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UNTESTED - psych final

Terms in this set (235)

A secondary amine tricyclic antidepressant is prescribed for a patient. The medication will significantly increase the availability of which neurotransmitter?
a. GABA
b. Glutamate
c. Serotonin
d. Norepinephrine

D

Secondary amines increase the availability and enhance the action of norepinephrine. They do have a similar effect on any of the other options.

Nortriptyline was prescribed for a 68-year-old patient diagnosed with depression and insomnia. What assessment question should the nurse ask to determine the effectiveness of nortriptyline?
a. "Are you having regular bowel movements?"
b. "Are you no longer experiencing insomnia?"
c. "Have you been successful with weight loss?"
d. "Would you say you are concentrating better?"

B

Nortriptyline is a secondary amine with a good side effect profile. It is somewhat sedating, which is helpful to patients with insomnia. The other options are not considered outcomes for this medication.

A 75-year-old patient with a long history of depression begins amitriptyline 100 mg/day. The patient also takes a diuretic daily for hypertension. What is the highest priority nursing diagnosis this patient is at risk for?
a. Falls related to dizziness and orthostatic hypotension.
b. Ineffective thermoregulation related to anhidrosis.
c. Infection related to suppressed white blood cell count.
d. Constipation related to slowed gastrointestinal peristalsis.

A

Amitriptyline is a tricyclic antidepressants (TCA) that has a high risk of producing orthostatic hypotension. The patient is placed at even greater risk because of older age and diuretic therapy, which reduces fluid volume. The other options are either unassociated or are remote possibilities.

A depressed patient preparing for discharge is prescribed desipramine and will have follow-up outpatient visits. The patient reports, "Why did they gave me only a 1-week supply of my medicine?" Select the nurse's best reply.
a. "Federal law limits the amount you may be given at any one time."
b. "It will save you money if the drug doesn't work well for your symptoms."
c. "This is a way of ensuring that you will come in for your follow-up appointment."
d. "Prescribing a small amount of drug addresses our concerns for your continuing safety."

D

Desipramine is an activating antidepressant, and it might provide a patient who has suicidal ideation with the energy to make an attempt. Because the therapeutic dose and lethal dose are not widely separated, tricyclic antidepressants (TCA) overdose is an often-used suicide plan. Because desipramine appears to be the most toxic TCA, prescribing only a 7-day supply limits the possibility of using the drug in a suicide attempt. The other options are either less relevant or incorrect.

A patient diagnosed with depression is prescribed the tricyclic antidepressant (TCA) bupropion. What is the benefit of this medication for nonhospitalized patients?
a. It has antianxiety properties as well as antidepressant effects.
b. It lowers the seizure threshold to a lesser extent than TCAs.
c. There is reduced potential for lethal overdose.
d. It stimulates appetite and weight gain.

C

Bupropion has no lethal-overdose potential, making it well suited for use in outpatient treatment of depression. Bupropion has a narrow therapeutic index but is far less lethal than TCAs or monoamine oxidase inhibitors (MAOIs). However, it might cause agitation, anxiety, seizures, anorexia, and weight loss.

A patient diagnosed with depression has taken a selective serotonin reuptake inhibitor (SSRI) for 1 month. The nurse should use direct questions to evaluate which potential side effect?
a. Aggressive impulses
b. Sexual dysfunction
c. Paranoid delusions
d. Weight gain

B

SSRIs often produce sexual dysfunction, such as decreased libido. Patients readily tell nurses about anticholinergic, gastrointestinal, and other side effects, but are not as forthcoming in reporting sexual problems. The nurse might need to ask directly to elicit this information. Patients are more willing to discuss the other options.

A patient prescribed fluoxetine is being changed to tranylcypromine. The nurse provides education on this change that will include a time lapse between the last dose of fluoxetine and the first dose of tranylcypromine of at least how long?
a. 7 days.
b. 14 days.
c. 3 weeks.
d. 6 weeks.

D

Drugs that have a high probability for serious interactions (e.g., monoamine oxidase inhibitors {MAOIs} like fluoxetine) will need to be withheld for up to 6 weeks or more as fluoxetine is washing out of the system. The remaining options are too short an interval.

A patient tells the nurse, "I've stopped taking sertraline because the drug made me impotent. Which statement by the nurse will provide the best patient support?
a. "Your doctor still wants you to continue taking your medication."
b. "Have you talked with your therapist regarding your feelings about sex?"
c. "Let's talk with your doctor. Changing your medication might be a possibility."
d. "Our priority is to treat your depression. Impotence can be addressed in a few weeks."

C

Selective serotonin reuptake inhibitor (SSRI) commonly causes sexual dysfunction. Changing to another type of antidepressant or adding bupropion in small doses can be helpful. The other options are not compassionate or therapeutic.

A tricyclic antidepressant (TCA) is prescribed for a patient newly diagnosed with depression. What information should be included in patient teaching?
a. "Take this medication on an empty stomach."
b. "Do not eat aged cheese while using this medication."
c. "You might experience sweating, tremors, and excessive urination."
d. "It might be 2 weeks or more before you notice the effects of this medicine."

D

Antidepressant effects might take several weeks to be noticeable. Avoidance of tyramine (as is present in aged cheeses) is necessary for monoamine oxidase inhibitors (MAOIs) therapy but not for TCAs. It is not necessary to take TCAs on an empty stomach. Sweating, tremors, and urination problems are not commonly experienced with TCA therapy.

Why do patients taking tricyclic antidepressants (TCAs) exhibit more side effects than patients taking selective serotonin reuptake inhibitors (SSRIs)?
a. TCAs inhibit reuptake of norepinephrine and serotonin.
b. TCAs selectively inhibit dopamine reuptake.
c. TCAs selectively block serotonin uptake.
d. TCAs block enzymatic breakdown.

A

TCAs inhibit the reuptake of both norepinephrine and serotonin and because of their nonselectivity produce many side effects. The other options are incorrect statements about the action of TCAs.

When teaching about the monoamine oxidase inhibitor (MAOI) tranylcypromine, the nurse should consider it a priority to provide what information?
a. A list of tyramine-rich foods
b. A warning to avoid direct sunlight
c. Instructions to manage fever with acetaminophen
d. Directions to report dry mouth and blurred vision

A

MAOIs and ingested tyramine interact to produce hypertensive crisis, a life-threatening medical emergency, so it is necessary to teach the patient foods to avoid. The other options are unrelated to tranylcypromine therapy.

A patient prescribed phenelzine reports a sudden headache and palpitations. What is the nurse's initial intervention when observing the patient demonstrating dilated pupils and diaphoresis?
a. Assess for cogwheel rigidity.
b. Notify the health care provider.
c. Assess the patient's blood pressure.
d. Withhold the morning dose of phenelzine.

C

The patient's symptoms are suggestive of hypertensive crisis. It is vital to know whether or not the blood pressure is elevated, so obtaining the blood pressure is the necessary first action. The most probable reason for the reaction would be drug-food interaction. The nurse may notify the health care provider and withhold the morning dose as subsequent actions. Cogwheel rigidity is associated with antipsychotic medications.

What is the nurse's highest priority when caring for a patient after a tricyclic antidepressant (TCA) overdose?
a. Frequently monitor blood pressure and heart rate/rhythm.
b. Monitor for skin rashes, particularly on the torso.
c. Measure and record intake and output every 12 hours.
d. Institute cooling blankets for hyperthermia.

A

It is necessary to assess cardiovascular function, because cardiovascular reactions can occur suddenly, even several days after the TCA overdose, and can result in acute heart failure. The other options are not as closely aligned with cardiovascular problems.

What is the nurse's priority assessment for a patient taking an antidepressant medication?
a. Presence of suicidal ideations
b. Presence of antiadrenergic side effects
c. Presence of anticholinergic side effects
d. Presence of symptoms of sexual dysfunction

A

Antidepressant medication tends to energize depressed patients, possibly giving them the impetus to act on suicidal ideation that has been present related to the depression. This complication is particularly applicable to adolescents. Some suggest that suicidal ideation might be the actual result of antidepressant therapy. In either case the implication for nursing is clear—patients should be carefully assessed for the presence of suicidal ideation, suicidal plans, and means for carrying out the plans. This option is related to patient safety and takes priority over the other options.

A pregnant patient took selective serotonin reuptake inhibitors (SSRIs) during the third trimester of pregnancy. The newborn will be carefully assessed for which neonatal complication?
a. Temperature dysregulation
b. Serotonin syndrome
c. Seizure disorder
d. Diabetes

B

The neonate whose mother has received SSRIs might experience respiratory depression, hypoglycemia, tremor, and low birth weight as part of neonatal serotonin syndrome. The disorder normally is resolved within 2 weeks of birth. The other options are not usually seen as a result of in utero exposure to SSRIs.

What are the priority history assessments for a patient beginning amitriptyline therapy? (Select all that apply.)
a. Agranulocytosis
b. Seizures
c. Sexual dysfunction
d. Orthostatic hypotension
e. Blurred vision

D, E

Tricyclic antidepressants (TCAs) like amitriptyline produce anticholinergic (blurred vision) and antiadrenergic (orthostatic hypotension leading to falls and arrhythmias) side effects. Gastrointestinal symptoms, sexual dysfunction, and weight variations are related to selective serotonin reuptake inhibitor (SSRI) therapy. Seizures are seen with bupropion therapy. Agranulocytosis is not considered a major problem with any of the groups of antidepressants.

Evaluation of a patient's response after 1 week of tricyclic antidepressant (TCA) therapy would be expected to focus on what assessment question? (Select all that apply.)
a. "Have you noticed a change in your sleep patterns?"
b. "Has your appetite improved?"
c. "Are you still having suicidal ideations?"
d. "Are you feeling less depressed?"
e. "Would you say you are less anxious now?"

A, B, E

Improved appetite is likely due to the antihistaminic effect of the drug. Anxiety reduction is another positive effect of TCAs. Sedation is a therapeutic effect of some of these drugs as well. Neither improvement in mood nor elimination of suicidal ideations are likely to occur for 2 to 4 weeks.

Which assessment finding warrants the nurse's priority attention when caring for a patient prescribed a selective serotonin reuptake inhibitor (SSRI)? (Select all that apply.)
a. Hyperthermia
b. Frontal headache
c. Confusion
d. Photophobia
e. Agitation

A, C, E

The correct response suggests serotonin syndrome, an acute medical problem requiring immediate medical and nursing attention. The distracters are examples of anticholinergic effects and are not considered emergencies.

A nurse teaches a patient taking a monoamine oxidase inhibitor (MAOI) about important dietary guidelines. Which nutritional choices by the patient indicate that the teaching was effective? (Select all that apply.)
a. Sausage
b. Avocados
c. Pork chops
d. Strawberries
e. Chocolate chip cookies

C, D

The patient must avoid foods high in tyramine so as to prevent a hypertensive crisis. Sausage, avocados, and chocolate contain significant amounts of tyramine.

1. Maintenance of a therapeutic serum level of lithium is dependent on adequate serum levels of:
a. sodium.
b. chloride.
c. potassium.
d. magnesium.

ANS: A
It is believed that lithium substitutes for the sodium (Na) ion in neurons. Reductions or increases in Na intake affect the serum lithium level. The other options have not been identified as critical to lithium level.

2. Select the accurate information about the pharmacokinetics of lithium.
a. Wide therapeutic index
b. Excreted by the kidneys
c. Poorly absorbed in the gastrointestinal (GI) tract
d. Provides immediate relief of symptoms

ANS: B
Lithium is excreted via the kidneys. The other options are incorrect. The nursing implication is that individuals with renal damage should not be given lithium or should be monitored closely if lithium must be administered.

3. For 2 weeks a patient has taken lithium (Lithane) and risperidone (Risperdal) daily for mania. The patient now reports diarrhea, vomiting, and blurred vision. The nurse observes a coarse hand tremor. Select the nurse's priority action.
a. Administer a PRN dose of benztropine (Cogentin) to relieve extrapyramidal symptoms (EPSEs).
b. Hold the next dose of risperidone to prevent further drug-drug interaction.
c. Reassure the patient that these side effects will decrease with time.
d. Notify the prescribing physician immediately.

ANS: D
The symptoms the patient is experiencing are consistent with a serum lithium level above the therapeutic level. The nurse should withhold the next dose, arrange for a stat serum lithium level determination, and notify the health care provider. Risperidone can be continued because this is not a drug-drug interaction problem. Administration of benztropine is inappropriate because these are not EPSE symptoms. Reassurance would be appropriate, but the patient should not be told that these symptoms will decrease with time and continued dosing.

4. A patient has taken lithium (Lithobid) 300 mg three times daily for 1 week. The patient reports the presence of fine hand tremors and thirst. Select the nurse's best action.
a. Increase sodium in the patient's diet.
b. Immediately obtain a serum lithium level determination.
c. Comfort the patient that these effects will probably decrease over time.
d. Withhold the lithium until the patient no longer exhibits these side effects.

ANS: C
These side effects are common and often decrease or disappear over time with continued lithium therapy. Dietary sodium should remain unchanged to keep the lithium level stable. These side effects do not suggest the need for determination of a lithium level. Lithium should not be withheld, because these are not toxic symptoms.

5. A patient who has taken lithium for 6 months reports, "I go to the bathroom many times a day and pass large amounts of very pale urine." The nurse's action should be based on the understanding that these symptoms may indicate which problem?
a. Atactic toxicity
b. Uremic syndrome
c. Diabetes insipidus
d. Interstitial nephritis

ANS: C
Symptoms of diabetes insipidus include voiding large amounts of dilute urine many times a day. Nephrogenic diabetes insipidus is caused by the inhibition of the cyclic adenosine monophosphate (cAMP)-dependent action of the antidiuretic hormone on the distal-tubule collecting duct cells. This problem is sometimes associated with lithium therapy. The symptoms detailed are not consistent with any of the other options.

6. Which patient should be assessed most carefully for evidence of lithium toxicity? A patient taking lithium (Lithobid) and:
a. indomethacin (Indocin).
b. risperidone (Risperdal).
c. ziprasidone (Geodon).
d. olanzapine (Zyprexa).

ANS: A
The combination of lithium and indomethacin is more likely to produce lithium toxicity than lithium and any other drug listed. Nonsteroidal antiinflammatory drugs reduce renal elimination of lithium, thereby increasing serum lithium levels.

7. A patient with rapid-cycling bipolar disorder is not responding to lithium therapy. At the next multidisciplinary team meeting, the nurse should point out that many rapid-cycling patients have been effectively treated using:
a. sertraline (Zoloft).
b. phenytoin (Dilantin).
c. benztropine (Cogentin).
d. divalproex (Depakote).

ANS: D
Valproates (like divalproex) are considered first-line agents in the treatment of mania. Valproates are especially effective in the treatment of rapid-cycling bipolar disorders. None of the other drugs mentioned are indicated for treatment of manic states.

8. A patient diagnosed with mania begins lithium therapy on October 1. What is the earliest date a nurse can expect to see clinical improvement in the patient's condition?
a. October 3
b. October 8
c. October 21
d. November 1

ANS: B
Lithium must be given for 7 to 10 days before clinical improvement is achieved.

9. A patient diagnosed with bipolar disorder asks the nurse, "Why can't I take my lithium just once a day at bedtime? It's hard to remember to take it three times." The nurse's reply should be based on what information?
a. The half-life of lithium is short.
b. Renal excretion is greater at night.
c. GI absorption is diminished at night.
d. The toxicity potential increases with once-a-day dosing.

ANS: A
Lithium has a short half-life, high toxicity, and rapid renal excretion, so multiple daily doses are required. The other statements are incorrect or are not factors considered in dosing.

10. A patient has taken lithium (Lithane) 600 mg three times daily for 1 week. A laboratory result in which range shows that the desired serum lithium level was achieved?
a. 0.2 to 0.6 mEq/L
b. 0.6 to 1.2 mEq/L
c. 1.2 to 2 mEq/L
d. 2 to 2.6 mEq/L

ANS: B
Therapeutic serum lithium levels are 0.6 to 1.2 mEq/L. The other options are either too low or too high. Serum levels above 1.5 mEq/L can cause symptoms of toxicity.

11. The nurse scheduling the serum lithium level blood draw for a patient should arrange for it to be obtained:
a. before the first morning dose.
b. 2 hours after the morning dose.
c. at bedtime.
d. any time during the day.

ANS: A
Lithium levels should be drawn 8 to 12 hours after the last dose, making premedication morning blood draws optimal.

12. A patient's serum lithium level is 1.8 mEq/L. Select the nurse's priority action.
a. Restrict fluid intake.
b. Assess for signs of toxicity.
c. Encourage intake of high-potassium foods.
d. Ensure that the patient is swallowing the capsules.

ANS: B
A serum level of 1.8 mEq/L is higher than desirable. It suggests that the patient might be experiencing toxic effects. Clinical assessment should be conducted. A nurse should not rely entirely on laboratory tests but should make careful clinical assessments. None of the other options would be appropriate.

13. A patient has mild lithium toxicity with a serum level of 1.6 mEq/L. Which assessment findings are most likely?
a. Coarse hand tremor, coordination problems, and dizziness
b. Elevated white blood cell count, temperature, and blood pressure
c. Orthostatic hypotension, fainting, and nystagmus
d. Restlessness, shuffling gait, and tics

ANS: A
The symptoms of mild toxicity are often related to central nervous system disturbance. Difficulty concentrating might also be noted. Mild GI disturbances are also seen. The other options are not symptoms of early lithium toxicity.

14. Before beginning lithium therapy, the nurse should educate a patient about laboratory tests to assess for adequate function of which system?
a. Peripheral vascular
b. Reproductive
c. Respiratory
d. Renal

ANS: D
Because lithium is excreted via the kidneys, renal system function must be adequate if lithium toxicity is to be prevented. Functioning of the other systems has no direct relationship to lithium therapy.

15. A patient who is to be discharged on a maintenance dose of lithium should be taught to report which symptoms/signs immediately?
a. Large amounts of dilute urine and blurred vision
b. Nasal congestion and dry mouth
c. Muscle stiffness and anorexia
d. Drowsiness and sweating

ANS: A
Patients must be taught the difference between symptoms of minor toxicity and those of major toxicity, such as giddiness, tinnitus, blurred vision, dilute urine, and ataxia.

16. Teaching for a patient who is to be discharged on a maintenance dose of lithium should emphasize the importance of:
a. keeping appointments for serum lithium level testing.
b. engaging in daily cardiotonic exercise.
c. reporting anticholinergic side effects.
d. maintaining a tyramine-free diet.

ANS: A
Regular evaluation of serum lithium levels will be part of the patient's aftercare for as long as he or she takes lithium. The other items are not included in discharge teaching for a patient taking lithium.

17. The spouse of a patient diagnosed with bipolar disorder tells the nurse, "Every time my partner recovers from a manic episode, depression follows soon. It's very discouraging." The nurse's reply should include what information?
a. As the partner ages, rapid cycling will decrease.
b. Combining lithium with haloperidol (Haldol) might prevent rapid cycling.
c. Depression associated with bipolar disorder is usually time-limited, so treatment is not indicated.
d. Recent addition of olanzapine (Zyprexa) to this patient's drug regime can be helpful as a mood stabilizer.

ANS: D
Olanzapine, an atypical antipsychotic, has proven effective in controlling mania and acting as a mood stabilizer to reduce depression following treatment for acute mania. The other statements are incorrect or irrelevant.

18. For patients with bipolar disorder, valproate anticonvulsants are likely to help control rapid-cycling episodes by:
a. inhibition of kindling activity in the brain.
b. decreasing availability of norepinephrine.
c. increasing dopamine levels at synapses.
d. decreasing GABA metabolism.

ANS: A
The effectiveness of valproate anticonvulsants for management of bipolar disorder may be related to inhibition of kindling activity, which stabilizes neuronal activity and increases the threshold of stimulation necessary for cell firing. There is no current research to support any of the other options.

19. A patient with a long history of multiple sclerosis developed psychosis with acute mania. The nurse should anticipate that the health care provider will probably prescribe which medication to help stabilize the mania?
a. Lithium (Lithobid)
b. Amitriptyline (Elavil)
c. Divalproex (Depakote)
d. Diphenhydramine (Benadryl)

ANS: C
The valproates are first-line drugs for treatment of manic episodes associated with bipolar disorder or resulting from general medical problems. They have a rapid onset and are well tolerated. Lithium takes 7 to 10 days to modify symptoms. Diphenhydramine and amitriptyline have sedative side effects but would not stabilize the mania.

20. Which patient would require careful assessment for toxic effects of lithium? The individual taking lithium and:
a. hydrochlorothiazide (HCTZ).
b. lorazepam (Ativan).
c. clozapine (Clozaril).
d. oxazepam (Serax).

ANS: A
Hydrochlorothiazide is a diuretic used to treat hypertension. The diuretic effect would increase serum concentrations of lithium, potentially producing toxicity. Benzodiazepine and antipsychotic drugs are commonly used concurrently with lithium to control mania.

21. A nurse should schedule a weekly complete blood cell count (CBC) for a patient beginning therapy with which antimanic drug?
a. Lithium
b. Valproate (Depakote)
c. Quetiapine (Seroquel)
d. Carbamazepine (Tegretol)

ANS: D
Agranulocytosis is known to be an occasional but potentially dangerous adverse effect of carbamazepine therapy, hence the need for regular CBCs. The other drugs have a lower risk of causing this effect.

1. Which assessment findings validate that a patient with bipolar disorder is experiencing mania? Select all that apply.
a. Pacing
b. Agitation
c. Drowsiness
d. Delusional thoughts
e. Psychomotor retardation

ANS: A, B, D
Agitation, increased motor activity (pacing), and delusional thoughts may all accompany mania. The patient with mania would have an increased level of alertness rather than drowsiness. Psychomotor retardation would be expected with depression.

2. A nurse prepares to lead a psychoeducational group for patients who take anticonvulsants to manage bipolar disorder. The nurse should invite patients who take which drugs? Select all that apply.
a. Lithium
b. Aripiprazole (Abilify)
c. Lamotrigine (Lamictal)
d. Gabapentin (Neurontin)
e. Carbamazepine (Tegretol)

ANS: C, D, E
Lamotrigine, carbamazepine, and gabapentin are anticonvulsants. Lithium is effective in treatment of bipolar disorder, but it is not an anticonvulsant. Aripiprazole is an antipsychotic medication.

Which account of history and symptoms is most consistent with dysthymia?
a.
Depressed mood for 2 weeks; anhedonia; feelings of worthlessness.
b.
Delusions of guilt and poverty; weight loss; agitation beginning 3 weeks ago.
c.
Depressed mood for 3 months; suicidal ruminations; hypersomnia; sullen affect.
d.
Depressed for 3 years; poor concentration; anhedonia; low-self esteem; indecision.

ANS: D
Dysthymia is a depressive disorder marked by chronicity. The depression must have been present more than 50% of the time for at least 2 years. The other options describe major depression and psychotic depression.

A 74-year-old patient is admitted with anhedonia, weight loss of 20 pounds in 6 weeks, and pervasive guilt over issues that occurred in early adulthood. The patient is diagnosed with melancholic depression. Which intervention has the highest priority for inclusion in the care plan?
a.
Assess history of seasonal variations of mood.
b.
Observe for increased sensitivity to rejection.
c.
Monitor and document sleep patterns.
d.
Assess for echolalia and posturing.

ANS: C
Individuals with the depressive variant of melancholia often display anhedonia, depression worse in the morning, early morning awakening, anorexia and/or weight loss, and inappropriate guilt. It is appropriate to monitor sleep patterns to ascertain if sleep disturbance is present. Homeostasis is contingent on adequate sleep. The distracters are seen in depression with catatonic features, atypical depression, and seasonal affective disorder.

A patient diagnosed with seasonal affective disorder asks, "Will I ever feel better?" Based on understanding of this psychopathology, the nurse's best response is:
a.
"Your depressed mood will probably spontaneously improve in 6 months to a year."
b.
"People with seasonal affective disorder usually feel better in spring and summer, when there are longer periods of light."
c.
"It's important to engage in community activities to improve your depressed mood. Activity stimulates important brain chemicals."
d.
"Most people with seasonal affective disorder feel better during the fall and winter seasons as they experience the pleasure of the holidays."

ANS: B
Seasonal affective disorder is a depression occurring in conjunction with a seasonal change, most often beginning in fall and winter and remitting in spring in the Northern Hemisphere. The correct answer is the only option that reflects the information regarding the seasonal nature of the disorder.

Which adolescent would the nurse consider to have the highest priority for health promotion interventions aimed at reducing risk for depression? An adolescent whose history shows:
a.
parents were killed in an auto accident.
b.
lived with adoptive parents since birth.
c.
allergies to dust, pollen, and mold.
d.
frequent conflicts with siblings.

ANS: A
The events that predispose children and adolescents to develop depression involve loss such as death or separation from parents, death of a close relative, death of a pet, a move to another neighborhood, academic problems, or illness or injury that requires hospitalization. It is the only answer that reflects the relationship of loss to the disorder.

A clinic nurse assesses a new Latino patient who repeatedly complains of feeling nervous and having headaches. No organic pathology is present. The symptoms began about 3 years ago when the patient's parent died. Select the nurse's best first action.
a.
Explore the patient's grief.
b.
Encourage the patient to take frequent rest periods.
c.
Reassure the patient that these feelings are normal.
d.
Screen for additional signs and symptoms of depression.

ANS: D
Latino patients often do not express depression as being related to their mood; rather, they present vague somatic symptoms. Nurses often have good understanding of cultural differences. The nurse should first screen for other signs and symptoms of depression. The patient's feelings are not normal when considered from a cultural viewpoint. Reassuring the patient that the feelings are normal would be nontherapeutic. Exploring grief may come later. Frequent rest periods would isolate the patient who actually needs support.

A patient with depression paces and pulls at clothing constantly. The patient cannot sit for longer than 5 minutes, even at meals. How should the nurse document this behavior?
a.
Perseveration
b.
Hypomanic activity
c.
Catatonic excitement
d.
Psychomotor agitation

ANS: D
Psychomotor agitation is marked by increased, purposeless, repetitive motor activity, often performed with a sense of urgency. The description of the patient's behavior is consistent with this definition, rather than any of the other options.

A patient with depression paces, pulls at clothing constantly, and cannot sit for longer than 5 minutes. The patient ruminates about being a "bad" person. Select the most effective nursing intervention.
a.
Reassure the patient.
b.
Direct the patient to lie down every 2 hours.
c.
Ask the patient to assist in a simple, repetitive activity.
d.
Seek a prescription for a PRN antipsychotic medication.

ANS: C
The psychomotor energy of agitation might be channeled into simple, repetitive activities. Providing an activity that is of value to others can help relieve guilt. As for the other options, the patient will be unable to lie down, global reassurance is ineffective, and an antipsychotic medication is not indicated.

When communicating with a depressed patient with psychomotor retardation, the nurse should:
a.
communicate using yes/no questions.
b.
avoid asking for the patient's preferences.
c.
be prepared to wait for the patient to respond.
d.
encourage the patient to nod if speaking is too difficult.

ANS: C
The patient with psychomotor retardation has slowed thinking and speech, pauses before responding, and uses few words. The nurse should avoid hurrying and/or seeming impatient when interacting with the patient. Allow ample time for the patient to formulate a response and articulate it. The other interventions would be nontherapeutic.

After breakfast, a depressed patient pleads with the nurse, "Please let me go to my room to lie down for a while." The nurse should:
a.
explain that the patient must attend scheduled activities.
b.
bargain with the patient to attend the next activity, then rest.
c.
rearrange the patient's schedule to accommodate the request.
d.
explain that the team will be displeased if the schedule is not followed.

ANS: A
Depressed patients often want to lie down, whether or not they wish to sleep. Solitude permits self-defeating ruminations and should not be encouraged. Kind firmness in helping the patient adhere to the treatment program is necessary. Because the patient has only been up long enough to eat breakfast, rest should not be necessary. Bargaining is not therapeutic. Threatening the team's displeasure is not therapeutic as a motivator.

The nurse sees a depressed patient who has psychomotor retardation leaving the dining room. The patient's shirt is soiled from spilled food. The nurse should:
a.
foster independence by suggesting changing shirts.
b.
ignore the spill to avoid embarrassing the patient.
c.
assist the patient to change into a clean shirt.
d.
notify the patient of the soiled shirt.

ANS: C
A patient with psychomotor retardation might need assistance with hygiene and grooming. It is important for the nurse to help the patient appear well groomed so as to avoid embarrassment. Ignoring the situation is nontherapeutic. The patient should be assisted by staff. The patient might not have the physical energy to respond to a suggestion.

Which nursing diagnosis is almost universally applicable to persons with depression?
a.
Ineffective denial
b.
Disturbed body image
c.
Chronic low self-esteem
d.
Risk for other-directed violence

ANS: C
The overall affective sense of the depressed person is one of low self-esteem. Guilt often accompanies the low self-esteem. Data about depressed individuals do not suggest the applicability of body image disturbance. Denial and risk for violence may or may not be present.

The medical record notes that a newly admitted depressed patient has delusional thoughts. Which statement by this patient is most likely?
a.
"I am a presidential advisor."
b.
"Cancer is rotting my body."
c.
"There are aliens chasing me."
d.
"I discovered a cure for cancer."

ANS: B
Delusions associated with depression are congruent with the depressed mood. They often relate to somatic function or being a bad person, or they focus on faults. The other delusions are more likely to be present in an individual with schizophrenia.

A patient who started a selective serotonin reuptake inhibitor (SSRI) 3 days ago says, "This medicine isn't working." The nurse's best intervention would be to:
a.
explain the time lag before antidepressants relieve symptoms.
b.
reassure the patient that the medication will be effective soon.
c.
critically assess the patient for lessening symptoms.
d.
explore the patient's self-concept.

ANS: A
Antidepressant medications typically have a lag time of 2 to 4 weeks before being maximally therapeutic. A patient should be made aware of this instead of expecting symptom relief within 24 to 48 hours. Global reassurance is meaningless. Symptom abatement would not have occurred. Exploring the patient's self-concept does not address the patient's question.

A patient is to have a dexamethasone suppression test in the morning. Which statement should be included in patient teaching?
a.
"This test will determine whether or not you are clinically depressed."
b.
"This test is like a CT scan. It will take about 20 minutes and will be painless."
c.
"You will be given an injection; then, blood and urine samples will be collected."
d.
"You will not be allowed to eat or drink after midnight, and a fasting blood sample will be collected in the morning."

ANS: C
After the dexamethasone is given, periodic blood and urine samples are collected and sent to the laboratory to determine whether or not cortisol suppression has occurred.

During an interview with a depressed person, it is important for the nurse to assess social interactions to determine:
a.
disruptions in relationships with others.
b.
needs for diversional activities therapy.
c.
needs for implementation of a no-harm contract.
d.
the patient's ability to make decisions about care.

ANS: A
Assessing for altered social interactions will give the nurse information about whether relationships with significant others are intact or disrupted. Often, the depressed person has withdrawn to the extent that formerly supportive relationships have been disrupted, leaving the patient without situational support. Diversional activities are an integral part of management of the therapeutic milieu. The patient's ability to make decisions would be assessed in other ways. A no-harm contract relates to suicidal ideation.

When communicating with a withdrawn, depressed patient who speaks slowly and in monosyllables, the nurse should:
a.
be as cheerful as possible.
b.
use simple, direct sentences.
c.
use silence while assisting the patient.
d.
frequently encourage the patient to elaborate.

ANS: B
The depressed patient is often preoccupied with ruminations and unable to focus on what is being said. Directions should be simple and direct. Cheerfulness emphasizes the emotional distance between the nurse and a depressed patient. Being largely silent suggests disinterest in the patient. Carrying on a stream of "chatter" reduces the patient's opportunity to communicate.

The plan for a depressed patient includes use of cognitive therapy. The nurse supports this therapy by:
a.
uncovering unconscious conflicts by encouraging description of childhood traumas.
b.
challenging pessimistic beliefs and recognizing the patient's accomplishments.
c.
determining areas of mutual understanding between the nurse and patient.
d.
using role playing to rehearse new behaviors.

ANS: B
Depressed patients evaluate situations as being negative. Cognitive therapy aims at symptom removal by identifying and correcting distorted negative thinking. The other options are not directed at correcting negative thinking.

In planning care for a newly admitted patient with depression, what is the nurse's highest priority?
a.
Providing a safe environment
b.
Encouraging expression of feelings
c.
Orienting the patient to the unit milieu
d.
Meeting the patient at an appropriate affective level

ANS: A
Safety is the highest priority. The other interventions are appropriate but of lesser importance than this basic need.

Which statement by a depressed patient confirms the need for suicide precautions?
a.
"God has helped see me through this illness."
b.
"I don't understand why God has abandoned me."
c.
"I believe God will lift the dark cloud of depression."
d.
"I am comforted when I read the Twenty-Third Psalm."

ANS: B
The answer reveals isolation even from God. When such profound isolation is experienced, the person might consider suicide as an option to relieve the emotional pain of illness. The other options relate to a sense of hope.

A nurse involved in a research study for biologic markers of depression will expect to prepare patients to undergo which diagnostic procedures?
a.
MRI, CBC, and TSH tests
b.
PET scan and a waking EEG
c.
Sleep EEG, DST, and TSH tests
d.
GABA suppression test and 5-HT serotonin ratio

ANS: C
Several biologic markers are being studied to advance understanding of depression. These include sleep EEGs to determine the role of decreased REM latency, DST, and TSH test to determine the role of hypothalamic-pituitary-adrenal dysregulation. Two options refer to actual diagnostic tests, but these tests are not being used to investigate depression. The last option refers to tests that are not actual tests.

This nursing diagnosis is documented for a depressed patient: situational low self-esteem, related to recent divorce, as evidenced by self-deprecatory statements and blaming self for marriage failure. Identify the best short-term outcome. Within 4 days, the patient will:
a.
state that both partners had faults for the failed marriage.
b.
express angry feelings toward the estranged spouse.
c.
list expected effects of antidepressant medication.
d.
have significantly improved self-esteem.

ANS: A
Outcomes should target the assessment findings and be measurable; in this instance, self-blame and self-deprecation. Progress will be evident when the patient is able to state that both partners had faults in the marriage. Expressing angry feelings toward the spouse does not relate directly to the patient's self-blame. An improved self-esteem is not measurable as stated. Antidepressant medication is unrelated to the diagnosis.

Which entry in the medical record best indicates that the treatment plan for a depressed patient was successful?
a.
Gained 2 pounds; sleeping 8 hours nightly; states, "I'm feeling better about my life situation."
b.
Weight stable; sleeping 6 hours nightly; complains of frequent abdominal pain and headache.
c.
Gained 6 pounds; sleeping 10 hours nightly; sensitive to interpersonal conflicts.
d.
Lost 2 pounds; sleeping 5 hours nightly; shows minimal interest in activities.

ANS: A
The correct entry suggests that weight, sleep pattern, and mood are returning to normal. The other entries suggest that symptoms of depression continue to be present.

A depressed patient has just responded to the nurse in an overtly angry manner. Select the nurse's best response.
a.
"I seem to have hit a raw nerve. I'm sorry."
b.
"You are angry. Let's talk about the issue."
c.
"Please watch your tone of voice when you speak to me."
d.
"I don't think I deserved to be shouted at. What's really the matter?"

ANS: B
To be of maximal benefit to the patient, anger should be accepted and explored. Apologies by the nurse are unnecessary. The other options are defensive and rigid reactions.

A patient says, "The doctor said I have dysthymic disorder." What priority assessment data should the nurse obtain to confirm the diagnosis?
a.
Changes in appetite and weight
b.
Presence of suicidal ideation
c.
How long symptoms have persisted
d.
Presence of delusions or hallucinations

ANS: C
The major distinguishing factor between MDD and dysthymic disorder is the fact that dysthymic disorder has persisted for 2 years or more, with low mood occurring more than 50% of the time. It is a disease of chronicity, whereas MDD is a disease of severity. Suicidal ideation can be present in any type of depression. Delusions and hallucinations are noted primarily in psychotic depression.

The sibling of a depressed patient says, "When we were children, my sister always gave up easily. Now as an adult, everyone in the family takes advantage of her." What is the most appropriate nursing intervention?
a.
Begin cognitive therapy to reduce negative thinking.
b.
Plan measures to reduce inappropriate feelings of guilt.
c.
Discuss the value of assertiveness training with the patient.
d.
Invite the sibling to join the patient's group therapy sessions.

ANS: C
Depressed patients often allow people to violate their rights, and then feel resentful or angry. Assertiveness training will help the patient change her interpersonal style from acquiescent to assertive and reduce resentfulness. Cognitive therapy and working on guilt feelings will not address the passive behavior. It would not be appropriate to include the sibling in the patient's group therapy.

Which topics should be included by the nurse preparing psychoeducational groups for patients with major depressive disorder and their families? Select all that apply.
a.
Flight of ideas
b.
Changes in weight and sleep
c.
Feelings of importance or elation
d.
Psychomotor retardation or agitation
e.
Inability to concentrate or make decisions

ANS: B, D, E
Patients with MDD characteristically display weight change—anorexia produces weight loss, and excessive eating produces weight gain. Sleep disturbance is characteristically present in MDD, with many or early awakenings and hypersomnia seen. Changes in activity include psychomotor retardation and excessive motor agitation. Indecision and poor concentration are characteristic cognitive symptoms. Flight of ideas and increased energy, importance, and elated mood are seen in bipolar disorder, manic type.

A caregiver tells the nurse at the mental health clinic, "My parent has changed over the past 2 months. Decision making is almost impossible. My parent sits and stares in space all day. There has been a 12-pound weight loss." What additional assessment data should the nurse gather to determine whether the depression is primary or secondary to another problem? Select all that apply.
a.
Cultural heritage
b.
Medical problems
c.
List of current medications
d.
Alcohol and/or substance use
e.
Presence of suicidal ideation strategies

ANS: B, C, D, E
Depressive symptoms in older adults might be caused by a variety of medical illnesses, including dementia, and by a variety of medication side effects. Alcohol and substance abuse might be a causative factor in the appearance of depression. Increased stressors suggest that this might be depression caused by MDD. Suicidal ideation is important to assess regardless of cause, because older adults are at increased risk for suicide. If depression is secondary to another cause, the primary cause is treated and the depression might improve. If the depression is primary, treatment for depression should be instituted. The nurse is often the individual who elicits important history. Cultural factors would have less bearing on causation.

A nurse can reduce the potential for experiencing negative feelings toward severely depressed patients by: Select all that apply.
a.
understanding the part neurotransmitters play in depression.
b.
disregarding empathic information originating in the patient.
c.
reducing focus on personal feelings toward the patient.
d.
establishing realistic expectations for patients and self.
e.
asking patients to explain why depression developed.

ANS: A, D
Patients should understand that neurotransmitter dysfunction is a greater causative factor in depressive symptoms than patient choice. Keeping expectations realistic decreases feelings of helplessness and contributes to the maintenance of self-esteem. Self-assessment of feelings toward the patient is appropriate and necessary. Awareness of empathic messaging originating in the patient is essential because it is a clue to what the patient is experiencing. Most patients do not know why depression developed.

1. Which indicator of disordered communication is the nurse most likely to assess in a patient having a manic episode?
a. Loose associations
b. Flight of ideas
c. Echolalia
d. Mutism

ANS: B
Flight of ideas is a continuous flow of speech marked by jumping from topic to topic. The other options are most likely to be assessed in patients with schizophrenia.

2. A patient at the clinic describes periods of sadness and depression as well as episodes of elation over the past 3 years. The patient adds, "Fortunately, I have been able to keep my job despite these mood changes." These findings are most consistent with which disorder?
a. Bipolar I
b. Bipolar II
c. Cyclothymic
d. Seasonal affective

ANS: C
Cyclothymic disorder is characterized by mood swings between hypomania and depressive symptoms, with behavior at the poles being less severe than mania or depression. The patient's ability to remain employed indicates that the periods of elation were hypomania rather than mania. The patient's description does not meet criteria for any of the other options listed.

3. Which principle is most useful and effective when interacting with a patient experiencing a manic episode?
a. Encourage the patient to freely express feelings.
b. Use a calm, matter-of-fact approach.
c. Do not interrupt the patient.
d. Frequently use silence.

ANS: B
A calm, matter-of-fact approach minimizes the need for the patient to respond defensively and avoids power struggles. Using this approach, the nurse conveys both control of the situation and empathy. The other options are not principles related to therapeutic interactions with a patient experiencing a manic episode. The distracters allow for manipulation of the nurse and for the patient to control the interaction.

4. A nurse assesses a new patient experiencing a manic episode. Which behavior is most likely to have occurred before hospitalization?
a. Watching others closely but avoiding interaction
b. Taking frequent rest periods during the day
c. Going rapidly from one activity to another
d. Remaining in the home for long periods

ANS: C
There is increased physical and mental activity exhibited during a manic episode. Moving rapidly from one activity to another is characteristic behavior during a manic episode. The other behaviors mentioned are not consistent with what occurs during a manic episode.

5. A patient diagnosed with bipolar I disorder says, "I will lead the next group about medications. I have studied all the effects and problems with drugs on the Internet, so I can answer patients' questions." How should the nurse document this finding?
a. Flight of ideas
b. Distractibility
c. Limit-testing
d. Grandiosity

ANS: D
Grandiosity is reflected when the individual makes statements that show an inflated sense of self-worth. Flight of ideas refers to rapidly shifting topics of conversation. Limit-testing refers to attempting to override the structure of the milieu. Distractibility refers to inability to maintain concentration when environmental stimuli shift.

6. The nurse prepares to take vital signs for a patient experiencing mania. What is the nurse's best intervention when the patient's talking interferes with the assessment?
a. Use a voice volume louder than the patient's to say, "Stop talking now."
b. Interrupt by saying, "It's time to take your vital signs now."
c. Delay taking the vital signs until the patient is quieter.
d. Wait tolerantly for the patient to finish talking.

ANS: B
There are times when the nurse must simply, calmly, and firmly interrupt a manic patient. Waiting is counterproductive. Yelling at the patient and delaying necessary assessments are inappropriate.

7. During community lunch, a manic patient tells another patient, "Push yourself away from the table. You're too fat for your own good!" How should the nurse intervene?
a. Say to the patient, "You may remain at lunch only if you apologize."
b. Tell the patient, "You must leave lunch and go to your room now."
c. Calmly tell the patient that insulting others is not permitted.
d. Extinguish the behavior by ignoring it.

ANS: C
The nurse must protect vulnerable patients and keep them from being drawn into the manic patient's angry behavior. By stating that the behavior is not permitted, the nurse sets limits and does not enter into an argument. The distracters will further anger the patient, may cause escalation, or may allow for loss of control

8. Within a 15-minute period, a patient having a manic episode voices these complaints. "Dinner was cold. The bath towels are rough. The solarium is too hot. I have a sore throat. Another patient needs a shower. The medication nurse is too slow." The nurse should:
a. listen but ignore the patient's complaints.
b. tell the patient to use the suggestion box.
c. assess the patient's throat, and take vital signs.
d. invite the patient to share the concerns at the community meeting

ANS: C
The hypercritical manic patient offers so many complaints that it is easy to discount his or her concerns. Legitimate complaints should always be investigated, however. By listening and ignoring complaints, the nurse might fail to intervene to provide care. Telling the patient to use the suggestion box or asking him to share his complaints at the community meeting are placating and may anger the patient.

9. A patient diagnosed with bipolar disorder is laughing and giddy one minute and seconds later is angry and sarcastic. How should the nurse document the patient's mood?
a. Incongruent
b. Inappropriate
c. Blunted
d. Labile

ANS D
Lability refers to rapid mood shifts, often seemingly without provocation. This is the only term that fits the description given in the scenario.

10. When a hyperactive, aggressive patient with bipolar disorder threatens to beat up another patient, the initial nursing intervention should be to:
a. provide firm verbal limits.
b. place the patient in seclusion.
c. ask the patient, "Why are you so angry?"
d. distract the patient with diversional activities.

ANS: A
Unless a physical attack has taken place, verbal limit-setting should precede the use of more restrictive measures.

11. A medication teaching plan for a patient receiving lithium should include:
a. directions to eat one or two bananas daily.
b. dietary teaching to limit daily sodium intake.
c. the need to restrict daily fluid intake to 1000 ml.
d. the importance of laboratory testing to monitor the lithium level.

ANS: D
Maintaining serum lithium levels within 0.6 and 1.2 mEq/L is vital to symptom control. The patient must be made aware that frequent monitoring will foster symptom control and prevent toxicity. The other options are inappropriate in a teaching plan.

12. The spouse of a patient diagnosed with bipolar I disorder says, "We want to have children, but I worry they could inherit this problem. There is also bipolar disorder on my side of the family." What is the nurse's most appropriate action?
a. Direct the couple to seek genetic counseling.
b. Encourage the couple to consider adopting children.
c. Encourage the spouse to discuss options with a spiritual advisor.
d. Educate the spouse about environmental determinants of bipolar disorder.

ANS: A
The nurse's advice should be based on knowledge that there appears to be a genetic role in the cause of bipolar disorder. Genetic counseling will provide the couple with the best possible basis for decision making. The other options will not provide the information that the couple needs to make an informed decision.

13. A newly admitted patient is experiencing a manic episode. The patient is verbally and physically aggressive. The plan for care should include:
a. setting clear limits, providing a quiet environment, and limiting activities.
b. avoiding use of antipsychotic drugs for 24 hours and providing nourishment ad lib.
c. orienting to unit activities, encouraging gross motor activity, and watching television.
d. avoiding confrontations by not enforcing limits and encouraging physical exercise at bedtime.

ANS: A
Stimuli should be reduced to provide a simple, quiet, and nonstimulating environment. Clear limits should be explained in as few words as possible, and then maintained. Gross motor activity should be limited to prevent exhaustion, and exercise should not be encouraged at bedtime. Quiet activity is more conducive to initiating sleep. Intake should be monitored and food and fluids encouraged to compensate for the higher energy expenditure of the patient. Antipsychotic drugs will probably be needed to reduce activity and aggressiveness.

14. A nurse presents a psychoeducational program to patients with bipolar disorder and their families. Information about signs of impending relapse of mania should include:
a. diarrhea, thirst, and gross tremor.
b. sleep disturbances and racing thoughts.
c. decreased libido, anhedonia, and hypersomnia.
d. delusional thinking, excessive guilt, and passivity.

ANS: B
Relapse symptoms are congruent with early symptoms of a manic episode. They include sleeping less, experiencing racing thoughts, and having boundless energy. Diarrhea, thirst, and tremor relate to lithium side effects. Libido increases. Delusional thinking may occur in an exacerbation of the illness but not usually before relapse.

15. A nurse presents a psychoeducational program to patients with bipolar disorder and their families. Information about signs of impending relapse of depressive episode should include:
a. diarrhea, thirst, and gross tremor.
b. sleep disturbances and racing thoughts.
c. decreased libido, anhedonia, and inertia.
d. anorexia, excessive guilt, and aggression.

ANS: C
Relapse symptoms are congruent with early symptoms of a depressive episode. They include decreased libido, loss of pleasure, and lack of energy. Sleeping less, experiencing racing thoughts, experiencing aggression, and having boundless energy suggest impending mania. Diarrhea, thirst, and tremor relate to lithium side effects.

1. A nurse teaching about bipolar disorder should inform patients and their families of possible depressive symptoms. Which symptoms should the nurse include? Select all that apply.
a. Passivity
b. Aggression
c. Hyperactivity
d. Psychomotor retardation
e. Preoccupation with death

ANS: A, D, E
The symptoms of a bipolar depressive episode are often atypical, such as those consistent with the atypical depressive symptoms of major depressive disorder. They include preoccupation with death, psychomotor retardation, and passivity.

2. What are the best menu selections for lunch for a hyperactive patient during a manic episode? Select all that apply.
a. Cherry pie
b. Macaroni and cheese
c. Chocolate chip cookies
d. Tossed salad with ranch dressing
e. Roast beef sandwich on whole-grain bread

ANS: C, E
A hyperactive patient experiencing a manic episode is often too overactive to sit and eat, so the nurse must provide food that can be eaten out of hand while the patient walks around. A sandwich and cookies provide protein, carbohydrates, fat, and fiber.

3. A patient is hospitalized with new onset of manic behavior. It would be important for the nurse to inspect and report results of which laboratory tests? Select all that apply.
a. Calcium
b. Creatinine
c. Potassium
d. Drug screens
e. Thyroid function

ANS: A, D, E
Medical conditions may cause mania, including hypercalcemia, hyperthyroidism, and selected drugs of abuse, particularly stimulants. Steroids may also produce mania.

1. Which statement accurately applies to personality disorders?
a. One aspect of personality is usually involved.
b. Personality traits are dysfunctional and inflexible.
c. Patients have subjective distress, but not impaired functioning.
d. Symptoms have a short duration and are responsive to treatment.

ANS: B
Patients with personality disorders suffer lifelong inflexible and dysfunctional patterns of relating and behaving. The patient experiences subjective distress, usually based on others' reactions to him or her, and functioning is impaired. More than one aspect of personality is involved: personality disorders are described as pervasive. Behaviors are complex and difficult to manage.

A patient demonstrating borderline personality disorder says, "When I met him, he was perfect and gave me everything. Now I know how bad he really is. He left me alone tonight to go out with others, so I had to cut myself." Which feature is evident?
a. Splitting
b. Paranoia
c. Grandiosity
d. Submissiveness

ANS: A
Splitting involves the inability to integrate the good and bad aspects of an object, so her boyfriend is seen as perfect or entirely bad, not as a person with some traits that she likes and some that she dislikes. Paranoid tendencies involve feelings of persecution. There is no indication that the patient is submissive or grandiose.

A patient has had long-term conflicts with two siblings over their parents' wills. The patient reacts quickly with anger, suspicious that the siblings are plotting to take all the inheritance. These characteristics are most consistent with which personality disorder?
a. Schizoid
b. Paranoid
c. Borderline
d. Narcissistic

ANS: B
The characteristics mentioned in the scenario fit the description of paranoid personality disorder. Schizoid personality is characterized by shyness, withdrawal, and poor social relationships. Borderline personality is characterized by problems with identity, self-image, mood, and impulsivity. Narcissistic personality is characterized by self-importance, grandiosity, and a sense of entitlement.

The nurse working with a patient diagnosed with borderline personality disorder expects:
a. grief and social isolation.
b. withdrawal and social avoidance.
c. mood shifts, impulsivity, and manipulation.
d. seductiveness, grandiosity, and overreaction.

ANS: C
Characteristic behaviors of individuals with borderline personality disorder include rapid mood shifts, impulsive acting out, and manipulation of others, as well as problems with identity, dependency, self-mutilation, and unstable, intense interpersonal relationships.

A nurse caring for a person diagnosed with schizoid personality disorder expects which assessment findings?
a. Impulsive, restless, socially aggressive behavior
b. Few interactions with others; little verbalization
c. Magical thinking; suspicious, odd behavior
d. Distrustful, cold, often angry behaviors

ANS: B
Individuals with schizoid personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The distractors characteristically apply to antisocial personality disorder, schizotypal personality disorder, and paranoid personality disorder

Which characteristic of individuals diagnosed with personality disorders in the dramatic-erratic cluster makes it advisable for staff to have frequent patient-centered meetings?
a. Manipulating others to avoid limits
b. Behaving responsibly in the peer group
c. Withdrawing from interactions with others
d. Depending excessively on others for support

ANS: A
The group of dramatic-erratic personality disorders includes antisocial and borderline personality disorders. These patients are particularly skillful at manipulating others to get their needs met. The distracters list characteristics that would not require frequent meetings

7. A clinic nurse encounters a new patient diagnosed with schizoid personality disorder. What is the best initial nursing intervention?
a. Set firm limits.
b. Engage in trust building.
c. Involve the patient in group activities.
d. Encourage identification of feelings.

ANS: B
Trust building is essential to developing a nurse-patient relationship. Firm limit-setting is rarely necessary when working with a patient with schizoid personality disorder. Involvement in activities might be difficult at first, because the patient will be highly uncomfortable around people. The patient must trust the nurse before responding to encouragement to express feelings.

When contrasting schizophrenia and schizotypal personality disorder, which statement applies?
a. In schizotypal personality disorder, the patient remains psychotic much longer.
b. The patient with schizophrenia has better social skills and is not usually overtly psychotic.
c. The person with schizotypal personality disorder may have cognitive distortions but not psychosis.
d. Schizotypal personality disorder is associated with more frequent and prolonged hospitalizations

ANS: C
The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, overt psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, have poorer social skills, and have more frequent and prolonged hospitalizations.

A distinctive characteristic in a patient with antisocial personality disorder is:
a. feelings of guilt and remorse.
b. disregarding the rights of others.
c. responsiveness to antipsychotics.
d. responsiveness to kind suggestions

ANS: B
Individuals with antisocial personality disorders have no concern for what is right or wrong or for the rights of others. They frequently violate others' rights and frequently break laws in their "me first" thinking. These individuals exhibit no guilt or remorse, show no improvement from antipsychotics, and walk all over anyone who is not able to set firm limits.

An adult has a history of intoxication and promiscuity. After stealing money from a grandparent, this person says, "I deserved that money. My family had no right to press charges against me." The scenario depicts features of which personality disorder?
a. Histrionic
b. Narcissistic
c. Antisocial
d. Borderline

ANS: C
Individuals with antisocial personality disorder have no concern for what is right or wrong or for the rights of others. They frequently violate others' rights and frequently break laws in their "me first" thinking. These individuals exhibit no guilt or remorse. Narcissistic personality disorder is characterized by grandiosity and a sense of entitlement. Borderline personality disorder is characterized by identity disturbances, impulsivity, self-mutilation, and affective instability.

Since admission, a patient diagnosed with antisocial personality disorder has been highly manipulative and constantly tests staff. Now, the patient insists on watching a late movie instead of complying with the bedtime. Select the nurse's best response.
a. "It's a unit rule that bedtime is at 10 PM."
b. "I will not allow you to manipulate me again."
c. "If you ask again, tomorrow's bedtime will be 9 PM."
d. "I understand your sleep problems and can allow it just this once."

ANS: A
Attempts at manipulation can be successfully handled by firm, matter-of-fact reiteration of unit policies and consistently adhering to them. The other responses are defensive, retaliative, or permissive.

A patient diagnosed with borderline personality disorder has demonstrated self-mutilation and inappropriate expressions of anger. Which statement by the patient would the nurse evaluate as an improvement?
a. "I think you are the nicest nurse on the unit."
b. "I got drunk last night, but I won't ever do it again."
c. "I felt like cutting myself, so I came to talk to you."
d. "I hate my friends. They never help me when I need it."

ANS: C
Ordinarily, the patient would impulsively engage in self-mutilation. When he or she is able to delay the action and seek the more adaptive coping strategy of talking with the nurse, the nurse can correctly evaluate the patient as showing improvement. The other responses suggest use of idealization, manipulation, impulsive behavior, and devaluation, all symptomatic of the disorder.

The history of an individual diagnosed with borderline personality disorder often includes:
a. the loss of a parent at an early age.
b. a family history of bipolar disorder.
c. a dysfunctional, abusive childhood.
d. an overindulged childhood with few limits.

ANS: C
There is no clear-cut cause for borderline personality disorder. It is probably multifactorial. Environmental factors include childhood neglect and abuse. Biologic theories suggest neurotransmitter dysregulation. Object losses, family history of bipolar disorder, and overindulgence as a child have not been identified as causative facto

Which nursing intervention is most likely to result in heightened self-awareness for a patient diagnosed with a personality disorder in the dramatic-erratic cluster?
a. Setting firm limits on behavior
b. Providing clear expectations for acceptable behavior
c. Using confrontational approaches to reduce self-mutilation
d. Encouraging the patient to keep a daily journal to be shared with the nurse

ANS: D
Patients can be helped to understand themselves and their feelings by keeping a journal. Sharing the journal with the nurse fosters greater understanding and a sense of autonomy and responsibility. The other options do not heighten self-awareness.

Characteristic behaviors a nurse would expect when working with a patient diagnosed with narcissistic personality disorder are:
a. preoccupied with details; perfectionism.
b. socially isolated; odd, eccentric behavior.
c. dramatic expression; easily influenced by others.
d. grandiosity; sense of entitlement; lack of empathy

ANS: D
The individual with narcissistic personality disorder displays grandiosity about self-importance and achievements, does not empathize or understand the feelings of others, exhibits a sense of entitlement, and expects special treatment. The other options reflect characteristics of histrionic personality disorder, obsessive-compulsive personality disorder, and schizotypal personality disorder

A person loves being the center of attention. Recently this person sustained a paper cut on a finger and called an ambulance. The patient says, "I can't believe my supervisor denied my sick leave request." This individual most clearly displays traits of:
a. dependent personality disorder.
b. histrionic personality disorder.
c. antisocial personality disorder.
d. borderline personality disorder

ANS: B
Individuals with histrionic personality disorder dramatize all events and draw attention to themselves. Patients might use somatic complaints to avoid responsibility and support dependency

Patients diagnosed with dependent personality disorders behave submissively and cling to others. What is the best explanation of this behavior?
a. The patients are afraid of being alone or functioning without direction.
b. The patients adhere to strict standards and fear failure.
c. The patients have little regard for the rights of others.
d. The patients are suspicious of the motives of others.

ANS: A
The individual with a dependent personality disorder has a pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviors. The other options are characteristic of individuals with obsessive-compulsive personality disorder, antisocial personality disorder, and paranoid personality disorder.

When caring for a patient diagnosed with dependent personality disorder, the nurse should positively reinforce which behavior?
a. Choosing which clothing to wear
b. Asking another patient for advice
c. Sitting next to the nurse at a community meeting
d. Concealing anger with a family member

ANS: A
Dependent patients find it difficult to make even simple decisions. They often ask advice; thus, independently choosing their own attire is a behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable.

19. Personality traits most likely to describe a patient diagnosed with obsessive-compulsive personality disorder are:
a. friendly; generous.
b. dramatic; impulsive.
c. perfectionist; inflexible.
d. suspicious; submissive.

ANS: C
The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with this personality disorder.

Which behaviors are expected in patients diagnosed with avoidant personality disorders?
a. Social aptitude; risk taking
b. Promiscuity; impulsiveness
c. Shyness; poor self-confidence
d. Attention seeking; helplessness

ANS: C
Individuals with avoidant personalities desire relationships but keep their anxiety at a low level by avoiding situations in which they might experience rejection. They are timid, uncertain, and often withdrawn. The other options describe behaviors that would not be seen in patients with avoidant personality disorder.

Select the best outcome for a patient with schizotypal personality disorder. The patient will:
a. adhere willingly to program norms.
b. introduce himself or herself to a stranger in a social situation.
c. report decreased incidence of impulses to self-mutilate.
d. demonstrate fewer attempts at splitting or manipulating staff.

ANS: B
Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal personality disorder usually have no issues with adherence to unit norms, nor are they self-mutilating or manipulative.

A psychiatric technician says, "I get annoyed with patients who self-mutilate over things other people would ignore. I think they just do it to get attention." Select the nurse's best response.
a. "Many people feel the way you do. If you are unable to come to terms with the issue, we can transfer you."
b. "Self-mutilation is a serious problem. Patients with this personality disorder may complete suicide."
c. "We have to consider each case individually. Some are manipulative, and others are serious."
d. "You seem to be having difficulty empathizing and remaining nonjudgmental."

ANS: B
Every patient is entitled to respectful care. The nurse must respond by teaching the psychiatric technician that what he considers a minor problem is actually a major mental health problem. The nurse should identify the risk for completed suicide. The other options do not capitalize on this teaching opportunity.

Which behaviors create interpersonal relationship problems for an individual diagnosed with narcissistic personality disorder? Select all that apply.
a. Grandiose self-importance
b. Sense of entitlement
c. Lack of empathy
d. Risk taking
e. Shyness

ANS: A, B, C
The individual with narcissistic personality disorder has difficult interpersonal relationships because of characteristic behaviors and tendencies toward grandiose self-importance, a sense of entitlement, and lack of empathy. Evidence does not suggest the other characteristics as behaviors or traits of individuals with this personality disorder

2. A patient diagnosed with borderline personality disorder impulsively self-mutilates and has severe mood lability with explosive outbursts, poor interpersonal relations, and inability to sustain employment. Which referrals should the nurse consider for the patient? Select all that apply.
a. Dialectic behavior therapy
b. Alcoholics Anonymous
c. Vocational rehabilitation
d. Desensitization therapy
e. Anger management

ANS: A, C, E
Referral to dialectic behavior therapy will address self-mutilation and interpersonal relations and might address mood lability. Vocational counseling can help with employment problems. Assertiveness training and anger management will address the explosive outbursts. Desensitization therapy is used for patients with phobias. There is no evidence of alcohol abuse.

14. A nurse cares for a man diagnosed with pedophilia. Medroxyprogesterone acetate was prescribed. One month later, which statement by the patient indicates that the medication is having a therapeutic effect?
a. "I feel a lot less depressed since taking this drug."
b. "My sexual desire has practically disappeared."
c. "I can sustain an erection longer than before."
d. "There's no pain during intercourse now."

ANS: B
Medroxyprogesterone acetate is an antiandrogen. When testosterone is reduced, sexual desire is decreased. The statement that sexual desire has "practically disappeared" suggests that the medication is having the desired effect. The distracters are unrelated to the desired effect of this drug.

1. When considering the definition of pedophila, which individuals are at highest risk of being sexually victimized by a 25-year-old pedophile? (Select all that apply.)
a. Male, age 15
b. Male, age 12
c. Female, age 13
d. Female, age 8
e. Either gender, age 5

ANS: B, D, E
By definition, the victim of pedophilia must be younger than 13 years old, and the pedophile must be 16 years old or older and at least 5 years older than the victim. Pedophilic behavior can be expressed for opposite-sex children, same-sex children, or both.

2. A school nurse uses a participative approach to teach about safety to a group of third graders. Which questions should the nurse pose to the students? (Select all that apply.)
a. "What would you do if a stranger told you to get in his or her car because your parents were hurt?"
b. "If you were playing on the Internet, and someone invited you into a private chat room, what would you do?"
c. "If your parents told you that your pet was hurt, would you go with them to the veterinarian?"
d. "Has anyone ever touched you in a way that embarrassed or frightened you?"
e. "Which members of your family can you trust?"

ANS: A, B
Teaching about the risk of sexual misconduct is important for school-age children. Trickery, bribes, and the Internet are sources of potential danger. It would not be appropriate to ask students in a group setting if they had been inappropriately touched or which family members were trustworthy.

3. A nurse assesses a patient recently diagnosed with pedophilia. Which assessment findings are most likely to be identified? (Select all that apply.)
a. History of childhood sexual abuse
b. Antisocial personality traits
c. Limbic system abnormalities
d. An endocrine disorder
e. Grandiosity

ANS: A, B, C
Pedophiles commonly have a history of sexual abuse, limbic system abnormalities, and traits of some personality disorders. Endocrine problems are not associated with pedophilia. Self-confidence is lacking; grandiosity would not be expected.

1. Paraphilia is defined as involving what behavior?
a. Engaging in homosexual sexual behaviors
b. Having difficulty maintaining a sexual arousal
c. Feeling discomfort with one's biological sexual gender
d. Experiencing climax only when sexual behavior is illegal

ANS: D
Paraphilias are conditions in which the sexual instinct is expressed in ways that are socially prohibited or unacceptable or are biologically undesirable. The distracters characterize other sexual behaviors.

2. Which characteristic fits the profile of an individual who is a pedophile?
a. Homosexual
b. High self-esteem
c. Seeks access to children
d. Self-confident and expressive

ANS: C
It is known that pedophiles usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilia.

3. A patient's medical record documents sexual masochism. Which behavior supports this diagnosis?
a. Arousal is possible only when masturbating with women's underwear.
b. Organism is achieved by inflicting pain on a sexual partner.
c. Sexual pleasure is a result of sexually humiliated by a partner.
d. Arousal results from the sexual touching of a nonconsenting person.

ANS: C
Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.

4. While volunteering at a homeless shelter, a nurse observes a known pedophile leaving the restroom with a small child. Select the nurse's priority action.
a. Report the observation to authorities by the child abuse hotline.
b. Protect the child without interacting with the perpetrator.
c. Notify staff of the homeless shelter to address the situation.
d. Continue to observe the interaction and document findings.

ANS: A
In every state, nurses are mandated reporters of child abuse. The nurse is obligated legally and morally to report the incident so that proper authorities can follow up. The distracters do not fulfill the nurse's ethical or legal responsibilities.

5. Prior to working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care would require what personal characteristic?
a. Sympathy
b. Assertiveness training
c. Sexual self-awareness
d. Effective communication

ANS: C
Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distracters are not prerequisites.

6. A patient approaches the nurse in the clinic waiting room and says, "I want to talk to you about a sexual matter." The nurse can best facilitate the discussion by providing which response?
a. "Let's go to my office."
b. "I want to help. Go ahead. I'm listening."
c. "Let's schedule an appointment with more time."
d. "Let's move to a private area in the waiting room."

ANS: A
A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. Offering to schedule an appointment blocks communication.

7. A man experiencing premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner. Can you help me?" What is the nurse's best response?
a. "Sex therapy is not my specialty, but I will try to help."
b. "I can refer you to a practitioner with experience regarding this problem."
c. "Have you asked your health care provider for prescription medication?"
d. "There are several techniques described in this pamphlet that might be helpful."

ANS: B
The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurse's role.

8. A pedophile receiving treatment tells the nurse, "I feel so guilty and shameful over molesting a child. My family will be so disgusted with me. I could save them from embarrassment if I were gone." What is the nurse's priority action?
a. Set limits on the patient's disclosures.
b. Further assess the patient's suicidality.
c. Administer a PRN medication for anxiety.
d. Explore the patient's feelings of guilt and shame.

ANS: B
Patients who describe guilt, shame, and the idea that others would be better off without them are suicide risks. The nurse should further assess the patient's comments, document, report the data, and consider the need for suicide precautions. The other options do not fully consider the primary issue of patient safety.

9. Contemporary cultural rejection of certain sexual behaviors is determined primarily based on what characteristic of the sexual act?
a. Involving coercion rather than consent
b. Associated with homosexual contacts
c. Using artificial devices
d. Resulting in orgasm

ANS: A
Sexual acts that are forced on another are considered both morally and legally unacceptable. The other options are used less often as evaluation criteria.

10. A 10-year-old boy is diagnosed with gender identity disorder. Which assessment finding would the nurse expect?
a. Having tea parties with dolls
b. A compromised sexual response cycle
c. Identifying with other boys who are athletic
d. Intense urges to watch his parents having sex

ANS: A
An individual with gender identity disorder feels trapped in the body of the "wrong" gender and at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender identity disorder.

15. A nurse cares for a patient demonstrating paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors by decreasing libido?
a. Selective serotonin reuptake inhibitor (SSRI)
b. Erectile dysfunction medication
c. Atypical antipsychotic
d. Mood stabilizer

ANS: A
SSRIs are reported to have a positive effect on paraphilia since they can cause decreased libido, impair orgasms, and interfere with ejaculation. The other medications are not indicated for this disorder.

16. The clinic nurse sees a patient with a long-standing diagnosis of pedophilia who was recently arrested and released on bail. Which perspective about pedophilia would the nurse expect from this patient?
a. Extreme remorse for traumatizing a child to meet his or her own needs.
b. Desire to be placed in jail to prevent acting on the sexual impulses.
c. The belief that the child was given valuable knowledge and pleasure.
d. A feeling of victimization related to genetic and environmental factors.

ANS: C
Individuals with pedophilia frequently do not believe that their behavior is harmful to the child. Instead, they point to having provided teaching and pleasure for the child. The other options are not characteristic of the thinking of the pedophile.

17. The clinic nurse sees a new patient with vague sexual complaints. Select the best question for the nurse to help the patient express these concerns more clearly.
a. "What are your concerns and feelings about your sexuality?"
b. "Patients are frequently embarrassed to talk about sexuality."
c. "Don't be embarrassed. Our conversation is completely private."
d. "As a clinician, I am accustomed to talking to patients about personal matters."

ANS: A
Individuals with sexual concerns may need help and support to express the problem. Approaching the subject directly is most appropriate. The patient is not concerned with the problems of other patients or the nurse's level of comfort.

18. A senator develops a sexual relationship with a 20-year-old receptionist. Which adjective most likely applies to this relationship?
a. Harmonious
b. Consensual
c. Coercive
d. Illegal

ANS: C
Relationships between powerful and less powerful persons usually have a coercive element. They are not illegal unless the less powerful person is a minor. The relationship may be harmonious and consensual in the minds of the involved parties.

11. A man tells the nurse, "I have trouble maintaining an erection." This comment indicates which possible sexual disorder?
a. Erectile disorder
b. Desire disorder
c. Pain disorder
d. Orgasm disorder

ANS: A
In sexual erectile disorders, the individual cannot maintain the physiologic requirements for sexual intercourse. The patient's statement does not provide data to suggest one of the other options.

12. Which behavior would relevant to a potential diagnosis of Exhibitionism?
a. Engaging in "Peeping Tom" behaviors
b. Going out in public dressed as a member of the opposite gender
c. Exposing one's genitalia while in a movie theater
d. Engaging in strangulating behaviors to enhance sexual pleasure

ANS: C
Exhibitionism is obtaining sexual pleasure from exposing one's genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. The primary characteristic of transvestic disorder is sexual arousal derived from cross-dressing or dressing as the opposite sex. Sexual masochism sometimes involves erotic asphyxiation as a means of enhancing arousal.

13. An adult who exposed himself to a group on strangers tells the nurse, "I had just lost my job and was afraid; I just did it without thinking". Which intervention would have the greatest benefit for this person?
a. Stress management
b. Problem-solving
c. Sex education
d. Social skills

ANS: A
Because the individual demonstrated the exhibitionistic behavior during a period of increased stress, providing stress management would be beneficial. The other interventions may be acceptable but would not have the relevance that stress management would have.

14. School nurses should be particularly vigilant for signs of eating disorders related to what timeline?
a. Fourth-graders who have never attended another school.
b. Rebellious, aggressive girls at any age.
c. Pre and post holidays and prior to summer break.
d. At transitions between elementary, middle, and high school.

ANS: D
Junior high and high school students are at particular risk for eating disorders, based on our culture's emphasis on thinness and the adolescent's need for peer approval. Stress makes the adolescent more vulnerable. Times of particular stress are moving from one school to another—thus, the need for vigilance on the part of the school nurse. Risk is lower in the other options since stress is not generally associated with these characteristics.

1. Which assessment findings related to the same patient help confirm a diagnosis of anorexia nervosa? (Select all that apply.)
a. Patient reports amenorrhea for 9 months
b. Patient is 5 feet 4 inches tall and weighs 85 lb
c. Blood pressure (BP) 70/42 mm Hg
d. Skin turgor is poor
e. Pulse 68 beats/min

ANS: A, B, C, D
Data confirming amenorrhea, low weight related to height, hypotension and poor skin turgor are consistent with the medical diagnosis of anorexia nervosa. A pulse rate of 68 beats/min is low normal.

2. What priority nursing assessments should be made early in the refeeding process for a patient with anorexia nervosa? (Select all that apply.)
a. Vital signs
b. Skin integrity
c. Peripheral edema
d. Lung and heart sounds
e. Level of consciousness

ANS: A, C, D, E
If refeeding results in too rapid weight gain, the cardiovascular system might be compromised, giving rise to symptoms such as pulse irregularities, peripheral edema, abnormal heart sounds, and moist lung sounds. Alterations in oxygenation and cardiac perfusion would produce changes in the level of consciousness. Changes in skin integrity would not be a priority.

1. Which assessment finding would the nurse document as subjective evidence of anorexia nervosa?
a.
Presence of lanugo on body
b.
Bradycardia notes upon regular assessment
c.
25-lb weight loss over 3-month period
d.
Patient states fear of gaining weight

ANS: D
Fear of weight gain is a subjective symptom, because it is voiced by the patient. The distracters are objective signs.

2. A patient diagnosed with anorexia nervosa has the nursing diagnosis imbalanced nutrition, less than body requirements, related to inadequate food intake. What is an appropriate long-term goal of the treatment plan for this patient?
a. Gain 1 to 3 lb weekly.
b. Exhibit fewer signs of malnutrition.
c. Restore healthy eating patterns and normalize weight.
d. Identify cognitive distortions about weight and shape.

ANS: C
The goal directly related to the nursing diagnosis is to restore healthy eating patterns and normalize weight. The distracters are short-term or vague or are not directly related to the nursing diagnosis.

3. The nurse interviews a patient who restricts food and is 25% underweight. When the patient says, "I still need to lose weight. I'm not thin enough" which defense mechanism is being implemented?
a. Rationalization
b. Projection
c. Splitting
d. Denial

ANS: D
When the individual with anorexia nervosa insists that being 25% underweight is not a problem (and thinking that she is too fat, when in fact she is emaciated), the defense mechanism responsible is denial. Rationalization involves making excuses, projection involves blaming others, and splitting involves the inability to integrate good and bad in one concept.

4. What should the nurse consider as the initial step in the nurse-patient relationship for a patient diagnosed with anorexia nervosa?
a. Formulate the nurse-patient contract.
b. Place limits on the family involvement in treatment.
c. Identify a therapeutic group of similar aged patients.
d. Use confrontation to establish boundaries and limits.

ANS: A
Trust is the foundation to the nurse's effectiveness. A contract is formulated early in therapy to give the patient the opportunity to participate in treatment. This increases the patient's sense of control. By establishing contractual behavioral limits, manipulation and power struggles can be minimized. Recommending a therapeutic group and using confrontation to attack denial are later interventions. Family members are encouraged to take part actively in the treatment of the patient.

5. A patient diagnosed with anorexia nervosa spills milk over a plate of partially eaten food. What is the nurse's best response to facilitate effective patient care?
a. "That won't work. You are manipulating."
b. "You are deliberately making mealtime difficult."
c. "I will get you a fresh plate of food so you can finish."
d. "You must eat your meal. I'll wait until you finish."

ANS: C
Patients with anorexia nervosa often use strategies to hide food, spill food, or discard it to avoid eating. The nurse can best handle these behaviors with nonjudgmental confrontation and adherence to established limits. Only the correct answer is a nonjudgmental response. The other options are judgmental or punitive.

6. A nurse planning care for a patient diagnosed with bulimia nervosa should recommend the use of what for therapy?
a. Psychodynamic group therapy.
b. Cognitive-behavioral therapy.
c. Pharmacotherapy.
d. Psychodrama.

ANS: B
Research findings indicate that cognitive-behavioral therapy is effective in the treatment of both anorexia nervosa and bulimia nervosa. There is no evidence to suggest that the other options are as useful.

7. Which personality characteristic would the nurse expect in a patient diagnosed with an eating disorder?
a. Grandiosity
b. Impulsivity
c. Perfectionism
d. Suspiciousness

ANS: C
Often, the individual with an eating disorder is seen as compliant, perfectionist, introverted, and having self-esteem and relationship problems. The other characteristics are rarely seen among patients with eating disorders.

8. Which information about a patient diagnosed with bulimia nervosa should the nurse document as subjective data?
a. Scarred fingers
b. Sores around mouth
c. Loss of tooth enamel
d. Feeling out of control

ANS: D
The distracters represent objective data, whereas the correct answer reflects feelings the patient has revealed.

9. A nurse teaches a class about bulimia nervosa to high school biology students. The nurse should provide what neurotransmitter process as a possible cause of this eating disorder?
a. Hypersensitivity of norepinephrine
b. Excessive dopamine activity
c. Overproduction of GABA
d. Serotonin deficits

ANS: D
Based on a few research studies, current thinking suggests that deficits in serotonin might play a role in bulimia nervosa. There is no research to support the correctness of any of the other options.

10. Which finding indicates that a patient diagnosed with anorexia nervosa has met a major objective of psychotherapeutic management?
a. The patient's residual volume is less than 30 mL before tube feedings.
b. The patient says, "I am no longer fearful of gaining weight."
c. The patient reads cookbooks and plans nutritious meals.
d. The patient weighs 90% of average body weight.

ANS: D
The three objectives are increasing self-esteem, increasing weight to 90% of average body weight, and re-establishing appropriate eating behavior. Reading cookbooks or planning nutritious meals may be evidence of manipulation. A low residual volume simply indicates that the patient is utilizing the feedings and there is no intestinal obstruction. Lack of fear does not translate to proper eating or an improved self-esteem.

11. A patient diagnosed with an eating disorder asks to be excused from a meal to use the restroom. What is the nurse's best response to the patient's request?
a. "No one is permitted to leave the table during meals."
b. "You may go after you've finished your meal."
c. "I will go with you to the restroom."
d. "No. I know you want to vomit."

ANS: C
Close observation is necessary to prevent patients with eating disorders from purging during and after meals. Patients should be accompanied to the bathroom and observed while in the bathroom to prevent purging. Bargaining, lying, and judgmental confrontation are not appropriate responses.

15. What assessment finding supports a diagnosis of anorexia rather than bulimia?
a. Body weight near normal for height
b. Fluid and electrolyte imbalances are present
c. Engages in strenuous exercise daily
d. Eating disorder begin at age 14

ANS: D
Anorexia tends to begin at an earlier age than bulimia. Engaging in strenuous exercise can occur in both disorders. The other options related to bulimia rather than anorexia.

16. A patient diagnosed with bulimia nervosa has not responded to psychotherapeutic management. The health care provider is likely to prescribe a drug from which classification?
a. Mood stabilizer
b. Selective serotonin reuptake inhibitor (SSRI) antidepressant
c. Typical antipsychotic
d. Monoamine oxidase inhibitor antidepressant

ANS: B
There is some evidence that SSRIs might be effective as adjunctive treatment of bulimia. The other drugs would not be considered appropriate.

17. A patient diagnosed with an eating disorder refuses to be weighed and says, "I just drank a big glass of water." What is the nurse's best response to the patient's comment?
a. "Call me after you have emptied your bladder."
b. "Being weighed today is not negotiable."
c. "I will weigh you tomorrow."
d. "You know the rules."

ANS: B
This response is matter-of-fact and reinforces the established limits. The distracters allow the patient to manipulate the nurse, are overly controlling, or use bargaining.

18. A nurse assesses a 25-year-old man with a suspected eating disorder. Which comment is most likely from this patient when the nurse asks about the patient's sexuality?
a. "I just don't have much of a sex drive anymore."
b. "I'm here because my girlfriend is worried about how much I exercise."
c. "I am sexually active, but I sometimes have trouble maintaining an erection."
d. "I've been involved in a satisfying relationship with my girlfriend for 3 years."

ANS: A
In anorectic men, low sex drive and low testosterone levels might be the equivalent of amenorrhea in female patients. None of the remaining options reflect this concern.

19. One bed is available on the inpatient eating disorders unit. Assessment findings for four patients are listed as follows. Which patient has priority for admission?
a. Weight decreased from 150 to 102 lb in 4 months. Vital signs are T 96.9°F; P 46 beats/min; BP 68/48 mm Hg. Amenorrhea for 8 months.
b. Weight decreased from 110 to 86 lb in 4 months. Vital signs are T 97.5°F; P 60 beats/min; BP 80/66 mm Hg. Amenorrhea for 2 months.
c. Weight decreased from 120 to 90 lb in 3 months. Vital signs are T 98°F; P 50 beats/min; BP 70/50 mm Hg. Menstruation scant for 3 months.
d. Weight decreased from 90 to 78 lb in 5 months. Vital signs are T 97.7°F; P 62 beats/min; BP 74/52 mm Hg. Menstruation irregular for 6 months.

ANS: A
Physical findings indicative of an acute status include amenorrhea for 3 consecutive menstrual cycles, weight loss more than 30% of body weight within 6 months, hypothermia, pulse less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

12. A nurse is engaged in psychoeducational activities with a hospitalized teenage patient diagnosed with bulimia nervosa. What response should the nurse provide when a patient asks, "What should I do when I feel the need to vomit?"
a. "Do vigorous aerobic exercise until the urge goes away."
b. "Seek out a staff member to talk about your feelings."
c. "Call your parents on the phone to show you care."
d. "Allow yourself to vomit, but avoid purging."

ANS: B
Resistance to the urge to vomit or purge can be strengthened by reporting it to a nurse and talking about the feelings that the individual experienced before the urge and the feelings being experienced presently. Once feelings are identified, the patient can begin to work on alternate coping strategies. The other options are not helpful.

13. To meet DSM-V criteria for bulimia nervosa, the patient's history must reveal episodes of binge eating and compensatory behaviors occurring at least how often?
a. Once a week for 6 months
b. Once weekly for 3 months
c. Three times weekly for a year
d. Four times weekly for 6 months

ANS: B
Bulimia nervosa is characterized by three behaviors: recurrent episodes of binge eating, continuing inappropriate compensatory behaviors to avoid weight gain, and an evaluation of self that is significantly influenced by body weight and shape. These behaviors must be present an average of at least once per week, for a minimum of 3 months according to the DSM-V criteria.

1. During the impact stage of response to a violent crime, which nursing interventions would be appropriate for a victim? (Select all that apply.)
a. Provide physical safety.
b. Use empathetic responses.
c. Distract the patient with humor.
d. Provide clear, simple directions.
e. Support expression of feelings.

ANS: A, B, D, E
Because the individual experiences disorganization during the impact stage, the nurse must provide for safety and security via use of empathy, encourage expression of feelings, and provide simple clear directions. Humor might be helpful in the reorganization stage, not the impact stage.

2. Which interventions should a nurse include in the plan of care for a woman who has been physically abused by a partner for 10 years? (Select all that apply.)
a. Be objective and nonthreatening.
b. Help the victim to assess strengths.
c. Make referrals contingent on leaving the abuser.
d. Inform the woman that marital counseling is rarely effective.
e. Help the victim recognize that the perpetrator's behavior is abusive.

ANS: A, B, E
An objective, nonthreatening approach builds trust. Identifying the perpetrator's behavior as abusive is honest and supports the seriousness of the behavior. Helping the victim assess strengths will be necessary if the patient is to see herself as having sufficient resources to leave the abusive relationship. The distracters are nontherapeutic. Referrals should never be offered contingently. Marital counseling should be supported, if that is what the victim chooses. It might help reduce guilt feelings when the victim leaves the relationship.

1. For a victim of spousal abuse, a deterrent to leaving the abusive situation are the events that occur in which stage?
a. Tension building
b. Honeymoon
c. Processing
d. Battering

ANS: B
In the honeymoon stage the perpetrator is apologetic and kind, attempting to undo the harm of the battering incident. The perpetrator promises never to repeat the battering. The events occurring in the other options would not be deterrents to leaving. The processing stage is not an actual stage in the cycle.

2. A woman who has been repeatedly abused by her partner comes to the emergency department with severe contusions. She tells the nurse, "I was almost killed me this time. I need to do something." What is the nurse's priority intervention?
a. Document the woman's injuries.
b. Help the patient devise a safety or escape plan.
c. Encourage the patient to take independent action.
d. Provide referrals contingent on the patient leaving the abuser.

ANS: B
Individuals who are victims of partner abuse should have an escape plan. This is of high priority when the victim's life is endangered. Encouraging the victim to take independent action is of less help than offering concrete assistance such as providing referrals and giving emergency phone numbers. Referrals should never be contingent on leaving, which might be possible only after the victim has made use of the referral and has assistance in place. Documentation is important, but not the nurse's first action.

3. Which intervention would be most therapeutic as a nurse provides initial care for a client who was abused by their partner?
a. Validate the truthfulness of the victim's comments.
b. Avoid pressuring the victim or disparaging the abuser.
c. Acknowledge the victim's inability to change the situation.
d. Allow the partner to stay with the victim during an interview.

ANS: B
Nurses should never pressure a victim to leave the abuser. The patient must make the decision without coercion. Leaving is dangerous, because it escalates the violence and might result in death. Neither should the nurse disparage the perpetrator. The victim still cares about the batterer. The nurse should ask directly about abuse. The nurse should not suggest that the individual is unable to take constructive action. The patient should have a safe environment, without the abuser, to discuss the events. The nurse should not question the truthfulness of the victim's complaints.

4. A survivor of childhood abuse is hospitalized following an episode of wrist cutting. The patient has a history of binge/purge eating disorder as well as difficulty trusting and relating to others. What is the nurse's priority intervention?
a. Set limits on self-harmful behavior.
b. Foster belief in and valuing of family unity.
c. Confront abnormal eating patterns and self-mutilation.
d. Encourage discussion of personal responsibilities associated with abuse.

ANS: A
Setting limits on self-mutilating behavior or purging is necessary to provide for the safety needs of the patient. Individuation should be fostered. The victim should not be encouraged to accept any personal responsibility for the abuse. The patient is aware of the eating patterns and self-mutilation; confrontation will not build trust.

5. A woman accompanied by her domestic partner is being assessed for reports of neck pain. When the nurse notes a bald spot on the client's scalp, the woman explains that she caught her hair in a door, which pulled it out and caused her neck injury. What is the nurse's best action to facilitate the assessment?
a. Ask the client if she prefers her partner to stay during the examination.
b. Require the partner to stay in the waiting room when the woman is examined.
c. Call hospital security to have them stand by to prevent violence.
d. Report the situation to local law enforcement authorities.

ANS: B
The victim's explanation of being injured does not sound plausible. The nurse should suspect partner abuse. Regarding the other options, the victim and perpetrator must be separated to permit the victim the privacy to discuss what has really happened to her. It is unlikely that the perpetrator will act out when he can be observed by others. It is too early to involve the local police.

6. The nurse is establishing treatment goals for a person who was a victim of mind control and physical abuse. What is the initially focus goal for this individual?
a. Making independent personal decisions
b. Repressing emotions experienced during the abuse
c. Re-establishing relationships with support persons
d. Using desensitization strategies to restore equilibrium

ANS: C
Relationships with family and former friends are invariably disrupted based on the victim's inability to trust. Re-establishing relationships would be the first step toward reorganization. Later, the victim will be able to make independent decisions for herself. Repression and desensitization are not the initial desirable outcomes since the client needs to work on reintegrating into the world.

7. A male victim of gang rape comes to the emergency department. The victim is severely anxious, but the nurse will not be able to care for the patient for at least 20 minutes based on the current patient load. How can the nurse best meet the client's needs?
a. Assigning a female nursing assistant to remain with the patient in a private cubicle
b. Assigning a male nursing assistant to help the patient undress in a private cubicle
c. Directing hospital security personnel to monitor the patient in the waiting room
d. Notifying law enforcement authorities of the situation immediately

ANS: A
The patient should be moved from the waiting room to a cubicle as quickly as possible. He needs the reassuring presence of a woman who can reduce the fear of further sexual abuse. Assigning a man would probably increase his anxiety to panic level. The initial priority would be to care for the patient rather than notifying law enforcement.

8. The nurse cares for a client who experienced a violent assault and battery attack. When considering the need to communicate with the client, what is the most therapeutic intervention?
a. Discourage expression of feelings until the victim enters the recoil stage.
b. Demonstrate empathetic communication techniques.
c. Educate the victim about strategies to avoid attacks in the future.
d. Maintain a matter-of-fact manner, and remain objective.

ANS: B
Victims of violence require the nurse to provide unconditional acceptance of them as individuals, because the victim often feels guilty and engages in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and promote establishment of trust.

9. A nurse plans care for a client who in the recoil phase of trauma recovery. What assessment question addresses a common focus of this phase?
a. "Are you having nightmares about the trauma you experienced?"
b. "Does it feel like the abuse happen to someone else?"
c. "Is there anyone you blame for putting you in that situation?"
d. "What are your fantasies about getting revenge on your abuser?"

ANS: D
In the recoil stage, emotional stress is high as the individual strives to come to terms with what has happened. Fantasies of revenge for the crime are natural during this stage. The initial reaction to a single-event trauma usually lasts a few minutes to a few days. Occasionally, the victim's reaction might include dissociative symptoms (amnesia, depersonalization, numbing, detachment), intrusive memories (nightmares, flashbacks), and severe anxiety. Disorganization may be a reaction in the impact stage. The beginning of this phase includes making sense of what happened and why ("Why me?"); attributing blame to self, others, or

10. Which comment by the nurse would best support relationship building with a client who has experienced partner abuse?
a. "It's normal to feel violated, because you thought you could trust your partner."
b. "I'm here for you. I want you to tell me about the bad things that happened to you."
c. "I'm very worried about you. I know you were living in a potentially violent situation."
d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

ANS: A
The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship build on acceptance. None of the other options would help the patient feel accepted.

11. The nurse is preparing a care plan for a client who experienced abuse by a domestic partner. It is most important to include a long-term outcome that addresses what client need?
a. Moving from the individual from victim to survivor status
b. Providing a support groups for emotional assistance
c. Using empathy to establish rapport and build trust
d. Shifting blame for the incident from patient to perpetrator

ANS: A
Moving from victim to survivor status is a process that can go on for months to years. It involves integrating the memories of the trauma and moving on in life with restored functioning, a reasonable sense of safety and security, healthy relationships, and improved self-esteem. The other needs can usually be met in the short term.

14. The emergency department triage nurse should assign to initially care for a female client who has been raped?
a. Social worker with good communication skills
b. Male nursing assistant who is tall and caring
c. Nurse who is efficient and attentive to detail
d. Soft-spoken and empathetic nurse

ANS: D
The female rape victim might be frightened of or reluctant to interact with men, so a female nurse is preferable. The patient should not be made to feel hurried or pressured, but needs to feel nurtured and understood. A social worker is not necessarily trained to address the physical or emotional issues created by a rape.

15. What assessment data supports the possibility that the sexual abuse is incestual in nature?
a. The abuse began when the client was 10 years old.
b. The abuser was the client's uncle.
c. The client's parents were aware that the abuse occurred.
d. The abuse involved only fondling.

ANS: B
Sexual abuse can involve anyone as the abuser, but incest refers to a family member. None of the other options sufficiently demonstrate the criteria required of incest.

16. A woman demonstrating characteristics of "battered woman syndrome" should be asked which assessment question to identify a comorbid psychological condition?
a. "Have you ever been sexually abused?"
b. "Have you ever been diagnosed with major depression?"
c. "Would you say you experience anxiety on a regular basis?"
d. "Are you aware of the condition known as posttraumatic stress disorder (PTSD)?"

ANS: D
Many of the symptoms of battered woman syndrome correspond to the symptoms of PTSD; however, battered woman syndrome has additional symptoms not delineated as part of PTSD (e.g., depression, low self-esteem, self-blame, fatalism). It is not related to the other options.

17. A patient, who reported being raped 2 hours ago, provides a medical history and assessment coherently, quietly, and calmly in a monotone voice. How should the nurse assess this behavior?
a. A delayed reaction to the trauma
b. Indicative of ego integrity
c. Evidence she is denying the rape occurred
d. Employment of the defense mechanism of sublimation

ANS: A
In the impact stage of trauma response, the individual might appear quite normal because the reality of the attack has not yet "registered." The emotional response might be delayed for hours or even days. The other options are not plausible. In psychology, sublimation is a mature type of defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior; denial is evidenced by a complete rejection that the event ever occurred. Ego integrity would indicate the client has accepted the event and moved on with life.

18. A mother and her two children are in the emergency department for treatment of trauma experienced when the woman's husband physically abused her and the children. What is the nurse's priority intervention?
a. Conduct a detail medical history on both mother and children.
b. Focus on physical safety and emotional security of mother and children.
c. Discuss the mother's legal rights in this situation.
d. Discuss the legal obligation to notify the Child Protection Services.

ANS: B
During the impact stage, the victim is acutely aware of the danger she has just escaped. Believing that the next beating could be fatal might provide incentive to take constructive action. The nurse can assist the victim to begin to consider a plan for escape when the next beating seems imminent and can provide information about resources. The remaining options are appropriately addressed after future safety is discussed.

19. Which assessment findings would prompt a nurse to suspect that a 15-year-old patient may be a victim of serial ritual abuse?
a. Lying in a fetal position; echolalia; body rocking
b. Multiple scars and burns; missing teeth; fear of being examined
c. Scarred index finger; tooth enamel erosion; sores around mouth
d. Acting-out behaviors; verbal aggression; arrested for grand larceny

ANS: B
Scarring, burns, and missing teeth fit the picture of ritual abuse. The fear of examination relates to having to remove clothes in preparation for torture. The distracters are more consistent with schizophrenia, bulimia nervosa, and antisocial personality disorder.

20. A patient comes to the clinic for the fifth time in a month with vague complaints of not feeling well. The nurse notices fresh bruises on the patient's upper body. Which assessment question should take priority?
a. "How much do you drink each day?"
b. "Are you annoying to anyone?"
c. "Did anyone hurt you?"
d. "Have you fallen?"

ANS: C
When the nurse suspects abuse, it is appropriate to speak directly to the issue. Two distracters are presumptuous and blaming. The other distracter offers a ready-made excuse for the bruises.

21. An adult in the emergency department has wrist slashes, suggesting self-mutilation. The patient's history reveals alcohol and drug abuse, binge eating, and unstable interpersonal relationships. Which history should the nurse suspect?
a. Rape trauma
b. Partner abuse
c. Serial ritual abuse
d. Childhood sexual abuse

ANS: D
Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in patients who were sexually abused as children and have repressed the trauma. These behaviors are not as closely aligned with any of the distracters.

22. A 15-year-old patient is seen for evaluation by court order. The parents seek to have this teen declared incorrigible because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize that these behaviors often occur in adolescents who have what experience?
a. Childhood sexual abuse
b. Antisocial personality disorder
c. Early onset schizophrenia
d. Ritual physical abused

ANS: A
Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in teens who are sexually abused. These behaviors are not as closely aligned with any of the other options.

12. What statement made by a client accused of sexual abuse is characteristic of the primary motivation for most rapes?
a. "I was so nervous I just couldn't stop myself."
b. "I know a lot of men who act the same way."
c. "She wanted the sex, she just didn't want to say so."
d. "She is such a tease; I needed to teach her a lesson."

ANS: D
Rape is not a crime of sex, but rather a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

13. When working with clients who have experienced rape, what should immediate care focus upon?
a. Collecting evidence for legal purposes
b. Notifying law enforcement to initiate a search for the rapist
c. Helping the client feel both physically and emotional safe
d. Documenting the victim's comments for future reference in care planning

ANS: C
The focus of care is first helping the victim feel safe. Assessment questions and the physical procedures often seem as intrusive violations of privacy, and even physically threatening to an already vulnerable individual. The remaining options are best addressed after the basic need for safety and security are met.

1. Which factor presents the most imminent risk for the development of a childhood psychiatric disorder?
a.Having an uncle diagnosed with schizophrenia
b. Living in a low-income family
c. Being the oldest child in a family
d. Living with an alcoholic parent

ANS: D
Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Neither being in a low-income family nor being the oldest child are considered psychosocial adversity situations. While having an extended family history of schizophrenia presents a risk, the negative childhood events associated with having an alcoholic parent present a higher level of risk.

2. Which behavior indicates that the treatment plan for a 5-year-old child diagnosed with autistic disorder has been effective?
a. Is content to play with one toy for hours.
b. Repeats words spoken by a parent.
c. Holds the parent's hand while walking.
d. Finds enjoyment in clapping his or her hands while walking.

ANS: C
Holding the hand of another person suggests relatedness. Usually, a child with autism would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The other options reflect behaviors that are consistent with autistic disorder.

3. A kindergartener is disruptive to the class. This child is unable to sit for expected lengths of time, inattentive to the teacher, and aggressive toward others, bursting out talking while the teacher is talking. Other children shun this child. The nurse plans interventions designed to address which of the child's needs?
a. Provide inpatient treatment for the child.
b. Reduce loneliness and increase self-esteem.
c. Improve language and communication skills.
d. Promote individuation and integration of self-concept.

ANS: B
Because of their disruptive behaviors, children with attention-deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These same behaviors lead peers to avoid the child with ADHD, who seems reckless and impulsive, and can rarely finish games, leaving the child with ADHD vulnerable to loneliness. The other options might or might not be relevant but are not the priority. The child does not need inpatient treatment at this time.

4. A nurse will prepare teaching materials regarding which drug for the parents of a child diagnosed with ADHD?
a. Paroxetine
b. Imipramine
c. Methylphenidate
d. Carbamazepine

ANS: C
Central nervous system (CNS) stimulants are the drugs of choice for treating children with ADHD. Methylphenidate and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD.

5. A desired outcome for a 12-year-old diagnosed with autism spectrum disorder (ASD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care?
a. Reality therapy
b. Social skills group
c. Response prevention
d. Insight-oriented group therapy

ANS: B
Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser to no impact on peer relationships.

6. Which finding necessitates immediate nursing action for a child being treated for depression with a selective serotonin reuptake inhibitor (SSRI)?
a. A weight gain of 10 lb in 4 weeks
b. Repeatedly hitting a younger sibling
c. Frequently reports being tired and just wanting to sleep
d. Has fallen three times as a result of "being dizzy"

ANS: B
Selective serotonin reuptake inhibitors (SSRIs) are frequently used in children and adolescents. Some aggressive and out of control behaviors, and even suicidality have been linked to these serotonin-enhancing drugs. The other drug side effects are associated with tricyclic antidepressants.

7. A child being treated for which medication has a high risk for suicide and should be monitored closely?
a. Depression with fluoxetine
b. ADHD with methylphenidate
c. Bipolar disorder with aripiprazole
d. Asperger disorder with social skills training

ANS: A
The child being treated for depression with fluoxetine is at risk for behavioral activation, a drug side effect. Increased suicide risk is part of the behavioral activation complex. The drugs mentioned in the other options do not place the individual in the same risk category as fluoxetine.

D

8. The parent of an 8-year-old says, "My child is in constant motion, talking all the time but is out of bed every morning before I am and into trouble." This description supports which mental health diagnosis?
a. Bipolar disorder (BPD)
b. Disruptive mood dysregulation disorder (DMDD)
c. Oppositional defiant disorder (ODD)
d. Attention-deficit hyperactivity disorder (ADHD)

ANS: D
The excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest the other possible choices. oppositional defiant disorder (ODD) in children and adolescents is defined as a pattern of angry/irritable mood symptoms. Bipolar disorder (BPD) in children differs from the adult type in that irritability is a more prominent symptom, and there are often high rates of co-occurring attention problems and anxiety. The diagnosis of disruptive mood dysregulation disorder (DMDD) was established in DSM-5 to help account for youngsters who are very irritable or angry much of the day, nearly every day, and who have severe recurrent temper outbursts.

9. A child diagnosed with attention-deficit hyperactivity disorder (ADHD) had this nursing diagnosis—impaired social interaction, related to excessive neuronal activity, as evidenced by aggressiveness and dysfunctional play with others. Which finding indicates the plan of care was effective?
a. Improved ability to identify anxiety and use self-control strategies.
b. Increased expressiveness in communication with others.
c. Engages in cooperative play with other children.
d. Increased responsiveness to authority figures.

ANS: C
The goal should be directly related to the defining characteristics of the nursing diagnosis; in this case improvement in the child's aggressiveness and play. The distracters are more relevant for a child with pervasive developmental disorder or anxiety disorder.

10. In the waiting room a 5-year-old child diagnosed with attention-deficit hyperactivity disorder (ADHD) bounces out of a chair, runs over to another child, and slaps the other child. What action implemented by the nurse would be most effective in therapeutically managing the situation?
a. Direct the aggressive child to stop immediately.
b. Call for emergency assistance from other staff.
c. Instruct the parents to take the child home.
d. Take the child to another waiting area.

ANS: D
The nurse should manage the milieu with structure and limit-setting. Removing the aggressive child to another waiting area is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency situation. Intervention is needed rather than sending the child away.

11. A child diagnosed with attention-deficit hyperactivity disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications prescribed to help manage the associated behaviors?
a. Central nervous system stimulants
b. Tricyclic antidepressants
c. Antipsychotics
d. Anxiolytics

ANS: A
Central nervous system stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with A

12. A nurse assesses a 3-year-old child diagnosed with autism spectrum disorder (ASD). Which finding is most associated with the child's disorder?
a. Cries when frustrated.
b. Inability to identify colors.
c. Shows no interest in playing with other children.
d. Anxiety when separated from a parent.

NS: C
Autistic disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers nearly always mention the child's failure to develop interpersonal skills. The distracters are expected behaviors for a 3-year-old child.

13. A 14-year-old is sent to a residential program after arrests for truancy and assault. At the program, the teen refused to participate in scheduled activities and pushed a staff member, causing a fall. Which statement made by the nurse demonstrates an effective strategy to manage the client effectively?
a. "I've enrolled you in the unit's social skills training group to help you interact with others better."
b. "What will it take to get you to obey unit rules?"
c. "If you don't want to go to movie night you don't have too."
d. "There is a loss of privileges following any refusal to comply with unit rules."

ANS: D
Firm limits are necessary to ensure physical safety and emotional security. Limit-setting will also protect other patients from the teen's thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.

14. Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness?
a. The child has been raised by a parent with chronic major depression.
b. The child's best friend has developed a chronic illness
c. The child was not promoted to the next grade one year.
d. The child moved to three new homes over a 2-year period.

ANS: A
Statistics indicate that children raised by a depressed parent have an increased risk of developing an emotional disorder. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk enhancing.

15. The child most likely to receive risperidone to manage symptoms is one diagnosed with what mental health disorder?
a. Attention-deficit hyperactivity disorder (ADHD)
b. Posttraumatic stress disorder (PTSD)
c. Anxiety
d. Autism

ANS: D
Risperidone is useful for relieving irritability and labile affect demonstrated by some autistic children. It is not indicated in any of the other disorders.

16. A child shares with the school nurse about painful verbal bullying by an aggressive classmate. What should be the nurse's initial action?
a. Give notice to the chief administrator at the school regarding the events.
b. Support the victimized child to share feelings about the experience.
c. Encourage the victimized child to ignore the bullying behavior.
d. Discuss the events with the aggressive classmate.

ANS: B
The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the child's complaints and validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.

17. An adolescent in a residential program threatens to throw a pool ball at another adolescent. Which comment by the nurse would effectively set limits?
a. "You will be taken to seclusion if you throw that ball."
b. "Do not throw the ball. Put it back on the pool table."
c. "Attention everyone: We're all going to the gym."
d. "Please do not lose control of your behavior."

ANS: B
Setting limits uses clear, sharp statements about which behavior is not allowed and guidance for performing a behavior that is expected. The distracters represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the child's developing self-control that may be ineffective.

1. Which behaviors are indicative of bullying by a child? (Select all that apply.)
a. Recruits other children to avoid a child who wears glasses.
b. Consistently calls another child "fat" and "stupid."
c. Trips another children, because "it's fun."
d. Repeatedly steals another child's lunch money.
e. Plays a practical joke on another child.

ANS: A, B, C, D
Bullying can be verbal, relational, or physical. It is repetitive and intentionally produces harm or pain in another person. Playful teasing, one-time aggression, and joking do not meet the criteria for bullying.

14. A community health nurse assesses four patients between ages 70 and 80. Which patient has the highest risk for alcohol dependence?
a. Patient with no history of alcohol-related problems until retirement but now drinks alcohol daily to distract himself from arthritis pain.
b. Patient who drank socially throughout adult life and continues this pattern, saying "I'm old enough to drink if I want to."
c. Patient who abused alcohol between ages 30 and 45 but now abstains and occasionally attends AA meetings.
d. Patient with intermittent problems of alcohol misuse early in life. Now drinks one glass of wine nightly with dinner.

ANS: A
Alcohol dependence can develop at any age, and the geriatric population is particularly at risk. The geriatric problem drinker is defined as someone who has no history of alcohol-related problems but develops an alcohol abuse pattern in response to the stresses of aging.

1. Which interventions should the nurse implement to facilitate an effective assessment of an older adult? (Select all that apply.)
a. Allow time for client to formulate answers.
b. Use open-ended questions to encourage conversation.
c. Ensure privacy to help minimize unwillingness to share information.
d. Speak loudly to assure client's ability to hear the questions clearly.
e. Explain the purpose of the assessment.

ANS: A, B, C, E
The general rules of interviewing apply. In addition, older adults respond better to open-ended questions than to a barrage of direct questions. Because it might take the older adult longer to formulate an answer, the nurse should allow time for the patient to answer. Making sure that the patient uses his or her glasses and hearing aid is advisable. Information should be obtained directly from the patient if possible. Direct questions might seem intrusive. Speaking loudly is necessary only if the patient has a hearing deficit. Setting a brisk pace and interrupting might frustrate the patient.

2. Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? (Select all that apply.)
a. "Lately I have had a lot of aches and pains and just haven't felt very well."
b. "My appetite is better than usual, and I am sleeping about 9 hours a night."
c. "People are in and out of my room all day and all night taking my things."
d. "Don't ask me to eat. I can't because my stomach is upset all the time."
e. "Life is more organized now that I don't live in my own home."

ANS: A, C, D
Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The other options do not suggest symptoms of mental disorder.

3. Which assessment findings related to a 68-year-old patient should be identified as risk factors for late-onset alcohol abuse and dependence? (Select all that apply.)
a. Chronic obstructive pulmonary disease
b. Insomnia
c. Male gender
d. Boredom and loneliness
e. Recent loss of spouse

ANS: A, B, D, E
Insomnia or chronic medical illness might lead the individual to use alcohol to self-medicate. Loss of a spouse, boredom, and loneliness often result in alcohol use to escape emotional distress. Statistics show that more women than men develop late-onset problem drinking.

1. A patient living in community housing for older adults says, "I don't go to the senior citizens club. They play cards and talk about the past, because that's all they can do." The nurse suspects that these remarks represent what personal behavior?
a. Failure to achieve developmental tasks
b. Thinking associated with ageism
c. Hypercritical behavior
d. Paranoid thinking

ANS: B
Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of using ageism as younger individuals. The other options are not substantiated by the information given in the scenario.

2. A community health nurse visits an older adult whose spouse died 6 months ago and notes several vodka bottles are in the trash. The person says, "I get lonely and drink a little to help me forget." What is the nurse's most therapeutic intervention?
a. Teach the person about alcoholism, and suggest other coping strategies.
b. Request a mental health consultation to assess for alcohol dependency.
c. Advise the person not to drink alone, because the risks for injury increase.
d. Arrange for the person to attend an Alcoholics Anonymous (AA) meeting for older adults.

ANS: D
This patient needs help with alcohol abuse as well as social involvement. The AA meeting for older adults will provide an opportunity for peer bonding and reminiscing as well as strategies for coping with stress without abusing alcohol. The other options are unnecessary or ineffective.

3. A nurse plans a staff education program for employees of a senior living community. Which topic has priority when considering client safety?
a. Late-onset schizophrenia
b. Depression and suicide
c. Dementia
d. Delirium

ANS: B
Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease

4. A resident in a senior community has lost weight, feels depressed, and has lost interest in former social activities. The nurse asks, "When you last saw your doctor, did you share these problems?" The resident replies, "Yes, but the doctor said I shouldn't expect to feel good every day." Which barrier to mental health care is evident?
a. Legislative failures to provide services for older adults
b. The physician's inadequate mental health assessment
c. The resident's inadequate description of symptoms
d. Economic obstacles to adequate programming

ANS: B
Primary-care physicians are often hurried and have little time to spend with patients. In addition, they are more attuned to and more comfortable treating physical problems than mental disorders. They often miss depressive symptoms in older adults, thus creating a barrier to effective treatment. The patient's description of symptoms was adequate. Economic and legislative policies are not discussed in the scenario.

5. An older adult patient is severely suicidal and the patient's physical condition is declining. When it is apparent that traditional interventions are ineffective, the nurse should prepare for which intervention?
a. Insertion of a feeding tube
b. Electroconvulsive therapy (ECT)
c. Behavior modification
d. Bright-light therapy

ANS: B
ECT is the treatment of choice for severe depression in older adults when a rapid response is necessary. Bright-light therapy and behavior modification will take too long. The patient does not have assessment findings that indicate enteral feeding is needed.

6. When assessing older adults, the nurse should pay particular attention to which demographic group with the highest suicide risk?
a. Hispanic men
b. Caucasian men
c. Caucasian women
d. African-American women

ANS: B
The suicide rate for Caucasian male older adults is higher than for any of the groups listed in the other options. Although women make more suicide attempts, men have a higher suicide attempt-to-completion ratio than women.

7. Which information is most important to obtain during assessment of an older adult with a mental disorder?
a. Functional ability and emotional status
b. Chronologic age and sexual functioning
c. Economic status and sources of income
d. Developmental history, interests, and activities

ANS: A
These data provide an overview of patient problems and ability to function. They guide the selection of interventions and services to meet identified needs. The other options reflect information of relevance but are not of highest priority.

8. What high priority assessment should a nurse caring for an older adult who self-administer medications preform?
a. Use of stimulants
b. Overuse of benzodiazepines
c. Misuse of antihypertensive medications
d. Trading medications with acquaintances

ANS: B
Benzodiazepines are among the most widely prescribed medications. They are often prescribed in high doses and for prolonged periods, leading to tolerance, physical dependence, and psychological dependence. The other options are relevant but are not of the highest priority.

9. What assessment question asked by the nurse planning care for an older client best minimizes the risk for ineffective medication administration by the client and impaired medication effectiveness?
a. "What do you expect this medication will do for you?"
b. "Can you explain how and when you should take your medication?"
c. "How many medications do you take each day?"
d. "Will you be able to easily get your medication prescriptions refilled?"

ANS: B
While many factors contribute to the effective self-administration of medications, an adequate understanding of the instructions related to the medications' administration is of primary importance to achieving medication-related goals.

10. A 65-year-old patient is diagnosed with late-onset schizophrenia. Both positive and negative symptoms of the disorder are present. The patient has a history of atrial fibrillation. The nurse should prepare patient education materials related to what medication?
a. Chlorpromazine
b. Risperidone
c. Thioridazine
d. Haloperidol

ANS: B
Atypical antipsychotics such as risperidone are effective against both positive and negative symptoms of schizophrenia and have the most favorable side effect profile. The distracters are typical antipsychotics. Chlorpromazine and thioridazine may cause cardiovascular side effects. Haloperidol may cause neurologic side effects.

15. An older adult patient diagnosed with depression is prescribed a selective serotonin reuptake inhibitor (SSRI). Nursing assessment should include careful collection of what information to best assure patient safety?
a. Other prescribed medications and over-the-counter remedies used
b. Evidence of pseudo-parkinsonism or tardive dyskinesia
c. History of psoriasis and other skin disorders
d. History of diarrhea and electrolyte imbalances

ANS: A
Drug interactions, both prescription and over-the-counter, can be problematic for the geriatric patient taking an SSRI. Careful collection of information is important. The distracters do not pose problems with SSRI drugs.

11. A nurse demonstrates an understanding of milieu management associated with the care of older client's diagnosed with psychiatric disorders when implementing which interventions?
a. Provide cognitive-behavior therapy (CBT) for all patients.
b. Provide unconditional acceptance of all client behaviors.
c. Prevent clients from self-isolating.
d. Limit time clients spend reminiscing.

ANS: C
Nurses have a responsibility to facilitate optimal function. Attention to the milieu can increase psychological functioning and prevent deterioration resulting from withdrawal and disuse of skills. Unconditional acceptance of the individual is appropriate, but not all behavior must be accepted. It would be impractical to provide CBT for all patients. Reminiscence is a positive activity that should be encouraged and integrated into a plan of care.

12. Reducing aggressive outbursts on a unit for older adults with mental disorders can be best achieved by implementing which intervention?
a. Administering antipsychotic medication when signs of aggression are first noted
b. Redirecting a client who demonstrates verbal aggression
c. Limiting diversional activities to manage stimuli
d. Restricting the clients' personal space to help facilitate visual observation of the group.

ANS: B
Redirection and diversion are effective techniques to prevent and/or manage aggressive outbursts. Liberal use of medication will result in oversedation. Diversional activity can provide constructive outlets, so it should not be restricted. Control over one's personal space reduces aggression. Real or imagined threats to personal space might incite aggression.

13. An 80-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the assessment, which initial action should be taken to maximize the effectiveness of the assessment?
a. Move the interview to a darkened room to reduce stimulation.
b. Ask if the patient can hear clearly as the nurse speaks.
c. Ask the patient to rate the level of pain.
d. Initiate a neurologic assessment.

ANS: B
Before proceeding with any further assessment, the nurse should assess the patient's ability to hear questions. Impaired hearing could lead to inaccurate answers.

1. A soldier was diagnosed with post-traumatic stress disorder (PTSD). The soldier's spouse reports that when a telephone rings during the night, the soldier rolls out of bed and assumes an aggressive stance. How will the nurse document this finding?
a) Flashback
b) Avoidance
c) Hyperarousal
d) Reexperiencing

ANS: C
Hyperarousal includes exaggerated responses to noises and other environmental stimuli. It is part of the constellation of problems that impair sleep for persons with PTSD. Flashbacks are an aspect of reexperiencing. Avoidance is another criterion for PTSD.

2. Which social event would likely be most disturbing for this soldier diagnosed with PTSD?
a) Halloween festival with neighborhood children
b) Picnic and fireworks display on July 4th
c) Singing carols around a Christmas tree
d)A family outing to the seashore

ANS: B
The exploding noises associated with fireworks are likely to provoke exaggerated responses from this soldier. The distracters are not associated with offensive sounds.

3. A nurse counsels an 87-year-old veteran of World War II who tearfully shares memories of sights associated with Nazi concentration camps. Which term will be most familiar to this veteran?
a) Shell shock
b) Battle fatigue
c) Soldier's heart
d) PTSD

ANS: B
Consequences of exposure to traumatic events associated with war have been addressed by different terms over generations. Battle fatigue was the term used in World War II. Soldier's heart was the term used after the Civil War. Shell shock was the term used in World War I. PTSD was the term used beginning with the Vietnam War.

4. When is it most important for the nurse to screen for signs and symptoms of post-combat PTSD?
a) Screening should be ongoing
b) Before departing to return to the United States
c) Immediately upon return from the combat zone
d) One year after returning from the combat experience

ANS: A
PTSD can have a very long lag time; in some instances, it can be 20 years or more. Screening should be ongoing. The other options are too limited.

5. A nurse assesses soldiers in a combat zone. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)?
a) After exposure to a blast
b) Before departing to return home.
c) One year after returning from combat
d) Immediately upon return to the United States

ANS: A
TBI manifests shortly after the injury and usually resolves in days or weeks. It would be most important to screen after exposure to an explosion and before returning to the United States. PTSD can have a very long lag time; in some instances, it can be 20 years or more.

6. General George Patton led U.S. troops in Europe and Africa during World War II. His career was marred by an incident of scolding a distressed, frightened soldier as "a coward" and "yellow." Patton's behavior embodied which phenomenon associated with symptom delay in PTSD?
a) Stigma
b) Lag time
c) Obscuration
d) Co-morbidity

ANS: A
Many soldiers and veterans fight the symptoms of mental illness associated with combat. They fear appearing weak or inadequate. These phenomena contribute to the stigma associated with war-related psychiatric illnesses.

7. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, but I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind." The soldier is describing which phenomenon associated with PTSD?
a) Reexperiencing
b) Hyperarousal
c) Avoidance
d) Psychosis

ANS: A
The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

8. A soldier who served in a combat zone tells the nurse, "I saw a child get blown up over 2 years ago, but even now when I see something red, the visions race back to my mind and I smell burnt flesh." How should the nurse document this experience?
a) Thought intrusion
b) Repetitive dreams
c) Hallucinations
d) Flashbacks

ANS: D
The soldier describes an event while awake related to reexperiencing the trauma. The description applies to flashbacks, which are common in PTSD. The statement is not associated with the remaining options.

9. A soldier who served in a combat zone returned home to the United States. The soldier's spouse reports to the nurse, "We had planned to start a family right away, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD?
a) Reexperiencing
b) Hyperarousal
c) Avoidance
d) Psychosis

ANS: C
Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence that this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

10. A soldier returned home last year after deployment to a war zone. The soldier's spouse reports, "We had planned to start a family right away, but now he won't talk about it. He won't even look at children. I wonder if we're going to make it as a couple." Select the nurse's best response.
a) "PTSD often changes a person's 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) "PTSD often strains relationships. Here are some community resources for help."

ANS: D
PTSD precipitates changes that often lead to divorce. It's important to provide support to both the veteran and spouse. Confrontation will not be effective. While it's important to provide information, ongoing support will be more effective.

11. A nurse manages a program providing day treatment services to combat veterans diagnosed with PTSD. During breaks between activities, which type of music would be most appropriate?
a) Rap
b) Jazz
c) Rock
d) Hip-Hop

ANS: B
Hypervigilance is a common symptom of PTSD and leads to difficulty with relaxation. Music can soothe if it is not overpowering. Jazz is mellow and would not contribute to hyperarousal. Rap, rock, and hip-hop would be overstimulating.

12. A soldier experienced a TBI associated with acceleration-deceleration forces. Which part of the neuron was most likely damaged?
a) Axon
b) Dendrite
c) Telomere
d) Cell body

ANS: A
Acceleration-deceleration forces cause shearing of axons not dendrites, which result in TBIs. The cell body is not believed to be traumatized. Telomeres are part of DNA, not neurons.

13. A veteran with a suspected TBI is scheduled for diffusion tensor imaging (DTI). What information should the nurse provide?
a) "This test will help show whether tracts in your central nervous system are damaged."
b) "This test will measure changes in chemicals that transmit messages between your brain and spinal cord."
c) "This test will help predict what types of medication will be effective for treating your symptoms."
d) "This test will help your health care provider decide whether or not a computed tomography (CT) scan is needed to further diagnose your injuries."

ANS: A
DTI is a form of magnetic resonance imaging that produces detailed microscopic images of neural tracts and related injuries. It provides better imaging of subtle injuries than CT scans. It does not measure neurotransmitters.

14. A combat veteran diagnosed with a mild TBI returned to college after discharge from the armed forces. The veteran began tutoring after scoring poorly in three courses. Which strategy can the tutor use to assist the veteran's academic achievement?
a) Decrease extraneous stimuli to improve attention span.
b) Practice deep breathing to increase the brain's oxygen supply.
c) Increase caffeine intake to counteract drowsiness and fatigue.
d) Play background music while studying to improve concentration.

ANS: A
TBI produces multiple cognitive problems that are likely to interfere with memory and learning. Many persons with these injuries have difficulty excluding sensory stimuli, which impairs concentration and attention span. Background music would further impair concentration. Caffeine would increase stimulation but not improve cognitive processing. Deep breathing is helpful for producing relaxation for anyone, but it would not support memory and learning.

15. Excitotoxicity in persons diagnosed with TBIs is associated primarily with which neurotransmitter?
a) Norepinephrine
b) Glutamate
c) Dopamine
d) Serotonin

ANS: B
Excitotoxicity is associated with overfiring of neurons secondary to activation of glutamate. The remaining options are not associated with this reaction.

16. A combat veteran with TBI, depression, and anxiety begins new prescriptions for sertraline (Zoloft) and lorazepam (Ativan). In recognition of potential long-term repercussions, the nurse should provide teaching related to which topic?
a) Nonpharmacologic strategies for managing anxiety
b) Identifying signs and symptoms of hepatotoxicity
c) Recognizing evidence of tardive dyskinesia
d) Strategies for preventing obesity

ANS: A
Lorazepam is a benzodiazepine, which has a high probability of causing dependence if taken long term. The nurse should teach nonpharmacologic strategies for managing anxiety to facilitate the patient's readiness to discontinue the lorazepam. Tardive dyskinesia is associated with antipsychotic drugs. Weight gain is associated with atypical antipsychotic drugs. Hepatotoxicity is not a likely complication.

17. A nurse talks with the caregiver of a combat veteran with severe traumatic brain injury. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Which resource should the nurse suggest?
a) Al-Anon
b) Pastoral care
c) Meals on Wheels
d) Multifamily support group

ANS: D
A multifamily support group will provide education, support, and socialization. These services support the needs of this caregiver. Pastoral care will offer support but not education and socialization. There is no indication of substance abuse or problems with meal preparation.

18. A combat veteran diagnosed with moderate traumatic brain injuries is agitated and aggressive. Which pharmacologic intervention would the nurse expect to be effective?
a) Bupropion (Wellbutrin)
b) Benztropine (Cogentin)
c) Propranolol (Inderal)
d) Buspirone (BuSpar)

ANS: C
Beta blockers such as propranolol (Inderal) effectively manage agitation and aggression in persons with TBIs. A dopamine-norepinephrine reuptake inhibitor such as bupropion would increase agitation. Anxiety is not the central problem for this patient. The patient does not have extrapyramidal side effects or Parkinson's disease.

MULTIPLE RESPONSE

1. 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) PTSD

ANS: C, E
TBI and PTSD each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distracters would be expected to parallel the general population.

2. Which terms have historically been applied to soldiers suffering psychiatric distress related to exposure to the horrors of war? Select all that apply.
a) Shell shock
b) Battle fatigue
c) Soldier's heart
d) Cyclothymic disorder
e) PTSD

ANS: A, B, C, E
Soldier's heart, shell shock, battle fatigue, and PTSD are terms that have been used over time to describe psychiatric distress related to exposure to the horrors of war. Cyclothymic disorder is an affective disturbance not related to traumatic experiences.

3. A combat veteran diagnosed with moderate traumatic brain injury (TBI) will begin pharmacologic therapies that include psychotropic medication. What information should the nurse provide? Select all that apply.
a) "We will monitor you closely for how each medication affects you."
b) "Medications can be expected to dramatically improve your symptoms."
c) "Please be patient as your health care provider identifies the best drugs for your problems."
d) "The blood levels of most medications you take will need to be checked with laboratory testing."
e) "Be prepared for frequent dose changes as your health care provider adjusts the dose to meet your needs."

ANS: A, C, E
Patients with TBIs are frequently overly sensitive to psychotropic medications, so close monitoring is important. However, TBI can also create drug resistance. As a consequence of both dynamics, medication adjustments are frequent and frustrating for the patient. Very few of the medications need serum monitoring; it would be misleading to say "most" do. It's important not to make promises related to how effective the drugs may or may not be.

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