Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach 7th Edition By Margaret Jordan Halter – Test Bank

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Varcarolis’ Foundations of Psychiatric Mental Health Nursing A Clinical Approach 7th Edition By  Margaret Jordan Halter- Test Bank

 

SAMPLE QUESTIONS

 

Chapter 02: Relevant Theories and Therapies for Nursing Practice

 

MULTIPLE CHOICE

 

  1. A parent says, “My 2-year-old child refuses toilet training and shouts ‘No!’ when given directions. What do you think is wrong?” Select the nurse’s best reply.
a. “Your child needs firmer control. It is important to set limits now.”
b. “This is normal for your child’s age. The child is striving for independence.”
c. “There may be developmental problems. Most children are toilet trained by age 2.”
d. “Some undesirable attitudes are developing. A child psychologist can help you develop a plan.”

 

 

ANS:  B

This behavior is typical of a child around the age of 2 years, whose developmental task is to develop autonomy. The distracters indicate the child’s behavior is abnormal.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 26-month-old displays negative behavior, refuses toilet training, and often says, “No!” Which stage of psychosexual development is evident?
a. Oral c. Phallic
b. Anal d. Genital

 

 

ANS:  B

The anal stage occurs from age 1 to 3 years and has as its focus toilet training and learning to delay immediate gratification. The oral stage occurs between birth and 1 year. The phallic stage occurs between 3 and 5 years, and the genital stage occurs between age 13 and 20 years.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22 (Table 2-1)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 26-month-old displays negative behavior, refuses toilet training, and often says, “No!” Which psychosocial crisis is evident?
a. Trust versus mistrust c. Industry versus inferiority
b. Initiative versus guilt d. Autonomy versus shame and doubt

 

 

ANS:  D

The crisis of autonomy versus shame and doubt relates to the developmental task of gaining control of self and environment, as exemplified by toilet training. This psychosocial crisis occurs during the period of early childhood. Trust versus mistrust is the crisis of the infant. Initiative versus guilt is the crisis of the preschool and early-school-aged child. Industry versus inferiority is the crisis of the 6- to 12-year-old child.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A 4-year-old grabs toys from siblings and says, “I want that now!” The siblings cry, and the child’s parent becomes upset with the behavior. According to Freudian theory, this behavior is a product of impulses originating in which system of the personality?
a. Id c. Superego
b. Ego d. Preconscious

 

 

ANS:  A

The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and weighs the consequences of the action, perhaps determining that taking the toy is not worth the mother’s wrath. The superego would oppose the impulsive behavior as “not nice.” The preconscious is a level of awareness. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20-21     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. The nurse supports this use of praise related to these behaviors. These qualities are likely to be internalized and become part of which system of the personality?
a. Id c. Superego
b. Ego d. Preconscious

 

 

ANS:  C

The superego contains the “thou shalts,” or moral standards internalized from interactions with significant others. Praise fosters internalization of desirable behaviors. The id is the center of basic instinctual drives, and the ego is the mediator. The ego is the problem-solving and reality-testing portion of the personality that negotiates solutions with the outside world. The preconscious is a level of awareness from which material can be retrieved easily with conscious effort.  This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20-21     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse supports a parent for praising a child behaving in a helpful way. When this child behaves with politeness and helpfulness in adulthood, which feeling will most likely result?
a. Guilt c. Humility
b. Anxiety d. Self-esteem

 

 

ANS:  D

The individual will be living up to the ego ideal, which will result in positive feelings about self. The other options are incorrect because each represents a negative feeling.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21 | Page 28                            TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. An adult says, “I never know the answers,” and “My opinion doesn’t count.” Which psychosocial crisis was unsuccessfully resolved for this adult?
a. Initiative versus guilt c. Autonomy versus shame and doubt
b. Trust versus mistrust d. Generativity versus self-absorption

 

 

ANS:  C

These statements show severe self-doubt, indicating that the crisis of gaining control over the environment was not met successfully. Unsuccessful resolution of the crisis of initiative versus guilt results in feelings of guilt. Unsuccessful resolution of the crisis of trust versus mistrust results in poor interpersonal relationships and suspicion of others. Unsuccessful resolution of the crisis of generativity versus self-absorption results in self-absorption that limits the ability to grow as a person.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which patient statement would lead the nurse to suspect unsuccessful completion of the developmental task of infancy?
a. “I have very warm and close friendships.”
b. “I’m afraid to allow anyone to really get to know me.”
c. “I’m always absolutely right, so don’t bother saying more.”
d. “I’m ashamed that I didn’t do things correctly in the first place.”

 

 

ANS:  B

According to Erikson, the developmental task of infancy is the development of trust. The correct response is the only statement clearly showing lack of ability to trust others. Warm, close relationships suggest the developmental task of infancy was successfully completed; rigidity and self-absorption are reflected in the belief one is always right; and shame for past actions suggests failure to resolve the crisis of initiative versus guilt.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient is suspicious and frequently manipulates others. To which psychosexual stage do these traits relate?
a. Oral c. Phallic
b. Anal d. Genital

 

 

ANS:  A

The behaviors in the stem develop as the result of attitudes formed during the oral stage, when an infant first learns to relate to the environment. Anal-stage traits include stinginess, stubbornness, orderliness, or their opposites. Phallic-stage traits include flirtatiousness, pride, vanity, difficulty with authority figures, and difficulties with sexual identity. Genital-stage traits include the ability to form satisfying sexual and emotional relationships with members of the opposite sex, emancipation from parents, a strong sense of personal identity, or the opposites of these traits.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22 (Table 2-1)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient expresses a desire to be cared for by others and often behaves in a helpless fashion. Which stage of psychosexual development is most relevant to the patient’s needs?
a. Latency c. Anal
b. Phallic d. Oral

 

 

ANS:  D

Fixation at the oral stage sometimes produces dependent infantile behaviors in adults. Latency fixations often result in difficulty identifying with others and developing social skills, resulting in a sense of inadequacy and inferiority. Phallic fixations result in having difficulty with authority figures and poor sexual identity. Anal fixation sometimes results in retentiveness, rigidity, messiness, destructiveness, and cruelty. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22 (Table 2-1)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse listens to a group of recent retirees. One says, “I volunteer with Meals on Wheels, coach teen sports, and do church visitation.” Another laughs and says, “I’m too busy taking care of myself to volunteer to help others.” Which developmental task do these statements contrast?
a. Trust and mistrust c. Industry and inferiority
b. Intimacy and isolation d. Generativity and self-absorption

 

 

ANS:  D

Both retirees are in middle adulthood, when the developmental crisis to be resolved is generativity versus self-absorption. One exemplifies generativity; the other embodies self-absorption. This developmental crisis would show a contrast between relating to others in a trusting fashion and being suspicious and lacking trust. Failure to negotiate this developmental crisis would result in a sense of inferiority or difficulty learning and working as opposed to the ability to work competently. Behaviors that would be contrasted would be emotional isolation and the ability to love and commit oneself.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Although ego defense mechanisms and security operations are mainly unconscious and designed to relieve anxiety, the major difference is that:
a. defense mechanisms are intrapsychic and not observable.
b. defense mechanisms cause arrested personal development.
c. security operations are masterminded by the id and superego.
d. security operations address interpersonal relationship activities.

 

 

ANS:  D

Sullivan’s theory explains that security operations are interpersonal relationship activities designed to relieve anxiety. Because they are interpersonal, they are observable. Defense mechanisms are unconscious and automatic. Repression is entirely intrapsychic, but other mechanisms result in observable behaviors. Frequent, continued use of many defense mechanisms often results in reality distortion and interference with healthy adjustment and emotional development. Occasional use of defense mechanisms is normal and does not markedly interfere with development. Security operations are ego-centered. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 33-34 (Table 2-6)                   TOP:   Nursing Process: Analysis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A student nurse says, “I don’t need to interact with my patients. I learn what I need to know by observation.” An instructor can best interpret the nursing implications of Sullivan’s theory to this student by responding:
a. “Interactions are required in order to help you develop therapeutic communication skills.”
b. “Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills.”
c. “Observing patient interactions will help you formulate priority nursing diagnoses and appropriate interventions.”
d. “It is important to pay attention to patients’ behavioral changes, because these signify adjustments in personality.”

 

 

ANS:  B

The nurse’s role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan’s theory. The nurse who does not interact with the patient cannot demonstrate these cornerstones. Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The other distracters relate to Maslow and behavioral theory. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 33-34 (Table 2-6)                   TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse consistently encourages patient to do his or her own activities of daily living (ADLs).  If the patient is unable to complete an activity, the nurse helps until the patient is once again independent.  This nurse’s practice is most influenced by which theorist?
a. Betty Neuman c. Dorothea Orem
b. Patricia Benner d. Joyce Travelbee

 

 

ANS:  C

Orem emphasizes the role of the nurse in promoting self-care activities of the patient; this has relevance to the seriously and persistently mentally ill patient.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 30-31     TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse uses Maslow’s hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority? The patient:
a. refuses to eat or bathe.
b. reports feelings of alienation from family.
c. is reluctant to participate in unit social activities.
d. is unaware of medication action and side effects.

 

 

ANS:  A

The need for food and hygiene are physiological and therefore take priority over psychological or meta-needs in care planning.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 31-32 (Figure 2-5)                  TOP:   Nursing Process: Planning/Outcomes Identification

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique applies?
a. Encourage the child to observe others talking.
b. Include the child in small group activities.
c. Give the child a small treat for speaking.
d. Teach the child relaxation techniques.

 

 

ANS:  C

Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards and reinforce speech through positive reinforcement.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 27 (Fig 2-3)                            TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. The parent of a child diagnosed with schizophrenia tearfully asks the nurse, “What could I have done differently to prevent this illness?” Select the nurse’s best response.
a. “Although schizophrenia results from impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance.”
b. “Schizophrenia is a biological illness resulting from changes in how the brain and nervous system function. You are not to blame for your child’s illness.”
c. “There is still hope. Changing your parenting style can help your child learn to cope effectively with the environment.”
d. “Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting.”

 

 

ANS:  B

The parent’s comment suggests feelings of guilt or inadequacy. The nurse’s response should address these feelings as well as provide information. Patients and families need reassurance that the major mental disorders are biological in origin and are not the “fault” of parents. One distracter places the burden of having faulty genes on the shoulders of the parents. The other distracters are neither wholly accurate nor reassuring.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 33          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse influenced by Peplau’s interpersonal theory works with an anxious, withdrawn patient. Interventions should focus on:
a. rewarding desired behaviors.
b. use of assertive communication.
c. changing the patient’s self-concept.
d. administering medications to relieve anxiety.

 

 

ANS:  B

The nurse-patient relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others. Helping the patient learn to use assertive communication will improve the patient’s interpersonal relationships. The distracters apply to theories of cognitive, behavioral, and biological therapy.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient had psychotherapy weekly for 5 months. The therapist used free association, dream analysis, and facilitated transference to help the patient understand conflicts and foster change. Select the term that applies to this method.
a. Rational-emotive behavior therapy c. Cognitive-behavioral therapy
b. Psychodynamic psychotherapy d. Operant conditioning

 

 

ANS:  B

The techniques are aspects of psychodynamic psychotherapy. The distracters use other techniques.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20-21 | Page 34 (Table 2-6)    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Consider this comment from a therapist: “The patient is homosexual but has kept this preference secret. Severe anxiety and depression occur when the patient anticipates family reactions to this sexual orientation.” Which perspective is evident in the speaker?
a. Theory of interpersonal relationships c. Psychosexual theory
b. Classical conditioning theory d. Behaviorism theory

 

 

ANS:  A

The theory of interpersonal relationships recognizes the anxiety and depression as resulting from unmet interpersonal security needs. Behaviorism and classical conditioning theories do not apply. A psychosexual formulation would focus on uncovering unconscious material that relates to the patient problem.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 24 | Page 34 (Table 2-6)         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A psychotherapist works with an anxious, dependent patient. Which strategy is most consistent with psychoanalytic psychotherapy?
a. Identifying the patient’s strengths and assets
b. Praising the patient for describing feelings of isolation
c. Focusing on feelings developed by the patient toward the therapist
d. Providing psychoeducation and emphasizing medication adherence

 

 

ANS:  C

Positive or negative feelings of the patient toward the therapist indicate transference. Transference is a psychoanalytic concept that can be used to explore previously unresolved conflicts. The distracters relate to biological therapy and supportive psychotherapy. Use of psychoeducational materials is a common “homework” assignment used in cognitive therapy.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 21-22 | Page 34 (Table 2-6)    TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A person says, “I was the only survivor in a small plane crash. Three business associates died. I got depressed and saw a counselor twice a week for 4 weeks. We talked about my feelings related to being a survivor, and I’m better now.” Which type of therapy was used?
a. Milieu therapy c. Behavior modification
b. Psychoanalysis d. Interpersonal psychotherapy

 

 

ANS:  D

Interpersonal psychotherapy returned the patient to his former level of functioning by helping him come to terms with the loss of friends and guilt over being a survivor. Milieu therapy refers to environmental therapy. Psychoanalysis would call for a long period of exploration of unconscious material. Behavior modification would focus on changing a behavior rather than helping the patient understand what is going on in his life.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 24-25 | Page 34 (Table 2-6)    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which technique is most applicable to aversion therapy?
a. Punishment c. Role modeling
b. Desensitization d. Positive reinforcement

 

 

ANS:  A

Aversion therapy is akin to punishment.  Aversive techniques include pairing of a maladaptive behavior with a noxious stimulus, punishment, and avoidance training.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 28          TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says to the nurse, “My father has been dead for over 10 years, but talking to you is almost as comforting as the talks he and I had when I was a child.”  Which term applies to the patient’s comment?
a. Superego c. Reality testing
b. Transference d. Counter-transference

 

 

ANS:  B

Transference refers to feelings a patient has toward the health care workers that were originally held toward significant others in his or her life. Counter-transference refers to unconscious feelings that the health care worker has toward the patient.  The superego represents the moral component of personality; it seeks perfection.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 21-22     TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A college student received an invitation to attend the wedding of a close friend who lives across the country. The student is afraid of flying. Which type of therapy would be most helpful for this patient?
a. Psychoanalysis c. Systematic desensitization
b. Milieu therapy d. Short-term dynamic therapy

 

 

ANS:  C

Systematic desensitization is a type of therapy aimed at extinguishing a specific behavior, such as the fear of flying. Psychoanalysis and short-term dynamic therapy seek to uncover conflicts. Milieu therapy involves environmental factors.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 27-28     TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient would benefit from therapy in which peers as well as staff have a voice in determining patients’ privileges and psychoeducational topics. Which approach would be best?
a. Milieu therapy c. Short-term dynamic therapy
b. Cognitive therapy d. Systematic desensitization

 

 

ANS:  A

Milieu therapy is based on the idea that all members of the environment contribute to the planning and functioning of the setting. The distracters are individual therapies that do not fit the description.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 33          TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient repeatedly stated, “I’m stupid.” Which statement by that patient would show progress resulting from cognitive behavioral therapy?
a. “Sometimes I do stupid things.”
b. “Things always go wrong for me.”
c. “I always fail when I try new things.”
d. “I’m disappointed in my lack of ability.”

 

 

ANS:  A

“I’m stupid” is a cognitive distortion. A more rational thought is “Sometimes I do stupid things.” The latter thinking promotes emotional self-control. The distracters reflect irrational or distorted thinking. This item relates to an audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 (Table 2-5)                   TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says, “All my life I’ve been surrounded by stupidity.  Everything I buy breaks because the entire American workforce is incompetent.”  This patient is experiencing a:
a. self-esteem deficit. c. deficit in motivation.
b. cognitive distortion. d. deficit in love and belonging.

 

 

ANS:  B

Automatic thoughts, or cognitive distortions, are irrational and lead to false assumptions and misinterpretations.  See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 (Table 2-5)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient is fearful of riding on elevators.  The therapist first rides an escalator with the patient.  The therapist and patient then stand in an elevator with the door open for five minutes and later with the elevator door closed for five minutes.  Which technique has the therapist used?
a. Classic psychoanalytic therapy c. Rational emotive therapy
b. Systematic desensitization d. Biofeedback

 

 

ANS:  B

Systematic desensitization is a form of behavior modification therapy that involves the development of behavior tasks customized to the patient’s specific fears.  These tasks are presented to the patient while using learned relaxation techniques. The patient is incrementally exposed to the fear.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 28          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient says, “I always feel good when I wear a size 2 petite.”  Which type of cognitive distortion is evident?
a. Disqualifying the positive c. Catastrophizing
b. Overgeneralization d. Personalization

 

 

ANS:  B

Automatic thoughts, or cognitive distortions, are irrational and lead to false assumptions and misinterpretations.  The stem offers an example of overgeneralization.  See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 (Table 2-5)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comment best indicates a patient is self-actualized?
a. “I have succeeded despite a world filled with evil.”
b. “I have a plan for my life.  If I follow it, everything will be fine.”
c. “I’m successful because I work hard.  No one has ever given me anything.”
d. “My favorite leisure is walking on the beach, hearing soft sounds of rolling waves.”

 

 

ANS:  D

The self-actualized personality is associated with high productivity and enjoyment of life.  Self-actualized persons experience pleasure in being alone and an ability to reflect on events.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 31-32 (Box 2-1)                                TOP:              Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse and patient discuss a problem the patient has kept secret for many years.  Afterward the patient says, “I feel so relieved that I finally told somebody.”  Which term best describes the patient’s feeling?
a. Catharsis c. Cognitive distortion
b. Superego d. Counter-transference

 

 

ANS:  A

Freud initially used talk therapy, known as the cathartic method. Today we refer to catharsis as “getting things off our chests.”  The superego represents the moral component of personality.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 20          TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which patient is the best candidate for brief psychodynamic therapy?
a. An accountant with a loving family and successful career who was involved in a short extramarital affair
b. An adult with a long history of major depression who was charged with driving under the influence (DUI)
c. A woman with a history of borderline personality disorder who recently cut both wrists
d. An adult male recently diagnosed with anorexia nervosa

 

 

ANS:  A

The best candidates for psychodynamic therapy are relatively healthy and well-functioning individuals, sometimes referred to as the “worried well,” who have a clearly circumscribed area of difficulty and are intelligent, psychologically minded, and well-motivated for change. Patients with psychosis, severe depression, borderline personality disorders, and severe character disorders are not appropriate candidates for this type of treatment.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 21-22     TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A patient states, “I’m starting cognitive-behavioral therapy. What can I expect from the sessions?” Which responses by the nurse would be appropriate? Select all that apply.
a. “The therapist will be active and questioning.”
b. “You will be given some homework assignments.”
c. “The therapist will ask you to describe your dreams.”
d. “The therapist will help you look at your ideas and beliefs about yourself.”
e. “The goal is to increase subjectivity about thoughts that govern your behavior.”

 

 

ANS:  A, B, D

Cognitive therapists are active rather than passive during therapy sessions because they help patients reality-test their thinking. Homework assignments are given and completed outside the therapy sessions. Homework is usually discussed at the next therapy session. The goal of cognitive therapy is to assist the patient in identifying inaccurate cognitions and in reality- testing and formulating new, accurate cognitions. One distracter applies to psychoanalysis. Increasing subjectivity is not desirable.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 29-31 | Page 34 (Table 2-6)    TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comments by an elderly person best indicate successful completion of the developmental task? Select all that apply.
a. “I am proud of my children’s successes in life.”
b. “I should have given to community charities more often.”
c. “My relationship with my father made life more difficult for me.”
d. “My experiences in the war helped me appreciate the meaning of life.”
e. “I often wonder what would have happened if I had chosen a different career.”

 

 

ANS:  A, D

The developmental crisis for an elderly person relates to integrity versus despair. Pride in one’s offspring indicates a sense of fulfillment. Recognition of the wisdom gained from difficult experiences (such as being in a war) indicates a sense of integrity. Blaming and regret indicate despair and unsuccessful resolution of the crisis.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22-23 (Table 2-2)                   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which comments by an adult best indicate self-actualization? Select all that apply.
a. “I am content with a good book.”
b. “I often wonder if I chose the right career.”
c. “Sometimes I think about how my parents would have handled problems.”
d. “It’s important for our country to provide basic health care services for everyone.”
e. “When I was lost at sea for 2 days, I gained an understanding of what is important.”

 

 

ANS:  A, D, E

Self-actualized persons enjoy privacy, have a sense of democracy, and show positive outcomes associated with peak experiences. Self-doubt, defensiveness, and blaming are not consistent with self-actualization.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 22 | Page 31-32                                 TOP:              Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which activities represent the art of nursing?  Select all that apply.
a. Administering medications on time to a group of patients
b. Listening to a new widow grieve her husband’s death
c. Helping a patient obtain groceries from a food bank
d. Teaching a patient about a new medication
e. Holding the hand of a frightened patient

 

 

ANS:  B, C, E

Peplau described the science and art of professional nursing practice.  The art component of nursing consists of the care, compassion, and advocacy nurses provide to enhance patient comfort and well-being. The science component of nursing involves the application of knowledge to understand a broad range of human problems and psychosocial phenomena, intervening to relieve patients’ suffering and promote growth.  See related audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 24-25     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

Chapter 04: Settings for Psychiatric Care

 

MULTIPLE CHOICE

 

  1. Inpatient hospitalization for persons with mental illness is generally reserved for patients who:
a. present a clear danger to self or others.
b. are noncompliant with medication at home.
c. have limited support systems in the community.
d. develop new symptoms during the course of an illness.

 

 

ANS:  A

Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The distracters do not necessarily describe patients who require inpatient treatment.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 74-75     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the patient received a notice of eviction immediately prior to admission. Select the case manager’s most appropriate action.
a. Postpone the patient’s discharge from the hospital.
b. Contact the landlord who evicted the patient to further discuss the situation.
c. Arrange a temporary place for the patient to stay until new housing can be arranged.
d. Determine whether the adverse medication reaction was genuine because the patient had nowhere to live.

 

 

ANS:  C

The case manager should intervene by arranging temporary shelter for the patient until an apartment can be found. This activity is part of the coordination and delivery of services that falls under the case manager role. None of the other options is a viable alternative.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 69-72     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Select the example of tertiary prevention.
a. Helping a person diagnosed with a serious mental illness learn to manage money
b. Restraining an agitated patient who has become aggressive and assaultive
c. Teaching school-age children about the dangers of drugs and alcohol
d. Genetic counseling with a young couple expecting their first child

 

 

ANS:  A

Tertiary prevention involves services that address residual impairments, with a goal of improved independent functioning. Restraint is a secondary prevention. Genetic counseling and teaching school-age children about substance abuse and dependence are examples of primary prevention.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 70          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The patient’s thoughts are now more organized, and discharge is planned. The patient’s family says, “It’s too soon for discharge. We will just go through all this again.” The nurse should:
a. ask the case manager to arrange a transfer to a long-term care facility.
b. notify hospital security to handle the disturbance and escort the family off the unit.
c. explain that the patient will continue to improve if the medication is taken regularly.
d. contact the health care provider to meet with the family and explain the discharge rationale.

 

 

ANS:  C

Patients do not stay in a hospital until every symptom disappears. The nurse must assume responsibility to advocate for the patient’s right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Security is unnecessary. The nurse can handle this matter.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 73-76     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitor’s closet is locked. These observations relate to:
a. coordinating care of patients.
b. management of milieu safety.
c. management of the interpersonal climate.
d. use of therapeutic intervention strategies.

 

 

ANS:  B

Nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse’s concerns, are unrelated to the observations cited.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 75-77     TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. The patients below were evaluated in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient:
a. feeling anxiety and a sad mood after separation from a spouse of 10 years.
b. who self-inflicted a superficial cut on the forearm after a family argument.
c. experiencing dry mouth and tremor related to taking haloperidol (Haldol).
d. who is a new parent and hears voices saying, “Smother your baby.”

 

 

ANS:  D

Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 74-75     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A suspicious, socially isolated patient lives alone, eats one meal a day at a local shelter, and spends the remaining daily food allowance on cigarettes. Select a community psychiatric nurse’s best initial action.
a. Explore ways to help the patient stop smoking.
b. Report the situation to the manager of the shelter.
c. Assess the patient’s weight; determine foods and amounts eaten.
d. Arrange hospitalization for the patient in order to formulate a new treatment plan.

 

 

ANS:  C

Assessment of biopsychosocial needs and general ability to live in the community is called for before any other action is taken. Both nutritional status and income adequacy are critical assessment parameters. A patient may be able to maintain adequate nutrition while eating only one meal a day. The rule is to assess before taking action. Hospitalization may not be necessary. Smoking cessation strategies can be pursued later.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 69-70     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. A nurse surveys medical records. Which finding signals a violation of patients’ rights?
a. A patient was not allowed to have visitors.
b. A patient’s belongings were searched at admission.
c. A patient with suicidal ideation was placed on continuous observation.
d. Physical restraint was used after a patient was assaultive toward a staff member.

 

 

ANS:  A

The patient has the right to have visitors. Inspecting patients’ belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 74-76 (Box 4-3)                                TOP:              Nursing Process: Evaluation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting?
a. Resolve the crisis with the least restrictive intervention possible.
b. Swift intervention is justified to maintain the integrity of a therapeutic milieu.
c. Rights of an individual patient are superseded by the rights of the majority of patients.
d. Patients should have opportunities to regain control without intervention if the safety of others is not compromised.

 

 

ANS:  A

The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the patient’s legal right. Planned interventions are nearly always preferable. Intervention may be necessary when the patient threatens harm to self.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 74-76 (Box 4-3)                                TOP:              Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Clinical pathways are used in managed care settings to:
a. stabilize aggressive patients.
b. identify obstacles to effective care.
c. relieve nurses of planning responsibilities.
d. streamline the care process and reduce costs.

 

 

ANS:  D

Clinical pathways provide guidelines for assessments, interventions, treatments, and outcomes as well as a designated timeline for accomplishment. Deviations from the timeline must be reported and investigated. Clinical pathways streamline the care process and save money. Care pathways do not identify obstacles or stabilize aggressive patients. Staff are responsible for the necessary interventions. Care pathways do not relieve nurses of the responsibility of planning; pathways may, however, make the task easier.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 75-76     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A nurse receives these three phone calls regarding a newly admitted patient.
  • The psychiatrist wants to complete an initial assessment.
  • An internist wants to perform a physical examination.
  • The patient’s attorney wants an appointment with the patient.

The nurse schedules the activities for the patient. Which role has the nurse fulfilled?

a. Advocate c. Milieu manager
b. Case manager d. Provider of care

 

 

ANS:  B

Nurses on psychiatric units routinely coordinate patient services, serving as case managers as described in this scenario. The role of advocate would require the nurse to speak out on the patient’s behalf. The role of milieu manager refers to maintaining a therapeutic environment. Provider of care refers to giving direct care to the patient.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 69-70     TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which aspect of direct care is an experienced, inpatient psychiatric nurse most likely to provide for a patient?
a. Hygiene assistance c. Assistance with job hunting
b. Diversional activities d. Building assertiveness skills

 

 

ANS:  D

Assertiveness training relies on the counseling and psychoeducational skills of the nurse. Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Diversional activities are usually the province of recreational therapists. The patient would probably be assisted in job hunting by a social worker or vocational therapist.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 76-79 (Box 4-3)                                TOP:              Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which characteristic would be more applicable to a community mental health nurse than to a nurse working in an operating room?
a. Kindness c. Compassion
b. Autonomy d. Professionalism

 

 

ANS:  B

A community mental health nurse often works autonomously. Kindness, compassion, and professionalism apply to both nurses.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 70          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which patient would be most appropriate to refer for assertive community treatment (ACT)? A patient diagnosed with:
a. a phobic fear of crowded places.
b. a single episode of major depression.
c. a catastrophic reaction to a tornado in the community.
d. schizophrenia and four hospitalizations in the past year.

 

 

ANS:  D

Assertive community treatment (ACT) provides intensive case management for persons with serious persistent mental illness who live in the community. Repeated hospitalization is a frequent reason for this intervention. The distracters identify mental health problems of a more episodic nature.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 69-70     TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patient’s projected length of stay. How should the nurse instruct the unit secretary to handle the request?
a. Obtain the information from the patient’s medical record and relay it to the caller.
b. Inform the caller that all information about patients is confidential.
c. Refer the request for information to the patient’s case manager.
d. Refer the request to the health care provider.

 

 

ANS:  C

The case manager usually confers with insurers and provides the treatment team with information about available resources. The unit secretary should be mindful of patient confidentiality and should neither confirm that the patient is an inpatient nor disclose other information.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 69-70 | Page 75-76 (Box 4-2) TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Select the example of primary prevention.
a. Assisting a person diagnosed with a serious mental illness to fill a pill-minder
b. Helping school-age children identify and describe normal emotions
c. Leading a psychoeducational group in a community care home
d. Medicating an acutely ill patient who assaulted a staff person

 

 

ANS:  B

Primary preventions are directed at healthy populations with a goal of preventing health problems from occurring. Helping school-age children describe normal emotions people experience promotes coping, a skill that is needed throughout life. Assisting a person with serious and persistent mental illness to fill a pill-minder is an example of tertiary prevention. Medicating an acutely ill patient who assaulted a staff person is a secondary prevention. Leading a psychoeducational group in a community care home is an example of tertiary prevention.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 70-71     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which level of prevention activities would a nurse in an emergency department employ most often?
a. Primary c. Tertiary
b. Secondary

 

 

ANS:  B

An emergency department nurse would generally see patients in crisis or with acute illness, so secondary prevention is used. Primary prevention involves preventing a health problem from developing, and tertiary prevention applies to rehabilitative activities.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 70-71     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse assigned to assertive community treatment (ACT) should explain the program’s treatment goal as:
a. assisting patients to maintain abstinence from alcohol and other substances of abuse.
b. providing structure and a therapeutic milieu for mentally ill patients whose symptoms require stabilization.
c. maintaining medications and stable psychiatric status for incarcerated inmates who have a history of mental illness.
d. providing services for mentally ill individuals who require intensive treatment to continue to live in the community.

 

 

ANS:  D

An assertive community treatment (ACT) program provides intensive community services to persons with serious, persistent mental illness who live in the community but require aggressive services to prevent repeated hospitalizations.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 69-70     TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which scenario best depicts a behavioral crisis? A patient is:
a. waving fists, cursing, and shouting threats at a nurse.
b. curled up in a corner of the bathroom, wrapped in a towel.
c. crying hysterically after receiving a phone call from a family member.
d. performing push-ups in the middle of the hall, forcing others to walk around.

 

 

ANS:  A

This behavior constitutes a behavioral crisis because the patient is threatening harm to another individual. Intervention is called for to defuse the situation. The other options speak of behaviors that may require intervention of a less urgent nature because the patients in question are not threatening harm to self or others.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 73-74     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. The case manager plans to discuss the treatment plan with a patient’s family. Select the case manager’s first action.
a. Determine an appropriate location for the conference.
b. Support the discussion with examples of the patient’s behavior.
c. Obtain the patient’s permission for the exchange of information.
d. Determine which family members should participate in the conference.

 

 

ANS:  C

The case manager must respect the patient’s right to privacy, which extends to discussions with family. Talking to family members is part of the case manager’s role. Actions identified in the distracters occur after the patient has given permission.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 69-70 | Page 74-75 (Box 4-2) TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient usually watches television all day, seldom going out in the community or socializing with others. The patient says, “I don’t know what to do with my free time.” Which member of the treatment team would be most helpful to this patient?
a. Psychologist c. Recreational therapist
b. Social worker d. Occupational therapist

 

 

ANS:  C

Recreational therapists help patients use leisure time to benefit their mental health. Occupational therapists assist with a broad range of skills, including those for employment. Psychologists conduct testing and provide other patient services. Social workers focus on the patient’s support system.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 76-78 (Box 4-3)                                TOP:              Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia has been stable for 2 months. Today the patient’s spouse calls the nurse to report the patient has not taken prescribed medication and is having disorganized thinking. The patient forgot to refill the prescription. The nurse arranges a refill. Select the best outcome to add to the plan of care.
a. The patient’s spouse will mark dates for prescription refills on the family calendar.
b. The nurse will obtain prescription refills every 90 days and deliver to the patient.
c. The patient will call the nurse weekly to discuss medication-related issues.
d. The patient will report to the clinic for medication follow-up every week.

 

 

ANS:  A

The nurse should use the patient’s support system to meet patient needs whenever possible. Delivery of medication by the nurse should be unnecessary for the nurse to do if patient or a significant other can be responsible. The patient may not need more intensive follow-up as long as medication is taken as prescribed.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 71 | Page 79-80 (Table 4-1)    TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A community mental health nurse has worked for months to establish a relationship with a delusional, suspicious patient. The patient recently lost employment and could no longer afford prescribed medications. The patient says, “Only a traitor would make me go to the hospital.” Select the nurse’s best initial intervention.
a. With the patient’s consent, contact resources to provide medications without charge temporarily.
b. Arrange a bed in a local homeless shelter with nightly on-site supervision.
c. Hospitalize the patient until the symptoms have stabilized.
d. Ask the patient, “Do you feel like I am a traitor?”

 

 

ANS:  A

Hospitalization may damage the nurse-patient relationship, even if it provides an opportunity for rapid stabilization. If medication is restarted, the patient may possibly be stabilized in the home setting, even if it takes a little longer. Programs are available to help patients who are unable to afford their medications. A homeless shelter is inappropriate and unnecessary. Hospitalization may be necessary later, but a less restrictive solution should be tried first, since the patient is not dangerous. A yes/no question is non-therapeutic communication.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 71 | Page 79-80 (Table 4-1)    TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which activity is appropriate for a nurse engaged exclusively in community-based primary prevention?
a. Medication follow-up c. Substance abuse counseling
b. Teaching parenting skills d. Making a referral for family therapy

 

 

ANS:  B

Primary prevention activities are directed to healthy populations to provide information for developing skills that promote mental health. The distracters represent secondary or tertiary prevention activities.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 70-71     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance?
a. The attitude of significant others toward the patient
b. Nutrition services in the patient’s neighborhood
c. The level of trust between the patient and nurse
d. The availability of transportation to the clinic

 

 

ANS:  D

The ability of the patient to get to the clinic is of paramount importance to the success of the plan. The depot medication relieves the patient of the necessity to take medication daily, but if he or she does not receive the injection at 3-week intervals, non-adherence will again be the issue. Attitude toward the patient, trusting relationships, and nutrition are important but not fundamental to this particular problem.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 70-71     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which assessment finding for a patient in the community deserves priority intervention by the psychiatric nurse? The patient:
a. receives Social Security disability income plus a small check from a trust fund every month.
b. was absent from two of six planned Alcoholics Anonymous meetings in the past 2 weeks.
c. lives in an apartment with two patients who attend partial hospitalization programs.
d. has a sibling who was recently diagnosed with a mental illness.

 

 

ANS:  B

Patients who use alcohol or illegal substances often become medication noncompliant. Medication noncompliance, along with the disorganizing influence of substances on cellular brain function, promotes relapse. The distracters do not suggest problems.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 70-72     TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse should refer which of the following patients to a partial hospitalization program? A patient who:
a. has a therapeutic lithium level and reports regularly for blood tests and clinic follow-up.
b. needs psychoeducation for relaxation therapy related to agoraphobia and panic episodes.
c. spent yesterday in a supervised crisis care center and continues to have active suicidal ideation.
d. states, “I’m not sure I can avoid using alcohol when my spouse goes to work every morning.”

 

 

ANS:  D

This patient could profit from the structure and supervision provided by spending the day at the partial hospitalization program. During the evening, at night, and on weekends, the spouse could assume responsibility for supervision. A suicidal patient needs inpatient hospitalization. The other patients can be served in the community or with individual visits.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 70          TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring?
a. Encouraging persons to describe their memories and feelings about the event
b. Arranging transportation to the local community mental health center
c. Referring a local resident to a community food bank
d. Coordinating psychiatric home care services

 

 

ANS:  A

Disaster victims benefit from telling their story. Nurses show compassion by listening and offering hope. The distracters identify other aspects of psychological first aid and services on the mental health continuum.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 73          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse makes an initial visit to a homebound patient diagnosed with a serious mental illness. A family member offers the nurse a cup of coffee. Select the nurse’s best response.
a. “Thank you. I would enjoy having a cup of coffee with you.”
b. “Thank you, but I would prefer to proceed with the assessment.”
c. “No, but thank you. I never accept drinks from patients or families.”
d. “Our agency policy prohibits me from eating or drinking in patients’ homes.”

 

 

ANS:  A

Accepting refreshments or chatting informally with the patient and family represent therapeutic use of self and help to establish rapport. The distracters fail to help establish rapport.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 69          TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse performed these actions while caring for patients in an inpatient psychiatric setting.   Which action violated patients’ rights?
a. Prohibited a patient from using the telephone
b. In patient’s presence, opened a package mailed to patient
c. Remained within arm’s length of patient with homicidal ideation
d. Permitted a patient with psychosis to refuse oral psychotropic medication

 

 

ANS:  A

The patient has a right to use the telephone. The patient should be protected against possible harm to self or others. Patients have rights to send and receive mail and be present during package inspection. Patients have rights to refuse treatment.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 74-75 (Box 4-2)                                TOP:              Nursing Process: Evaluation

MSC:  Client Needs: Safe, Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. A nurse can best address factors of critical importance to successful community treatment by including making assessments relative to: (Select all that apply.)
a. housing adequacy.
b. family and support systems.
c. income adequacy and stability.
d. early psychosocial development.
e. substance abuse history and current use.

 

 

ANS:  A, B, C, E

Early psychosocial developmental history is less relevant to successful outcomes in the community than the assessments listed in the other options. If a patient is homeless or fears homelessness, focusing on other treatment issues is impossible. Sufficient income for basic needs and medication is necessary. Adequate support is a requisite to community placement. Substance abuse undermines medication effectiveness and interferes with community adjustment.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 70-71     TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. The health care team at an inpatient psychiatric facility drafts these criteria for admission. Which criteria should be included in the final version of the admission policy? Select all that apply.
a. Clear risk of danger to self or others
b. Adjustment needed for doses of psychotropic medication
c. Detoxification from long-term heavy alcohol consumption needed
d. Respite for caregivers of persons with serious and persistent mental illness
e. Failure of community-based treatment, demonstrating need for intensive treatment

 

 

ANS:  A, C, E

Medication doses can be adjusted on an outpatient basis. The goal of caregiver respite can be accomplished without hospitalizing the patient. The other options are acceptable, evidence-based criteria for admission of a patient to an inpatient service.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 74-75     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A psychiatric nurse discusses rules of the therapeutic milieu and patients’ rights with a newly admitted patient. Which rights should be included? (Select all that apply.)

The right to:

a. have visitors
b. confidentiality
c. a private room
d. complain about inadequate care
e. select the nurse assigned to their care

 

 

ANS:  A, B, D

Patients’ rights should be discussed shortly after admission. Patients have rights related to receiving/refusing visitors, privacy, filing complaints about inadequate care, and accepting/refusing treatments (including medications). Patients do not have a right to a private room or selecting which nurse will provide care.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 74-75 (Box 4-2)                                TOP:              Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Which statements by patients diagnosed with a serious mental illness best demonstrate that the case manager has established an effective long-term relationship? “My case manager:

    (select all that apply)

a. talks in language I can understand.”
b. helps me keep track of my medication.”
c. gives me little gifts from time to time.”
d. looks at me as a whole person with many needs.”
e. lets me do whatever I choose without interfering.”

 

 

ANS:  A, B, D

Each correct answer is an example of appropriate nursing foci: communicating at a level understandable to the patient, providing medication supervision, and using holistic principles to guide care. The distracters violate relationship boundaries or suggest a laissez faire attitude on the part of the nurse.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 70-71 (Table 4-1)                   TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  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. “Mental illness results from the breakdown of American families.”
e. “If people with mental illness went to church, their symptoms would vanish.”

 

 

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.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 65-66     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A person in the community asks, “People with mental illnesses went to state hospitals in earlier times. Why has that changed?” Select the nurse’s accurate responses. Select all that apply.
a. “Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities.”
b. “There’s now a better selection of less restrictive treatment options available in communities to care for people with mental illness.”
c. “National rates of mental illness have declined significantly. There actually is not a need for state institutions anymore.”
d. “Most psychiatric institutions were closed because of serious violations of patients’ rights and unsafe conditions.”
e. “Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings.”

 

 

ANS:  A, B, E

The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. Funding for treatment of mental illness remains largely inadequate but now focuses on community rather than institutional care. Antipsychotic medications improve more symptoms of mental illness; hence, management of psychiatric disorders has improved. Rates of mental illness have increased, not decreased. Hospitals were closed because funding shifted to the community. Conditions in institutions have improved.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 65-66     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient diagnosed with schizophrenia lives in the community. On a home visit, the community psychiatric nurse case manager learns that the patient:
  • wants to attend an activity group at the mental health outreach center.
  • is worried about being able to pay for the therapy.
  • does not know how to get from home to the outreach center.
  • has an appointment to have blood work at the same time an activity group meets.
  • wants to attend services at a church that is a half-mile from the patient’s home.

Which tasks are part of the role of a community mental health nurse? Select all that apply.

a. Rearranging conflicting care appointments
b. Negotiating the cost of therapy for the patient
c. Arranging transportation to the outreach center
d. Accompanying the patient to church services weekly
e. Monitoring to ensure the patient’s basic needs are met

 

 

ANS:  A, C, E

The correct answers reflect the coordinating role of the community psychiatric nurse case manager. Negotiating the cost of therapy and accompanying the patient to church services are interventions the nurse would not be expected to undertake. The patient can walk to the church services; the nurse can provide encouragement.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 71-72     TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

Chapter 12: Schizophrenia and Schizophrenia Spectrum Disorders

 

MULTIPLE CHOICE

 

  1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, “They’re all plotting to destroy me. Isn’t that true?” Select the nurse’s most therapeutic response.
a. “Everyone here is trying to help you. No one wants to harm you.”
b. “Feeling that people want to destroy you must be very frightening.”
c. “That is not true. People here are trying to help you if you will let them.”
d. “Staff members are health care professionals who are qualified to help you.”

 

 

ANS:  B

Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 205-206 | Page 213-215 (Box 12-4)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, “I saw two doctors talking in the hall. They were plotting to kill me.” The nurse may correctly assess this behavior as:
a. echolalia. c. a delusion of infidelity.
b. an idea of reference. d. an auditory hallucination.

 

 

ANS:  B

Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 206 (Table 12-1)                    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two doctors plotting to kill me.” How does this patient perceive the environment?
a. Disorganized c. Supportive
b. Dangerous d. Bizarre

 

 

ANS:  B

The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 210 (Table 12-3) | Page 213 (Box 12-4)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, “I stopped taking those pills. They made me feel like a robot.” What are common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose

 

 

ANS:  A

Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a “robot.” The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 215-216 (Table 12-4)             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. Which hallucination necessitates the nurse to implement safety measures? The patient says,
a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill me.”
c. “My dead father tells me I am a good person.”
d. “The voices talk only at night when I’m trying to sleep.”

 

 

ANS:  B

The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 207 | Page 212-213                TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase

 

 

ANS:  B

Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 206-207 | Page 212-213         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine (Clozaril) c. Olanzapine (Zyprexa)
b. Ziprasidone (Geodon) d. Aripiprazole (Abilify)

 

 

ANS:  D

Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 215-219 (Table 12-5)             TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows away. Get it?” Select the nurse’s best response.
a. “Nothing you are saying is clear.”
b. “Your thoughts are very disconnected.”
c. “Try to organize your thoughts and then tell me again.”
d. “I am having difficulty understanding what you are saying.”

 

 

ANS:  D

When a patient’s speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 205 | Page 213-214                TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?
a. Self-esteem c. Physiological
b. Psychosocial d. Self-actualization

 

 

ANS:  C

Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 207 | Page 209-210                TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient’s activities of daily living are severely compromised. An appropriate outcome would be that the patient will:
a. demonstrate increased interest in the environment by the end of week 1.
b. perform self-care activities with coaching by the end of day 3.
c. gradually take the initiative for self-care by the end of week 2.
d. accept tube feeding without objection by day 2.

 

 

ANS:  B

Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 209-210                                 TOP:   Nursing Process: Outcomes Identification

MSC:  Client Needs: Physiological Integrity

 

  1. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
a. Echolalia c. Depersonalization
b. Waxy flexibility d. Thought withdrawal

 

 

ANS:  B

Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 207-208                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?
a. Allowing the patient supervised access to food vending machines
b. Allowing the patient to phone a local restaurant to deliver meals
c. Offering to taste each portion on the tray for the patient
d. Providing tube feedings or total parenteral nutrition

 

 

ANS:  A

The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 205-206 (Table 12-1)             TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family.  Select the nurse’s best plan.
a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return.
b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences.
c. Visit twice daily; sit beside the patient with a hand on the patient’s arm; leave if the patient does not respond within 10 minutes.
d. Visit every other day; remind the patient of the nurse’s identity; encourage the patient to talk while the nurse works on reports.

 

 

ANS:  A

Severe constraints on the community mental health nurse’s time will probably not allow more time than what is mentioned in the correct option; yet, important principles can be used. A severely withdrawn patient should be met “at the patient’s own level,” with silence accepted. Short periods of contact are helpful to minimize both the patient’s and the nurse’s anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 210-211 | Page 215 (Box 12-6) | Page 222 (Case study and Nursing Care Plan 12-1)

TOP:   Nursing Process: Planning              MSC:  Client Needs: Psychosocial Integrity

 

  1. Withdrawn patients diagnosed with schizophrenia:
a. are usually violent toward caregivers.
b. universally fear sexual involvement with therapists.
c. exhibit a high degree of hostility as evidenced by rejecting behavior.
d. avoid relationships because they become anxious with emotional closeness.

 

 

ANS:  D

When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient’s anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 211        TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A newly admitted patient diagnosed with schizophrenia says, “The voices are bothering me. They yell and tell me I am bad. I have got to get away from them.”  Select the nurse’s most helpful reply.
a. “Do you hear the voices often?”
b. “Do you have a plan for getting away from the voices?”
c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”
d. “Forget the voices and ask some other patients to play cards with you.”

 

 

ANS:  C

Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to “get away from the voices” is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 206-207 | Page 212-213 (Box 12-3)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?
a. Neuroleptic malignant syndrome c. Pseudoparkinsonism
b. Hepatocellular effects d. Akathisia

 

 

ANS:  C

Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson’s disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 215-216 (Table 12-4)             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient’s head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?
a. An acute dystonic reaction c. Waxy flexibility
b. Tardive dyskinesia d. Akathisia

 

 

ANS:  A

Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis.  It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 215-216 (Table 12-4)             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?
a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.
b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient.
c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time.
d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

 

 

ANS:  A

Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 215-216 (Table 12-4)             TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity

 

  1. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
a. Agranulocytosis c. Tourette’s syndrome
b. Tardive dyskinesia d. Anticholinergic effects

 

 

ANS:  B

Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette’s syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 215-216 (Table 12-4)             TOP:   Nursing Process: Evaluation

MSC:  Client Needs: Physiological Integrity

 

  1. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse’s best response.
a. “Why are you laughing?”
b. “Please share the joke with me.”
c. “I don’t think I said anything funny.”
d. “You’re laughing. Tell me what’s happening.”

 

 

ANS:  D

The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy.  Focus on the hallucinatory clue (the patient’s laughter) and then elicit the patient’s observation. The incorrect options are less useful in eliciting a response: no joke may be involved, “why” questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 206-207 | Page 212-213 (Box 12-3)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
a. Auditory hallucinations c. Poor personal hygiene
b. Delusions of grandeur d. Psychomotor agitation

 

 

ANS:  C

Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 207-208 (Table 12-2)             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting
c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms

 

 

ANS:  A

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 201-202 | Page 204-205         TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia says, “Contagious bacteria are everywhere.  When they get in your body, you will be locked up with other infected people.”  Which problem is evident?
a. Poverty of content c. Neologisms
b. Concrete thinking d. Paranoia

 

 

ANS:  D

The patient’s unrealistic fear of harm indicates paranoia. Neologisms are invented words.  Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 205-206                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda).  The patient is 5’6” and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication?
a. How to recognize tardive dyskinesia c. Ways to manage constipation
b. Weight management strategies d. Sleep hygiene measures

 

 

ANS:  B

Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 218-219 (Table 12-5)             TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident?
a. Neologism c. Thought broadcasting
b. Idea of reference d. Associative looseness

 

 

ANS:  D

Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one’s thoughts.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 205        TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?
a. Haloperidol (Haldol) c. Chlorpromazine (Thorazine)
b. Olanzapine (Zyprexa) d. Diphenhydramine (Benadryl)

 

 

ANS:  B

Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.

See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 219        TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family’s role in recovery.  Which type of therapy should the nurse recommend?
a. Psychoeducational c. Transactional
b. Psychoanalytic d. Family

 

 

ANS:  A

A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 214 (Box 12-5) | Page 221     TOP:   Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, “My computer is sending out infected radiation beams.”  The nurse can correctly assess this information as an indication of:
a. the need for psychoeducation. c. chronic deterioration.
b. medication noncompliance. d. relapse.

 

 

ANS:  D

Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient’s symptoms are stable. Chronic deterioration is not the best explanation.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 213-215 (Box 12-6)               TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia begins to talks about “macnabs” hiding in the warehouse at work. The term “macnabs” should be documented as:
a. a neologism. c. thought insertion.
b. concrete thinking. d. an idea of reference.

 

 

ANS:  A

A neologism is a newly coined word having special meaning to the patient. “Macnabs” is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one’s mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 205-206                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror.” While listening, the nurse should:
a. sit close to the patient.
b. place an arm protectively around the patient’s shoulders.
c. place a hand on the patient’s arm and exert light pressure.
d. maintain a normal social interaction distance from the patient.

 

 

ANS:  D

The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 204 | Page 212-213                TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, “The voice is telling me to do things.” Select the nurse’s priority assessment question.
a. “How long has the voice been directing your behavior?”
b. “Does what the voice tell you to do frighten you?”
c. “Do you recognize the voice speaking to you?’
d. “What is the voice telling you to do?”

 

 

ANS:  D

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 207-209                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action.
a. Agranulocytosis; institute reverse isolation.
b. Tardive dyskinesia; withhold the next dose of medication.
c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat.

 

 

ANS:  D

Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 210 (Table 12-3) | Page 219-220

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?”  Which response by the patient indicates concrete thinking?
a. “The table of contents tells what a book is about.”
b. “You can’t judge a book by looking at the cover.”
c. “Things are not always as they first appear.”
d. “Why are you asking me about books?”

 

 

ANS:  A

Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient’s interpretation of proverbs. Concreteness reduces one’s ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 205-206                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group?  Members will:
a. gain insight into unconscious factors that contribute to their illness.
b. explore situations that trigger hostility and anger.
c. learn to manage delusional thinking.
d. demonstrate improved social skills.

 

 

ANS:  D

Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 211-215 (Box 12-6)               TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client says, “Facebook has a new tracking capacity.  If I use the Internet, Homeland Security will detain me as a terrorist.” Select the nurse’s best initial action.
a. Tell the client, “Facebook is a safe website. You don’t need to worry about Homeland Security.”
b. Tell the client, “You are in a safe place where you will be helped.”
c. Administer a prn dose of an antipsychotic medication.
d. Tell the client, “You don’t need to worry about that.”

 

 

ANS:  B

The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 205-206 (Table 12-1) | Page 213-215 (Box 12-4)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which finding constitutes a negative symptom associated with schizophrenia?
a. Hostility c. Poverty of thought
b. Bizarre behavior d. Auditory hallucinations

 

 

ANS:  C

Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 207-208 (Table 12-2)             TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient insistently states, “I can decipher codes of DNA just by looking at someone.”   Which problem is evident?
a. Visual hallucinations c. Idea of reference
b. Magical thinking d. Thought insertion

 

 

ANS:  B

Magical thinking is evident in the patient’s appraisal of his own abilities. There is no evidence of the distracters.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 205-206                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A newly hospitalized patient experiencing psychosis says, “Red chair out town board.”  Which term should the nurse use to document this finding?
a. Word salad c. Anhedonia
b. Neologism d. Echolalia

 

 

ANS:  A

Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 205-206                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority?
a. “The importance of taking your medication correctly”
b. “How to complete an application for employment”
c. “How to dress when attending community events”
d. “How to give and receive compliments”
e. “Ways to quit smoking”

 

 

ANS:  A, E

Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients’ physiological well-being. The other topics are also important but are not priority topics.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 204 | Page 211-212 | Page 215 (Box 12-6) | Page 224

TOP:   Nursing Process: Planning/Outcomes Identification

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, “Two staff members I saw talking were plotting to kill me.”  Based on data gathered at this point, which nursing diagnoses relate? Select all that apply.
a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation

 

 

ANS:  A, B

Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient’s feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 209-210 (Table 12-3)             TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Psychosocial Integrity

Chapter 22: Substance Related and Addictive Disorders

 

MULTIPLE CHOICE

 

  1. A patient diagnosed with alcoholism asks, “How will Alcoholics Anonymous (AA) help me?”  Select the nurse’s best response.
a. “The goal of AA is for members to learn controlled drinking with the support of a higher power.”
b. “An individual is supported by peers while striving for abstinence one day at a time.”
c. “You must make a commitment to permanently abstain from alcohol and other drugs.”
d. “You will be assigned a sponsor who will plan your treatment program.”

 

 

ANS:  B

Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 422 | Page 424-425                TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:

0200:  118/78 mm Hg and 72 beats/min

0400:  126/80 mm Hg and 76 beats/min

0600:  128/82 mm Hg and 72 beats/min

0800:  132/88 mm Hg and 80 beats/min

1000:  148/94 mm Hg and 96 beats/min

What is the nurse’s priority action?

a. Force fluids.
b. Consult the health care provider.
c. Obtain a clean-catch urine sample.
d. Place the patient in a vest-type restraint.

 

 

ANS:  B

Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 421 (Table 22-5)                    TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity

 

  1. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority?
a. Cardiovascular c. Neurologic
b. Respiratory d. Hepatic

 

 

ANS:  B

Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 413 (Table 22-1)                    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” Select the most accurate assessment of this situation. The patient:
a. is attempting to obtain attention by manipulating staff.
b. may have sustained a head injury before admission.
c. has symptoms of alcohol-withdrawal delirium.
d. is having an acute psychosis.

 

 

ANS:  C

Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 421 (Table 22-5)                    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
a. Disturbed sensory perception c. Ineffective denial
b. Ineffective coping d. Risk for injury

 

 

ANS:  D

The patient’s clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 421 (Table 22-5) | Page 423 (Table 22-8)

TOP:   Nursing Process: Diagnosis/Analysis

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n):
a. narcotic analgesic, such as hydromorphone (Dilaudid).
b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).
c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril).
d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).

 

 

ANS:  B

Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 421 (Table 22-5)                    TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?
a. Check the patient every 15 minutes c. Keep the room dimly lit
b. One-on-one supervision d. Force fluids

 

 

ANS:  B

One-on-one supervision is necessary to promote physical safety until sedation reduces the patient’s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 422-423 (Table 22-8)             TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient diagnosed with an alcohol abuse disorder says, “Drinking helps me cope with being a single parent.” Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively?
a. “Sooner or later, alcohol will kill you. Then what will happen to your children?”
b. “I hear a lot of defensiveness in your voice. Do you really believe this?”
c. “If you were coping so well, why were you hospitalized again?”
d. “Tell me what happened the last time you drank.”

 

 

ANS:  D

The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse’s frustration with the patient.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 424-425                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient asks for information about Alcoholics Anonymous. Select the nurse’s best response. “Alcoholics Anonymous is a:
a. form of group therapy led by a psychiatrist.”
b. self-help group for which the goal is sobriety.”
c. group that learns about drinking from a group leader.”
d. network that advocates strong punishment for drunk drivers.”

 

 

ANS:  B

Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 424-425                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has ingested both alcohol and sedative drugs recently.

 

 

ANS:  B

A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient’s body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 420 (Table 22-4)                    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity

 

  1. A patient admitted to an alcoholism rehabilitation program tells the nurse, “I’m actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening.” The patient is using which defense mechanism?
a. Denial c. Introjection
b. Projection d. Rationalization

 

 

ANS:  A

Minimizing one’s drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one’s own personality.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 425-426 (Nursing Care Plan 22-1)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?
a. Bromocriptine (Parlodel) c. Disulfiram (Antabuse)
b. Methadone (Dolophine) d. Naltrexone (ReVia)

 

 

ANS:  D

Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 427 (Table 22-9)                    TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, “After this treatment program, I think everything will be all right.” Which remark by the nurse will be most helpful to the spouse?
a. “While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol.”
b. “It will be important for you to structure life to avoid as much stress as you can and provide social protection.”
c. “Addiction is a lifelong disease of self-destruction. You will need to observe your spouse’s behavior carefully.”
d. “It is good that you are supportive of your spouse’s sobriety and want to help maintain it.”

 

 

ANS:  A

During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 420 | Page 424-426 (Nursing Care Plan 22-1)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should:
a. provide long-term care for the patient in a residential facility.
b. withdraw the patient from cannabis, then treat the schizophrenia.
c. consider each diagnosis primary and provide simultaneous treatment.
d. first treat the schizophrenia, then establish goals for substance abuse treatment.

 

 

ANS:  C

Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 412-413 | Page 417-418 | Page 422                         TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction.
a. Empathetic, supportive c. Cool, distant
b. Skeptical, guarded d. Confrontational

 

 

ANS:  A

Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 424-426 (Nursing Care Plan 22-1)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose?
a. Simple and safe c. Stimulating and colorful
b. Active and bright d. Confrontational and challenging

 

 

ANS:  A

Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a “bad trip.”

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 413 (Table 22-1)                    TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred?
a. Tolerance has developed.
b. Antagonistic effects are evident.
c. Metabolism of the alcohol is now delayed.
d. Pharmacokinetics of the alcohol have changed.

 

 

ANS:  A

Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 413 | Page 426 (Nursing Care Plan 22-1)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. At a meeting for family members of alcoholics, a spouse says, “I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work.” The nurse assesses these comments as:
a. codependence. c. role reversal.
b. assertiveness. d. homeostasis.

 

 

ANS:  A

Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. See relationship to audience response question.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 420-421                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. In the emergency department, a patient’s vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome.
a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization.
b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min.
c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department.
d. Within 6 hours, the patient’s breath sounds will be clear bilaterally and throughout lung fields.

 

 

ANS:  B

The correct short-term outcome is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient’s respirations are slow and shallow, but there is no evidence of congestion.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 413 (Table 22-1) | Page 421 (Table 22-6)

TOP:   Nursing Process: Planning/Outcomes Identification

MSC:  Client Needs: Physiological Integrity

 

  1. Family members of an individual undergoing a residential alcohol rehabilitation program ask, “How can we help?”  Select the nurse’s best response.
a. “Alcoholism is a lifelong disease. Relapses are expected.”
b. “Use search and destroy tactics to keep the home alcohol free.”
c. “It’s important that you visit your family member on a regular basis.”
d. “Make your loved one responsible for the consequences of behavior.”

 

 

ANS:  D

Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 424-425                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which goal for treatment of alcoholism should the nurse address first?
a. Learn about addiction and recovery. c. Develop a peer support system.
b. Develop alternate coping strategies. d. Achieve physiologic stability.

 

 

ANS:  D

The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 422 | Page 426 (Nursing Care Plan 22-1)

TOP:   Nursing Process: Outcomes Identification

MSC:  Client Needs: Physiological Integrity

 

  1. A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate?
a. 1-week detoxification program c. 12-step self-help program
b. Long-term outpatient therapy d. Residential program

 

 

ANS:  D

Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 424-425                                 TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines.
a. Monitor vital signs.
b. Observe for depression.
c. Awaken the patient every 15 minutes.
d. Use warmers to maintain body temperature.

 

 

ANS:  A

Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 413 (Table 22-1) | Page 423 (Table 22-8)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. Symptoms of withdrawal from opioids for which the nurse should assess include:
a. dilated pupils, tachycardia, elevated blood pressure, and elation.
b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
c. mood lability, incoordination, fever, and drowsiness.
d. excessive eating, constipation, and headache.

 

 

ANS:  B

The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal.  Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 413 (Table 22-1) | Page 423 (Table 22-8)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes:
a. cross-tolerance. c. substance addiction.
b. substance abuse. d. substance intoxication.

 

 

ANS:  C

Nicotine meets the criteria for a “substance,” the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 413 | Page 423 (Table 22-8)   TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which assessment findings are likely for an individual who recently injected heroin?
a. Anxiety, restlessness, paranoid delusions
b. Muscle aching, dilated pupils, tachycardia
c. Heightened sexuality, insomnia, euphoria
d. Drowsiness, constricted pupils, slurred speech

 

 

ANS:  D

Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.  (Educators may alter this question to multiple answers if desired.)

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 413 (Table 22-1) | Page 423 (Table 22-8)

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiological Integrity

 

  1. An adult in the emergency department states, “Everything I see appears to be waving. I am outside my body looking at myself. I think I’m losing my mind.” Vital signs are slightly elevated. The nurse should suspect:
a. a schizophrenic episode. c. opium intoxication.
b. hallucinogen ingestion. d. cocaine overdose.

 

 

ANS:  B

The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going “crazy.” Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 413 (Table 22-1)                    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information?
a. Substance Abuse and Mental Health Services Administration (SAMHSA)
b. Institute of Medicine – National Research Council (IOM)
c. National Council of State Boards of Nursing (NCSBN)
d. American Society of Addictions Medicine

 

 

ANS:  A

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 416-418                                 TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe, Effective Care Environment

 

  1. A patient is thin, tense, jittery, and has dilated pupils. The patient says, “My heart is pounding in my chest. I need help.” The patient allows vital signs to be taken but then becomes suspicious and says, “You could be trying to kill me.” The patient refuses further examination. Abuse of which substance is most likely?
a. PCP c. Barbiturates
b. Heroin d. Amphetamines

 

 

ANS:  D

The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

 

PTS:   1                    DIF:    Cognitive Level: Understand (Comprehension)

REF:   Page 413 (Table 22-1)                    TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

  1. Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will:
a. state, “I know I need long-term treatment.”
b. use denial and rationalization in healthy ways.
c. identify constructive outlets for expression of anger.
d. develop a trusting relationship with one staff member.

 

 

ANS:  A

The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 424-425                                 TOP:   Nursing Process: Planning/Outcomes Identification

MSC:  Client Needs: Psychosocial Integrity

 

  1. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse’s best first action?
a. Perform a thorough assessment of the patient.
b. Verify that security services are immediately available.
c. Self-assess personal attitude, values, and beliefs about this health problem.
d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

 

 

ANS:  C

The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one’s own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 420-421                                 TOP:   Nursing Process: Assessment

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply)
a. avoid aged cheeses.
b. avoid alcohol-based skin products.
c. read labels of all liquid medications.
d. wear sunscreen and avoid bright sunlight.
e. maintain an adequate dietary intake of sodium.
f. avoid breathing fumes of paints, stains, and stripping compounds.

 

 

ANS:  B, C, F

The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 427 (Table 22-11)                  TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity

 

  1. The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply)
a. rehearsing techniques to handle anticipated stressful situations.
b. advising the patient to accept residential treatment if relapse occurs.
c. assisting the patient to identify life skills needed for effective coping.
d. advising isolating self from significant others until sobriety is established.
e. informing the patient of physical changes to expect as the body adapts to functioning without substances.

 

 

ANS:  A, C, E

Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 424-425                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply)
a. administration of naloxone (Narcan).
b. vitamin B12 and folate supplements.
c. restoring nutritional integrity.
d. management of heart rate.
e. environmental safety.

 

 

ANS:  D, E

Care of patients who have taken bath salts is similar to those who have used other stimulants.  Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

 

PTS:   1                    DIF:    Cognitive Level: Apply (Application)

REF:   Page 413 (Table 22-1) | Page 416 (Health Policy Box)

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiological Integrity

 

  1. A new patient beginning an alcoholism rehabilitation program says, “I’m just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening.” Select the nurse’s most therapeutic responses. Select all that apply.
a. “I see,” and use interested silence.
b. “I think you are drinking more than you report.”
c. “Social drinkers have one or two drinks, once or twice a week.”
d. “You describe drinking steadily throughout the day and evening.”
e. “Your comments show denial of the seriousness of your problem.”

 

 

ANS:  C, D

The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

 

PTS:   1                    DIF:    Cognitive Level: Analyze (Analysis)

REF:   Page 424-425                                 TOP:   Nursing Process: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

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