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Flashcards in Exam II Deck (83):
1

A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?

A.
Administering lorazepam (Ativan) prn, because the client is angry at exposure of plan.
B.
Establishing room restrictions, because the client’s threat is an attempt to manipulate the staff.
C.
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.
D.
Calling an emergency treatment team meeting, because the client’s threat must be addressed.

C

2

In planning care for a suicidal client, which outcome should be a nurse’s first priority?

A.
The client will not physically harm self.
B.
The client will express hope for the future by day 3.
C.
The client will establish a trusting relationship with the nurse.
D.
The client will remain safe during hospital stay.

D

3

A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment. What is the nurse’s rationale for this procedure?

A.
To prevent increased intracranial pressure resulting from anoxia.
B.
To prevent decreased blood pressure, pulse, and respiration due to electrical stimulation.
C.
To prevent anoxia due to medication-induced paralysis of respiratory muscles.
D.
To prevent blocked airway, resulting from seizure activity.

C

4

Immediately after electroconvulsive therapy, in which position should a nurse place the client?

A.
On his or her side to prevent aspiration.
B.
In high Fowler’s position to promote consciousness.
C.
In Trendelenburg’s position to promote blood flow to vital organs.
D.
In prone position to prevent airway blockage.

A

5

A client is diagnosed with dysthymic disorder. Which symptom should a nurse classify as an affective symptom of this disorder?

A.
Social isolation with a focus on self.
B.
Low energy level.
C.
Difficulty concentrating.
D.
Gloomy and pessimistic outlook on life.

D

6

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder?

A.
Altered communication R/T feelings of worthlessness AEB anhedonia.
B.
Social isolation R/T poor self-esteem AEB secluding self in room.
C.
Altered thought processes R/T hopelessness AEB persecutory delusions.
D.
Altered nutrition: less than body requirements R/T high anxiety AEB anorexia.

B

7

A client diagnosed with major depression with psychotic features hears voices commanding self-harm. A nurse is unable to elicit a contract for safety. What should be the nurse’s priority intervention at this time?

A.
Obtaining an order for locked seclusion until client is no longer suicidal.
B.
Conducting 15-minute checks to ensure safety.
C.
Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
D.
Encouraging client to express feelings related to suicide.

C

8

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis?

A.
The client is disheveled and malodorous.
B.
The client refuses to interact with others.
C.
The client is unable to feel any pleasure.
D.
The client has maxed-out charge cards and exhibits promiscuous behaviors.

D

9

A client with a history of suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse’s priority at this time?

A.
Give the client off-unit privileges as positive reinforcement.
B.
Encourage the client to share mood improvement in group.
C.
Increase the level of this client’s suicide precautions.
D.
Request that the psychiatrist reevaluate the current medication protocol.

C

10

A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which lab value would potentially rule out this diagnosis?

A.
Thyroid-stimulating hormone (TSH) level of 0.25 U/mL
B.
Potassium (K+) level of 4.2 mEq/L
C.
Sodium (Na+) level of 140 mEq/L
D.
Calcium (Ca2+) level of 9.5 mg/dL

A

11

A depressed client reports a history of divorce, job loss, family estrangement, and cocaine abuse to a nurse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?

A.
According to psychoanalytic theory, depression is a result of anger turned inward.
B.
According to object-loss theory, depression is a result of abandonment.
C.
According to learning theory, depression is a result of repeated failures.
D.
According to cognitive theory, depression is a result of negative perceptions.

C

12

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder?
B
A.
The attention during the assessment is beneficial in decreasing social isolation.
B.
Depression can generate somatic symptoms that can mask actual physical disorders.
C.
Physical health complications are likely to arise from antidepressant therapy.
D.
Depressed clients avoid addressing physical health and ignore medical problems.

B

13

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in children and adolescents?

A.
Paroxetine (Paxil)
B.
Sertraline (Zoloft)
C.
Citalopram (Celexa)
D.
Fluoxetine (Prozac)

D

14

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?

A.
To rule out bipolar disorder.
B.
To rule out schizophrenia.
C.
To rule out senile dementia.
D.
To rule out a personality disorder.

C

15

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client’s safety upon discharge?

A.
Provide a 6-month supply of Elavil to ensure long-term compliance.
B.
Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.
C.
Provide pill dispenser as a memory aid.
D.
Provide education regarding the avoidance of foods containing tyramine.

B

16

An older client has recently been prescribed sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?

A.
Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs).
B.
Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI).
C.
Serotonin syndrome possibly caused by ingestion of an SSRI and an MAOI.
D.
Serotonin syndrome possibly caused by ingestion of two different SSRIs.

D

17

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing response?

A.
“This combination of drugs can lead to delirium tremens.”
B.
“A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.”
C.
“That’s a good idea. There have been good results with the combination of these two drugs.”
D.
“The only disadvantage would be the exorbitant cost of the MAOI.”

B

18

A psychiatrist prescribes a monoamine oxidase inhibitor for a client. Which foods should the nurse teach the client to avoid?

A.
Pepperoni pizza and red wine
B.
Bagels with cream cheese and tea
C.
Apple pie and coffee
D.
Potato chips and diet cola

A

19

A highly agitated client paces the unit and states, “I could buy and sell this place.” The client’s mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client’s behavior?

A.
“Rates mood 8/10. Exhibiting looseness of association. Euphoric.”
B.
“Mood euthymic. Exhibiting magical thinking. Restless.”
C.
“Mood labile. Exhibiting delusions of reference. Hyperactive.”
D.
“Agitated and pacing. Exhibiting grandiosity. Mood labile.”

D

20

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?

A.
Knowledge deficit R/T bipolar disorder AEB concern about symptoms.
B.
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss.
C.
Risk for suicide R/T powerlessness AEB insomnia and anorexia.
D.
Altered sleep patterns R/T mania AEB insomnia for the past 3 nights.

B

21

A nurse is planning care for a client diagnosed with bipolar disorder: manic phase. In which order should the nurse prioritize the client outcomes in the exhibit?
Client Outcomes:
1. Maintains nutritional status.
2. Interacts appropriately with peers.
3. Remains free from injury.
4. Sleeps 6 to 8 hours a night.

A.
2, 1, 3, 4
B.
4, 1, 2, 3
C.
3, 1, 4, 2
D.
1, 4, 2, 3

C

22

A client diagnosed with bipolar disorder: depressive phase intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?

A.
Risk for suicide R/T hopelessness.
B.
Anxiety: severe R/T hyperactivity.
C.
Imbalanced nutrition: less than body requirements R/T refusal to eat.
D.
Dysfunctional grieving R/T loss of employment.

A

23

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate due to excessive weight gain. In order to increase compliance, which medication should a nurse anticipate that a physician will prescribe?

A.
Sertraline (Zoloft)
B.
Valproic acid (Depakote)
C.
Trazodone (Desyrel)
D.
Paroxetine (Paxil)

B

24

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa order. Which is the appropriate nursing response?

A.
“Zyprexa in combination with Eskalith cures manic symptoms.”
B.
“Zyprexa prevents extrapyramidal side effects.”
C.
“Zyprexa ensures a good night’s sleep.”
D.
“Zyprexa calms hyperactivity until the Eskalith takes effect.”

D

25

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?

A.
“That’s strange. Weight loss is the typical pattern.”
B.
“What have you been eating? Weight gain is not usually associated with lithium.”
C.
“Weight gain is a common, but troubling, side effect.”
D.
“Weight gain only occurs during the first month of treatment with this drug.”

C

26

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?

A.
“This disorder is more prevalent in the lower socioeconomic groups.”
B.
“This disorder is more prevalent in the higher socioeconomic groups.”
C.
“This disorder is equally prevalent in all socioeconomic groups.”
D.
“This disorder’s prevalence cannot be evaluated based on socioeconomic groups.”

B

27

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithane) for 1 year. The client presents in an emergency department with a temperature of 101?F (38?C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

A.
Symptoms indicate consumption of foods high in tyramine.
B.
Symptoms indicate lithium carbonate discontinuation syndrome.
C.
Symptoms indicate the development of lithium carbonate tolerance.
D.
Symptoms indicate lithium carbonate toxicity.

D

28

What tool should a nurse utilize to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?

A.
“Risky Activity” tool
B.
“FIND” tool
C.
“Consensus Committee” tool
D.
“Monotherapy” tool

B

29

A client diagnosed with bipolar disorder weighs 220 lb. A physician orders lamotrigine (Lamictal) 10 mg/kg/day to a maximum of 400 mg/day for mood stabilization. Which is a true statement about this medication order?

A.
This calculated dosage is within the recommended dosage range.
B.
This calculated dosage is lower than the recommended dosage range.
C.
This calculated dosage is more than twice the recommended dosage range.
D.
This calculated dosage is four times higher than the recommended dosage range.

C

30

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?

A.
“Treatment is compromised when clients can’t sleep.”
B.
“Treatment is compromised when irritability interferes with social interactions.”
C.
“Treatment is compromised when clients have no insight into their problems.”
D.
“Treatment is compromised when clients choose not to take their medications.”

D

31

A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 lb by the end of the week?”

A.
Provide client with high-calorie finger foods throughout the day.
B.
Accompany client to cafeteria to encourage adequate dietary consumption.
C.
Initiate total parenteral nutrition to meet dietary needs.
D.
Teach the importance of a varied diet to meet nutritional needs.

A

32

A nursing instructor is teaching about specific phobias. Which student statement should indicate to the instructor that learning has occurred?

A.
“These clients recognize that their fear is excessive and seek treatment to promote change.”
B.
“These clients have a panic level of fear that is overwhelming and unreasonable.”
C.
“These clients experience symptoms that mirror a cerebrovascular accident (CVA).”
D.
“These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.”

B

33

A client has a history of excessive fear of water. What is the term that a nurse should use to describe the specific phobia, and what is the subtype of the specific phobia?

A.
Aquaphobia, a natural environment type of phobia.
B.
Aquaphobia, a situational type of phobia.
C.
Acrophobia, a natural environment type of phobia.
D.
Acrophobia, a situational type of phobia.

A

34

Which nursing statement to a client about social phobias versus schizoid personality disorder (SPD) is most accurate?

A.
“Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications.”
B.
“Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not.”
C.
“Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”
D.
“Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.”

C

35

What symptoms should a nurse use to differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?

A.
GAD is acute in nature, and panic disorder is chronic.
B.
Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
C.
Hyperventilation is a common symptom in GAD and rare in panic disorder.
D.
Depersonalization is commonly seen in panic disorder and absent in GAD.

D

36

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?

A.
Long-term treatment with diazepam (Valium).
B.
Acute symptom control with citalopram (Celexa).
C.
Long-term treatment with buspirone (BuSpar).
D.
Acute symptom control with ziprasidone (Geodon).

C

37

A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. How should a nurse explain the etiology of this fear to the spouse from a cognitive perspective?

A.
The client is unable to resolve intrapsychic conflicts, which result in projected anxiety.
B.
The client is experiencing a distorted and unrealistic appraisal of the situation.
C.
The client’s family has a history of overreaction to potential danger.
D.
The client’s high norepinephrine levels have distorted thinking.

B

38

Which symptoms should a nurse use to differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?

A.
Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.
B.
Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.
C.
Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.
D.
Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

A

39

A cab driver, stuck in traffic, suddenly is lightheaded, tremulous, diaphoretic, and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse’s first priority?

A.
Generalized anxiety disorder and a nursing diagnosis of fear.
B.
Altered sensory perception and a nursing diagnosis of panic disorder.
C.
Pain disorder and a nursing diagnosis of altered role performance.
D.
Panic disorder and a nursing diagnosis of anxiety.

D

40

A client diagnosed with panic disorder states, “When an attack happens, I feel like I am going to die.” Which is the most appropriate nursing response?

A.
“I know it’s frightening, but try to remind yourself that this will only last a short time.”
B.
“Death from a panic attack happens so infrequently that there is no need to worry.”
C.
“Most people who experience panic attacks have feelings of impending doom.”
D.
“Tell me why you think you are going to die every time you have a panic attack.”

A

41

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?

A.
“Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.”
B.
“Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.”
C.
“Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.”
D.
“Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.”

A

42

A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “Should I seek psychiatric help for my mother?” Which is an appropriate nursing response?

A.
“My mother also worries unnecessarily. I think it is part of the aging process.”
B.
“Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”
C.
“From what you have told me, you should get her to a psychiatrist as soon as possible.”
D.
“Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.”

B

43

A client is experiencing a severe panic attack. Which nursing intervention would meet this client’s physiological need?

A.
Teach deep breathing relaxation exercises.
B.
Place the client in a Trendelenburg position.
C.
Have the client breathe into a paper bag.
D.
Administer the ordered prn buspirone (BuSpar).

C

44

A college student is unable to take a final exam due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?

A.
Noncompliance R/T test taking
B.
Ineffective role performance R/T helplessness
C.
Altered coping R/T anxiety
D.
Powerlessness R/T fear

C

45

A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation to the client is most accurate?

A.
“Using your imagination, we will attempt to achieve a state of relaxation.”
B.
“Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.”
C.
“Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.”
D.
“In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.”

C

46

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

A.
The client will refrain from ritualistic behaviors during daylight hours.
B.
The client will wake early enough to complete rituals prior to breakfast.
C.
The client will participate in three unit activities by day 3.
D.
The client will substitute a productive activity for rituals by day 1.

B

47

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?

A.
“I will need scheduled blood work in order to monitor for toxic levels of this drug.”
B.
“I won’t stop taking this medication abruptly because there could be serious complications.”
C.
“I will not drink alcohol while taking this medication.”
D.
“I won’t take extra doses of this drug because I can become addicted.”

A

48

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?

A.
Sublimation
B.
Dissociation
C.
Rationalization
D.
Intellectualization

D

49

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client’s problem?

A.
Distract the client with other activities whenever ritual behaviors begin.
B.
Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
C.
Lock the room to discourage ritualistic behavior.
D.
Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

D

50

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate?

A.
High does of tricyclic medications will be required for effective treatment of OCD.
B.
Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.
C.
The dose of Luvox is low due to the side effect of daytime drowsiness.
D.
The dosage of Luvox is outside the therapeutic range and needs to be questioned.

B

51

A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What realistic goals should be included in this client’s plan of care?

A.
The client will have no flashbacks.
B.
The client will be able to feel a full range of emotions by discharge.
C.
The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
D.
The client will refrain from discussing the traumatic event.

C

52

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?

A.
History of alcohol dependence
B.
History of personality disorder
C.
History of schizophrenia
D.
History of hypertension

A

53

A client diagnosed with post traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication?

A.
Flat affect and anhedonia.
B.
Persistent anorexia and 10 lb weight loss in 3 weeks.
C.
Flashbacks of killing the enemy.
D.
Distant and guarded in relationships.

C

54

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client’s home environment should a nurse associate with the development of anorexia nervosa?

A.
The home environment maintains loose personal boundaries.
B.
The home environment places an overemphasis on food.
C.
The home environment is overprotective and demands perfection.
D.
The home environment condones corporal punishment.

C

55

A client’s altered body image is evidenced by claims of “feeling fat” even though the client is emaciated. Which is the appropriate outcome criterion for this client’s disorder?

A.
The client will consume adequate calories to sustain normal weight.
B.
The client will cease strenuous exercise programs.
C.
The client will perceive personal ideal body weight and shape as normal.
D.
The client will not express a preoccupation with food.

C

56

When counseling a client diagnosed with bulimia nervosa, a nurse explains that the client’s teeth will deteriorate because:

A.
The emesis produced during purging is acidic and corrodes the tooth enamel.
B.
Purging causes the depletion of dietary calcium.
C.
Food is rapidly ingested without proper mastication.
D.
Poor dental and oral hygiene leads to dental caries.

A

57

A nurse should explain to a client diagnosed with an eating disorder that behavior-modification programs are the treatment of choice because these programs:

A.
Help the client correct a distorted body image.
B.
Address the underlying client anger.
C.
Manage the client’s uncontrollable behaviors.
D.
Allow clients to maintain control.

D

58

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. Her treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice?

A.
This therapy will increase the client’s motivation to gain weight.
B.
This therapy will reward the client for perfectionist achievements.
C.
This therapy will provide the client with control over behavioral choices.
D.
This therapy will protect the client from parental overindulgence.

C

59

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder?

A.
“Skaters need to be thin to improve their daily performance.”
B.
“All the skaters on the team are following an approved 1,200-calorie diet.”
C.
“The exercise of skating reduces my appetite but improves my energy level.”
D.
“I am angry at my mother. I can only get her approval when I win competitions.”

D

60

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response?

A.
“Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions.”
B.
“Eating disorders have been correlated to certain familial patterns; without addressing these, your child’s condition will not improve.”
C.
“Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support.”
D.
“Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed.”

B

61

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?

A.
The client gained 2 pounds in 1 week.
B.
The client focused conversations on nutritious food.
C.
The client demonstrated healthy coping mechanisms that decreased anxiety.
D.
The client verbalized an understanding of the etiology of the disorder.

C

62

A morbidly obese client is prescribed an anorexiant medication. About which medication should a nurse teach the client?

A.
Diazepam (Valium)
B.
Dexfenfluramine (Redux)
C.
Sibutramine (Meridia)
D.
Pemoline (Cylert)

C

63

A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement should the nurse identify as correct?

A.
Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.
B.
Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
C.
Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not.
D.
Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

A

64

A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, “My parents watch me like a hawk and never let me out of their sight.” Which nursing diagnosis would take priority at this time?

A.
Altered nutrition less than body requirements
B.
Altered social interaction
C.
Impaired verbal communication
D.
Altered family processes

D

65

A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed?

A. “The trauma that women experience is more likely to be sexual assault and child sexual abuse.”
B. “The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury.”
C. “After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD).”
D. “Research shows that PTSD is more common in men than in women.”

D

66

Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)?

A. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to “normal” daily events.
B. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to “normal” daily events.
C. Depressive symptoms occur in PTSD and not in AD.
D. Depressive symptoms occur in AD and not in PTSD.

A

67

Which client would a nurse recognize as being at highest risk for the development of an AD?

A. A young married woman
B. An elderly unmarried man
C. A young unmarried woman
D. A young unmarried man

C

68

A nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates that learning has occurred?

A. “How clients perceive events and view the world affect their response to trauma.”
B. “The psychic numbing in PTSD is a result of negative reinforcement.”
C. “The individual becomes addicted to the trauma owing to an endogenous opioid response.”
D. “Believing that the world is meaningful and controllable can protect an individual from PTSD.”

B

69

As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client’s symptom?

A. Anxiety
B. Altered thought processes
C. Complicated grieving
D. Altered sensory perception

C

70

A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ?

A. Encourage the journaling of feelings.
B. Assess for the stage of grief in which the client is fixed.
C. Provide community resources to address the client’s concerns.
D. Encourage attending a grief therapy group.

B

71

Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)?

A. Anxiety, feelings of hopelessness, and worry
B. Truancy, vandalism, and fighting
C. Nervousness, worry, and jitteriness
D. Depressed mood, tearfulness, and hopelessness

D

72

Both situational and intrapersonal factors most likely contribute to an individual’s stress response. Which factor would a nurse categorize as interpersonal?

A. Occupational opportunities
B. Economic conditions
C. Degree of flexibility
D. Availability of social supports

C

73

A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/T divorce. Which correctly written outcome addresses this client’s problem?

A. Rates anxiety as 4 out of 10 by discharge.
B. States anxiety level has decreased by day one.
C. Accomplishes activities of daily living independently.
D. Demonstrates ability for adequate social functioning by day three.

A

74

Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder?

A. Adjustment disorder
B. Generalized anxiety disorder
C. Panic disorder
D. Post-traumatic stress disorder

D

75

After a teaching session about grief, a client says to the nurse, “I seem to be stuck in the anger stage of grieving over the loss of my son.” How would the nurse assess this statement, and in what phase of the nursing process would this occur?

A. Assessment phase; nursing actions have been successful in achieving the objectives of care.
B. Evaluation phase; nursing actions have been successful in achieving the objectives of care.
C. Implementation phase; nursing actions have been successful in achieving the objectives of care.
D. Diagnosis phase; nursing actions have been successful in achieving the objectives of care.

B

76

By which biological mechanism does EMDR achieve its therapeutic effect?

A. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown.
B. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness.
C. EMDR achieves its therapeutic effect by causing an increase in memory access.
D. EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.

A

77

A client receiving EMDR therapy says, “After only two sessions of my therapy, I am feeling great. Now I can stop and get on with my life.” Which of the following nursing responses is most appropriate?

A. “I am thrilled that you have responded so rapidly to EMDR.”
B. “To achieve lasting results, all eight phases of EMDR must be completed.”
C. “If I were you, I would complete the EMDR and comply with doctor’s orders.”
D. “How do you feel about continuing the therapy?”

B

78

A nurse would recognize which treatment as most commonly used for AD and its appropriate rationale?

A. Psychotherapy; to examine the stressor and confront unresolved issues
B. Fluoxetine (Prozac); to stabilize mood and resolve symptoms
C. Eye movement desensitization therapy; to reprocess traumatic events
D. Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety

A

79

A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client’s plan of care?

A. The client will have no flashbacks.
B. The client will be able to feel a full range of emotions by discharge.
C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
D. The client will refrain from discussing the traumatic event.

C

80

A client diagnosed with PTSD is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication?

A. Flat affect and anhedonia
B. Persistent anorexia and 10 lb weight loss in 3 weeks
C. Flashbacks of killing the enemy
D. Distant and guarded in relationships

C

81

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 others’ rights, and defaults on legal responsibilities.
D. The client complains of many physical ailments, refuses to socialize, and quits her job

D

82

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 AD, within what time frame should the nurse expect the client to exhibit symptoms?

A. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within one year of the accident.
B. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within three months of the accident.
C. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within six months of the accident.
D. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within nine months of the accident.

B

83

A 20-year-old client and a 60-year-old client have had drunk driving accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of these clients would be predisposed to the diagnosis of adjustment disorder?

A. The 60-year-old, because of memory deficits.
B. The 60-year-old, because of decreased cognitive processing ability.
C. The 20-year-old, because of limited cognitive experiences.
D. The 20-year-old, because of lack of developmental maturity.

D