NURS 410 test 2 (Ch. 4 & 7-11) PQ's

A patient asks a nurse, What are neurotransmitters? My doctor says mine are out of balance. The best reply would be:
a. You must feel relieved to know that your problem has a physical basis.
b. Neurotransmitters are chemicals that pass messages between brain cells.
c. It is a high-level concept to explain. You should ask the doctor to tell you more.
d. Neurotransmitters are substances we eat daily that influence memory and mood.

Click the card to flip 👆

1 / 169

Terms in this set (169)

b. Neurotransmitters are chemicals that pass messages between brain cells.

The parent of an adolescent diagnosed with schizophrenia asks a nurse, My childs doctor ordered a positron- emission tomography (PET) scan. What is that? Select the nurses best reply.
a. PET uses a magnetic field and gamma waves to identify problems areas in the brain. Does your teenager have any metal implants?
b. Its a special type of x-ray image that shows structures of the brain and whether a brain injury has ever occurred.
c. PET is a scan that passes an electrical current through the brain and shows brain wave activity. PET can help diagnose seizures.
d. PET is a special scan that shows blood flow and activity in the brain.

d. PET is a special scan that shows blood flow and activity in the brain.

A patient has dementia. The health care provider wants to make a differential diagnosis between Alzheimer disease and multiple infarctions. Which diagnostic procedure should a nurse expect to prepare the patient for first?
a. Computed tomography (CT) scan
b. Positron emission tomography (PET) scan
c. Functional magnetic resonance imaging (fMRI)
d. Single-photon emission computed tomography (SPECT) scan

a. Computed tomography (CT) scan

A patient has delusions and hallucinations. Before beginning treatment with a psychotropic medication, the health care provider wants to rule out the presence of a brain tumor. For which test will a nurse need to prepare the patient?
a. Cerebral arteriogram
b. Functional magnetic resonance imaging (fMRI)
c. Computed tomography (CT) scan or magnetic resonance imaging (MRI)
d. Positron emission tomography (PET) or single-photon emission computed tomography (SPECT)

c. Computed tomography (CT) scan or magnetic resonance imaging (MRI)

The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for major depressive disorder. Which question best implements this assessment?
a. Do you ever see or hear things that others do not?
b. Do you have problems with short-term memory?
c. What are your worst and best times of day?
d. How would you describe your thinking?

c. What are your worst and best times of day?

A nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which finding would be expected?
a. Reduced anxiety
b. Improved memory
c. More organized thinking
d. Fewer sensory perceptual alterations

a. Reduced anxiety

On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to:
a. inhibit GABA production.
b. increase dopamine sensitivity.
c. decrease dopamine at receptor sites.
d. prevent destruction of acetylcholine.

d. prevent destruction of acetylcholine.

A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain?
a. Brainstem
b. Cerebellum
c. Temporal lobe
d. Prefrontal cortex

d. Prefrontal cortex

A nurse should assess a patient taking a medication with anticholinergic properties for inhibited function of the:
a. parasympathetic nervous system.
b. sympathetic nervous system.
c. reticular activating system.
d. medulla oblongata.

a. parasympathetic nervous system.

The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing:
a. increased concentration of neurotransmitters in the synaptic gap.
b. decreased concentration of neurotransmitters in serum.
c. destruction of receptor sites.
d. limbic system stimulation.

a. increased concentration of neurotransmitters in the synaptic gap.

A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? a. Anticholinergic effects b. Dopamine-blocking effects c. Endocrine-stimulating effects d. Ability to stimulate spinal nervesb. Dopamine-blocking effectsA patient has anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? a. GABA b. Histamine c. Acetylcholine d. Norepinephrined. NorepinephrineA patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should anticipate administering a medication from which group? a. Tricyclic antidepressants b. Atypical antipsychotics c. Anticonvulsants d. Benzodiazepinesd. BenzodiazepinesA patient is hospitalized for major depressive disorder. Of the medications listed, a nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium). b. fluoxetine (Prozac). c. clozapine (Clozaril). d. tacrine (Cognex).b. fluoxetine (Prozac).A patient hospitalized with a mood disorder has aggression, agitation, talkativeness, and irritability. A nurse begins the care plan based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): a. anticholinergic. b. mood stabilizer. c. psychostimulant. d. tricyclic antidepressant.b. mood stabilizer.A drug causes muscarinic-receptor blockade. A nurse will assess the patient for: a. dry mouth. b. gynecomastia. c. pseudoparkinsonism. d. orthostatic hypotension.a. dry mouth.A patient begins therapy with a phenothiazine medication. What teaching should a nurse provide related to the drugs strong dopaminergic effect? a. Chew sugarless gum. b. Increase dietary fiber. c. Arise slowly from bed. d. Report muscle stiffness.d. Report muscle stiffness.A nurse can anticipate anticholinergic side effects are likely to occur when a patient is taking: a. lithium (Lithobid). b. buspirone (BuSpar). c. risperidone (Risperdal). d. fluphenazine (Prolixin).d. fluphenazine (Prolixin).Priority teaching for a patient taking clozapine (Clozaril) should include which instruction? a. Report sore throat and fever immediately. b. Avoid foods high in polyunsaturated fat. c. Use water-based lotions for rashes. d. Avoid unprotected sex.a. Report sore throat and fever immediately.A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking: a. buspirone. b. haloperidol. c. trazodone. d. phenelzine.d. phenelzine.A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. mood improvement. b. logical thought processes. c. reduced levels of motor activity. d. decreased extrapyramidal symptoms.a. mood improvement.A patients spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. The nurse should explain that SSRIs: a. destroy increased amounts of neurotransmitters. b. make more serotonin available at the synaptic gap. c. increase production of acetylcholine and dopamine. d. block muscarinic and alpha1-norepinephrine receptors.b. make more serotonin available at the synaptic gap.A patient has taken many conventional antipsychotic drugs over years. The health care provider, who is concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: a. are less costly. b. have higher potency. c. are more readily available. d. produce fewer motor side effects.d. produce fewer motor side effects.The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 and a granulocyte count of 1500 mm3. The nurse should: a. report the laboratory results to the health care provider. b. give the next dose as prescribed. c. administer aspirin and force fluids. d. repeat the laboratory tests.a. report the laboratory results to the health care provider.A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha1 receptors because the patient may experience: a. increased psychotic symptoms. b. severe appetite disturbance. c. orthostatic hypotension. d. hypertensive crisis.c. orthostatic hypotension.A nurse prepares to administer an antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring of the medications effects and side effects will be most important if the patient is also diagnosed with which health problem? Select all that apply. a. Parkinson disease b. Graves disease c. Osteoarthritis d. Epilepsy e. Diabetesa. Parkinson disease d. Epilepsy e. DiabetesThe spouse of a patient diagnosed with schizophrenia asks, Which neurotransmitters are more active when a person has schizophrenia? The nurse should state, The current thinking is that the thought disturbances are related to increased activity of: (Select all that apply.) a. GABA. b. substance P. c. histamine. d. dopamine. e. norepinephrine.d. dopamine. e. norepinephrine.An individual is experiencing problems associated with memory. Which cerebral structures are most likely to be involved in this deficit? Select all that apply. a. Prefrontal cortex b. Occipital lobe c. Temporal lobe d. Parietal lobe e. Basal gangliaa. Prefrontal cortex c. Temporal lobe d. Parietal lobeA new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Establish therapeutic relationships. c. Prescribe psychotropic medications. d. Individualize nursing care plans.c. Prescribe psychotropic medications.A newly admitted patient with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: Less than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessnessc. Risk for suicideA patient with major depressive disorder has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: Patient will refrain from gestures and attempts to harm self? a. Implement suicide precautions. b. Frequently offer high-calorie snacks and fluids. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.a. Implement suicide precautions.A patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented? a. Consistently demonstrated b. Often demonstrated c. Sometimes demonstrated d. Never demonstratedd. Never demonstratedA patients nursing diagnosis is Insomnia. The desired outcome is: Patient will sleep for a minimum of 5 hours nightly by October 31. On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurses next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the outcome target date and interventions.d. Revise the outcome target date and interventions.A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item Encourage patient to attend one psychoeducational group daily? a. Assessment b. Analysis c. Planning d. Implementation e. Evaluationd. ImplementationBefore assessing a new patient, a nurse is told by another health care worker, I know that patient. No matter how hard we work, there isnt much improvement by the time of discharge. The nurses responsibility is to: a. document the other workers assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the workers impression by contacting the patients significant other. d. discuss the workers impression with the patient during the assessment interview.b. assess the patient based on data collected from all sources.A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patients best interest. What is the nurses best action? a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate a more appropriate outcome without the patients input.c. Explore with the patient possible consequences of the outcome.A patient states, Im not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up. Which nursing intervention should have the highest priority? a. Self-esteembuilding activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide precautionsd. Suicide precautionsSelect the best outcome for a patient with this nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, Although Id like to, I dont join in because I dont speak the language very well. The patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.d. select and participate in one group activity per day.Nursing behaviors associated with the implementation phase of the nursing process are concerned with: a. participating in the mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.d. carrying out interventions and coordinating care.Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. I can always trust my family. b. It seems like I always have bad luck. c. You never know who will turn against you. d. I hear evil voices that tell me to do bad things.d. I hear evil voices that tell me to do bad things.Which entry in the medical record best meets the requirement for problem-oriented charting? a. A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV. b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV. c. Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV. d. Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, Im no longer bothered by the voices.b. S: States, I feel like Im ready to blow up. O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg. I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV.A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, I cant find my way home. The patient is confused and unable to answer questions. Select the nurses best action. a. Document the patients mental status. Obtain other assessment data from the family member. b. Record the patients answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patients rights.a. Document the patients mental status. Obtain other assessment data from the family member.A nurse asks a patient, If you had fever and vomiting for 3 days, what would you do? Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbancesb. CognitionAn adolescent asks a nurse conducting an assessment interview, Why should I tell you anything? Youll just tell my parents whatever you find out. Select the nurses best reply. a. That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know. b. Yes, your parents may find out what you say, but it is important that they know about your problems. c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team. d. It sounds as though you are not really ready to work on your problems and make changes.c. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.A nurse assessing a new patient asks, What is meant by the saying, You cant judge a book by its cover? Which aspect of cognition is the nurse assessing? a. Mood b. Attention c. Orientation d. Abstractiond. AbstractionWhen a nurse assesses an older adult patient, the patients answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. Are you having difficulty hearing when I speak? b. How can I make this assessment interview easier for you?c. I notice you are frowning. Are you feeling annoyed with me? d. Youre having trouble focusing on what Im saying. What is distracting you?a. Are you having difficulty hearing when I speak?At one point in an assessment interview a nurse asks, How does your faith help you in stressful situations? This question would be asked during the assessment of: a. childhood growth and development. b. substance use and abuse. c. educational background. d. coping strategies.d. coping strategies.When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention.c. milieu management.After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment.b. Determine the goals and outcome criteria.Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolationd. Social isolationThe acronym QSEN refers to: a. Qualitative Standardized Excellence in Nursing. b. Quality and Safety Education for Nurses. c. Quantitative Effectiveness in Nursing. d. Quick Standards Essential for Nurses.b. Quality and Safety Education for Nurses.A nurse documents: Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker. Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communicationd. Impaired verbal communicationA nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply. a. Uncooperative patient b. Patients subjective responses c. Only data obtained from the patients verbal responses d. Description of the patients behavior during the interview e. Analysis of why the patient is unresponsive during the interviewb. Patients subjective responses d. Description of the patients behavior during the interviewA nurse performing an assessment interview for a patient with a substance abuse disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) e. Recovery Attitude and Treatment Evaluator (RAATE)What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Goals and outcomes for the plan of care c. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventionsc. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventionsA patient is very suspicious and states, The FBI has me under surveillance. Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, Tell me about the problem as you see it. c. Seek information about when the problem began. d. Tell the patient, Your ideas are not realistic. e. Reassure the patient, You are safe here.b. Ask the patient, Tell me about the problem as you see it. c. Seek information about when the problem began. e. Reassure the patient, You are safe here.A patient says to the nurse, I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadnt rested well. Which comment would be appropriate if the nurse seeks clarification? a. It sounds as though you were uncomfortable with the content of your dream. b. I understand what youre saying. Bad dreams leave me feeling tired, too. c. So, all in all, you feel as though you had a rather poor nights sleep? d. Can you give me an example of what you mean by stoned?d. Can you give me an example of what you mean by stoned?A patient diagnosed with schizophrenia tells the nurse, The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say. Which response by the nurse would be most therapeutic? a. Lets talk about something other than the CIA. b. It sounds like youre concerned about your privacy. c. The CIA is prohibited from operating in health care facilities. d. You have lost touch with reality, which is a symptom of your illness.b. It sounds like youre concerned about your privacy.The patient says, My marriage is just great. My spouse and I usually agree on everything. The nurse observes the patients foot moving continuously as the patient twirls a shirt button. What conclusion can the nurse draw? The patients communication is: a. clear. b. mixed. c. precise. d. inadequate.b. mixed.A nurse interacts with a newly hospitalized patient. Select the nurses comment that applies the communication technique of offering self. a. Ive also had traumatic life experiences. Maybe it would help if I told you about them. b. Why do you think you had so much difficulty adjusting to this change in your life? c. I hope you will feel better after getting accustomed to how this unit operates. d. Id like to sit with you for a while to help you get comfortable talking to me.d. Id like to sit with you for a while to help you get comfortable talking to me.Which technique will best communicate to a patient that the nurse is interested in listening? a. Restate a feeling or thought the patient has expressed. b. Ask a direct question, such as, Did you feel angry? c. Make a judgment about the patients problem. d. Say, I understand what youre saying.a. Restate a feeling or thought the patient has expressed.A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. What are the common elements here? b. Tell me again about your experiences. c. Am I correct in understanding that? d. Tell me everything from the beginning.c. Am I correct in understanding that?A patient tells the nurse, I dont think I will ever get out of here. Select the nurses most therapeutic response. a. Dont talk that way. Of course you will leave here! b. Keep up the good work and you certainly will. c. You dont think youre making progress? d. Everyone feels that way sometimes.c. You dont think youre making progress?Documentation in a patients chart shows, Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, I enjoy spending time with you. Which analysis is most accurate? a. Patient is giving positive feedback about the nurses communication techniques. b. Nurse is viewing the patients behavior through a cultural filter. c. Patients verbal and nonverbal messages are incongruent. d. Patient is demonstrating psychotic behaviors.c. Patients verbal and nonverbal messages are incongruent.While talking with a patient with severe depression, a nurse notices the patient is unable to maintain eye contact. The patients chin lowers to the chest while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skillsa. Nonverbal communicationDuring the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patients hand. Select the correct analysis of the nurses behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patients cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Patients in a psychiatric setting should not be touched.b. The gesture is premature. The patients cultural and individual interpretation of touch is unknown.A Mexican-American patient puts a picture of the Virgin Mary on the bedside table. Under which section of the assessment should the nurse document this behavior? a. Culture b. Ethnicity c. Verbal communication d. Nonverbal communicationa. CultureAn African-American patient says to a Caucasian nurse, Theres no sense talking. You wouldnt understand because you live in a white world. The nurses best action would be to: a. explain, Yes, I do understand. Everyone goes through the same experiences. b. say, Please give an example of something you think I wouldnt understand. c. reassure the patient that nurses interact with people from all cultures. d. change the subject to one that is less emotionally disturbing.b. say, Please give an example of something you think I wouldnt understand.A Filipino-American patient had this nursing diagnosis: Situational low self-esteem, related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patients self-esteem; however, after 3 weeks, the patients eye contact did not improve. What is the most accurate analysis of this scenario? a. The patients eye contact should have been directly addressed by role-playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient. c. The patients poor eye contact is indicative of anger and hostility that remain unaddressed. d. The nurse should have assessed the patients culture before making this diagnosis and plan.d. The nurse should have assessed the patients culture before making this diagnosis and plan.When a female Mexican-American patient and a female nurse sit together, the patient often holds the nurses hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior and thinks the patient is homosexual. Which alternative is a more accurate assessment? a. The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The nurse is homophobic.a. The patient is accustomed to touch during conversations, as are members of many Hispanic subcultures.A Puerto Rican American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patients behavior? The patient: a. likely has a histrionic personality disorder. b. believes dramatic body language is sexually appealing. c. wishes to impress staff with the degree of emotional pain. d. belongs to a culture in which dramatic body language is the norm.d. belongs to a culture in which dramatic body language is the norm.During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying: a. Youve turned the tables on me. b. Nurses direct the interviews with patients. c. Do not ask questions about my personal life. d. The time we spend together is to discuss your concerns.d. The time we spend together is to discuss your concerns.Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. Nurses are responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps patients know that what they said is understood.c. Silence can provide meaningful moments for reflection.A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. is rarely helpful. b. fosters independence. c. lifts the burden of personal decision making. d. helps the patient develop feelings of personal adequacy.a. is rarely helpful.The relationship between a nurse and patient as it relates to status and power is best described by which term? a. Symmetric b. Complementary c. Incongruent d. Paralinguisticb. ComplementaryA patient with severe depression states, God is punishing me for my past sins. What is the nurses best response? a. Why do you think that? b. You sound very upset about this. c. You believe God is punishing you for your sins? d. If you feel this way, you should talk to a member of your clergy.b. You sound very upset about this.A patient cries as the nurse explores the patients relationship with a deceased parent. The patient says, I shouldnt be crying like this. It happened a long time ago. Which responses by the nurse will facilitate communication? Select all that apply. a. Why do you think you are so upset? b. I can see that you feel sad about this situation. c. The loss of your parent is very painful for you. d. Crying is a way of expressing the hurt youre experiencing. e. Lets talk about something else because this subject is upsetting you.b. I can see that you feel sad about this situation. c. The loss of your parent is very painful for you. d. Crying is a way of expressing the hurt youre experiencing.Which benefits are most associated with the use of telehealth? Select all that apply. a. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areas d. Prompt reimbursement by third-party payers e. Rapid development of trusting relationships with patientsa. Cost savings for patients b. Maximization of care management c. Access to services for patients in rural areasA nurse assesses a confused older adult. The nurse experiences sadness and reflects, The patient is like one of my grandparents . . . so helpless. What feelings does the nurse describe? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reactionb. CountertransferenceWhich statement shows a nurse has empathy for a patient who made a suicide attempt? a. You must have been very upset when you tried to hurt yourself. b. It makes me sad to see you going through such a difficult experience. c. If you tell me what is troubling you, I can help you solve your problems. d. Suicide is a drastic solution to a problem that may not be such a serious matter.a. You must have been very upset when you tried to hurt yourself.After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patients reactions toward the nurse seem realistic and appropriate. b. The patient states, Talking to you feels like talking to my parents. c. The nurse feels unusually happy when the patients mood begins to lift. d. The nurse develops a trusting relationship with the patient.c. The nurse feels unusually happy when the patients mood begins to lift.A patient says, Please dont share information about me with the other people. How should the nurse respond? a. I wont share information with others without your permission, but I will share information about you with other staff members. b. A therapeutic relationship is just between the nurse and the patient. Its up to you to tell others what you want them to know. c. It really depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others. d. I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us.a. I wont share information with others without your permission, but I will share information about you with other staff members.A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, I really need to talk to you right now. The nurse should: a. say to the interrupting patient, I am not available to talk with you at the present time. b. end the unproductive session with the current patient and spend time with the patient who has just interrupted. c. invite the interrupting patient to join in the session with the current patient. d. tell the patient who interrupted, This session is 5 more minutes; then, I will talk with you.d. tell the patient who interrupted, This session is 5 more minutes; then, I will talk with you.Termination of a therapeutic nurse-patient relationship with a patient has been successful when the nurse: a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that have happened during the relationship and evaluates the outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.c. discusses with the patient changes that have happened during the relationship and evaluates the outcomes.What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. great sense of independence. b. rapport and trust with the nurse. c. self-responsibility and autonomy. d. resolution of feelings of transference.b. rapport and trust with the nurse.During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Terminationc. WorkingAt what point in the nurse-patient relationship should a nurse plan to first address termination? a. In the orientation phase b. During the working phase c. In the termination phase d. When the patient initially brings up the topica. In the orientation phaseA nurse should introduce the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.b. spell out the participation and responsibilities of each party.As a nurse escorts a patient being discharged after treatment for major depressive disorder, the patient gives the nurse a gold necklace with a heart pendant and says, Thank you for helping mend my broken heart. Which is the nurses best response? a. Accepting gifts violates the policies and procedures of the facility. b. Im glad you feel so much better now. Thank you for the beautiful necklace. c. Im glad I could help you, but I cant accept the gift. My reward is seeing you with a renewed sense of hope. d. Helping people is what nursing is all about. Its rewarding to me when patients recognize how hard we work.c. Im glad I could help you, but I cant accept the gift. My reward is seeing you with a renewed sense of hope.Which remark by a patient indicates passage from the orientation phase to the working phase of a nurse- patient relationship? a. I dont have any problems. b. It is so difficult for me to talk about my problems. c. I dont know how talking about things twice a week can help. d. I want to find a way to deal with my anger without becoming violent.d. I want to find a way to deal with my anger without becoming violent.A nurse explains to the family of a patient who is mentally ill how the nurse-patient relationship differs from social relationships. Which is the best explanation? a. The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient. b. The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented. c. The focus of the relationship is socialization. Mutual needs are met, and feelings are openly shared. d. The focus is the creation of a partnership in which each member is concerned with the growth and satisfaction of the other.a. The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient.A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-disclosure in patient interactions. d. consistently interpret the patients behaviors.b. use congruent communication strategies.A nurse caring for a withdrawn, suspicious patient recognizes the development of feelings of anger toward the patient. The nurse should: a. suppress the angry feelings. b. express the anger openly and directly with the patient. c. tell the nurse manager to assign the patient to another nurse. d. discuss the anger with a clinician during a supervisory session.d. discuss the anger with a clinician during a supervisory session.A nurse wants to enhance the growth of a patient by showing positive regard. The action consistent with this wish is: a. making rounds daily. b. staying with a tearful patient. c. administering daily medication as prescribed. d. examining personal feelings about a patient.b. staying with a tearful patient.A patient says, Ive done a lot of cheating and manipulating in my relationships. Select a nonjudgmental response by the nurse. a. How do you feel about that? b. Its good that you realize this. c. Thats not a good way to behave. d. Have you outgrown that type of behavior?a. How do you feel about that?A patient says, People should be allowed to commit suicide without interference from others. A nurse replies, Youre wrong. Nothing is bad enough to justify death. What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is totally correct. d. Differing values are reflected in the two statements.d. Differing values are reflected in the two statements.Which issues should a nurse address during the first interview with a patient diagnosed with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resourcesc. Relationship parameters, the contract, confidentiality, and terminationDuring the first interview, a nurse notices that the patient does not make eye contact. The nurse can correctly analyze that: a. the patient is not truthful. b. the patient is feeling sad. c. the patient has a poor self-concept. d. more information is needed to draw a conclusion.d. more information is needed to draw a conclusion.Which behavior shows that a nurse values autonomy? The nurse: a. sets limits on a patients romantic overtures toward the nurse. b. suggests one-on-one supervision for a patient who is suicidal. c. informs a patient that the spouse will not be in during visiting hours. d. discusses available alternatives and helps the patient weigh the consequences.d. discusses available alternatives and helps the patient weigh the consequences.As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurses best action? a. Recognize the effectiveness of the relationship and patients thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates the policies of the facility. Decline the card. c. Acknowledge the patients transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.a. Recognize the effectiveness of the relationship and patients thoughtfulness. Accept the card.A patient says, Im still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges? What is the nurses best response? a. Why are you asking me when youre able to speak for yourself? b. I will be glad to address it when I see your doctor later today. c. Thats a good topic for you to take up with your doctor. d. Do you think you cant speak to a doctor?c. Thats a good topic for you to take up with your doctor.A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. A new nurse who begins work with this patient will: a. begin at the orientation phase. b. resume the working relationship. c. enter into a social relationship. d. return to the emotional catharsis phase.a. begin at the orientation phase.As a patient diagnosed with mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurses action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patients diversional activity deficit. d. The nurses action assists the patients integration into community living.b. The nurses action blurs the boundaries of the therapeutic relationship.A nurse says, I am the only one who truly understands this patient. Other staff members are too critical. The nurses statement indicates: a. boundary blurring. b. sexual harassment. c. positive regard. d. advocacy.a. boundary blurring.Which descriptors exemplify consistency regarding therapeutic nurse-patient relationships? Select all that apply. a. Having the same nurse care for a patient on a daily basis b. Encouraging a patient to share initial impressions of staff c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patient e. Offering solutions to a patients problemsa. Having the same nurse care for a patient on a daily basis c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patientA nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a. Focus dialog with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient identify strengths, limitations, and problems.a. Focus dialog with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse.A new psychiatric nurse has a parent diagnosed with bipolar disorder. This nurse angrily recalls embarrassing events concerning the parents behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply. a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy, and try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice, and explore other nursing specialties. d. Begin new patient relationships by saying, My own parent had mental illness, so I accept it without stigma. e. Recognize that the feelings may add sensitivity to the nurses practice, but supervision is important.a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. e. Recognize that the feelings may add sensitivity to the nurses practice, but supervision is important.A new nurse tells a mentor, I want to convey to my patients that I am interested in them and that I want to listen to what they have to say. Which behaviors are helpful in meeting the nurses goal? Select all that apply. a. Sitting behind a desk, facing the patient. b. Introducing self to a patient and identifying own role. c. Using facial expressions that convey interest and encouragement. d. Assuming an open body posture and sometimes mirror imaging. e. Maintaining control of the topic under discussion by asking direct questions.b. Introducing self to a patient and identifying own role. c. Using facial expressions that convey interest and encouragement. d. Assuming an open body posture and sometimes mirror imaging.Which scenario best demonstrates an example of eustress? An individual: a. loses a beloved family pet. b. prepares to take a 1 week vacation to a tropical island with a group of close friends. c. receives a bank notice there were insufficient funds in their account for a recent rent payment. d. receives notification that their current employer is experiencing financial problems and some workers will be terminated.b. prepares to take a 1 week vacation to a tropical island with a group of close friends.A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, Why is it taking so long to have the surgery? Maybe Im meant to die for all the bad things Ive done. The nurse should document the patients comment in which section of the assessment? a. Physical b. Spiritual c. Financial d. Psychologicalb. SpiritualA person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system? a. Thalamus b. Parietal lobe c. Hypothalamus d. Pituitary glandc. HypothalamusA person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system is stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous systemc. Sympathetic nervous systemA patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patients vital signs are temperature (T), 98.6 F; pulse (P), 72 beats per minute (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected? a. T, 98.6; P, 64; R, 14 b. T, 98.6; P, 68; R, 12 c. T, 98.6; P, 62; R, 16 d. T, 98.6; P, 84; R, 22d. T, 98.6; P, 84; R, 22As part of the stress response, the HPA axis is stimulated. Which structures make up this system? a. Hippocampus, parietal lobe, and amygdala b. Hypothalamus, pituitary gland, and adrenal glands c. Hind brain, pyramidal nervous system, and anterior cerebrum d. Hepatic artery, parasympathetic nervous system, and acoustic nerveb. Hypothalamus, pituitary gland, and adrenal glandsCortisol is released in response to a patients prolonged stress. Which initial effect would the nurse expect to result from the increased cortisol level? a. Diuresis and electrolyte imbalance b. Focused and alert mental status c. Drowsiness and lethargy d. Restlessness and anxietyb. Focused and alert mental statusA soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurses highest priority is to screen this soldier for which problem? a. Major depressive disorder b. Bipolar disorder c. Schizophrenia d. Dementiaa. Major depressive disorderA soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention? a. Its good to be home. I missed my family and friends. b. I saw my best friend get killed by a roadside bomb. It should have been me instead. c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown. d. I want to continue my education but Im not sure how I will fit in with other college students.b. I saw my best friend get killed by a roadside bomb. It should have been me instead.A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post- traumatic stress disorder (PTSD). The soldier says, If theres a loud noise at night, I get under my bed because I think were getting bombed. What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucinationb. FlashbackA soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier?a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. Family outing to the seashore d. Fireworks display on July 4thd. Fireworks display on July 4thA soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)? a. Immediately upon return to the United States from Afghanistan b. Before departing Afghanistan to return to the United States c. One year after returning from Afghanistan d. Screening should be ongoingd. Screening should be ongoingA nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)? a. After a fall, vehicle crash, or exposure to a blast b. Before departing Afghanistan to return to the United States c. One year after returning to the United States from Afghanistan d. Immediately upon return to the United States from Afghanistana. After a fall, vehicle crash, or exposure to a blastA soldier in a combat zone tells the nurse, I saw a child get blown up over a year ago, and now I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind. Which phenomenon associated with post-traumatic stress disorder (PTSD) is this soldier describing? a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosisa. Re-experiencingA soldier who served in a combat zone returned to the United States. The soldiers spouse complains to the nurse, We had planned to start a family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosisc. AvoidanceA soldier returned home last year after deployment to a war zone. The soldiers spouse complains, We were going to start a family but now he wont talk about it. He will not look at children. I wonder if were going to make it as a couple. Select the nurses best response. a. Post-traumatic stress disorder often changes a persons sexual functioning. b. I encourage you to continue to participate in social activities where children are present. c. Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior. d. Post-traumatic stress disorder often strains relationships. I will suggest some community resources for help and support.d. Post-traumatic stress disorder often strains relationships. I will suggest some community resources for help and support.A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, I dont know how much longer I can do it. My whole life is consumed with taking care of my partner. Select the nurses best response. a. How are you taking care of yourself? b. Lets review your partners diagnostic results. c. I have some web-based programs for you to visit. d. Your partner is lucky to have someone so devoted.a. How are you taking care of yourself?A professors 4-year-old child has a fever of 101.6 F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which nursing diagnosis best applies to this scenario? a. Decisional conflict b. Unilateral neglect c. Disabled family coping d. Ineffective management of the therapeutic regimena. Decisional conflictAn individual says to the nurse, I feel so stressed out lately. I think the stress is affecting my body also. Which somatic complaints are most likely to accompany this feeling? Select all that apply. a. Headache b. Neck pain c. Insomnia d. Anorexia e. Myopiaa. Headache b. Neck pain c. Insomnia d. AnorexiaWhich experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? Select all that apply. a. An 8-year-old child watches an R-rated movie with both parents. b. A young adult jumps from a bridge with a bungee cord with a best friend. c. An adolescent is kidnapped and held for 2 years in the home of a sexual predator. d. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. e. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.c. An adolescent is kidnapped and held for 2 years in the home of a sexual predator. d. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. e. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Post-traumatic stress disorderc. Traumatic brain injury e. Post-traumatic stress disorderA professors 4-year-old child has a temperature of 101.6 F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? Select all that apply. a. Telephoning a grandparent to stay with the child at home for the day. b. Telephoning a colleague to teach his classes and staying home with the sick child. c. Taking the child to the university and keeping the child in a private office for the day. d. Taking the child to a daycare center and hoping daycare workers will not notice the child is sick. e. Giving the child one dose of ibuprofen (Motrin) and taking the child to the daycare center.a. Telephoning a grandparent to stay with the child at home for the day. b. Telephoning a colleague to teach his classes and staying home with the sick child.A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to: a. Verify the patients learning style. b. Create outcomes and a teaching plan. c. Lower the patients current anxiety level. d. Assess how the patient uses defense mechanisms.c. Lower the patients current anxiety level.A patient approaches the nurse and impatiently blurts out, Youve got to help me! Something terrible is happening. My heart is pounding. The nurse responds, Its almost time for visiting hours. Lets get your hair combed. Which approach has the nurse used? a. Bringing up an irrelevant topic b. Responding to physical needs c. Addressing false cognitions d. Focusinga. Bringing up an irrelevant topicA patient experiencing moderate anxiety says, I feel undone. An appropriate response for the nurse would be: a. Why do you suppose you are feeling anxious? b. What would you like me to do to help you? c. Im not sure I understand. Give me an example. d. You must get your feelings under control before we can continue.c. Im not sure I understand. Give me an example.A patient with a high level of motor activity runs from chair to chair and cries, Theyre coming! Theyre coming! The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patients personal space. d. encourage the clarification of feelings.a. provide for patient safety.A patient with a high level of motor activity runs from chair to chair and cries, Theyre coming! Theyre coming! The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processesa. Risk for injuryA supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, Ive been working on other things. When asked 4 hours later, the worker says, Someone else was using the copier, so I couldnt finish it. The workers behavior demonstrates: a. acting out. b. projection. c. suppression. d. passive aggression.d. passive aggression.A patient is undergoing diagnostic tests. The patient says, Nothing is wrong with me except a stubborn chest cold. The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Deniald. DenialA patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurses comments and asks, What are they going to do? Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patients level of anxiety? a. Mild b. Moderate c. Severe d. Panicb. ModerateA patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner, using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.b. Describe the procedure again in a calm manner, using simple language.A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patients anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.b. Concerns stated aloud become less overwhelming and help problem solving to begin.Which assessment question would be most appropriate for the nurse to ask a patient who has possible generalized anxiety disorder (GAD)? a. Have you been a victim of a crime or seen someone badly injured or killed? b. Do you feel especially uncomfortable in social situations involving people? c. Do you repeatedly do certain things over and over again? d. Do you find it difficult to control your worrying?d. Do you find it difficult to control your worrying?A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurses office, furnished with chairs, files, magazines, and bookcasesa. Interview room furnished with a desk and two chairsA person has minor physical injuries after an automobile accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is this persons level of anxiety? a. Mild b. Moderate c. Severe d. Panicc. SevereTwo staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, The nurse manager had a headache the day I was interviewed. Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splittingc. ProjectionA patient tells a nurse, My new friend is the most perfect person one could imaginekind, considerate, and good looking. I cant find a single flaw. This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation.c. idealization.A patient experiences an episode of severe anxiety. Of these medications in the patients medical record, which is most appropriate to administer as an as-needed (PRN) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)b. lorazepam (Ativan)Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurses response? a. Altruism b. Sublimation c. Suppression d. Passive aggressiona. AltruismA person who feels unattractive repeatedly says, Although Im not beautiful, I am smart. This is an example of: a. repression. b. devaluation. c. identification. d. compensation.d. compensation.A person who is speaking about a contender for a significant others affection says in a gushy, syrupy voice, What a lovely person. Thats someone I simply adore. The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial.a. reaction formation.An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regressiona. RationalizationA student says, Before taking a test, I feel a heightened sense of awareness and restlessness. The nurse can correctly assess the students experience as: a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety.d. mild anxiety.A student says, Before taking a test, I feel a heightened sense of awareness and restlessness. The nursing intervention most suitable for assisting the student is to: a. explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. b. advise the student to discuss this experience with a health care provider. c. encourage the student to begin antioxidant vitamin supplements. d. listen without comment.a. explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects.If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. I dont know why it happens. b. I have always had poor impulse control. c. That person should not have provoked me. d. Inside I am a coward who is afraid of being hurt.c. That person should not have provoked me.A patient experiencing severe anxiety suddenly begins running and shouting, Im going to explode! The nurse should: a. say, Im not sure what you mean. Give me an example. b. chase after the patient, and give instructions to stop running. c. capture the patient in a basket-hold to increase feelings of control. d. assemble several staff members and state, We will help you regain control.d. assemble several staff members and state, We will help you regain control.A person who has been unable to leave home for more than a week because of severe anxiety says, I know it does not make sense, but I just cant bring myself to leave my apartment alone. Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.a. Teach the person to use positive self-talk.Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder? a. I check where my car keys are eight times. b. My legs often feel weak and spastic. c. Im embarrassed to go out in public. d. I keep reliving the car accident.a. I check where my car keys are eight times.Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to: a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.c. avoid alcoholic beverages.Which statement is mostly likely to be made by a patient diagnosed with agoraphobia? a. Being afraid to go out seems ridiculous, but I cant go out the door. b. Im sure Ill get over not wanting to leave home soon. It takes time. c. When I have a good incentive to go out, I can do it. d. My family says they like it now that I stay home.a. Being afraid to go out seems ridiculous, but I cant go out the door.A patient has the nursing diagnosis Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. ensuring the health of household members b. attempting to avoid interactions with others c. having persistent thoughts about bacteria, germs, and dirt d. needing approval for cleanliness from friends and familyc. having persistent thoughts about bacteria, germs, and dirtA patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patients symptoms rather than on the patient.b. Encourage the patient to participate in social activities.For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.c. Provide calm, brief, directive communication.Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. asks, Whats the matter with me? b. stays in a room alone and paces rapidly. c. can concentrate on what the nurse is saying. d. states, I dont want anything to eat. My stomach is upset.c. can concentrate on what the nurse is saying.A patient tells the nurse, I dont go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at. The nurse assesses this behavior as consistent with: a. acrophobia. b. agoraphobia. c. social anxiety disorder (social phobia). d. Post-traumatic stress disorder (PTSD).c. social anxiety disorder (social phobia).A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.d. cognitive restructuring.A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication? a. Beta-blockers b. Antipsychotic medications c. Tricyclic antidepressant agents d. Monoamine oxidase inhibitorsa. Beta-blockersA patient tells the nurse, I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why? The nurses reply should be based on the knowledge that buspirone: a. does not produce blood dyscrasias. b. does not cause dependence. c. can be administered as needed. d. is faster acting than diazepam.b. does not cause dependence.A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.a. Use a calm manner and low voice. b. Maintain simplicity in the environment. e. Explain and reinforce reality to avoid distortions.A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder (GAD) who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allow only tyramine-free foods in diet. c. Restrict intake of caffeine. d. Avoid using alcohol and other sedatives. e. Take the medication on an empty stomach.a. Use caution when operating machinery. c. Restrict intake of caffeine. d. Avoid using alcohol and other sedatives.Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. Have you been a victim of a crime or seen someone badly injured or killed? b. Are there certain social situations that cause you to feel especially uncomfortable? c. Do you have to do things in a certain way to feel comfortable? d. Is it difficult to keep certain thoughts out of awareness? e. Do you do certain things over and over again?c. Do you have to do things in a certain way to feel comfortable? d. Is it difficult to keep certain thoughts out of awareness? e. Do you do certain things over and over again?

NURS 410 test 2 (Ch. 4 & 7-11) PQ's

Sets found in the same folder

Other sets by this creator

Verified questions

Other Quizlet sets