from both positive and negative events, while achieving a positive sense of self. From an interpersonal theory perspective, which intervention would a nurse use to assist a client diagnosed with major depressive disorder? A. Encourage discussion of feelings B. Offer family therapy sessions C. Discuss childhood events D. Teach alternate coping skills - Correct Answers ANS: B Sullivan, an interpersonal theorist, believed that individual behavior and personality development are the direct result of interpersonal relationships. Family therapy would assist the client to deal with relationships within the family system. Which concepts should a nurse identify as being included in the DSM-IV- TR definition of personality? (Select all that apply.) A. Personality is an enduring pattern of perceiving. B. Personality is influenced by relationships between the environment and self. C. Personality is developed in sporadic stages that vary from person to person. D. Personality is influenced by a wide range of social and personal contexts. E. Personality is inborn and cannot be influenced by developmental progression. - Correct Answers ANS: A, B, D The nurse should identify that the following concepts are included in the DSM-IV-TR definition of personality: Personality is an enduring pattern of perceiving, a wide range of social and personal contexts influences it, and it is inborn. Personality disorders are coded on Axis II of the DSM-IV-TR multiaxial diagnosis and include disorders organized into three clusters: odd and eccentric disorders (cluster A); dramatic, emotional, or erratic disorders (cluster B); and anxious or fearful disorders (cluster C). What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences - Correct Answers ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia. A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician? A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration - Correct Answers ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption. Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children." - Correct Answers ANS: D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors - Correct Answers ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity. Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping - Correct Answers ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods. A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy." - Correct Answers ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance. A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?" - Correct Answers ANS: C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own. Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepan (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin) - Correct Answers ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long- lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity. During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy. - Correct Answers ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior. A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use. - Correct Answers ANS: D D. A reaction to tannins in the red wine - Correct Answers ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia. A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal." - Correct Answers ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation. A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug." - Correct Answers ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks. Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body. - Correct Answers ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation. A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor. - Correct Answers ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable. In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life- saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP) - Correct Answers ANS: B If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation - Correct Answers ANS: C The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.) A. "I am easily manipulated and need to work on this prior to caring for these clients." B. "Because of my father's alcoholism, I need to examine my attitude toward these clients." C. "I need to review the side effects of the medications used in the withdrawal process." D. "I'll need to set boundaries to maintain a therapeutic relationship." E. "I need to take charge when dealing with clients diagnosed with substance disorders." - Correct Answers ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse's ability to establish therapeutic relationships with these clients. A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.) A. "A diet rich in protein will promote hepatic healing." B. "This condition leads to a rise in serum ammonia resulting in impaired mental functioning." C. "In this condition, blood accumulates in the abdominal cavity." D. "Neomycin and lactulose are used in the treatment of this condition." E. "This condition is caused by the inability of the liver to convert ammonia to urea." - Correct Answers ANS: A, C The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing and that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal the stairs. Which action should make the nurse supect that the child was abused? -the child cries uncontrollably throughout the examination -the child pulls away from the contact with the doctor -the child does not cry when the shoulder is examined - Correct Answers the child does not cry when the shoulder is examined -a characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers which of the folowing is a priority intervention when dealing with child abuse or neglect? - Correct Answers safety -the first part of treatment for child abuse or neglect is to ensure the childs safety and well-being what percentage of staking victims is female? - Correct Answers 80% during 2001, what percentage of children died form neglect? -15% -48% -50% -33% - Correct Answers 33% -1,300 children died from maltreatment, with 33% dying from neglect in 2001 when interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem? - Correct Answers the injury is not consistent with the history or the childs age -when the childs injuries are inconsistent witht he history given or impossible b/c of the childs age and development stage, the emergency nurse should be suspicious that child abuse is occuring. - the parents may tell different stories cause their perception may be difference regarding what happended. If they change their stroty when different health care workers ask the same question, this is a clue that child abuse may be a problem. -child abuse happens in all socioeconomic groups. -parents may argue and be demanding b/c of the stress of having an injured child what percentage of victims of intimate violence report that alcohol was involved in the violent incident? -75% -1/4 -2/3 1/2 - Correct Answers two thirds of victims of intimate violence report that alcohol was involved in the violent incident which medicaiton classification has been used successfully to treat PTSD? - Correct Answers antidepressants such as Paxil and Zoloft, have been used to treat PTSD which of the following is the most common trait found in abused wives who stay with their husbands? -dependency -jealousy -emotional immaturity -possessiveness - Correct Answers dependency -dependency is the most common trait seen in abused wives who stay with their husbands. -women often cite personal and financial dependency as reasons why they find leaving an abusive relationship extremely difficult which of the following is an inaccurate picture of the cycle of abuse that occurs over time? -severity of the injuries worsen -violent episodes are less frequent -violent episodes are more frequent -the period of remorse disappears - Correct Answers violent episodes are less frequent -over time, the violent episodes are more frequent, the period of remorse disappears altogether, and the level of violence and severity of injuries worsen PTSD occurs w/i what frame of the experience? - Correct Answers 3 months -in PTSD, the symptoms occur 3 months or more after the trauma, which distinguished PTSD from acute stress disorder which happens right after and last four weeks the majority of perpetrators of elder abuse include which of the following populations? - Correct Answers spouses -nearly 60% of the perpetrators of elder abuse are spouses, 20% are adult children, and 20% are others such as siblings, grandchildren, and boarders a client comes to the emergency department after being attacked and sexually assualted. What is the most accurate nursing diagnosis for this client? -fear -hopelessness -rape-trauma syndrome -anxiety - Correct Answers rape-trauma syndrome -this refers to both the acute and long-term phases experienced by the victim of sexual assault. Specific nursing interventions can be planned based on this diagnosis. The rape victim may experience fear, anxiety, and hopelessness, but these are not specific diagnoses. which of the following nursing diagoses has the highest priority for the client diagnosed with PTSD? -depersonalization disorder occurs when the client has a persistent or recurrent feeling of being detached from his or her mental processes or body which type of dissociative disorder involves the clients inability to rememner important personal information - Correct Answers dissociative amnesia --dissociative identity disorder occurs when the client displays two or more distinct identities or personality staes that recurrently take control of his or her behavior. -dissociative fugue occurs when the clients has episodes of suddenly leaving the home or place of work w/o any explanation. -dissociative amnesia occurs when the client cannot remember important personal information. -depersonalization disorder occurs when the client has a persistent or recurrent feeling of being detached from his or her mental processes or body which of the following is a priority intervention in the treatment of the client diagnosed w/ PTSD? - Correct Answers safety of the client -promoting the client safety is the priority intervention for the client diagnosed with PTSD. Thenurse continually must assess the clients potential for self-harm or suicide and take action immediately which of the following is a warning indicator form a caregiver that may indicate elder abuse? -inability to manage finances -failure to keep medical appointments -blaming the elder for his or her illness or limitations -lack of toilet facilities - Correct Answers blaming the elder for his or her illness or limitations -indicators of self-neglect are inability to manage finances, failure to keep mecial appointments, and lack of toilet facilites which type of male rapist impulsively ices his victims as objects for gratification? -inadequate men -sexual sad*sts -exploitive predators -men for who anger is displaced - Correct Answers exploitive predators -exploitive predators impulsively use their victims as objects for gratification. -Sexual sad*sts are aroused by the pain of their victim -inadequate men believe that no woman would voluntarily have sexual relations with them and are obsessed with fantasies about sex when the client has a persistnet or recurrent feeling of being detached form his or her mental processes or body, this is documented as which of the following? -dissociative fugue -dissociative identity disorder -dissociative amnesia -depersonalization disorder - Correct Answers depersonalization disorder ---dissociative identity disorder occurs when the client displays two or more distinct identities or personality staes that recurrently take control of his or her behavior. -dissociative fugue occurs when the clients has episodes of suddenly leaving the home or place of work w/o any explanation. -dissociative amnesia occurs when the client cannot remember important personal information. -depersonalization disorder occurs when the client has a persistent or recurrent feeling of being detached from his or her mental processes or body Intergenerational transmission process suggests that family violence is a pattern of behavior learned form on generation to the next - Correct Answers true symptoms of posttraumatic stress disorder occur within 1 month after the trauma and do not persist longer than 4 weeks - Correct Answers false dissociative amnesia involves episodes of suddenly leaving the home or place of work without any explanation, traveling to another city, and being unable to remember one's past or identity - Correct Answers false Depression and suicidal behavior are common in surveyors of abuse - Correct Answers true the classification of sodomy as a crime can impede same-sex victims reporting partner abuse? - Correct Answers true ________is the repeated and persistent attempts to impose unwanted communication or contact with another person - Correct Answers Stalking _______is the malicious or ignorant withholding of physical, emotional, or educational necessities to a dependents well-being - Correct Answers Neglect Spouse battering, child abuse, elder abuse, and marital rape are examples of ___________violence - Correct Answers Family The _____phase in the cycle of violence is a period in which the perpetrator expresses remorse and regret - Correct Answers Honeymoon Date rape, also known as_______rape, can occur on a first date or when the two individuals have known eachother for some time - Correct Answers acquaintance Sensorimotor - Correct Answers Piaget stage for birth to 2 years Separation Object permanence Mental representation - Correct Answers Piaget sensorimotor stage characteristics Preoperational - Correct Answers Piaget stage for 2 to 7 years Have and demonstrate memories of events that relate to them (egocentrism) Domestic mimicry - Correct Answers Piaget preoperational stage characteristics Create or nurture things that will outlast them, often by having children or creating change that benefits other people Usefulness and accomplishment - Correct Answers Characteristics of generativity vs. stagnation Ego integrity vs. despair - Correct Answers Erikson's stages for maturity (65 to death) Reflection on life Look back on life and feel a sense of fulfillment Success-wisdom Failure-regret, bitterness, despair - Correct Answers Characteristics of ego integrity vs. despair Therapeutic Communication Techniques - Correct Answers Silence B. Offering self 1. "Let me help you." 2. "I will stay with you." C. Reflection/Restatement 1. Reflection: repeating back part of what the patient has just said 2. Restatement: putting what the patient has just said in different words 3. Opens communication D. Empathy 1. Recognizing patient's feelings 2. Opens communication E. Giving information F. Focusing/Exploring 1. Clarify information 2. Focuses patient concerns 3. Not usually initial communication Barriers to Communication - Correct Answers Advising: Nurse gives opinion B. Devaluing: Example "Don't cry." C. Disapproval D. Focus on nurse E. Asking "Why?" F. Clichés and false reassurance G. Defending H. Changing the subject I. Verbs that encourage sharing are better than "nurse as authority verbs 1. Suggest or discuss better than demand or request 2. Better to involve patient Types of admission - Correct Answers Voluntary a. Any citizen of legal age may seek admission b. Client retains all rights c. Client can refuse treatment 2. Involuntary a. Admission request does not originate with client b. Civil rights may not be retained c. Criteria a. Mentally ill and one or more of the following 1) Danger to self or others 2) Needs treatment 3) Unable to meet basic needs b. Certified by two physicians d. Will be reassessed at regular intervals 3. Criminals who are "not guilty by reason of insanity" do not retain all their rights Rights of psychiatric clients - Correct Answers Informed consent 2. Unopened mail 3. Phone calls/visits 4. Visits by physicians, attorney, clergy 5. Keep personal possessions 6. Keep and spend money 7. Hold property, vote, and marry 8. Education 9. Treatment in the least restrictive setting 10. Refuse treatment Freud - Correct Answers Structure of the mind a. Id 1) Unconscious mind 2) The pleasure principle. "I want it now!" b. Super ego 1) "Thou shalt not." 2) Conscience 3) Part conscious and part unconscious c. Ego: balances between Id and superego Stages of psychosexual development - Correct Answers Oral 1) Infancy 2) Explores the world through the mouth b. Anal 1) Toddler 2) Toilet training stage c. Phallic (Oedipal) 1) Preschool 2) Little boy wants to marry his mother; little girl wants to marry her father d. Latent 1) School age 2) Development of conscience or super ego. e. Genital 1) Adolescence 2) Major concern is genital sex Erikson - Correct Answers Infant; 0-2 years: Trust Vs. mistrust 2. Toddler; 2-3 years: Autonomy Vs shame and doubt 3. Preschool; 3-5 years: Initiative Vs guilt 4. School age; 6-12 years: Industry Vs inferiority 5. Adolescent; 12-18 years: Identity Vs identity (or role) confusion 6. Young adult: 18-25 years: Intimacy Vs isolation 7. Middle adult: 25-45 years: Generativity Vs stagnation 8. Older adult: 45-death: Ego integrity Vs despair Establishing a Nurse Client Relationship - Correct Answers Initiation phase a. Who? b. What? c. Where? d. When? e. Why? 2. Working phase a. Set client goals b. Promote insight c. Work for client independence 3. Termination phase a. Start early b. Expect regression c. Discuss coming separation/termination d. Review progress made e. Promote closure Types of group therapy - Correct Answers Structured groups 1) Goal: to accomplish a specific outcome 2) Leader: directive b. Unstructured groups 1) Goal: Express feelings and receive feedback 2) Leader: nondirective 3) Focus: group concerns c. Family groups 1) Change in one family member causes changes in others 2) Goal is to improve communication d. Special problem group: group members share similar problems e. Self-help group: Individuals with common problems who give support to each other Milieu of Therapy - Correct Answers Management of the environment to produce change in personality and behavior. 2. Assumptions a. Clients have strengths b. Clients have abilities to influence their own treatment and the treatment of others c. Clients are responsible and accountable for their own behavior Crisis Intervention - Correct Answers Brief intense therapy 2. Goal: To return to the level of functioning before the crisis 3. Assess: a. Level of functioning b. Precipitating event c. Past coping mechanisms d. Available support systems 4. Plan a. Consistent b. Appropriate c. Collaborative 5. Intervention a. Here and now b. Time limited: 6-8 weeks Levels of anxiety - Correct Answers Mild: Broad perceptual field; a little muscle tension 2. Moderate: Narrowed perceptual field; more physical symptoms 3. Severe: Greatly narrowed perceptual field. Connections between details not perceived. More severe physical symptoms. 4. Panic: Perceptual field closed; details out of proportion; logical thinking impaired. Defense mechanisms - Correct Answers Repression a. Unconscious forgetting b. Defense mechanisms in anxiety disorders 2. Suppression: Conscious forgetting 3. Denial a. Refusal to admit there is a problem b. Commonly seen in substance abuse 4. Displacement a. Feelings toward one person or situation are displaced onto something that is safer b. Example: Mad at the boss, yell at your spouse or children 5. Regression a. Behave in ways more appropriate for an earlier stage. b. Example: Six-year old hospitalized patient wets bed. 6. Rationalization a. Makes an excuse and does not admit the real reason b. Very common 7. Projection a. Mechanism of paranoia b. Puts own feelings on someone else 8. Ideas of reference a. Patient thinks everything is about them and it is bad. b. Common in persons with paranoia and Alzheimer's. 9. Reaction formation: Acting opposite underlying drives and desires 10. Transference: The patient transfers feelings they had for someone earlier in life onto the nurse. Childhood Autism - Correct Answers Characteristics 1. Bizarre behavior 2. No awareness of others 3. No awareness of feelings of others 4. Stereotyped body movements B. Interventions 1. Communication 2. Minimize holding 3. Structured activities losers because of aggressive behaviors C. Establish relationship- D. Short frequent contacts E. Clarify 1. Be specific- no double meanings 2. Use short phrases F. Hallucinations: present reality; I don't see these things G. Delusions 1. Do not attack 2. Express doubt H. Provide individually packaged or canned food- don't suggest family bring in food I. Illusions: explain stimuli; misinterpretation of reality Common Drugs - Correct Answers Thorazine, Haldol, Side effects of drugs 1. Sedation 2. Extrapyramidal- parkinson type symptoms 3. Anticholinergic- red, hot, dry, blind, mad 4. Hypotension- monitor blood pressure 5. Photosensitivity- sensitive to light 6. Agranulocytosis Response to Loss - Correct Answers Denial "not me" B. Anger "why me?" C. Bargaining " If only..., I will..." teaching (good time) D. Depression "Woe is me!" E. Acceptance "The situation exists and I will cope," Depression Characteristics - Correct Answers Sad mood 2. Diminished pleasure 3. Weight loss or gain- change in eating habits and therefore a change in weight 4. Insomnia or hypersomnia 5. Psychom*otor agitation or retardation 6. Fatigue 7. Feelings of worthlessness 8. Diminished ability to concentrate 9. Recurrent thoughts of death or suicide Depression Interventions - Correct Answers Major goal: increase self- esteem 2. Schedule activities of daily living ( structure activities for success) 3. Encourage appropriate amounts of sleep 4. Family or group therapy 5. Unconditional acceptance 6. Encourage expression of feelings Tricyclic side effects - Correct Answers Anticholinergic b. Cardiovascular c. Photosensitivity d. Two to four weeks to be effective- tricyclics; triweeks MonAmine Oxidase Inhibitors - Correct Answers Examples and dosage a. Isocarboxazid (Marplan) 10-30 mg b. Phenelzine (Nardil) 45-90 mg c. Tranylcypromine (Parnate) 20-30 mg 2. Combination drugs a. Parphenazine (Etrafon) 16-64 mg b. Amitriptyline (Triavil) 100-300 mg 3. Avoid foods containing tyramine hypertensive crisis a. Aged cheese b. Alcohol c. Fermented foods d. Chocolate e. Yeast f. Raisins g. Bananas 4. Side effects a. Anticholinergic severe b. Central nervous system- sedation c. Many drug interactions Electroconvulsive Therapy (ECT) - Correct Answers Treatment for severe depression B. Pre-procedure preparation 1. Permit 2. NPO after midnight C. Electric current applied to temples; induces grand mal seizure D. Anesthesia and muscle relaxants given E. Patient has no memory of treatment F. ECT safer than medication; more effective than drugs alone G. After procedure 1. Temporary confusion 2. Orient time and place, date and treatment H. Requires many treatments Suicide - Correct Answers Direct statements "I'm going to kill myself" 2. Indirect statements or hints 3. Gestures or half-hearted suicide attempts- lightly cut wrists, taking 5 pills 4. Giving away personal items 5. Major interest in rewriting will- extremely overwhelmed B. Suicide precautions 1. Keep patient under observation 2. Remove harmful objects a. Sharp objects and cutting implements b. Things that could be used for hanging: shoe laces, belts, bed sheets 3. Supervision during use of sharp objects Bipolar Disorder - Correct Answers Periods of elation alternating with periods of depression B. Manic: Periods of abnormally elevated mood that are persistent and interfere with functioning C. Assessment findings 1. Quick but superficial wit 2. Flight of ideas 3. Aggressive and argumentative 4. Irritable and hypercritical 5. Increased motor activity Bipolar Interventions - Correct Answers Set limits 2. Decrease stimuli 3. Basic needs such as finger foods 4. Pace speech 5. Redirect thoughts 6. Avoid arguing 7. Movement activities 8. Distract Lithium - Correct Answers Initially dose regulated by daily monitoring of blood levels 12 hours after last dose 3. Blood levels a. Therapeutic levels: 0.6-1.2 mEq/L b. Toxic levels: >1.5 mEq/L c. Lethal: >2.5 mEq/L 4. Toxicity 1. Gait disturbances 2. Gastrointestinal 3. Cardiac dysrhythmias 4. Cardiac arrest and death 5. Client education a. It takes 1-4 weeks for therapeutic level to be reached b. Take meds as directed c. Avoid driving until lithium dose stable d. Don't reduce sodium in diet e. Avoid: caffeine, thiazide diuretics, NSAIDs f. Get regular blood tests g. May gain weight h. Notify physician if signs of toxicity Phobia - Correct Answers Types 1. Simple phobia: fear of an object or situation 2. Agoraphobia: fear of open or public places 3. Claustrophobia: fear of enclosed or small places C. Defense mechanisms 1. Repression 2. Displacement D. Interventions 1. Gradual desensitization- step by step 2. Behavior modification- rewarding desired behavior 3. Relaxation techniques 4. Do not force confrontation with objects or situation causing phobia 5. Reasoning doesn't work 6. Administer anti-anxiety meds as ordered OCD - Correct Answers Obsession: Uncontrollable, recurring thoughts B. Compulsion: Ritualistic act done in an attempt to relieve the anxiety related to the thoughts or to make the thoughts go away. C. Interventions 1. Do not interrupt rituals but set limits 2. Set limits 3. Allow time to complete rituals 4. Distract 5. Desensitization 6. Physical protection from repetitive acts usually washing 7. Help client express feelings in appropriate ways 8. Individual and group therapy 9. Anafranil Antisocial Personality - Correct Answers Characteristics 1. Conflicts with society and its rules 2. Unreliable 3. Self-centered 4. Blames others 5. Normal to superior intelligence 6. Poor judgment and insight 7. Unsatisfactory social adjustment 8. Charming Homicidal 9. Difficulty maintaining lasting relationships B. Interventions 1. Set limits 2. Give positive feedback for acceptable behavior 3. Maintain staff communication Borderline Personality - Correct Answers Characteristics 1. Manipulates others 2. Impulsive 3. Suicidal 4. Poor self-image 5. Bored, trouble being alone 6. Mood swings 7. Anger expressed without control B. Interventions 1. Suicide assessment 2. Set limits 3. Give positive feedback for acceptable behavior 4. Confront inappropriate behavior 5. Encourage expression of feelings, not acting on feelings 6. Don't make decisions for client Characteristics of Abuser - Correct Answers Low self-esteem B. Substance abuser C. Projects D. Anxious E. Depressed F. Abused as a child G. Socially isolated H. Impulsive, immature I. Possessive Characteristics of Abused - Correct Answers Same as abuser B. Accepts responsibility for others C. Helpless D. Suicidal at times E. Submissive F. Frightened G. Guilt ridden Rape Interventions - Correct Answers Interventions 1. Provide privacy 2. Gather evidence if needed 3. During acute phase a. Establish priorities b. Stay with victim or arrange for someone to do so c. Allow client to wash after assessment and collection of evidence 4. During outward adjustment Conditions necessary for the development of a positive sense of self- esteem include: - Correct Answers consistent limits. In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which of the following roles is the client playing? - Correct Answers Aggressor The nurse is performing an assessment on a newly admitted client. She asks the client to remember three words: apple, house, and umbrella. Then she asks the client, "What are the three words I want you to remember?" What is the nurse assessing? - Correct Answers Immediate recall What is the nurse's most important role in caring for a client with a mental health disorder? - Correct Answers To establish trust and rapport On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with the client? - Correct Answers "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person's conscious awareness? - Correct Answers Repression The nurse enters the room of a client who is visibly shaken. The nurse states, "You seem upset." The client doesn't respond, so the nurse sits down with the client and remains silent. By using this therapeutic communication technique the nurse is exercising her knowledge that silence is: - Correct Answers a means of allowing the client space in which to respond and a way of communicating patience. (SELECT ALL THAT APPLY) The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage? - Correct Answers (1) The client addresses how the addiction has contributed to family distress., (4) The client discusses the financial problems related to the addiction., (6) The client acknowledges the addiction's effects on the children. A person loses an important advertising account and has a flat tire while driving home. That evening, the person begins to find fault with everyone. Which defense mechanism is the person using? - Correct Answers Displacement A women seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self conscious. She also has aches and pains. A nursing diagnosis for this client might include: - Correct Answers Situational low self-esteem. A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following? - Correct Answers False imprisonment When should the nurse introduce information about the end of the nurse- client relationship? - Correct Answers During the orientation phase Which nursing intervention is initially most important when restraining a violent client? - Correct Answers Ensuring that the restraints have been applied correctly Which of the following statements accurately describes therapeutic communication? - Correct Answers Avoiding judgment and false reassurance Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions? - Correct Answers Tachycardia, weight loss, and mood swings SELECT ALL THAT APPLY client suffering posttraumatic stress disorder is prescribed sertraline (Zoloft), 50 mg by mouth once daily. Which actions should the nurse take when administering this drug? - Correct Answers (2) Mix the oral concentrate with 4 oz (120 ml) of water, ginger ale, or lemon-lime soda., (3) Administer the oral solution immediately after dilution., (4) Instruct the client to check with the prescriber or pharmacist before taking over-the-counter preparations., (5) Advise the client to use caution when performing hazardous tasks that require alertness. The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's: - Correct Answers affect. The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to: - Correct Answers understand the nature of one's problem or situation. The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The primary purpose of these techniques is to help the child: - Correct Answers express feelings that he can't articulate. A nurse places a client in full leather restraints. How often must the nurse check the client's circulation? - Correct Answers Every 15 minutes In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The appropriate response by the nurse would be: - Correct Answers "Will you briefly summarize your point because others need time also?" What occurs during the working phase of the nurse-client relationship? - Correct Answers The nurse and client evaluate and modify the goals of the relationship. Common adverse effects of electroconvulsive therapy (ECT) include: - Correct Answers short-term memory loss. An agitated client demands to see her chart so she can read what has been written about her. Which statement is the nurse's best response to the client? - Correct Answers "You have the right to see your chart. Please discuss this with your primary care provider." A nurse is assessing a psychiatric client's ability to make sound judgments. Which assessment request best helps evaluate the client's judgment? - Correct Answers "What would you do if you smelled gas in your house?" television. He begins cursing and throwing furniture. The nurse's first action is to: - Correct Answers remove all other clients from the day room. Mental health laws in each state specify when restraints can be used and which type of restraints are allowed. Most laws stipulate that restraints can be used: - Correct Answers if the client poses a present danger to himself or others. Nursing care for a client after electroconvulsive therapy (ECT) should include: - Correct Answers assessment of short-term memory loss. The nurse is documenting a plan of care for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention? - Correct Answers Reorienting the client to time and place According to Freud's psychosexual theory, the ego has several functions. The primary function of the ego is to: - Correct Answers test reality and direct behavior. An elderly client is prescribed fluoxetine (Prozac), 40 mg by mouth twice per day, for treatment of depression. The client has difficulty swallowing, so the pharmacy dispenses the oral solution containing 20 mg/5 ml. How many milliliters of solution should the nurse administer to achieve the prescribed dose? - Correct Answers 10 A client is brought to the facility in an agitated state and is admitted to the psychiatric unit for observation and treatment. While putting personal items away, the client talks rapidly and folds and unfolds garments several times. The client can't seem to settle down. Which nursing diagnosis is most applicable at this time? - Correct Answers Anxiety The nurse's goal in crisis intervention is to provide: - Correct Answers problem-solving techniques and structured activities. A family member visiting on an acute care psychiatric unit approaches the nurse's station and reports that an elderly client is walking in the hall without her clothing. The nurse doesn't assist the client and suggests that the family member inform the nurse assigned to that client. Which term describes the nurse's action? - Correct Answers Negligent A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle? - Correct Answers Veracity A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique? - Correct Answers Reflecting Erikson described the psychosocial tasks of the developing person in his theoretical model. He proposed that the primary developmental task of the young adult (ages 18 to 25) is: - Correct Answers intimacy versus isolation. A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique? - Correct Answers Focusing The nurse is caring for a client who continually has paranoid thoughts. How should the nurse interact with this client? - Correct Answers Approach him in a nonthreatening way. Which goal is most important for a nurse to concentrate on when leading a group session using a therapeutic milieu? - Correct Answers Focusing on the here and now A 22-year-old male client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which of the following responses would be best? - Correct Answers "Clients are permitted to smoke at designated times. You'll have to follow the rules." Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of: - Correct Answers abuse and neglect. The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should: - Correct Answers encourage verbalizations about fears and stressful life situations. An 8-year-old girl and her 5-year-old sister tell the school nurse that their mother frequently yells and spits in their faces when she is mad at them. The nurse hesitates to intervene because she knows the family personally. Which action by the nurse is appropriate? - Correct Answers Report the information to child protective services. A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. This client is demonstrating which behavior? - Correct Answers Splitting The nurse collecting data on a client asks the client the meaning of the proverb "People in glass houses shouldn't throw stones." What is the nurse assessing by asking this question? - Correct Answers Concept formation Which of the following indications is the appropriate use for electroconvulsive therapy (ECT)? - Correct Answers Major depression with psychotic features The goal of crisis intervention is: - Correct Answers psychological resolution of the immediate crisis. A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique? - Correct Answers Exploring A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be appropriate? - Correct Answers "What were you feeling before you hurt yourself?" A client is transferred to the locked psychiatric unit from the emergency department after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. Now the client is awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to: - Correct Answers ensure safety by initiating suicide precautions. The charge nurse in an acute care setting assigns a client, who is on one- to-one suicide precautions, to a psychiatric aide. This assignment is o One to one relationship between the patient and the nurse is a major focus o The goal is for the client to eliminate negative behaviors - Correct Answers Punishments are used to eliminate negative behaviors The nurse considers a client's response to crisis intervention successful if the client is at a minimum: o Returns to his previous level of functioning o Learns to relate better to others o Develops insight into the reasons why the crisis occurred. - Correct Answers Returns to his previous level of functioning When planning group therapy, which configuration should a nurse identify as most optimal for a therapeutic group? o Circle of chairs, 5-10 people o Members choose chair placement o Chairs around a table, 5-10 people - Correct Answers Circle of chairs, 5-10 people A man diagnosed with alcohol dependence experiences his first relapse. During his AA meeting, another group member states, I relapsed three times, but now have been sober for 15 years. Which of Yalom's curative group factors does this illustrate? o Instillation of hope o Catharisis o Universality - Correct Answers instillation of hope What should be the priority nursing dx for a client experiencing alcohol withdrawal? o Disturbed thought process r/t tactile hallucinations o Ineffective denial e/t continued alcohol despite negative consequence o Risk for injury r/t CNS stimulation - Correct Answers Risk for injury r/t CNS stimulation From which of the following symptoms might the nurse identify a chronic cocaine user? -Clear, constricted pupils -Red, irritated nostrils -Muscle aches -Conjunctival redness - Correct Answers Red, irritated nostrils A patient with physical dependence of opiates is likely to experience which symptoms of withdrawal? o Nausea, vomiting, diarrhea, and piloerection o Tremors, hallucinations, seizures o Incoordination and unsteady gait - Correct Answers Nausea, vomiting, diarrhea, and piloerection Bupropion -action on neurotransmitter/receptor -physiological effect -side effect - Correct Answers -inhibits reuptake of NE and dopamine -reduces depression, aid in smoking cessation, decrease in symptoms of ADHD -insomnia, dry mouth, tremor, seizures Aaron, age 27, was brought to the E.D by police. he smelled strongly of alcohol and was combative. His B.A.C was measured 293 mg/dL. His girlfriend reports that he drinks excessively every day and is verbally and physically abusive. The nurses give John the nursing dx of Risk for other- directed violence. What would be appropriate outcome objectives for this diagnosis? Select all that apply. -client will not verbalize anger or hit anyone -will verbalize anger rather than hit others -client will not harm self or others -client will be restrained if becomes verbally/physically abusive - Correct Answers -will verbalize anger rather than hit others -client will not harm self or others A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini mental status exam? -rule out bipolar disorder -rule out schizophrenia -rule out senile dementia -rule out personality disorder - Correct Answers rule out senile dementia Ms. T has been diagnosed with agoraphobia. Which behavior would be most characteristic of this disorder? - Correct Answers She stays in her home for fear of being in a place from which she cannot escape. Which of therapy is the most appropriate for a client with agoraphobia? - Correct Answers Facing his or her fear in gradual step regression. With implosion therapy, a client with phobic anxiety would be: - Correct Answers Presented with massive exposure to a variety of stimuli associated with the phobic object/situation. A client with OCD spends many hours each day washing his hands. The most likely reason he washes his hands so much is that: - Correct Answers It relieves his anxiety. The initial care plan for a client with OCD who washes her hands obsessively would include which nursing intervention? - Correct Answers Sets limitations on the amount of time the client may engage in the ritualistic behavior. John, a veteran of the war in Iraq, is diagnosed with PTSD. he says to the nurse, "I can't figure out why God took my buddy instead of me." From this statement, the nurse assesses that John suffers from: - Correct Answers Survivor's guilt. John, a veteran of the war in Iraq, is diagnosed with PTSD. He experiences a nightmare during his first night in the hospital. He explains to the nurse that he was dreaming about gunfire all around and people being killed. The nurse's most appropriate initial intervention is to: - Correct Answers Stay with John and reassure him of his safety. John, a veteran of the war in Iraq, is diagnosed with PTSD. Which therapy regimen is most appropriate for John? - Correct Answers Paroxetine and group therapy. What may be influential in the predisposition to PTSD? - Correct Answers Severity of the stressor and availability of support systems. Three years ago, Anna's dog Lucky, whom she had for 16 years, was run over by a car and killed. Anna's daughter reports that since that time, Anna -Trust vs. Mistrust -Autonomy vs. Shame and Doubt - Correct Answers Trust vs. Mistrust Janet, a psychiatric client diagnosed with Borderline Personality Disorder, has just been hospitalized for threatening suicide. According to Mahler's theory, Janet did not receive the critical "emotional refueling" required during the rapprochement phase of development. That are the consequences of this deficiency? -she has not yet learned to delay gratification -she does not feel guilt about wrong doings to others -she is unable to trust others -she has internalized rage and fears of abandonment - Correct Answers She has internalized rage and fears of abandonment John is on the alcohol treatment unit. He walks into the dayroom where other clients are watching a program on TV. He picks up the remote and changes the channel and says, "That's a stupid program! I want to watch something else!" In what stage of development is John fixed according to Sullivan's interpersonal theory? -Juvenile because he is learning to form satisfactory peer relationships. -Childhood because he has not learned to delay gratification. -Early adolescence because he is struggling to form an identity. -Late adolescence because he is working to develop a lasting relationship. - Correct Answers Childhood because he has not learned to delay gratification. Which of the following are considered to be the chemical messengers of the brain? - Neurotransmitters -Dendrites -Axons -Synapses - Correct Answers Neurotransmitters All of the following are competing biological theories of depression except: -Dysregulation of limbic system, -Imbalance of neurotransmitters such as serotonin, dopamine, and norepinephrine -Thyroid dysfunction -Excessive amount of inhibitory amino acids such as GABA. - Correct Answers Excessive amount of inhibitory amino acids such as GABA Most anti-depressants work by blocking ___________ of certain neurotransmitters, like serotonin, after they are released into the synaptic cleft: -Reuptake -Regeneration -Recycling -Retransmission - Correct Answers Reuptake A decrease in acetylcholine may play a significant role in which of the following illnesses? - Alzheimer's disease - Schizophrenia -Anxiety Disorder -Depression - Correct Answers Alzheimer's disease A decrease in norepinephrine may pay a significant role in: o Bipolar disorder o Schizophrenia o Alzheimer's o Depression - Correct Answers Depression An increase in dopamine activity may play a significant role in which of the following illness? o Schizophrenia o Anxiety disorders o Depression o Alzheimer's - Correct Answers Schizophrenia The nurse-client therapeutic relationship includes all of the following characteristics except: -Meeting the social needs of both the nurse and the client -Ensuring therapeutic termination -Promoting client insight into problematic behavior -Collaboration on a set of goals - Correct Answers Meeting the social needs of both the nurse and the client The most essential task for a nurse to conduct before forming a therapeutic relationship with a client is: o Clarifying one's attitudes, values, and beliefs o Ensuring therapeutic termination o Promoting client insight - Correct Answers Clarifying one's attitudes, values, and beliefs The phase of the nurse patient relationship that may be the most difficult for the patient because of anxieties may reappear and feelings of past losses are triggered is the: o Working phase o Preinteraction o Orientation o Termination - Correct Answers Termination Resistance, although potentially present in all stages, is most often found in the following phase: o Preinteraction o Working o Orientation o Termination - Correct Answers Working The client is very hostile toward one of the staff for no apparent reason. The client is probably manifesting: o Transference o Splitting o Countertransference o Resistance - Correct Answers Transference When there is congruence between what the nurse is feeling and what is being expressed the nurse is conveying: o Genuineness o Respect o Sympathy o Rapport - Correct Answers Genuineness Which therapeutic communication technique is being used in the following example? Patient: "Every time I get angry, I wind up getting into a fistfight with my wife or I take it out on the kids."