Essentials of Psychiatric Mental Health Nursing ,2nd Edition by Elizabeth M. Varcarolis Test Bank

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Essentials of Psychiatric Mental Health Nursing ,2nd Edition by Elizabeth M. Varcarolis Test Bank

Chapter 2: Mental Health and Mental Illness

Test Bank

 

MULTIPLE CHOICE

 

  1. A nurse explains multiaxial diagnoses to a psychiatric technician. Which information is accurate?
a. It is a template for treatment planning.
b. Nursing and medical diagnoses are included.
c. Assessments of several aspects of functioning are included.
d. It incorporates the framework of a specific biopsychosocial theory.

 

 

ANS:  C

The use of five axes requires an assessment beyond the diagnosis of a mental disorder and includes relevant medical conditions, psychosocial and environmental problems, and global assessment of functioning. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) is not a template for treatment planning and does not use a specific biopsychosocial theory. Nursing diagnoses are not included in multiaxial diagnoses.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 18

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. Which documentation of diagnosis would a nurse expect for a person with mental illness?
a. I Rheumatoid arthritis

II 100

III Posttraumatic stress disorder

IV Arrested for shoplifting 2 months earlier

V None

b. I Mental retardation

II Histrionic personality disorder

III 75

IV Hypertension

V Home destroyed by tornado last year

c. I Schizophrenia, paranoid

II Death of spouse last year

III 40

IV None

V Alcohol abuse

d. I Generalized anxiety disorder

II Avoidant personality disorder

III Fibromyalgia

IV Declared bankruptcy 6 months ago

V 60

 

 

ANS:  D

The option beginning with a diagnosis of generalized anxiety disorder places a clinical disorder on Axis I, a personality disorder on Axis II, a medical problem on Axis III, a psychosocial problem on Axis IV, and global assessment of functioning (GAF) on Axis V. The other options misplace and incorrectly order the clinical data.

 

DIF:    Cognitive Level: Application          REF:   Page: 18

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A patient is admitted to the psychiatric hospital for assessment and evaluation. Which assessment finding best indicates that the patient has a mental illness? The patient:
a. describes coping and relaxation strategies used when feeling anxious.
b. describes mood as consistently sad, discouraged, and hopeless.
c. can perform tasks attempted within the limits of own abilities.
d. reports occasional problems with insomnia.

 

 

ANS:  B

A patient who reports having a consistently negative mood is describing a mood alteration. The incorrect options describe mentally healthy behaviors and common problems that do not indicate mental illness.

 

DIF:    Cognitive Level: Application          REF:   Page: 19

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will:
a. describe feelings associated with loss and stress.
b. meet own needs without considering the rights of others.
c. identify healthy coping behaviors in response to stressful events.
d. allow others to assume responsibility for major areas of own life.

 

 

ANS:  C

The patient’s ability to identify healthy coping behaviors indicates adaptive, healthy behavior and demonstrates an increased ability to recover from severe stress. Describing feelings associated with loss and stress does not move the patient toward adaptation. The remaining options are maladaptive behaviors.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 14

TOP:   Nursing Process: Outcomes Identification

MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient’s insurance form. Which resource should the nurse consult to discern the criteria used to establish this diagnosis?
a. DSM-IV-TR
b. Nursing Diagnosis Manual
c. A psychiatric nursing textbook
d. A behavioral health reference manual

 

 

ANS:  A

The DSM-IV-TR gives the criteria used to diagnose each mental disorder. The Nursing Diagnosis Manual focuses on nursing diagnoses. A psychiatric nursing textbook or behavioral health reference manual may not contain diagnostic criteria.

 

DIF:    Cognitive Level: Application          REF:   Page: 14|Page: 17

TOP:   Nursing Process: Analysis| Nursing Process: Diagnosis

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of:
a. the degree of conformity of the individual to society’s norms.
b. the degree to which an individual is logical and rational.
c. a continuum from mentally healthy to unhealthy.
d. the rate of intellectual and emotional growth.

 

 

ANS:  C

Because mental health and mental illness are relative concepts, assessment of functioning is made by using a continuum. Mental health is not based on conformity; some mentally healthy individuals do not conform to society’s norms. Most individuals occasionally display illogical or irrational thinking. The rate of intellectual and emotional growth is not the most useful criterion to assess mental health or mental illness.

 

DIF:    Cognitive Level: Application          REF:   Pages: 13-14

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. A 40-year-old adult living with parents states, “I’m happy but I don’t socialize much. My work is routine. When new things come up, my boss explains them a few times to make sure I understand. At home, my parents make decisions for me, and I go along with them.” A nurse should identify interventions to improve this patient’s:
a. self-concept.
b. overall happiness.
c. appraisal of reality.
d. control over behavior.

 

 

ANS:  A

The patient feels the need for multiple explanations of new tasks at work and, despite being 40 years of age, allows both parents to make all decisions. These behaviors indicate a poorly developed self-concept.

 

DIF:    Cognitive Level: Application          REF:   Pages: 12-14  TOP:   Nursing Process: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient tells a nurse, “I have psychiatric problems and am in and out of hospitals all the time. Not one of my friends or relatives has these problems.” Select the nurse’s best response.
a. “Comparing yourself with others has no real advantages.”
b. “Why do you blame yourself for having a psychiatric illness?”
c. “Mental illness affects 50% of the adult population in any given year.”
d. “It sounds like you are concerned that others don’t experience the same challenges as you.”

 

 

ANS:  D

Mental illness affects many people at various times in their lives. No class, culture, or creed is immune to the challenges of mental illness. The correct response also demonstrates the use of reflection, a therapeutic communication technique. It is not true that mental illness affects 50% of the population in any given year. Asking patients if they blame themselves is an example of probing.

 

DIF:    Cognitive Level: Application          REF:   Pages: 14-15

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A critical care nurse asks a psychiatric nurse about the difference between a DSM-IV-TR diagnosis and a nursing diagnosis. Select the psychiatric nurse’s best response.
a. “No functional difference exists between the two diagnoses. Both serve to identify a human deviance.”
b. “The DSM-IV-TR diagnosis disregards culture, whereas the nursing diagnosis includes cultural variables.”
c. “The DSM-IV-TR diagnosis profiles present distress or disability, whereas a nursing diagnosis considers past and present responses to actual mental health problems.”
d. “The DSM-IV-TR diagnosis influences the medical treatment; the nursing diagnosis offers a framework to identify interventions for problems a patient has or may experience.”

 

 

ANS:  D

The medical diagnosis is concerned with the patient’s disease state, causes, and cures, whereas the nursing diagnosis focuses on the patient’s response to stress and possible caring interventions. Both the DSM-IV-TR and a nursing diagnosis consider culture. The DSM-IV-TR is multiaxial. Nursing diagnoses also consider potential problems.

 

DIF:    Cognitive Level: Application          REF:   Page: 17|Pages: 21-22

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A nurse finds a new patient uncommunicative about recent life events. The nurse suspects marital and economic problems. The social worker’s assessment is not available. The most effective action the nurse can take is to:
a. ask the patient who shares a room with him or her.
b. consult Axis IV of the DSM-IV-TR in the medical record.
c. focus questions on the topics of marital and economic issues.
d. delay discussion of these topics until the social worker’s assessment is available.

 

 

ANS:  B

The physician’s admission note identifies psychosocial and environmental problems on Axis IV pertinent to the patient’s situation, providing another source of information for the nurse. Asking the patient who shares a room with him or her violates patient privacy rights. Persistent questioning may cause the patient to withdraw. Delaying the discussion until the social worker’s assessment is available is not an effective solution.

 

DIF:    Cognitive Level: Application          REF:   Page: 18

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A newly admitted patient is profoundly depressed, mute, and motionless. The patient has refused to bathe and eat for a week. Which score would be expected on the patient’s global assessment of functioning?
a. 100
b. 80
c. 50
d. 10

 

 

ANS:  D

The patient is unable to maintain personal hygiene, oral intake, or verbal communication. The patient is dangerous to self because of the potential for starvation. A GAF score of 100 indicates high-level functioning. A score of 80 or 50 suggests higher functional abilities than the patient presently displays.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 19

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. The spouse of a patient with schizophrenia says, “I don’t understand why childhood experiences have anything to do with this disabling illness.” Select the nurse’s response that will best help the spouse understand this condition.
a. “Psychological stress is actually at the root of most mental disorders.”
b. “We now know that all mental illnesses are the result of genetic factors.”
c. “It must be frustrating for you that your spouse is sick so much of the time.”
d. “Although this disorder more likely has a biological rather than psychological origin, the support and involvement of caregivers is very important.”

 

 

ANS:  D

Many of the most prevalent and disabling mental disorders have been found to have strong biological influences. Helping the spouse understand the importance of his or her role as a caregiver is also important. Empathy is important but does not increase the spouse’s level of knowledge about the cause of the patient’s condition. Not all mental illnesses are the result of genetic factors. Psychologic stress is not at the root of most mental disorders.

 

DIF:    Cognitive Level: Application          REF:   Pages: 15-16

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which belief by a nurse supports the highest degree of patient advocacy during a multidisciplinary patient care planning session?
a. All mental illnesses are culturally determined.
b. Schizophrenia and bipolar disorder are cross-cultural disorders.
c. Symptoms of mental disorders are constant from culture to culture.
d. Some symptoms of mental disorders reflect a person’s cultural patterns.

 

 

ANS:  D

A nurse who understands that a patient’s symptoms are influenced by culture will be able to advocate for the patient to a greater degree than a nurse who believes that culture is of little relevance. All mental illnesses are not culturally determined. Schizophrenia and bipolar disorder are cross-cultural disorders, but this understanding has little relevance to patient advocacy. Symptoms of mental disorders change from culture to culture.

 

DIF:    Cognitive Level: Application          REF:   Pages: 21-22  TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A patient’s history shows intense and unstable relationships with others. The patient initially idealizes an individual and then devalues the person when the patient’s needs are not met. Which aspect of mental health is a problem?
a. Effectiveness in work
b. Communication skills
c. Productive activities
d. Fulfilling relationships

 

 

ANS:  D

The information provided centers on relationships with others, which are described as intense and unstable. The relationships of mentally healthy individuals are stable, satisfying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities.

 

DIF:    Cognitive Level: Application          REF:   Pages: 12-13

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. In the majority culture of the United States, which individual is at greatest risk to be incorrectly labeled mentally ill?
a. Person who is usually pessimistic but strives to meet personal goals
b. Wealthy person who gives $20 bills to needy individuals in the community
c. Person with an optimistic viewpoint about life and getting his or her own needs met
d. Person who attends a charismatic church and describes hearing God’s voice

 

 

ANS:  D

Hearing voices is generally associated with mental illness; however, in charismatic religious groups, hearing the voice of God or a prophet is a desirable event. In this situation, cultural norms vary, making it more difficult to make an accurate DSM-IV-TR diagnosis. The individuals described in the other options are less likely to be labeled as mentally ill.

 

DIF:    Cognitive Level: Application          REF:   Pages: 21-22

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A psychiatric nurse addresses Axis I of the DSM-IV-TR as the focus of care but also considers the presence of other long-term, nonmedical disorders that may affect treatment. To which axis should the nurse refer for this information?
a. II
b. III
c. IV
d. V

 

 

ANS:  A

Axis II refers to personality disorders and mental retardation. Together, Axis I and Axis II constitute the classification of abnormal behavior diagnosed in the individual. Axis III indicates any relevant general medical conditions. Axis IV reports psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis. Axis V is the GAF score.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 18-19  TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A mentally ill person’s current global assessment of functioning (GAF) score is 10. Select the nurse’s highest priority related to this patient’s care.
a. Safety
b. Hygiene
c. Nutrition
d. Socialization

 

 

ANS:  A

This low GAF score indicates a consistent risk for self-harm exists; therefore the nurse’s highest priority is safety.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 21-22  TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A participant at a community education conference asks, “What is the most prevalent mental disorder in the United States?” Select the nurse’s best response.
a. “Why do you ask?”
b. “Schizophrenia”
c. “Affective disorders”
d. “Anxiety disorders”

 

 

ANS:  D

The prevalence for schizophrenia is 1.1% per year. The prevalence of all affective disorders (e.g., depression, dysthymia, bipolar) is 9.5%. The prevalence of anxiety disorders is 13.3%.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 15

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A nurse wants to find a description of diagnostic criteria for a person with schizophrenia. Which resource should the nurse consult?
a. U.S. Department of Health and Human Services
b. Journal of the American Psychiatric Association
c. North American Nursing Diagnosis Association (NANDA) International
d. DSM-IV-TR

 

 

ANS:  D

The DSM-IV-TR identifies diagnostic criteria for psychiatric diagnoses. The other sources have useful information but are not the best resources for finding a description of the diagnostic criteria for a psychiatric disorder.

 

DIF:    Cognitive Level: Application          REF:   Page: 13|Page: 18

TOP:   Nursing Process: Analysis| Nursing Process: Diagnosis

MSC:  NCLEX: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A patient asks a nurse, “The pamphlet I read about depression says psychosocial factors influence depression. What does that mean?” Which examples could the nurse cite to support the information? Select all that apply.
a. Having a hostile family
b. Having an over- or underinvolved family
c. Having two first-degree relatives with bipolar disorder
d. Experiencing the sudden death of a parent or loved one
e. Feeling strong guilt over having an abortion when one’s religion forbids it
f. Experiencing symptom remission when treated with an antidepressant medication

 

 

ANS:  A, B, D, E

Family influence is considered a psychosocial factor affecting a patient’s mental health. A hostile under- or overinvolved family is critical of the patient and contributes to low self-esteem. Religious influences are considered psychosocial in nature. Life experiences, especially crises and losses, are considered psychosocial influences on mental health. Having two first-degree relatives with bipolar disorder would be considered a factor that influences the individual’s risk for mental disorder, but it is a genetic, not psychosocial, factor. Treatment with a biological agent such as an antidepressant medication is an example of a biological influence.

 

DIF:    Cognitive Level: Application          REF:   Page: 18

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient in the emergency department reports, “I hear voices saying someone is stalking me. They want to kill me because I found the cure for cancer. I will stab anyone that threatens me.” Which aspects of mental health have the greatest immediate concern to a nurse? Select all that apply.
a. Happiness
b. Appraisal of reality
c. Control over behavior
d. Effectiveness in work
e. Healthy self-concept

 

 

ANS:  B, C, E

The aspects of mental health of greatest concern are the patient’s appraisal of and control over behavior. The patient’s appraisal of reality is inaccurate, and auditory hallucinations are evident, as well as delusions of persecution and grandeur. In addition, the patient’s control over behavior is tenuous, as evidenced by the plan to “stab” anyone who seems threatening. A healthy self-concept is lacking. Data are not present to suggest that the other aspects of mental health (happiness and effectiveness in work) are of immediate concern.

 

DIF:    Cognitive Level: Application          REF:   Page: 12

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which statements most clearly reflect the stigma of mental illness? Select all that apply.
a. “Many mental illnesses are hereditary.”
b. “Mental illness can be evidence of a brain disorder.”
c. “People claim mental illness so they can get disability checks.”
d. “If people with mental illness went to church, they would be fine.”
e. “Mental illness is a result of the breakdown of the American family.”

 

 

ANS:  C, D, E

Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 18-19

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

Chapter 14: Eating Disorders

Test Bank

 

MULTIPLE CHOICE

 

  1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely?
a. Binge eating
b. Bulimia nervosa
c. Anorexia nervosa
d. Eating disorder not otherwise specified

 

 

ANS:  C

Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with an eating disorder not otherwise specified may be obese.

 

DIF:    Cognitive Level: Application          REF:   Pages: 230-232

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor?
a. Weight, muscle, and fat are congruent with height, frame, age, and sex.
b. Calorie intake is within the required parameters of the treatment plan.
c. Weight reaches the established normal range for the patient.
d. Patient expresses satisfaction with body appearance.

 

 

ANS:  D

Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

 

DIF:    Cognitive Level: Application          REF:   Pages: 234-239

TOP:   Nursing Process: Outcomes Identification

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient:
a. “Do you often feel fat?”
b. “Who plans the family meals?”
c. “What do you eat in a typical day?”
d. “What do you think about your present weight?”

 

 

ANS:  C

Although all the questions might be appropriate to ask, only “What do you eat in a typical day?” focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient’s thoughts on present weight explores the patient’s feelings about weight.

 

DIF:    Cognitive Level: Application          REF:   Pages: 232-233

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, “Describe what you think about your present weight and how you look.” Which response by the patient is most consistent with the diagnosis?
a. “I’m fat and ugly.”
b. “What I think about myself is my business.”
c. “I’m grossly underweight, but that’s what I want.”
d. “I’m a few pounds overweight, but I can live with it.”

 

 

ANS:  A

Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell others perceptions of self. The patient with anorexia will persist in trying to lose more weight.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 232-235

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dl. Which nursing diagnosis applies?
a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss
b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

 

 

ANS:  D

The patient’s history and laboratory results support the fourth nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 232-234

TOP:   Nursing Process: Diagnosis             MSC:  NCLEX: Physiological Integrity

 

  1. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:
a. Weigh self accurately using balanced scales.
b. Limit exercise to less than 2 hours daily.
c. Select clothing that fits properly.
d. Gain 1 to 2 pounds.

 

 

ANS:  D

Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

 

DIF:    Cognitive Level: Application          REF:   Page: 231|Pages: 234-235

TOP:   Nursing Process: Outcomes Identification

MSC:  NCLEX: Physiological Integrity

 

  1. Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight?
a. Assess for depression and anxiety.
b. Observe for adverse effects of refeeding.
c. Communicate empathy for the patient’s feelings.
d. Help the patient balance energy expenditure and caloric intake.

 

 

ANS:  B

The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention.

 

DIF:    Cognitive Level: Application          REF:   Page: 234

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?
a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected.
b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment.
c. A team approach to planning the diet ensures that physical and emotional needs are met.
d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.

 

 

ANS:  B

A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

 

DIF:    Cognitive Level: Application          REF:   Pages: 237-238

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A nursing care plan for a patient with anorexia nervosa includes the intervention “monitor for complications of refeeding.” Which system should a nurse closely monitor for dysfunction?
a. Renal
b. Endocrine
c. Central nervous
d. Cardiovascular

 

 

ANS:  D

Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

 

DIF:    Cognitive Level: Application          REF:   Page: 234

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy?
a. “What are your feelings about not eating the food that you prepare?”
b. “You seem to feel much better about yourself when you eat something.”
c. “It must be difficult to talk about private matters to someone you just met.”
d. “Being thin doesn’t seem to solve your problems. You’re thin now but still unhappy.”

 

 

ANS:  D

The correct response is the only strategy that attempts to question the patient’s distorted thinking.

 

DIF:    Cognitive Level: Application          REF:   Pages: 237-238

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to:
a. eat a small meal after purging.
b. avoid skipping meals or restricting food.
c. concentrate intake after 4 PM daily.
d. understand the value of reading journal entries aloud to others.

 

 

ANS:  B

One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private.

 

DIF:    Cognitive Level: Application          REF:   Pages: 238-239

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision?
a. The nurse’s comments are nonjudgmental.
b. The nurse uses an authoritarian manner when interacting with the patient.
c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene.
d. The nurse refers the patient to a self-help group for individuals with eating disorders.

 

 

ANS:  B

In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient’s feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.

 

DIF:    Cognitive Level: Application          REF:   Page: 231       TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Psychosocial Integrity

 

  1. A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will:
a. appropriately express angry feelings.
b. verbalize two positive things about self.
c. verbalize the importance of eating a balanced diet.
d. identify two alternative methods of coping with loneliness.

 

 

ANS:  D

The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

 

DIF:    Cognitive Level: Application          REF:   Pages: 238-239

TOP:   Nursing Process: Outcomes Identification

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which nursing intervention has the highest priority for a patient with bulimia nervosa?
a. Assist the patient to identify triggers to binge eating.
b. Provide corrective consequences for weight loss.
c. Assess for signs of impulsive eating.
d. Explore patient needs for health teaching.

 

 

ANS:  A

For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 239-240

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from:
a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg
b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg
c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg
d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

 

 

ANS:  A

Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 232-234

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe, Effective Care Environment

 

  1. While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about:
a. self-monitoring of daily food and fluid intake.
b. establishing the desired daily weight gain.
c. recognizing the symptoms of hypokalemia.
d. self-esteem maintenance.

 

 

ANS:  C

Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

 

DIF:    Cognitive Level: Application          REF:   Page: 232|Page: 239

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient’s body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented?
a. Amenorrhea
b. Alopecia
c. Lanugo
d. Stupor

 

 

ANS:  C

The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 231-232

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, “I won’t eat until I look thin.” What is the priority initial nursing diagnosis?
a. Anxiety, related to fear of weight gain
b. Disturbed body image, related to weight loss
c. Ineffective coping, related to lack of conflict resolution skills
d. Imbalanced nutrition: less than body requirements, related to self-starvation

 

 

ANS:  D

The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient’s self-starvation is the priority.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 234

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of:
a. Maintaining patients’ concentration and attention.
b. Shifting the patients’ focus from food to psychotherapy.
c. Focusing on weight control mechanisms and food preparation.
d. Processing the heightened anxiety levels associated with eating.

 

 

ANS:  D

Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients’ focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients’ concentration and attention is important, but not the primary purpose of the schedule.

 

DIF:    Cognitive Level: Application          REF:   Pages: 235-237

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. Physical assessment of a patient with bulimia often reveals:
a. prominent parotid glands.
b. peripheral edema.
c. thin, brittle hair.
d. amenorrhea.

 

 

ANS:  A

Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 232-233|Page: 238

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. Which personality characteristic is a nurse most likely to assess in a patient with anorexia nervosa?
a. Carefree flexibility
b. Rigidity, perfectionism
c. Open displays of emotion
d. High spirits and optimism

 

 

ANS:  B

Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the norm.

 

DIF:    Cognitive Level: Application          REF:   Pages: 231-232

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization?
a. Urine output: 40 ml/hr
b. Pulse rate: 58 beats/min
c. Serum potassium: 3.4 mEq/L
d. Systolic blood pressure: 62 mm Hg

 

 

ANS:  D

Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

 

DIF:    Cognitive Level: Application          REF:   Page: 233

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. Which statement is a nurse most likely to hear from a patient with anorexia nervosa?
a. “I’m fat and ugly.”
b. “I have nice eyes.”
c. “I’m thin for my height.”
d. “My parents don’t pay much attention to me.”

 

 

ANS:  A

Patients with eating disorders have distorted body images; they see themselves as overweight even when their weight is subnormal. “I’m thin for my height” is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as “I have nice eyes.” Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

 

DIF:    Cognitive Level: Application          REF:   Pages: 231-235

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. Which nursing diagnosis is more applicable to a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges?
a. Powerlessness
b. Ineffective coping
c. Disturbed body image
d. Imbalanced nutrition: less than body requirements

 

 

ANS:  D

The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 234|Page: 239

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Physiological Integrity

 

  1. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should:
a. assess lung sounds and extremities.
b. suggest the use of an aerobic exercise program.
c. positively reinforce the patient for the weight gain.
d. establish a higher goal for weight gain the next week.

 

 

ANS:  A

Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart’s capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

 

DIF:    Cognitive Level: Application          REF:   Pages: 232-234

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state:
a. “You and I will have to sit down and discuss this problem.”
b. “It bothers me to see you exercising. You’ll lose more weight.”
c. “Let’s discuss the relationship between exercise and weight loss and how that affects your body.”
d. “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.”

 

 

ANS:  D

A matter-of-fact statement that the nurse’s perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

 

DIF:    Cognitive Level: Application          REF:   Page: 235

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply.
a. Peripheral edema
b. Parotid swelling
c. Constipation
d. Hypotension
e. Dental caries
f. Lanugo

 

 

ANS:  A, C, D, F

Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

 

DIF:    Cognitive Level: Application          REF:   Pages: 231-233

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply.
a. Flexible mealtimes
b. Unscheduled weight checks
c. Adherence to a selected menu
d. Observation during and after meals
e. Monitoring during bathroom trips
f. Privileges correlated with emotional expression

 

 

ANS:  C, D, E

Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patient’s eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

 

DIF:    Cognitive Level: Application          REF:   Pages: 234-236

TOP:   Nursing Process: Planning              MSC:  NCLEX: Safe, Effective Care Environment

 

Chapter 28: Older Adults

Test Bank

 

MULTIPLE CHOICE

 

  1. A student nurse visiting a senior center tells the instructor, “It’s so depressing to see all these old people. They are so weak and frail. They are probably all senile.” The student is expressing:
a. reality.
b. ageism.
c. empathy.
d. advocacy.

 

 

ANS:  B

Ageism is defined as a bias against older people because of their age. None of the other options can be identified from the ideas expressed by the student.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 527-528

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A community mental health nurse plans an educational program for the staff members of a home health agency that specializes in the care of older adults. A topic of high priority should be:
a. identifying clinical depression in older adults.
b. providing cost-effective foot care for older adults.
c. identifying nutritional deficiencies in older adults.
d. psychosocial stimulation for those who live alone.

 

 

ANS:  A

The topic of greatest immediacy is the identification of clinical depression in older adults. Home health staff members are better versed in the physical aspects of care and less knowledgeable about mental health topics. Statistics show that older adult patients with mental health problems are less likely than young adults to be diagnosed accurately. This is especially true for those with depression and anxiety, both of which are likely to be misinterpreted as normal aging. Undiagnosed and untreated depression and anxiety result in unnecessary suffering. The other options are of lesser importance.

 

DIF:    Cognitive Level: Application          REF:   Pages: 529-530

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. Which is the best comment for a nurse to use when beginning an interview with an older adult patient?
a. “Hello, [call patient by first name]. I am going to ask you some questions to get to know you better.”
b. “Hello. My name is [nurse’s name]. I am a nurse. Please tell me how you would like to be addressed by the staff.”
c. “I am going to ask you some questions about yourself. I would like to call you by your first name if you don’t mind.”
d. “You look as though you are comfortable and ready to participate in an admission interview. Shall we get started?”

 

 

ANS:  B

This opening identifies the nurse’s role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name, but should not assume a patient wants to be called by his or her first name. The nurse should always introduce him- or herself.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 529-530

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A 75-year-old patient comes to the clinic reporting frequent headaches. After an introduction at the beginning of the interview, the nurse should:
a. initiate a neurologic assessment.
b. ask if the patient can hear clearly as the nurse speaks.
c. suggest that the patient lie down in a darkened room for a few minutes.
d. administer medication to relieve the patient’s pain before performing the assessment.

 

 

ANS:  B

Before proceeding, the nurse should assess the patient’s ability to hear questions. Impaired hearing could lead to inaccurate answers. The nurse should not administer medication (an intervention) until after the assessment is complete.

 

DIF:    Cognitive Level: Application          REF:   Page: 529

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Health Promotion and Maintenance

 

  1. Which statement about aging provides the best rationale for focused assessment of older adult patients?
a. Older adults are often socially isolated and lonely.
b. As people age, they become more rigid in their thinking.
c. The majority of older adults sleep more than 12 hours per day.
d. The senses of vision, hearing, touch, taste, and smell decline with age.

 

 

ANS:  D

Only the correct answer is true and cues the nurse to assess carefully the sensory functions of the older adult patient. The incorrect options are myths about aging.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 529

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers “yes” to which question?
a. “Would you say your mood is often low?”
b. “Are you having any trouble with your memory?”
c. “Have you noticed an increase in your alcohol use?”
d. “Do you often experience moderate-to-severe pain?”

 

 

ANS:  A

Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need to assess further for other symptoms of depression. The other options do not focus on mood.

 

DIF:    Cognitive Level: Application          REF:   Pages: 534-535

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A 78-year-old nursing home resident with hypertension and cardiac disease is usually alert and oriented. This morning, however, the resident says, “My family visited during the night. They stood by the bed and talked to me.” In reality, the patient’s family lives 200 miles away. The nurse should first suspect that the resident:
a. may have a cognitive impairment associated with medication effects.
b. may be developing Alzheimer‘s disease associated with advanced age.
c. had a transient ischemic attack and developed sensory perceptual alterations.
d. has a previously unidentified alcohol dependency and is beginning alcohol withdrawal delirium.

 

 

ANS:  A

A resident taking medications is at high risk for becoming confused because of medication side effects, drug interactions, and delayed excretion. The nurse should report the event and continue to assess for cognitive impairment. Symptoms of dementia develop slowly but persist over time. Alcohol dependency and withdrawal are not the nurse’s first suspicion in this scenario.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 527-528

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A health care provider writes these new prescriptions for a resident in a skilled care facility: 2 G sodium diet; restraint as needed; limit fluids to 2000 ml daily; 1 dose milk of magnesia 30 ml orally if no bowel movement occurs for 3 days. Which prescription should the nurse question?
a. Restraint
b. Fluid restriction
c. Milk of magnesia
d. Sodium restriction

 

 

ANS:  A

Restraints may be applied only on the written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other orders may be appropriate for implementation.

 

DIF:    Cognitive Level: Application          REF:   Pages: 539-540

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

  1. If an older adult patient must be physically restrained, who is responsible for the patient’s safety?
a. Nurse assigned to care for the patient
b. Nursing assistant who applies the restraint
c. Health care provider who ordered the application of restraint
d. Family member who agrees to the application of the restraint

 

 

ANS:  A

Although restraint is ordered by a health care provider, it is carried out by a nursing staff member. The nurse caring for the patient is responsible for the safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint but remain responsible for outcomes. Even when the family agrees to restraint, nurses are responsible for providing safe outcomes.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 540-541

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A health care provider decided that the emotional distress of an older adult patient who experiences threatening auditory hallucinations warrants the use of risperidone (Risperdal). Which intervention should the nurse add to the patient’s plan of care?
a. Use disposable briefs for incontinence.
b. Monitor for psychomotor changes.
c. Implement a tyramine-free diet.
d. Monitor for dehydration.

 

 

ANS:  B

Use of atypical antipsychotic medications increases the risk of cerebrovascular events in the older adult population; therefore the nurse should carefully monitor the patient for psychomotor changes. This medication does not place the patient at great risk for the other options.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 540-541

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Physiological Integrity

 

  1. An older adult patient brings a bag of medication to the clinic. The nurse finds one bottle labeled “Ativan” and one labeled “lorazepam,” and both are labeled “Take two times daily.” Bottles of hydrochlorothiazide, Inderal, and rofecoxib, each labeled “Take one daily,” are also included. Which conclusion is accurate?
a. Rofecoxib should not be taken with Ativan.
b. The patient’s blood pressure is likely to be very high.
c. This patient should not self-administer any medication.
d. Lorazepam and Ativan are the same drug; consequently, the dose is excessive.

 

 

ANS:  D

Lorazepam and Ativan are generic and trade names for the same drug, creating an accidental misuse situation. The patient needs medication education and help with proper, consistent labeling of bottles; no evidence suggests that the patient cannot self-administer medication. The distracters are not factual statements.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 527-528|Pages: 537-538

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. An advance directive gives valid direction to health care providers when a patient is:
a. aggressive
b. dehydrated
c. unable to verbally communicate
d. unable to make decisions for him- or herself

 

 

ANS:  D

Advance directives are invoked when patients are unable to make their own decisions. Aggression, dehydration, or an inability to speak does not mean the patient is unable to make a decision.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 540-541

TOP:   Nursing Process: Planning              MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A patient with whom the nurse is discussing advance directives asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply that a durable power of attorney for health care:
a. “Gives your agent the authority to make decisions about your care if you are unable to during any illness.”
b. “Can be given only to a relative, usually the next of kin, who has your best interests at heart.”
c. “Authorizes your physician to make decisions about your care that are in your best interest.”
d. “Can be used only if you have a terminal illness and become incapacitated.”

 

 

ANS:  A

A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individual’s agent in the event that he or she is unable to make medical decisions. The patient does not have to be terminally ill or incompetent for the appointed person to act on his or her behalf.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 540-541

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Recognizing the risk for acquired immunodeficiency syndrome (AIDS) among older adults, nurses should provide health teaching aimed at:
a. discouraging sexual expression
b. using birth controls measures
c. avoiding blood transfusions
d. encouraging condom use

 

 

ANS:  D

Because the risk for pregnancy is nonexistent in postmenopausal women, condom use is diminished, which places older adults at risk for AIDS and other sexually transmitted diseases. Safe sex continues to be important and should be taught to the older adult population. Little to no danger exists from blood transfusions.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 539-540

TOP:   Nursing Process: Planning              MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A 79-year-old white man tells a visiting nurse, “I’ve been feeling down lately. My family and friends are all dead. My money is running out, and my health is failing.” The nurse should analyze this comment as:
a. normal pessimism of older adults.
b. evidence of suicide risk.
c. a cry for sympathy.
d. normal grieving.

 

 

ANS:  B

The patient describes the loss of significant others, economic insecurity, and declining health. He describes mood alteration and expresses the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Older adult white men have the highest risk for completed suicide.

 

DIF:    Cognitive Level: Application          REF:   Pages: 532-535

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. In a sad voice, a patient tells the nurse of the recent deaths of a spouse of 50 years and their adult child in an automobile accident. The patient has no other family and only a few friends in the community. What is the priority nursing diagnosis?
a. Spiritual distress, related to being angry with God for taking the family
b. Risk for suicide, related to recent deaths of significant others
c. Anxiety, related to sudden and abrupt lifestyle changes
d. Social isolation, related to loss of existing family

 

 

ANS:  B

The patient appears to be experiencing normal grief related to the loss of the family; however, because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnosis of anxiety or spiritual distress. Risk for suicide is a higher priority than social isolation.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 534-535

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. When making a distinction as to whether a patient is experiencing confusion related to depression or dementia, what information would be most important for the nurse to consider?
a. The patient with dementia is persistently angry and hostile.
b. Early morning agitation and hyperactivity occur in dementia.
c. Confusion seems to worsen at night when dementia is present.
d. A patient who is depressed is constantly preoccupied with somatic symptoms.

 

 

ANS:  C

Both dementia and depression in older adults may produce symptoms of confusion. Noting whether the confusion seems to increase at night, which occurs more often with dementia than with depression, will help distinguish whether depression or dementia is producing the confused behavior. The other options are not necessarily true.

 

DIF:    Cognitive Level: Application          REF:   Page: 531

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. An 80-year-old patient has difficulty walking because of arthritis and says, “It’s awful to be old. Every day is a struggle. No one cares about old people.” Which is the nurse’s most therapeutic response?
a. “Everyone here cares about old people. That’s why we work here.”
b. “It sounds like you’re having a difficult time. Tell me about it.”
c. “Let’s not focus on the negative. Tell me something good.”
d. “You are still able to get around, and your mind is alert.”

 

 

ANS:  B

The nurse uses empathic understanding to permit the patient to express frustration and clarify the “struggle” for the nurse. The other options block communication.

 

DIF:    Cognitive Level: Application          REF:   Pages: 528-529

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. A 74-year-old patient is regressed and apathetic and responds to others only when they initiate the interaction. What form of therapy would be most useful to promote resocialization?
a. Life review
b. Remotivation
c. Group psychotherapy
d. Individual psychotherapy

 

 

ANS:  B

Remotivation therapy is designed to resocialize patients who are regressed and apathetic by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work, and hobbies related to the topic. Group leaders give group members acceptance and appreciation.

 

DIF:    Cognitive Level: Application          REF:   Pages: 534-535

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A clinic nurse interviews four patients between 70 and 80 years of age. Which patient should have further assessment regarding the risk of alcohol dependence? The patient:
a. with a history of intermittent problems of alcohol misuse early in life and who now consumes one glass of wine nightly with dinner.
b. with no history of alcohol-related problems until age 65 years, when the patient began to drink alcohol daily “to keep my mind off my arthritis.”
c. who drank socially throughout adult life and continues this pattern, saying, “I’ve earned the right to do as I please.”
d. who abused alcohol between the ages of 25 and 40 years but now abstains and occasionally attends Alcoholics Anonymous.

 

 

ANS:  B

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.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 536-537

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. An SSRI is prescribed for an older adult patient with depression. Nursing assessment should include careful collection of information regarding:
a. use of other prescribed medications and over-the-counter products.
b. evidence of pseudoparkinsonism or tardive dyskinesia.
c. history of psoriasis and any other skin disorders.
d. history of diarrhea and electrolyte imbalances.

 

 

ANS:  A

Drug interactions, with both prescription and over-the-counter products, can be problematic for the geriatric patient taking an SSRI. Careful collection of information is important. The incorrect options do not pose problems with SSRIs.

 

DIF:    Cognitive Level: Application          REF:   Pages: 533-534

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Physiological Integrity

 

  1. An older adult patient with depression is being treated with sertraline (Zoloft). This medication is often chosen for older adult patients because it:
a. has a high degree of sedation.
b. is effective when given in smaller doses.
c. has few adverse interactions with other drugs.
d. is less affected by changes associated with aging.

 

 

ANS:  D

Older adults are particularly susceptible to side effects, so selecting a drug with a low side-effect profile is desirable. The pharmacokinetics of sertraline are less affected by changes associated with aging. The incorrect options are either incorrect or of lesser relevance.

 

DIF:    Cognitive Level: Application          REF:   Pages: 533-534

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

 

  1. When admitting older adult patients, health care agencies receiving federal funds must provide written information about:
a. advance health care directives
b. the financial status of the institution
c. how to sign out against medical advice
d. the institution’s policy on the use of restraints

 

 

ANS:  A

The Patient Self-Determination Act of 1990 requires that patients have the opportunity to prepare advance directives.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 540-541

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The highest priority for assessment by nurses caring for older adults who self-administer medications is:
a. use of multiple drugs with anticholinergic effects
b. overuse of medications for erectile dysfunction
c. misuse of antihypertensive medications
d. trading medications with acquaintances

 

 

ANS:  A

Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The incorrect options are relevant but are not of the highest priority.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 527-528

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A nurse and social worker co-lead a reminiscence group for eight “elite-old” adults. Which activity is appropriate to include in the group?
a. Performing mild aerobic exercises
b. Singing a song from World War II
c. Discussing national leadership during the Vietnam War
d. Identifying the most troubling story in today’s newspaper

 

 

ANS:  B

“Elite-old” adults are persons over 94 years of age; they were young during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 527|Page: 534

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse wants to perform a preliminary assessment for suicidal ideation in an older adult patient. Which question would obtain the desired data?
a. “What thoughts do you have about a person’s right to take his or her own life?”
b. “If you felt suicidal, would you communicate your feelings to anyone?”
c. “Do you have any risk factors that potentially contribute to suicide?”
d. “Do you think you are vulnerable to developing a depressed mood?”

 

 

ANS:  A

This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, then no further assessment is necessary. If the patient deems suicide as acceptable, then the nurse can continue to assess the patient’s intent, plan, and means to carry out the plan, as well as the lethality of the chosen method. The incorrect options are less direct.

 

DIF:    Cognitive Level: Application          REF:   Pages: 534-535

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse and social worker co-lead a reminiscence group for eight “young-old” adults. Which activity is most appropriate to include in the group?
a. Performing mild aerobic exercises
b. Singing a song from World War II
c. Discussing national leadership during the Vietnam War
d. Identifying the most troubling story in today’s newspaper

 

 

ANS:  C

“Young-old” adults are persons 65 to 74 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 527|Page: 534

TOP:   Nursing Process: Planning              MSC:  NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? Select all that apply.
a. Failure of older adults to receive necessary medical information
b. Development of public policy that favors programs for older adults
c. Staff shortages because caregivers prefer working with younger adults
d. Perception that older adults consume a small share of medical resources
e. More ancillary than professional personnel discriminate with regard to age

 

 

ANS:  A, C

Because of society’s negative stereotyping of older adults as having little to offer, some staff members avoid working with older patients. Staff shortages in long-term care facilities are often greater than those for acute care settings. Older adult patients often receive less information about their conditions and are offered fewer treatment options than younger patients; some health care staff members perceive them as less able to understand. This problem exists among professional and ancillary personnel. Public policy discriminates against programs for older adults. Societal anger exists because older adults are perceived to consume a disproportionately large share of the medical resources.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 527-529

TOP:   Nursing Process: Implementation   MSC:  NCLEX: Psychosocial Integrity

 

  1. Which beliefs facilitate the provision of safe, effective care for older adult patients? Select all that apply.
a. Sexual interest declines with aging.
b. Older adults are able to learn new tasks.
c. Aging results in a decline in restorative sleep.
d. Older adults are prone to become crime victims.
e. Older adults are usually lonely and socially isolated.

 

 

ANS:  B, C, D

Myths about aging are common and can negatively impact the quality of care older patients receive. Older individuals are more prone to become crime victims. A decline in restorative sleep occurs as one ages. Learning continues long into life. These factors affect care delivery.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 529       TOP:   Nursing Process: Planning

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A nurse assessing an older adult patient for suicide potential should include questions about mood and which other symptoms? Select all that apply.
a. Increased appetite
b. Sleep pattern changes
c. Anhedonia and anergia
d. Increased social isolation
e. Increased concern with bodily functions

 

 

ANS:  B, C, D, E

These symptoms are often noted in older adult patients with depression. Somatic symptoms are often present but are missed by nurses as being related to depression. Anorexia, rather than hyperphagia, is observed in major depression. Low self-esteem is more often associated with major depression.

 

DIF:    Cognitive Level: Application          REF:   Pages: 531-533

TOP:   Nursing Process: Assessment          MSC:  NCLEX: Safe, Effective Care Environment

 

  1. An older patient drinks a six-pack of beer daily. The patient tells the community health nurse, “I’ve been having trouble with my arthritis lately, so I take acetaminophen four times a day for pain.” What are the nurse’s priority interventions? Select all that apply.
a. Inquiring about sleep disturbances caused by mixing alcohol and analgesic medications
b. Determining the safety of the daily acetaminophen dose the patient is ingesting
c. Advising the patient of the harmful effects of alcohol and acetaminophen on the liver
d. Suggesting an increase in the acetaminophen dose because alcohol causes faster excretion
e. Assessing the patient for declining functional status associated with medication-induced dementia

 

 

ANS:  B, C

The nurse should be concerned with the patient’s use of alcohol and acetaminophen because the toxicity of acetaminophen is enhanced by alcohol and by the age-related decrease in clearance. The nurse must determine whether the acetaminophen dose is within safe limits or is excessive and provide this information to the patient. Next, the nurse must provide health education regarding the danger of combined use of acetaminophen and alcohol. The patient will need to discontinue or reduce alcohol intake. Another analgesic with less hepatotoxicity could be used. Additional acetaminophen would cause greater liver damage. The scenario does not suggest dementia.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 527-528|Pages: 536-537

TOP:   Nursing Process: Planning              MSC:  NCLEX: Physiological Integrity

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