Examen Final SM 2

1. One month ago, a patient diagnosed with borderline personality disorder and a history of self- mutilation began dialectical behavior therapy. Today the patient phones to say, “I feel empty and want to hurt myself.” The nurse should. a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an antianxiety medication to decrease the anxiety level.

2. A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will (Select all that apply). a. graduate from high school. b. live independently in an apartment. c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

3. A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, “What should we do?” Select the nurse’s best response. a. “Ask the teacher to let the child call you at play time.”. b. “Withdraw the child from preschool until maturity increases.”. c. “Remain with your child for the first hour of preschool time.”. d. “Give your child a kiss before you leave the preschool program.”.

4. Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders?. a. Impaired social interaction related to difficulty maintaining relationships. b. Chronic low self-esteem related to excessive negative feedback. c. Deficient fluid volume related to abnormal eating habits. d. Anxiety related to nightmares and repetitive activities.

5. Which assessment findings present familial risks for a child to develop a psychiatric disorder? (Select all that apply.). a. Having a mother diagnosed with schizophrenia. b. Being the oldest child in a family. c. Living with an alcoholic parent. d. Being an only child. e. Living in an urban community.

6. A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, “My three friends and I got an A on our school science project.” The nurse can assess that the child. a. displays resiliency. b. has a passive temperament. c. is at risk for PTSD. d. uses intellectualization to deal with problems.

7. Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others’ conversations. How should the nurse document these behaviors?. a. Disobedience. b. Hyperactivity. c. Impulsivity. d. Anxiety.

8. A child diagnosed with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?. a. Central Nervous System stimulants. b. Tricyclic antidepressants. c. Antipsychotics. d. Anxiolytics.

9. A desired outcome for a 12-year-old diagnosed with ADHD is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care?. a. Reality therapy. b. Simple restitution. c. Social skills group. d. Insight-oriented group therapy.

10. The parent of a child diagnosed with Tourette’s disorder says to the nurse, “I think my child is faking the tics because they come and go.” Which response by the nurse is accurate?. a. “Perhaps your child was misdiagnosed.”. b. “Your observation indicates the medication is effective.”. c. “Tics often change frequency or severity. That doesn’t mean they aren’t real.”. d. “This finding is unexpected. How have you been administering your child’s medication?”.

11. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings 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.

12. 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.”.

13. A patient diagnosed with alcohol use disorder 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.”.

14. 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.

15. A patient asks for information about AA. Select the nurse’s best response. “AA 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.”.

16. A patient diagnosed with alcohol use 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.”.

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

18. 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.

19. 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.

20. 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.

21. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient?. a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse’s desk while awake. Provide rest periods in a room with a television on.

22. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?. a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment. b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks. c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations. d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations.

23. An older adult patient in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful?. a. Use the patient’s glasses. b. Place personally meaningful objects in view. c. Position large clocks and calendars on the wall. d. Assure that the room is brightly lit but very quiet at all times.

24. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?. a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

25. Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein -amyloid. Which diagnosis applies?. a. Cyclothymia. b. Dementia. c. Delirium. d. Amnesia.

26. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs. Get them off!” Which problem is the patient experiencing?. a. Aphasia. b. Dystonia. c. Tactile hallucinations. d. Mnemonic disturbance.

27. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s family?. a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 mL/day.

28. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of. a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer’s disease.

29. A hospitalized patient diagnosed with delirium misinterprets reality. A patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will. a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

30. A patient diagnosed with Alzheimer’s disease calls the fire department saying, “My smoke detectors are going off.” Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing?. a. Hyperorality. b. Aphasia. c. Apraxia. d. Agnosia.

31. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should. a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

32. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed?. a. Benzodiazepine. b. Mood stabilizing medication. c. Monoamine oxidase inhibitor (MAOI). d. Cholinesterase inhibitor.

33. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, “Just leave it on the table. I’ll take it when I finish combing my hair.” What is the nurse’s best response?. a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, “I’m worried that you might not take it. I’ll come back later.”. c. Say to the patient, “I must watch you take the medication. Please take it now.”. d. Ask the patient, “Why don’t you want to take your medication now?”.

34. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is. a. nonadherence. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

35. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include. a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

36. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, “You used to care about me. I thought you were wonderful. Now I can see I was wrong. You’re evil.” This outburst can be assessed as. a. denial. b. splitting. c. defensive. d. reaction formation.

37. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation?. a. Supporting behavioral change. b. Maintaining consistent limits. c. Monitoring suicide attempts. d. Using aversive therapy.

38. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, “Another nurse said you don’t do your job right.” Collectively, these interactions can be assessed as. a. seductive. b. detached. c. manipulative. d. guilt-producing.

39. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting?. a. Flattering the nurse. b. Lying to other patients. c. Verbal abuse of another patient. d. Detached superficiality during counseling.