Exam 2 Flashcards
(189 cards)
1
Q
a syndrome caused by brain disease, evidenced by chronic personality disintegration, confusion, memory impairment, and deteriration of intellectual capacity and function
A
dementia
2
Q
a chronic, progressive, degenerative disease of the brain
A
Alzheimer’s disease (AD)
3
Q
a rare and fatal brain disorder caused by a prion protein
A
Creutzfeldt-Jakob disease
4
Q
a mental state characterized by a disturbance of cognition, which is manifested by confusion, excitement, disorientation, and a clouding of consciousness/ hallucinations and illusions are common
A
delirium
5
Q
a condition characterized by the presence of Lewy bodies (abnormal deposits of the protein a-synuclein) in the brainstem and cortex- this disease has features of both AD and Parkinson’s
A
dementia with Lewy bodies
6
Q
familial Alzheimer’s disease
A
individuals with a clear pattern of inheritance within a family for developing Alzheimer’s
7
Q
a rare disorder caused by shrinking frontal and temporal lobes of the brain; characterized by disturbances in behavior, sleep, personality, and eventually memory
A
frontotemporal lobar degeneration (FTLD)
8
Q
mild cognitive impairment (MCI)
A
a stage of cognition and funcitional ability between normal aging and early Alzheimer’s disease
9
Q
mixed dementia
A
presentation of two or more types of dementia simultaneously
10
Q
neurofibrillary tangles
A
tangled bundles of fibers seen in the cytoplasm of abnormal neurons in those areas of the brain most affected by Alzheimer’s disease
11
Q
normal pressure hydrocephalus
A
an uncommon disorder characterized by an obstruction in the flow of cerebrospinal fluid; causes a buildup of this fluid in the brain
12
Q
retrogenesis
A
the process in AD patients in which degenerative changes occur in the reverse order in which they were acquired
13
Q
sundowning
A
a condition in which the individual becomes more confused and agitated in the late afternoon or evening
14
Q
vascular dementia
A
the loss of cognitive function resulting from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease
15
Q
prion
A
small infectious pathogen containing protein but lacking nucleic acids
16
Q
Dementia is defines as a
a. syndrome that resuts only in memory loss
b. disease associated with abrupt changes in behavior
c. disease that is always due to reduced blood flow to the brain
d. syndrome characterized by cognitive dysfunction and loss of memory
A
D. syndrome characterized by cognitive dysfunction and loss of memory
17
Q
Vascular dementia is associated with
a. transient ischemic attacks
b. bacterial or viral infection of neuronal tissue
c. cognitive changes secondary to cerebral ischemia
d. abrupt changes in cognitive function that are irreversible
A
C. cognitive changes secondary to cerebral ischemia
18
Q
The clinical diagnosis of dementia is based on
a. CT or MRS
b. brain biopsy
c. electroencephalogram
d. patient history and cognitive assessment
A
D. patient history and cognitive assessment
19
Q
Which statement(s) accurately describe(s) mild cognitive impairment?
a. always progresses to AD
b. caused by variety of factors and may progress to AD
c. should be aggressively treated with acetylcholinesterase drugs
d. caused by vascular infarcts that, if treated, will delay progression to AD
e. patient is usually not aware that there is a problem with his or her memory
A
B. caused by variety of factors and may progress to AD
20
Q
The early stage of AD is characterized by
a. no noticeable change in behavior
b. memory problems and mild confusion
c. increased time spent sleeping or in bed
d. incontinence, agitation, and wandering behavior
A
B. memory problems and mild confusion
21
Q
A major goal of treatment for the patient with AD is to
a. maintain patient safety
b. maintain or increase body weight
c. return to a higher level of self care
d. enhance functional ability over time
A
A. maitain patient safety
22
Q
Creutzfeldt-Jakob disease is characterized by
a. remissions and exacerbations over many years
b. memory impairment, muscle jerks, and blindness
c. parkinsonian symptoms, including muscle rigidity and tremors at rest
d. increased intracranial pressure secondary to decreased CSF drainage
A
B. memory impairment, muscle jerks, and blindness
23
Q
Which patient is most at risk for developing delirium?
a. a 50 year old woman with cholecystitis
b. a 19 year old man with a fractured femur
c. a 42 year old woman having an elective hysterectomy
d. a 78 year old man admitted to the medical unit with complications related to heart failure
A
D. a 78 year old man admitte to the medical unit with complications related to heart failure
24
Q
amnesia
A
an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness- the condition may be temporary or permanent, depending on etiology
25
aphasia
inability to communicate through speech, writing, or signs, caused by dysfunction of brain centers
26
apraxia
inability to carry out motor activities despite intact motor function
27
ataxia
muscular incoordination
28
confabulation
creating imaginary events to fill in memory gaps
29
primary dementia
dementia, such as AD, in which the dementia itself is the major sign of some organic brain disease not directly related to any other organic illness
30
pseudodementia
symptoms of depression that mimic those of dementia
31
secondary dementia
dementia that is caused by or related to another disease or condition, such as HIV disease or a cerebral trauma
32
An example of a treatable (reversible) form of dementia is one that is caused by which of the following?
a. multiple sclerosis
b. multiple small brain infarcts
c. electrolyte imbalances
d. HIV disease
e. Folate deficiency
C. electrolyte imbalances
| E. folate deficiency
33
Mrs. G has been diagnosed with dementia of the AD type. The cause of this disorder is which of the following?
a. multiple small brain infarcts
b. chronic alcohol abuses
c. cerebral abscess
d. unknown
D. unknown
34
Mrs. G has been diagnosed with dementia of the AD type. The primary nursing intervention in working with Mrs. G is which of the following?
a. ensuring that she receives food she likes, to prevent hunger
b. ensuring that the environment is safe, to prevent injury
c. ensuring that she meets the other patients, to prevent social isolation
d. ensuring that she takes care of her own ADLs, to prevent dependence
B. ensuring that the environment is safe, to prevent injury
35
Which of the following medications have been indicated for improvement in cognitive functioning in mild to moderate AD?
a. Donepezil (Aricept)
b. Rivastigmine (Exelon)
c. Risperidone (Risperdal)
d. Sertaline (Zoloft)
e. Tacrine (Cognex)
A. Donepezil, B. Rivastigmine, E. Tacrine
36
Mrs. G, who has AD, says to the nurse, "I have a date tonight. I always have a date on Christmas." Which of the following is the most appropriate response?
a. Don't be silly. It's not Christmas, Mrs. G
b. Today is Tuesday, October 21st, Mrs. G We will have supper soon, and then your daughter will come to visit.
c. Who is your date with Mrs. G?
d. I think you need some more medication, Mrs. G I'll bring it to you.
B. Today is Tuesday, Oct 21st, Mrs G. We will have supper soon, and then your daughter will come to visit.
37
In addition to disturbances in cognition and orientation, individuals with AD may also show changes in which of the following?
a. personality
b. vision
c. speech
d. hearing
e. mobiity
A. personality, C. speech, E. mobility
38
Mrs. G, who has AD, has trouble sleeping and wanders around at night. Which of the following nursing actions would be best to promote sleep in Mrs. G?
a. ask the doctor to prescribe flurazepam (Dalmane)
b. ensure that Mrs. G gets an afternoon nap so she will not be overtired at bedtime
c. make Mrs. G a cup of tea with honey before bedtime
d. ensure that Mrs. G gets regular physical exercise during the day
D. ensure that Mrs. G gets regular physical exercise during the day
39
The night nurse finds Mrs. G (client with AD) wandering the hallway at 4am & trying to open the door to the side yard. Which statement by the nurse probably reflects the most accurate assessment of the situation?
a. That door leads out to the patio, Mrs G. It's nightime. You don't want to go outside right now.
b. You look confused, Mrs. G. What's bothering you.
c. This is the patio door. Are you looking for the bathroom?
d. Are you lonely? Perhaps you'd like to go back to your room and talk for a while.
C. This is the patio door. Are you looking for the bathroom?
40
A client says to the nurse, "I read an article about AD and it said the disease is hereditary. My mother has AD. Does that mean I'll get it when I'm old? The nurse bases her response on the knowledge that which of the following factors is not associated with increased incidence of dementia of the AD type?
a. multiple small strokes
b. family history of AD
c. head trauma
d. advanced age
A. multiple small strokes
41
Mr. Stone is a client in the hospital with a diagnosis of Vascular Dementia. In explaining this disorder to Mr. Stone's family, which of the following statements by the nurse is correct?
a. He will probably live longer than if his dementia was of the AD type.
b. Vascular dementia shows stepwise progression. This is why he sometimes seems okay.
c. Vascular dementia is caused by placques and tangles that form in the brain.
d. The cause of vascular dementia is unknown.
C. vascular dementia is caused by placques and tangles that form in the brain
42
Which of the following interventions is most appropriate in helping a client with AD with her ADLs?
a. perform ADLs for her while she is in the hospital
b. provide her with a written list of activities she is expected to perform
c. assist her with step by step instructions
d. tell her that, if her morning care is not complete by 9am, it will be performed for her by the nurse's aide so that she can attend group therapy
e. encourage her and give her plenty of time to perform as many of her ADLs as possible independently
C. assist her with step by step instructions
| E. encourage her and give her plenty of time to perform as many of her ADLs as possible independently
43
assault
act that results in a person's genuine fear and apprehension that he or she will be touched without consent. Nurses may be guilty of assault for threatening to place an individual in restraints against her/his will
44
autonomy
independence; self-governance, an ethical principle that emphasizes the status of persons as autonomous moral agents whose right to determine their destinies should always be respected
45
battery
the unconsented touching of another person. nurses may be charged with battery should they participate in the treatment of a client without his/her consent and outside of an emergency
46
an ethical principle that refers to one's duty to benefit or promote the good of others
beneficence
47
the term used with ethical principles that refer to concepts within the scope of medicine, nursing, and allied health
bioethics
48
the ethical philosophy that states one should treat others as moral equals, and recognize the equality of other persons by permitting them to act as we do when they occupy a position similar to ours; sometimes referred to as "the ethic of the golden rule"
Chrisitan ethics
49
law that protects the private and property rights of individuals and businesses
civil law
50
laws that are derived from decisions made in previous cases
common law
51
law that provides protection from conduct deemed injurious to the public welfare/ it provides for punishment of those found to have engaged in such contact
criminal law
52
an individual may be liable for defamation of character by sharing with others information about a person that is detrimental to that person's reputation
defamation of character
53
a branch of philosophy dealing with values related to human conduct, to the rightness and wrongness of certain actions, and to the goodness and badness of the motives and ends of such actions
ethics
54
a situation that arises when, on the basis of moral considerations, an appeal can be made for taking each of two opposing courses of action
ethical dilemma
55
an ethical theory espousing that what is "right" and "good" is what is best for the individual making the decision
ethical egoism
56
the deliberate and unauthorized confinement of a person within fixed limits by the use of threat or force
false imprisonment
57
permission granted to a physician by a client to perform therapeutic procedure
informed consent
58
an ethical principle reflecting that all individuals should be treated equally and fairly
justice
59
the ethical principle espousing that decisions should be made and actions taken out of a sense of duty
Kantianism
60
an action with which an individual may be charged for sharing with another individual, in writing, information that is detrimental to someone's reputation
Libel
61
the failure of one rendering professional services to exercise that degree of skill and learning commonly applied under all the circumstances in the community by the average prudent reputable member of the profession, with the result of injury, loss, or damage to the recipient of those services or to those entitled to rely upon them
malpractice
62
conduct that results from serious critical thinking about how individuals ought to treat others; reflects respect for human life, freedom, justice, or confidentiality
moral behavior
63
the failure to do something that a reasonable person, guided by those considerations that ordinarily regulate human affairs, would do, or doing something that a prudent and reasonable person would not not
negligence
64
the ethical principle that espouses abstaining from negative acts toward another, including acting carefully to avoid harm
nonmaleficence
65
a doctrine common to most states that grants certain privileges under which health-care professionals may refuse to reveal information about and communications with clients
privileged communication
66
an action with which an individual may be charged for orally sharing information that is detrimental to a person's reputation
slander
67
a law that has been enacted by legislative bodies, such as a country or city council, state legislature, or the US Congress
statutory law
68
the violation of a civil law in which an individual has been wronged
tort
69
the ethical theory that espouses "the greatest happiness for the greatest number" under this theory, action would be taken based on the end results that will produce the most good for the most people
ultilitarianism
70
personal beliefs about the truth, beauty, or worth of a thought, object, or behavior, that influence an individual's actions
values
71
a process of self-discovery by which people identify their personal values and their value rankings.
value clarification
72
an ethical principle that refers to one's duty to always be truthful
veracity
73
Nurse Jones decides to go against family wishes and tell the client of his terminal status because that is what she would want if she were the client. Which of the following ethical theories is considered in this decision?
a. Kantianism
b. Christian ethics
c. Natural law theories
d. Ethical egoism
B. Christian ethics
74
Nurse Jones decides to respect family wishes and not tell the client of his terminal status because that would bring the most happiness to the most people. Which of the following ethical theories is considered in this decision?
a. Utilitarianism
b. Kantianism
c. Christian ethics
d. Ethical egoism
A. Utilitarianism
75
Nurse Jones decides to tell the client of his terminal status because she believes it is her duty to do so. Which of the following ethical theories is considered in this decision?
a. Natural law theories
b. Ethical egoism
c. Kantianism
d. Utilitarianism
C. Kantianism
76
The nurse assists the physician with electroconvulsive therapy on his client who has refused to give consent. With which of the following legal actions might the nurse be charged because of this nursing action?
a. assault
b. battery
c. false imprisonment
d. breach of confidentiality
B. battery
77
A competent, voluntary client has stated he wants to leave the hospital. The nurse hides his clothes in an effort to keep him from leaving. Which of the following legal actions might the nurse be charged with?
a. assault
b. battery
c. false imprisonment
d. breach of confidentiality
C. false imprisonment
78
Joe is very restless and is pacing alot. The nurse says to Joe,"If you don't sit down in the chair and be still, I'm going to put you in restraints!" Which legal action might the nurse be charged with?
a. defamation of character
b. battery
c. breach of confidentiality
d. assault
D. assault
79
An individual may be considered gravely disabled for which of the following reasons?
a. a person, because of mental illness, cannot fufill basic needs
b. a mentally ill person is in danger of physical harm based on inability to care for self
c. a mentally ill person lacks the resources to provide the necessities of life
d. a mentally ill person is unable to make use of available resources to meet daily living requirements
A, B, D
80
Which of the following statements is(are) correct regarding the use of restraints?
a. restraints may never be initiated w/o physician's order
b. orders for restraints must be reissued by a physician every 2 hours for children and adolescents
c. clients in restraints must be observed and assessed every hour for issues regarding circulation, nutrition, respiration, hydration & elimination
d. an in-person evaluation must be conducted within 1 hour of initiating restraints
B & D
81
Guidelines relating to "duty to warn" state that a therapist should consider taking action to warn a third party when his or her client:
a. threatens violence toward another individual
b. identifies a specific intended victim
c. is having command hallucinations
d. reveals paranoid delusions about another individual
A. threatens violence toward another individual
| B. identifies a specific intended victim
82
Attempting to calm an angry client by using talk therapy is an example of which of the following clients' rights?
a. right to privacy
b. right to refuse medication
c. right to the least-restrictive treatment alternative
d. right to confidentiality
C. right to the least restrictive treatment alternative
83
a particular society's entire way of living, encompassing shared patterns of belief, feeling, and knowledge that guide people's conduct and are passed down from generation to generation
culture
84
a female folk hero in the Latino culture
curandera
85
a male folk hero in the Latino culture. C cachexia. A state of ill health, malnutrition, and wasting; extreme emaciation
curandero
86
the number of people in a given environmental space, influencing interpersonal interaction
density
87
the concept of people indentifying with each other because of a shared heritage
ethnicity
88
a system of health care within various cultures that is provided by a local practioner, not professionally trained, but who uses techniques specific to that culture in the art of healing
folk medicine
89
a set of beliefs, values, rites, and rituals adopted by a group of people. the practices are usually grounded in the teachings of spiritual leader
religion
90
the Native American medicine man or folk healer
shaman
91
the human quality that gives meaning and sense of purpose to an individual's existence.
spirituality
92
the process of classifying all individuals from the same culture of ethnic group as identical
stereotyping
93
the innate tendency of individuals to own space. individuals lay claim to areas around them as their own.
territoriality
94
concept of Asian health practices/ opposite forces of energy such as negative/positive, dark/light, cold/hot
yin and yang
95
Miss Lee is and Asian American on the psychiatric unit. She tells the nurse "I must have the hot ginger root for my headache. It is the only thing that it will help." What meaning does the nurse attach to this statement?
a. she is being obstinate and wants control over her care
b. she believes that ginger root has magical qualities
c. she subscribes to the restoration of health through the balance of yin and yang
d. Asian Americans refuse to take traditional medicine for pain
C. She subscribes to the restoration of health through the balance of yin and yang
96
Miss Lee, an Asian American on the psych unit, says she is afraid that no one from her family will visit her. On what belief does Miss Lee base her statement?
a. many Asian Americans do not believe in hospitals
b. many Asian Americans do not have close family support systems
c. many Asian Americans believe the body will heal itself if left alone
d. many Asian Americans view psychiatric problems as bringing shame to family
D. many Asian Americans view psychiatric problems as bringing shame to the family
97
Joe, A Native American. appears at the community health clinic with an oozing stasis ulcer on his lower right leg. It is obviously infected, he tells the nurse that the shaman has been treating it with herbs. The nurse determines that Joe needs emergency care, but Joe states he will not go to the emergency department unless the shaman is allowed to help treat him. How should the nurse handle this situation? A. Contact the shaman and have him meet Them at the ED to consult with the attending physician B. Tell Joe the shaman is not allowed in the ED C. Explain to Joe that the shaman is at fault for his leg being in the condition it is and now the D. have the shaman try to Joe into going to the ED without him
A. Contact the shaman and have him meet them at the ED to consult with the attending physician
98
Joe, a Native American goes to the emergency department because he has an oozing stasis ulcer on his leg. He is accompanied by his tribal Shaman, who has been treating Joe on the reservation. As a greeting, the physician extends his hand to the Shaman, who lightly touches the physician's hand, then quickly moves away. How should the physician interpret this gesture? A. The shaman is snubbing the physician B. The shaman is angry at Joe for wanting to go to the ED C. The shaman does not believe in traditional medicine D. The shaman does not feel comfortable with touch
D. The shaman does not feel comfortable with touch
99
Sarah is an African-American woman who received a visit from the psychiatric home health nurse. A referral for a mental health assessment was made by the public health nurse, who noticed that Sarah was becoming exceedingly with withdrawn. When the psychiatric nurse arrives, Sarah says to her," no one can help me. I was an evil person in my youth, and now I must pay." How might the nurse assess this statement? A. Sarah is having delusions of persecution B. Some African-Americans believe illness is God's punishment for their sins C. Sarah is depressed and just wants to be left alone D. African-Americans do not believe in psychiatric help
B. Some African Americans believe illness is God's punishment for their sins
100
Sarah is an African-American woman who lives in the rural south. She receives a visit from the public health nurse. Sarah says to the nurse, granny told me to eat a lot of poke greens and I would feel better. How should the nurse interpret this statement? A. Sarah's grandmother believes in the healing power of Polk greens B. Sarah believes everything her grandmother tells her C. Sarah has been receiving healthcare from a folk practitioner D. Sarah is trying to determine if the nurse agrees with her grandmother
C. Sarah has been receiving health care from a folk practitioner
101
Frank is a Latino American who has an appointment at the community health center for 1 PM. The nurse is angry when Frank shows up at 3:30 PM stating, I was visiting with my brother. How must the nurse interpret this behavior? A. Frank is being passive aggressive by showing up late B. This is Frank's way of defying authority C. Frank is a member of a cultural group that is present time oriented D. Frank is a member of a cultural group that rejects traditional medicine
C. Frank is a member of a cultural group that is present time oriented
102
The nurse must give Frank, a Latino American, a physical examination. She tells him to remove his clothing and put on an examination down. Frank refuses. How should the nurse interpret this behavior? A. Frank does not believe in taking orders from a woman B. Frank is modest and embarrassed to remove his clothes C. Frank doesn't understand why he must remove his clothes D. Frank does not think he needs a physical examination
B. Frank is modest and embarrassed to remove his clothes
103
Maria is an Italian American who is in the hospital after having suffered a miscarriage at five months gestation. Her room is filled with relatives who have brought a variety of foods and gifts for Maria. They are all talking, seemingly at the same time, and some, including Maria are crying. They repeatedly touch and hug Maria and each other how should the nurse handle this situation? A. Explain to the family that Maria needs her rest and they must all leave B. Allow the family to remain and continue their activity as described, as long as they do not disturb other clients C. Explain that Maria will not get over her loss if they keep bringing up and causing her to cry so much D. Call the family priest to come and take charge of this family situation
B. Allow the family to remain and continue their activity as described, as long as they do not disturb other clients
104
Maria is an Italian American who is in the hospital after having suffered a miscarriage at five months gestation. Maria's mother says to the nurse, if only Maria had told me she wanted the biscotti. I would've made them for her. What is the meaning behind Maria's mother's statement? A. Some Italian-Americans believe miscarriage can occur if a woman does not eat the food she craves B. Some Italian-Americans think biscotti can prevent miscarriage C. Maria's mother is taking the blame for Maria's miscarriage D. Maria's mother believes the physician should've told Maria to eat biscotti
A. Some Italian Americans believe a miscarriage can occur of a woman does not eat a food she craves
105
Joe, who has come to the mental health clinic with symptoms of depression, says to the nurse, my father is dying. I have always hated my father. He physically abused me when I was a child. We haven't spoken for many years. He wants to see me now, but I don't know if I want to see him. With which spiritual need is Joe struggling? A. forgiveness B. faith C. Hope D. Meaning and purpose in life
A. Forgiveness
106
As a child, Joe was physically abused by his father. The father is now dying and has expressed a desire to see his son before he dies. Joe is depressed and says to the mental health nurse, I'm so angry! Why did God have to give me a father like this? I feel cheated out of a father! I have always been a good person. I deserved better. I hate God! From this objective data, which nursing diagnosis might the nurse apply to Joe? A. readiness for enhanced religiosity B. risk for impaired religiosity C. readiness for enhanced spiritual well-being D. deep spiritual distress
D. Spiritual distress
107
an interaction between two people (usually a caregiver and a care receiver( in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention
therapeutic relationship
108
a frame of reference around which an individual organizes knowledge about his/her world. It includes an emotional element and can have a positive or negative connotation.
attitude
109
an idea that one holds to be true.
belief
110
Thought processes that are focused on specifics rather than on generalities and immediate issues rather than eventual outcomes.
concrete thinking
111
The rightof an individual to the assurance that his/her case will not be discussed outside the boundaries of the health-care team.
confidentiality
112
The ability to be open, honest and real in interactions with others
genuineness
113
the development between two people in a relationship of special feelings based on mutual acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude
rapport
114
The actual sharing of another's thoughts and behaviors.
sympathy
115
Carl Rogers' term for the respect and dignity of an individual regardless of his/her unacceptable behavior.
unconditional positive regard
116
The ability to see beyond outward behavior, and sense accurately another's inner experiencing. One can accurately perceive and understand the meaning and relevance in the thoughts and feelings of another.
empathy
117
Nurse Mary has been providing care for Tom during his hospital stay. On Tom's discharge day, his wife brings a bouquet of flowers and box of chocolates to his room. He presents these gifts to Nurse Mary saying "thank you for taking care of me". What is the correct response by the nurse?
a. I don't accept gifts from patients
b. Thank you so much! It's so nice to be appreciated.
c. Thank you, I will share these with the rest of the staff
d. hospital policy forbids me to accept gifts from patients
C. Thank you, I will share these with the rest of the staff
118
Nancy says to the nurse, "I worked as a secretary to put my husband through colleg, and as soon as he graduated, he left me. I hate him! I hate all men! Which is an empathetic response by the nurse?
a. You are very angry now. This is a normal response to your loss
b. I know what you mean. Men can be very insensitive
c. I understand completely. My husband divorced me too
d. You are depressed now, but you will feel better in time.
A. You are very angry now. This is a normal response to your loss.
119
Which of the following behaviors suggest a possible breach of professional boundaries?
a. The nurse repeatedly requests to be assigned to a specific client
b. The nurse shares the details of her divorce with the client
c. The nurse makes arrangements to meet the client outside of the therapeutic environment
d. The nurse shares how she dealt with a similar difficult situation.
A B C
120
Which of the following tasks are associated with the orientation phase of relationship development?
a. promoting the client's insight and perception of reality
b. creating an environment for the establishment of trust and rapport
c. using the problem solving model toward goal fulfillment
d. obtaining available information about the client from various sources
e. formulating nursing diagnoses and setting goals
B. creating an environment for the establishment of trust and rapport
E. formulating nursing diagnoses and setting goals
121
Nurse Carol, who is an adult COA, is working with John, a client who abuses alcohol. John has experienced a successful detoxificiation process and is beginning a program of rehab. He says, "I'm not going to those stupid AA meetings. They don't help." Carol whose father died of complications of alcoholism, responds with anger. "Don't you even care about what happens to your children?" Carol's response is an example of....
a. transference
b. countertransference
c. self disclosure
d. a breach of professional boundaries
B. countertransference
122
Nurse Jones is working with Kim, a client in the anger-management program. Which of the following identifies actions associated with the working phase of the therapeutic relationship?
a. Kim tells Nurse Jones she wants to learn more adaptive ways to handle her anger. Together, they set some goals
b. The goals of therapy have been met, but Kim cries and says she has to keep coming to therapy in order to be able to handle her anger appropriately
c. Nurse Jones reads Kim's previous medical records. She explores her feelings about working with a woman who has abused her child.
d. Nurse Jones helps Kim practice various techniques to control her angry outbursts. She gives Kim positive feedback for attempting to improve maladaptive behaviors.
D. Nurse Jones helps Kim practice various techniques to control her angry outbursts. She gives Kim positive feedback for attempting to improve maladaptive behaviors.
123
When there is congruence between what is felt and what is being expressed, the nurse is exhibiting which of the following characteristics?
a. trust
b. respect
c. genuineness
d. empathy
C. genuineness
124
When the nurse shows unconditional acceptance of an individual as a worthwhile and unique human being, he or she is exhibiting which of the following characteristics?
a. trust
b. respect
c. genuineness
d. empathy
B. respect
125
Peplau identified six subroles within the role of nurse. She believed the emphasis in psychiatric nursing was on which of the subroles?
a. the resource person
b. the teacher
c. the surrogate
d. the counselor
D. the counselor
126
Which of the following behaviors are associated with the phenomenon of transference?
a. the client attributes toward the nurse feelings associated with a person from the client's past
b. the nurse attributes toward the client feelings associated with a person from the nurse's past
c. the client forms an overwhelming affection for the nurse
d. the client becomes excessively dependent on the nurse and forms unrealistic expectations of him/her
A C D
127
an interactive process of transmitting information between to or more entities
communication
128
verbal and nonverbal techniques that encourage exploration of fellings and fosters understanding of behavioral motivation
therapeutic communication
129
the number of people in a given environmental space, influencing interpersonal interaction
density
130
the closest distance that individuals will allow between themselves and others
intimate distance
131
the gestural component of the spoken word, consists of pitch, tone, and loudness of spoke messages, the rate of speaking, expressively placed pauses, and emphasis assigned to certain words
paralanguage
132
the distance between individuals who are having interactions of a personal nature, such as a close conversation. 18-40 inches
personal distance
133
appropriate interactional distance for speaking in public or yelling to someone some distance away. 12 feet or more
public distance
134
the distance considered acceptable in interactions with strangers or acquaintances, such as at a party or in a public building. 4-12 feet
social distance
135
the innate tendency of individuals to "own" space. Individuals lay claim to areas around them as their own. This phenomenon can have an influence of intepersonal communication
territoriality
136
A client states "I refuse to shower in this room. I must be very cautious. The FBI has placed a camera in here to monitor my every move. Which of the following is the therpeutic response?
a. that's not true
b. I have a hard time believing that is true
c. surely you don't really believe that
d. I will help you search this room so that you can see there is no camera
B. I have a hard time believing that is true
137
Nancy, a depressed client who has been unkept and untidy for weeks, today comes to group therapy wearing makeup and clean dress and freshly washed hair. Which of the following responses by the nurse is most appropriate?
a. Nancy, I see you have put on a clean dress and combed your hair
b. Nancy you look wonderful today
c. Nancy, I'm sure everyone will appreciate that you have cleaned up for group today
d. Now that you see how important it is, I hope you will do this every day
A. Nancy, I see you have put on a clean dress and combed your hair
138
Dorothy was involved in an automobile accident while under the influence of alcohol. She swerved her car into a tree and narrowly missed hitting a child on a bicycle. She is in the hospital with mulitiple abrasions and contusions. She is talking about the accident with the nurse. Which of the following statements by the nurse is most appropriate?
a. Now that you know what can happen when you drink and drive, I'm sure you won't let it happen again.
b. You know that was a terrible thing you did. That child could have been killed.
c. I'm sure everything is going to be okay now that you understand the possible consequence of such behavior.
d. How are you feeling about what happened
D. How are you feeling about what happened?
139
Judy has been in the hospital for 3 weeks. She has used Valium "to settle my nerves" for the past 15 years. She was admitted by her psychiatrist for safe withdrawal from the drug. She has passed the physical symptoms of withdrawal at this time, but states to the nurse, "I don't know if I will be able to make it without Valium after I go home. Most appropriate response???
a. Why do you think you have to use drugs to deal with your problems?
b. Everybody has problems, but not everybody uses drugs to deal with them. You'll just have to do the best that you can.
c. We will just have to think about some things that you can do to decrease your anxiety without resorting to drugs.
d. Just hang in there. I'm sure everything is going to be okay.
C. We will just have to think about some things that you can do to decrease your anxiety without resorting to drugs.
140
Mrs. S asks the nurse. "Do you think I should tell my husband about my affair with my boss?" Appropriate response???
a. What do you think would be best for you to do
b. Of course you should. Marriage has to be based on truth.
c. Of course not. That would only make things worse.
d. I can't tell you what to do. You have to decide for yourself.
A. What do you think would be best for you to do?
141
Carol, an adolescent, just returned from group therapy and is crying. She says to the nurse, "all the other kids laughed at me! I try to fit in, but I always seem to say the wrong thing. I've never had a close friend. I guess I never will.
Appropriate response???
a. What makes you think you will never have friends?
b. You're feeling pretty down on yourself right now.
c. I'm sure they didn't mean to hurt your feelings
d. Why do you feel this way about yourself?
B. You're feeling pretty down on yourself right now.
142
Walter is angry with his psychiatrist and says to the nurse,"He doesn't know what he is doing. That medication isn't helping anything!" The nurse responds "He has been a doctor many years and has helped many people." This is an example of what nontherapeutic technique?
a. rejecting
b. disapproving
c. probing
d. defending
D. defending
143
The client says to the nurse,"I've been offered a promotion, but I don't know if I can handle it". The nurse replies,"You're afraid you may fail in the new position." This is an example of which therapeutic technique?
a. restating
b. making observations
c. focusing
d. verbalizing the implied
A. restating
144
The environment in which the communication takes place influences the outcome of the interaction. Which of the following are aspects of the environment that influence communication?
a. territoriality
b. density
c. dimension
d. distance
e. intensity
A B D
145
The nurse says to a client,"You are being readmitted to the hospital. Why did you stop taking your medication?" What communication technique does this represent?
a. disapproving
b. requesting an explanation
c. disagreeing
d. probing
B requesting an explanation
146
the process of determing the progress toward attainment of expected outcomes, including the effectiveness of care
evaluation
147
a health care delivery process, the goals of which are to provide quality health care, decrease fragmentation, enhance the client's quality of life, and contain costs.
case managment
148
the individual responsible for negotiating with multiple health-care providers to obtain a variety of services for a client
case manager
149
a diagrammatic teaching and learning strategy that allows students & faculty to visualize interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments. A diagram of client problems and interventions
concept mapping
150
an abbreviated plan of care that provides outcome-based guidelines for goal achievement within a designated length of time
critical pathways of care
151
a concept purposefully designed to control the balance between cost and quality of care.
managed care
152
a comprehensive, research based, standardized classification of interventions that nurses perform
Nursing Interventions Classification
153
a comprehensive, standardized classifcation of patient/client outcomes developed to evaluate the effects of nursing interventions
Nursing Outcomes Classification
154
method of documentation that has an assessment, problem, intervention, and evaluation format and is problem oriented to document the nursing process
PIE charting
155
a dynamic systematic process by which nurses assess, diagnose, identify outcomes, plan, implement, and evaluate nursing care.
nursing process
156
The nurse is using the nursing process to care for a suicidal client. Which of the following nursing actions is a part of the assessment step of the nursing process?
a. identifies nursing diagnosis: Risk for suicide
b. notes client's family reports recent suicide attempts
c. prioritizes the necessity for maintaining a safe environment for the client
d. obtains a short term contract from the client to seek out staff if feeling suicidal
B. notes client's family reports recent suicide attempts
157
The nurse is using the nursing process to care for a suicidal client. Which of the following nursing actions is a part of the diagnosis step of the nursing process?
a. identifies nursing diagnosis: Risk for suicide
b. notes client's family reports recent suicide attempt
c. prioritizes the necessity for maintaining a safe environment for the client
d. obtains a short term contract from the client to seek out staff if feeling suicidal
A. identifies nursing diagnosis: Risk for suicide
158
The nurse is using the nursing process to care for a suicidal client. Which of the following nursing actions is a part of the outcome identification step of the nursing process?
a. prioritizes the necessity for maintaining a safe environment for the client
b. determines if nursing interventions have been appropriate to achieve desired results
c. obtains a short-term contract from the client to seek out staff if feeling suicidal
d. establishes goal of care: Client will not harm self during hospitalization
D. Establishes goal of care: Client will not harm self during hospitalization
159
The nurse is using the nursing process to care for a suicidal client. Which of the following nursing actions is a part of the planning step of the nursing process?
a. prioritizes the necessity for maintaining a safe environment for the client
b. determines if nursing interventions have been appropriate to achieve desired results
c. obtains a short term contract from the client to seek out staff if feeling suicidal
d. establishes goal of care: Client will not harm self during hospitalization
A. prioritizes the necessity for maintaining a safe environment for the client
160
The nurse is using the nursing process to care for a suicidal client. Which of the following nursing actions is a part of the implementation step of the nursing process?
a. prioritizes the necessity for maintaining a safe environment for the client
b. determines if nursing interventions have been appropriate to achieve desired results
c. obtains a short term contract from the client to seek out staff if feeling suicidal
d. establishes goal of care: Client will not harm self during hospitalization
C. obtains a short term contract from the client to seek out staff if feeling suicidal
161
The nurse is using the nursing process to care for a suicidal client. Which of the following nursing actions is a part of the evaluation step of the nursing process?
a. prioritizes the necesity for maintaining a safe environment for the client
b. determines if nursing interventions have been appropriate to achieve desired results
c. obtains a short term contract from the client to seek out staff if feeling suicidal
d. establishes goal of care: Client will not harm self during hospitalization
B. determines if nursing interventions have been appropriate to achieve desired results
162
S.T. is a 15 year old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5'5" tall and weighs 82lb. She was elected to the cheer squad for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be appropriate for S.T.?
a. social isolation
b. disturbed body image
c. low self esteem
d. imbalanced nutrition: less than body requirements
A B C D
163
S.T. is a 15 year old girl who has just been admitted to the adolescent psychiatric unit with a diagnosis of anorexia nervosa. She is 5'5" tall and weighs 82lb. She was elected to the cheer squad for the fall but states that she is not as good as the others on the squad. The treatment team has identified the following problems: refusal to eat, occasional purging, refusing to interact with staff and peers, and fear of failure. Which of the following nursing diagnoses would be the priority diagnosis for S.T.?
a. social isolation
b, disturbed body image
c. low self esteem
d. imbalanced nutrition: less than body requirements
D. imbalanced nutrition: less than body requirements
164
Nursing diagnoses are prioritized according to
a. degree of potential for resolution
b. legal implications associated with nursing intervention
c. life-threatening potential
d. client and family requests
C. life-threatening potential
165
Which of the following describe advantages to electronic health records?
a. they reduce redundancy of information
b. they reduce issues regarding privacy
c. they decrease charting time
d. they facilitate communication between disciplines
A C D
166
an alteration in mood that is expessed by feelings of sadness, despair, and pessimism. there is a loss of usual activities and somatic symptoms may be evident. changes in appetite and sleep patterns are common
depression
167
an individual's sustained emotional tone, which significantly influences behavior, personality, and perception
mood
168
a type of therapy in which the individual is taught to control thought distortions that are considered to be a factor in the development and maintenance of emotional disorders
cognitive therapy
169
a depressive neurosis. the symptoms are similar to, if somewhat milder than, those ascribed to major depression. there is no loss of contact with reality
dysthymic disorder
170
a severe form of major depressive episode. symptoms are exxagerated, and interest or pleasure in virtually all activities is lost
melacholia
171
depression that occurs during the postpartum depression
postpartum depression
172
a disorder that is characterized by depressed mood, anxiety, mood swings, and decreased interest in activities during the week prior to menses
premenstrual dysphoric disorder
173
extreme slowdown of physical movements; posture slumps, speech is slowed, digestion becomes sluggish. common in severe depression
psychomotor retardation
174
an amino acid found in aged cheeses or other aged, fermented foods. if foods high in this amino acid are consumed while taking MAOIs, a potentially life threatening syndrome called hypertensive crisis can result
tyramine
175
Margaret, age 68, is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, lost weight, and does litte else but visit the cemetary where her husband is buried. She told her sister today that she had nothing to live for. She has been hospitalized for major depressive disorder. The priority nursing diagnosis for Margaret would be:
a. imbalanced nutrition: less than body requirements
b. complicated grieving
c. risk for suicide
d. social isolation
C. risk for suicide
176
The physician orders sertraline (Zoloft)50mg bid for Margaret, a 68 year old woman with major depressive disorder. After 3 days of medication, Margaret says to the nurse, "I don't think this medicine is working. I don't feel any better." What is the appropriate response by the nurse?
a. Cheer up Margaret, you have so much to be happy about
b. sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms
c. I'll report that to the physician, Margaret. Maybe he will order something different
d. try not to dwell on your symptoms, Margaret. Why don't you join the others down in the dayroom?
B. sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms
177
The goal of cognitive therapy with depressed clients is to
a. identify and change dysfunctional patterns of thinking
b. resolve the symptoms and initiate or restore adaptive family functioning
c. alter the neurotransmitters that are creating the depressed mood
d. provide feedback from peers who are having similar experiences
A. identify and change dysfunctional patterns of thinking
178
Education for the client who is taking MAOIs should include which of the following?
a. fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity
b. lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks
c. short-term use, possible tolerance to beneficial effects, careful tapering of the drug at end of treatment
d. tyramine-restricted diet, prohibitive concurrent use of over the counter medications without physician notification
D. tyramine-restricted diet, prohibitive concurrent use of over the counter medications without physician notification
179
In teaching a client about his antidepressant medication, fluoxetine, which of the following would the nurse include?
a. Don't eat chocolate while taking this medication
b. Keep taking this medication, even if you don't feel it is helping. It sometimes takes awhile to take effect
c. Don't take this medication with the migraine drugs "triptans"
d. Go to the lab each week to have your blood drawn for therapeutic level of this drug.
e. This drug causes a high degree of sedation, so take it just before bedtime.
B C
180
A client has just been admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder. Which of the following behavioral manifestations might the nurse expect to assess?
a. slumped posture
b. delusional thinking
c. feelings of despair
d. feels best early in the morning and worse as the day progresses
e. anorexia
A. slumped posture
181
A client with depression has just been prescribed the antidepressant phenelzine (Nardil). She says to the nurse, "the doctor says I will need to watch my diet while I'm on this medication. What foods should I avoid?" Which of the following is the correct response?
a. blue cheese and red wine
b. black beans, garlic, and pears
c. pork, shellfish, egg yolks
d. milk, peanuts, tomatoes
C.. pork, shellfish, egg yolks
182
A client whose husband died 6 months ago is diagnosed with Major Depressive Disorder. She says to the nurse, "I started feeling angry that Harold died and left me alone, he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse.
a. Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer.
b. I can understand how you must feel.
c. Those feelings are a normal part of the grief response.
d. Just think about the good times that you had while he was alive.
B. I can understand how you must feel.
183
A newly admitted depressed client isolates herself in her room and just sits and stares into space. How best might the nurse begin an therapeutic relationship with this patient?
a. Say, "Come with me. I will go with you to group.
b. make frequent short visits to her room and sit with her.
c. offer to introduce her to the other clients
d. Help her identify stressors in her life that precipitate crises.
C. offer to introduce her to the other clients
184
John is a client at the mental health clinic. He is depressed, has been expressing suicidal ideations, and has been seeing the psychiatric nurse every 3 days. He has been taking 100mg of sertaline daily for about a month, receiving small amount of the medication from his nurse at each visit. Today he comes to the clinic in a cheerful mood, much different than he seemed just 3 days ago. How might the nurse assess this behavioral change?
a. The sertraline is finally taking effect
b. He is no longer in need of antidepressant medication
c. He has been completed the grief response over loss of his wife.
d. He may have decided to carry out his suicide plan.
D. He may have decided to carry out his suicide plan.
185
a type of bipolar disorder in which the predominant mood is elevated, expansive, or irritable. Motor activity is frenzied and excessive. Psychotic features may or may not be present
mania
186
charcterized by mood swings from profound depression to extreme euphoria, with intervening periods of normalcy. Psychotic symptoms may or may not be present.
bipolar disorders
187
chronic mood disturbance involving numerous episodes of hypomania and depressed mood, of insufficient severity or duration to meet the criteria for bipolar disorder.
cyclothymic disorder
188
A grave form of mania characterized by severe clouding of consciousness and representing an intesification of the symptoms associated with mania. The symptoms of delirious mania have become relatively rare since the availability of antipsychotic medications.
delirious mania
189
a mild form of mania. symptoms are excessive hyperactivity, but not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization
hypomania
