Final Exam practice

Question 1

Children and Adolescents
1. Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual disability?
A. The client can perform some self-care activities independently.
B. The client has advanced speech development.
C. Other than possible coordination problems, the clients psychomotor skills are not affected.
D. The client communicates wants and needs by acting out behaviors.

Answer 1

D
The nurse should identify that a client diagnosed with severe intellectual disability may communicate wants and needs by acting out behaviors. Severe intellectual disability indicates an IQ between 20 and 34. Individuals diagnosed with severe intellectual disability require complete supervision and have minimal verbal skills and poor psychomotor development.

Question 2

Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate intellectual disability?
A. Meeting all of the clients self-care needs to avoid injury
B. Providing simple directions and praising clients independent self-care efforts
C. Avoiding interference with the clients self-care efforts in order to promote autonomy
D. Encouraging family to meet the clients self-care needs to promote bonding

Answer 2

B
Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate intellectual disability. Individuals with moderate intellectual disability can perform some activities independently and may be capable of academic skill to a second-grade level.

Question 3

A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, Im such a terrible mother. What did I do to cause this? Which nursing reply is most appropriate?
A. Researchers really dont know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored.
B. Poor parenting doesnt cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control.
C. Research has shown that the mother appears to play a greater role in the development of this disorder than the father.
D. Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?

Answer 3

B
The most appropriate reply by the nurse is to explain to the parent that autism spectrum disorder is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism spectrum disorder occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys

Question 4

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome?
A. The client will communicate all needs verbally by discharge.
B. The client will participate with peers in a team sport by day 4.
C. The client will establish trust with at least one caregiver by day 5.
D. The client will perform most self-care tasks independently.

Answer 4

C
The most realistic client outcome for a child diagnosed with autism spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.

Question 5

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss?
A. The pharmacological action of Ritalin causes a decrease in appetite.
B. Hyperactivity seen in ADHD causes increased caloric expenditure.
C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased.
D. Increased ability to concentrate allows the client to focus on activities rather than food.

Answer 5

A
The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD.

Question 6

A child has been recently diagnosed with mild intellectual disability (ID). What information about this diagnosis should the nurse include when teaching the child’s mother?
A. Children with mild ID need constant supervision.
B. Children with mild ID develop academic skills up to a sixth-grade level.
C. Children with mild ID appear different from their peers.
D. Children with mild ID have significant sensory-motor impairment.

Answer 6

B
The nurse should inform the childs mother that children with mild ID develop academic skills up to a sixth-grade level. Individuals with mild ID are capable of independent living, capable of developing social skills, and have normal psychomotor skills.

Question 7

A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual disability (ID). Which student statement indicates that further instruction is needed?
A. These clients can work in a sheltered workshop setting.
B. These clients can perform some personal care activities.
C. These clients may have difficulties relating to peers.
D. These clients can successfully complete elementary school.

Answer 7

D
The nursing student needs further instruction about moderate mental retardation because individuals diagnosed with moderate ID are capable of academic skill up to only a second-grade level. Moderate ID reflects an IQ range of 35 to 49.

Question 8

Which nursing intervention should be prioritized when caring for a child diagnosed with intellectual disability?
A. Encourage the parents to always prioritize the needs of the child.
B. Modify the childs environment to promote independence and encourage impulse control.
C. Delay extensive diagnostic studies until the child is developmentally mature.
D. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

Answer 8

B
The nurse should prioritize modifying the childs environment to promote independence and encourage impulse control. This intervention is related to the nursing diagnosis self-care deficit. Positive reinforcement can serve to increase self-esteem and encourage repetition of behaviors.

Question 9

A preschool child is admitted to a psychiatric unit with a diagnosis of autism spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this clients plan of care?
A. Encourage and reward peer contact.
B. Provide consistent caregivers.
C. Provide a variety of safe daily activities.
D. Maintain close physical contact throughout the day.

Answer 9

B
The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autism spectrum disorder. Children diagnosed with autism spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

Question 10

A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate?
A. Place client in restraints until the aggression subsides.
B. Sedate the client with neuroleptic medications.
C. Hold clients head steady and apply a helmet.
D. Distract the client with a variety of games and puzzles.

Answer 10

C
The most appropriate intervention for head banging is to hold the clients head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the clients head from injury.

Question 11

A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this clients diagnosis?
A. The client will name own body parts as separate from others by day 5.
B. The client will establish a means of communicating personal needs by discharge.
C. The client will initiate social interactions with caregivers by day 4.
D. The client will not harm self or others by discharge.

Answer 11

A
An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.

Question 12

A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this childs behavior. Which student response indicates an appropriate evaluation of the situation?
A. This childs behavior must be evaluated according to developmental norms.
B. This child has symptoms of attention deficit hyperactivity disorder.
C. This child has symptoms of the early stages of autistic disorder.
D. This childs behavior indicates possible symptoms of oppositional defiant disorder.

Answer 12

A
The students evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

Question 13

A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of intellectual disability?
A. Risk for injury R/T self-mutilation
B. Altered social interaction R/T nonadherence to social convention
C. Altered verbal communication R/T delusional thinking
D. Social isolation R/T severely decreased gross motor skills

Answer 13

B
The appropriate nursing diagnosis associated with this degree of intellectual disability is altered social interaction R/T nonadherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual disability and may also experience some limitations in speech communications.

Question 14

A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first?
A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff
B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu
C. A client diagnosed with conduct disorder who is demanding special attention from staff
D. A client diagnosed with attention deficit disorder who has a history of self-mutilation

Answer 14

B
A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately.

Question 15

Which of the following risk factors noted during a family history assessment should a nurse associate with the potential development of intellectual disability? Select all that apply.
A. A family history of Tay-Sachs disease
B. Childhood meningococcal infection
C. Deprivation of nurturance and social contact
D. History of maternal multiple motor and verbal tics
E. A diagnosis of maternal major depressive disorder

Answer 15

A, B, C
The nurse should associate a family history of Tay-Sachs disease, childhood meningococcal infections, and deprivation of nurturance and social contact as risk factors that would predispose a child to intellectual disability. Major predisposing factors of intellectual disability include: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, environmental influences, and other mental disorders.

Question 16

A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred?
A. These clients do not recognize that their fear is excessive, and they rarely seek treatment.
B. These clients have overwhelming symptoms of panic when exposed to the phobic stimulus.
C. These clients experience symptoms that mirror a cerebrovascular accident (CVA).
D. These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.

Answer 16

B
The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response.

Question 17

Anxiety Disorders
How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)?
A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications.
B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not.
C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.
D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

Answer 17

C
Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

Question 18

How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?
A. GAD is acute in nature, and panic disorder is chronic.
B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
C. Hyperventilation is a common symptom in GAD and rare in panic disorder.
D. Depersonalization is commonly seen in panic disorder and absent in GAD.

Answer 18

D
The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

Question 19

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?
A. Long-term treatment with diazepam (Valium)
B. Acute symptom control with citalopram (Celexa)
C. Long-term treatment with buspirone (BuSpar)
D. Acute symptom control with ziprasidone (Geodon)

Answer 19

C
The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

Question 20

A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear?
A. Your spouse may be unable to resolve internal conflicts, which result in projected anxiety.
B. Your spouse may be experiencing a distorted and unrealistic appraisal of the situation.
C. Your spouse may have a genetic predisposition to overreacting to potential danger.
D. Your spouse may have high levels of brain chemicals that may distort thinking.

Answer 20

B
The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.

Question 21

A pt who is diagnosed with obsessive-compulsive disorder, reports to the nurse that he cant stop thinking about all the potentially life threatening germs in the environment. What is the most accurate way for the nurse to document this symptom?
A. Patient is expressing an obsession with germs.
B. Patient is manifesting compulsive thinking.
C. Patient is expressing delusional thinking about germs.
D. Patient is manifesting arachnophobia of germs.

Answer 21

A
Obsessions are unwanted, intrusive, repetitive thoughts. Compulsions are unwanted, repetitive behavior patterns in response to obsessive thoughts that are efforts to reduce anxiety.

Question 22

A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?
A. Generalized anxiety disorder and a nursing diagnosis of fear
B. Altered sensory perception and a nursing diagnosis of panic disorder
C. Pain disorder and a nursing diagnosis of altered role performance
D. Panic disorder and a nursing diagnosis of panic anxiety

Answer 22

D
The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be panic anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

Question 23

A client diagnosed with panic disorder states, When an attack happens, I feel like I am going to die. Which is the most appropriate nursing reply?
A. I know its frightening, but try to remind yourself that this will only last a short time.
B. Death from a panic attack happens so infrequently that there is no need to worry.
C. Most people who experience panic attacks have feelings of impending doom.
D. Tell me why you think you are going to die every time you have a panic attack.

Answer 23

A
The most appropriate nursing reply to the clients concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.

Question 24

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?
A. Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.
B. Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.
C. Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.
D. Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks

Answer 24

A
The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

Question 25

family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, Should I seek psychiatric help for my mother? Which is an appropriate nursing reply?
A. My mother also worries unnecessarily. I think it is part of the aging process.
B. Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.
C. From what you have told me, you should get her to a psychiatrist as soon as possible.
D. Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.

Answer 25

B
The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

Question 26

A client is experiencing a severe panic attack. Which nursing intervention would meet this clients immediate need?
A. Teach deep breathing relaxation exercises
B. Place the client in a Trendelenburg position
C. Stay with the client and offer reassurance of safety
D. Administer the ordered prn buspirone (BuSpar)

Answer 26

C
The nurse can meet this clients immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life, and the presence of a trusted individual provides assurance of personal safety.

Question 27

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

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

Answer 27

C
The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the clients healthy coping skills and reduce anxiety.

Question 28

A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client?
A. Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge.
B. Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.
C. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.
D. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.

Answer 28

ANS: C
The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety-provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

Question 29

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?
A. The client will refrain from ritualistic behaviors during daylight hours.
B. The client will wake early enough to complete rituals prior to breakfast.
C. The client will participate in three unit activities by day 3.
D. The client will substitute a productive activity for rituals by day 1.

Answer 29

ANS: B
An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.
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Question 30

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
B. I wont stop taking this medication abruptly, because there could be serious complications.
C. I will not drink alcohol while taking this medication.
D. I wont take extra doses of this drug because I can become addicted.

Answer 30

A
The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

Question 31

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

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

Answer 31

D
The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.

Question 32

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this clients problem?
A. Distract the client with other activities whenever ritual behaviors begin.
B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
C. Lock the room to discourage ritualistic behavior.
D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

Answer 32

D
The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the clients room are not appropriate interventions because they do not help the client recognize anxiety triggers.

Question 33

A client presents in the emergency department with complaints of overwhelming anxiety. Which of the following is a priority for the nurse to assess?
A. Risk for suicide
B. Cardiac status
C. Current stressors
D. Substance use history

Answer 33

B
Although all of the listed aspects of assessment are important, the priority is to evaluate cardiac status since a person having an MI, CHF, or mitral valve prolapse can present with symptoms of anxiety.

Question 34

How should a nurse best describe the major maladaptive client response to panic disorder?
A. Clients overuse medical care because of physical symptoms.
B. Clients use illegal drugs to ease symptoms.
C. Clients perceive having no control over life situations.
D. Clients develop compulsions to deal with anxiety.

Answer 34

C
The major maladaptive client response to panic disorder is the perception of having no control over life situations, which leads to nonparticipation in decision making and doubts regarding role performance.

Question 35

Warrens college roommate actively resists going out with friends whenever they invite him. He says he cant stand to be around other people and confides to Warren They wouldnt like me anyway. Which disorder is Warrens roommate likely suffering from?
A. Agoraphobia
B. Mysophobia
C. Social anxiety disorder (social phobia)
D. Panic disorder

Answer 35

C
Social anxiety disorder is an excessive fear of social situations R/T fear that one might do something embarrassing or be evaluated negatively by others.

Question 36

A client diagnosed with generalized anxiety states, I know the best thing for me to do now is to just forget my worries. How should the nurse evaluate this statement?
A. The client is developing insight.
B. The clients coping skills are improving.
C. The client has a distorted perception of problem resolution.
D. The client is meeting outcomes and moving toward discharge.

Answer 36

: C
This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.

Question 37

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this clients symptoms? Select all that apply.
A. Encourage the client to recognize the signs of escalating anxiety.
B. Encourage the client to avoid any situation that causes stress.
C. Encourage the client to employ newly learned relaxation techniques.
D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety.
E. Encourage the client to avoid caffeinated products.

Answer 37

A, C, D, E
Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.

Question 38

A client who has been diagnosed with a phobic disorder asks the nurse if there are any medications that would be beneficial in treating phobic disorders. Which of the following would be accurate responses by the nurse? Select all that apply.
A. Some antianxiety agents have been successful in treating social phobias.
B. Some antidepressant agents have been successful in diminishing symptoms of agoraphobia and social anxiety disorder (social phobia).
C. Specific phobias are generally not treated with medication unless accompanied by panic attacks.
D. Beta-blockers have been used successfully to treat phobic responses to public performance.

Answer 38

A, B, C, D
All of the listed pharmacological treatments are evidence-based treatments for phobic disorders.

Question 39

A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis?
A. This type of crisis is precipitated by unexpected external stressors.
B. This type of crisis is precipitated by preexisting psychopathology.
C. This type of crisis is precipitated by an acute response to an external situational stressor.
D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

Answer 39

D
The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.

Question 40

A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, I cant function any longer under all this stress. Which type of crisis is the client experiencing?
A. Maturational/developmental crisis
B. Psychiatric emergency crisis
C. Anticipated life transition crisis

Answer 40

B
The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility.

Question 41

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice?
A. This therapy will increase the clients motivation to gain weight.
B. This therapy will reward the client for perfectionist achievements.
C. This therapy will provide the client with control over behavioral choices.
D. This therapy will protect the client from parental overindulgence.

Answer 41

C
The nurse should identify that behavior modification therapy will be used because it provides the client with control over behavioral choices. Clients diagnosed with anorexia nervosa are often allowed to contract privileges based on weight gain. The client maintains control over eating and exercise.

Question 42

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a clients home environment should a nurse associate with the development of this disorder?
A. The home environment maintains loose personal boundaries.
B. The home environment places an overemphasis on food.
C. The home environment is overprotective and demands perfection.
D. The home environment condones corporal punishment.

Answer 42

: C
The nurse should assess that a home environment that is overprotective and demands perfection may be an influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

Question 43

A clients altered body image is evidenced by claims of feeling fat, even though the client is emaciated. Which is the appropriate outcome criterion for this clients problem?
A. The client will consume adequate calories to sustain normal weight.
B. The client will cease strenuous exercise programs.
C. The client will perceive an ideal body weight and shape as normal.
D. The client will not express a preoccupation with food.

Answer 43

C
The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self on the basis of self-attributes instead of appearance and to realize that perfection is unrealistic.

Question 44

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding?
A. The emesis produced during purging is acidic and corrodes the tooth enamel.
B. Purging causes the depletion of dietary calcium.
C. Food is rapidly ingested without proper mastication.
D. Poor dental and oral hygiene leads to dental caries.

Answer 44

A
The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

Question 45

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders?
A. These programs help clients correct distorted body image.
B. These programs address underlying client anger.
C. These programs help clients manage uncontrollable behaviors.
D. These programs allow clients to maintain control.

Answer 45

D
Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because the programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

Question 46

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects a theory about the underlying etiology of this disorder?
A. I was just trying to be like everyone else.
B. All the skaters on the team are following an approved 1,200-calorie diet.
C. When I lose skating competitions, I also lose my appetite.
D. I am angry at my mother. I can get her approval only when I win competitions.

Answer 46

D
This client statement reflects a possible underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family members development of anorexia nervosa.

Question 47

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?
A. The client gains 2 pounds in 1 week.
B. The client focuses conversations on nutritious food.
C. The client demonstrates healthy coping mechanisms that decrease anxiety.
D. The client verbalizes an understanding of the etiology of the disorder.

Answer 47

C
The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behaviors.

Question 48

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred?
A. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.
B. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
C. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not.
D. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.**

Answer 48

A
The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food, followed by purging.

Question 49

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100-mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense?
A. 25 mL
B. 20 mL
C. 15 mL
D. 10 mL

Answer 49

C
Twenty mg of Prozac multiplied by three results in the calculated 60-mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.

Question 50

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time?
A. Ineffective coping R/T food obsession
B. Altered nutrition: less than body requirements R/T inadequate food intake
C. Risk for injury R/T suicidal tendencies
D. Altered body image R/T perceived obesity

Answer 50

B
Based on Maslows hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

Question 51

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client?
A. The client will use stress-reducing techniques to avoid purging.
B. The client will discuss chaos in personal life and be able to verbalize a link to purging.
C. The client will gain 2 pounds prior to the next weekly appointment.
D. The client will remain free of signs and symptoms of malnutrition and dehydration.

Answer 51

C
The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, and measurable and also include a time frame.

Question 52

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this clients symptoms?
A. Increased creatinine and blood urea nitrogen (BUN) levels
B. Abnormal electroencephalogram (EEG)
C. Metabolic acidosis
D. Metabolic alkalosis

Answer 52

C
Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this clients fainting to the loss of alkaline stool due to laxative abuse, which would lead to a relative metabolic acidotic condition.

Question 53

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients?
A. The nurse who understands the importance of three balanced meals a day
B. The nurse who permits children to have dessert only after finishing the food on their plate
C. The nurse who refuses to engage in power struggles related to food consumption
D. The nurse who grew up poor and frequently did not have enough food to eat

Answer 53

C
The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

Question 54

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention?
A. To gain additional information about the progression of the disease process
B. To emphasize that the client is capable of consuming food without purging
C. To incorporate specific foods into the meal plan to reflect pleasant memories
D. To assist the client to become more compliant with the treatment plan

Answer 54

B
By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

Question 55

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis?
A. I do not use any laxatives or diuretics to lose weight.
B. I am losing lots of hair. Its coming out in handfuls.
C. I know that I am thin, but I refuse to be fat!
D. I dont know why people are worried. I need to lose this weight.

Answer 55

D
When the client states, I dont know why people are worried. I need to lose this weight, the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

Question 56

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis?
A. The client will identify two alternative methods of dealing with isolation by day 3.
B. The client will appropriately express angry feelings about lack of control by week 2.
C. The client will verbalize two positive self attributes by day 3.
D. The client will list five ways that the body reacts to bingeing and purging.

Answer 56

A
The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

Question 57

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time?
A. To shift the clients focus from food to psychotherapy
B. To prevent the use of maladaptive defense mechanisms
C. To promote the processing of anxiety associated with eating
D. To focus on weight control mechanisms and food preparation

Answer 57

: C
When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

Question 58

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa?
A. Provide privacy during meals.
B. Remain with the client for at least 1 hour after the meal.
C. Encourage the client to keep a journal to document types of food consumed.
D. Restrict client privileges when provided food is not completely consumed.

Answer 58

B
A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

Question 59

A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kbler-Rosss grief stage of anger?
A. The client registers for an iron-man marathon to be held in 9 months.
B. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him.
C. The client promises God to give up smoking if allowed to live long enough to witness a grandchilds birth.
D. The client gathers family in order to plan a funeral and make last wishes known.

Answer 59

B
The nurse should assess that the client is in the anger stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kbler-Rosss grief process, in which the reality of the situation is realized and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness.

Question 60

A nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, Im planning an elaborate wake and funeral. According to George Engel, what purpose would these rituals serve?
A. To delay the recovery process initiated by the loss of the clients spouse
B. To facilitate the acceptance of the loss of the clients spouse
C. To avoid dealing with grief associated with the loss of the clients spouse
D. To eliminate emotional pain related to the loss of the clients spouse

Answer 60

B
The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the clients spouse. Resolution of the loss is the fourth stage in Engels grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time.

Question 61

A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how should a nurse expect the neighbors action to affect the womans grieving task completion?
A. This action may hamper the woman from accepting the reality of the loss.
B. This action would help the woman forget the sorrow and move on with life.
C. This action communicates full support from her neighbors.
D. This action would motivate the woman to look to the future and not the past.

Answer 61

A
The nurse should anticipate that this action could hinder the woman from accepting the reality of the loss. The first task in Wordens grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one so as not to have to face reality. The bereaved person is considered an active participant in the grief process and the above-mentioned behaviors are part of that process.

Question 62

A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client?
A. Denial of personal mortality
B. Preoccupation with the loss
C. Clinging behaviors and personal insecurity
D. Acting-out behaviors, exhibited in aggression and defiance

Answer 62

The school nurse should anticipate that this teenager would exhibit aggression and acting-out behaviors. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to express sorrow by acting out rather than typical emotional expressions of the grieving process.

Question 63

The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurses assessment?
A. The clients spouse died 12 months ago.
B. The client still cries when recalling memories of the deceased.
C. The client reports feelings of worthlessness.
D. The client reports intermittent anxiety.

Answer 63

C
Several authors identify loss of self-esteem as the differentiating factor between normal and maladaptive grieving. The length of time needed to grieve is variable, so it is difficult to establish a time frame as indicative of maladaptive grief.

Question 64

A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process?
A. Stage I: Numbness or protest
B. Stage II: Disequilibrium
C. Stage III: Disorganization and despair
D. Stage IV: Reorganization

Answer 64

C
The nurse should identify that this client is in the third stage of Bowlbys grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost individual may occur.

Question 65

An instructor is teaching nursing students about Wordens grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? Select all that apply.
A. Refusing to allow self to think painful thoughts
B. Indulging in the pain of loss
C. Using alcohol and drugs
D. Idealizing the object of loss
E. Recognizing that time will heal

Answer 65

A, C, D
The nurse should identify that refusing to allow self to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Wordens grief process is working through the pain or grief. Pain must be acknowledged and resolved in order to move on.

Question 66

Which of the following types of care should the interdisciplinary team of hospice provide? Select all that apply.
A. Physical care available on a 24/7 basis
B. Counseling on the addictive properties of pain-management medications
C. Discussions related to death and dying
D. Explorations of new, aggressive treatments
E. Assistance with obtaining spiritual support and guidance

Answer 66

A, C, E
The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying. Support is also provided to client families.