Which suggestions are appropriate for the family of a patient diagnosed with bipolar
disorder who is being treated as an outpatient during a hypomanic episode? (Select all that
apply.) Limit credit card access. Provide a structured environment. Encourage group social interaction. Supervise medication administration. Monitor the patient’s sleep patterns.
A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which
nursing diagnoses are most likely? (Select all that apply.) Imbalanced nutrition: more than body requirements Impaired mood regulation Sleep deprivation Chronic confusion Social isolation.
A patient tells the nurse, “I’m ashamed of being bipolar. When I’m manic, my behavior
embarrasses everyone. Even if I take my medication, there are no guarantees. I’m a burden
to my family.” These statements support which nursing diagnoses? (Select all that apply.) Powerlessness Defensive coping Chronic low self-esteem Chronic low self-esteem Risk-prone health behavior.
The plan of care for a patient in the manic state of bipolar disorder should include which
interventions? (Select all that apply.) Touch the patient to provide reassurance. Invite the patient to lead a community meeting. Provide a structured environment for the patient. Ensure that the patient’s nutritional needs are met. Design activities that require the patient’s concentration.
A patient became severely depressed when the last of the family’s six children moved out of
the home 4 months ago. The patient repeatedly says, “No one cares about me. I’m not worth
anything.” Which response by the nurse would be the most helpful? “Things will look brighter soon. Everyone feels down once in a while.” “Our staff members care about you and want to try to help you get better.” “It is difficult for others to care about you when you repeatedly say the same
negative things.” “I’ll sit with you for 10 minutes now and 10 minutes after lunch to help you feel
that I care about you.”.
A patient became depressed after the last of the family’s six children moved out of the home 4
months ago. Select the best initial outcome for the nursing diagnosis Situational low selfesteem
related to feelings of abandonment. The patient will verbalize realistic positive characteristics about self by (date). agree to take an antidepressant medication regularly by (date). initiate social interaction with another person daily by (date). identify two personal behaviors that alienate others by (date).
A patient diagnosed with major depressive disorder says, “No one cares about me anymore.
I’m not worth anything.” Today the patient is wearing a new shirt and has neat, clean hair.
Which remark by the nurse supports building a positive self-esteem for this patient? “You look nice this morning.” “You’re wearing a new shirt.” “I like the shirt you are wearing.” “You must be feeling better today.”.
An adult diagnosed with major depressive disorder was treated with medication and
cognitive-behavioral therapy. The patient now recognizes how passivity contributed to the
depression. Which intervention should the nurse suggest? Social skills training Relaxation training classes Desensitization techniques Use of complementary therapy.
Priority interventions for a patient diagnosed with major depressive disorder and feelings of
worthlessness should include distracting the patient from self-absorption. careful unobtrusive observation around the clock. allowing the patient to spend long periods alone in meditation. opportunities to assume a leadership role in the therapeutic milieu.
When counseling patients diagnosed with major depressive disorder, an advanced practice
nurse will address the negative thought patterns by using psychoanalytic therapy. desensitization therapy. cognitive-behavioral therapy. alternative and complementary therapies.
A patient says to the nurse, “My life doesn’t have any happiness in it anymore. I once enjoyed
holidays, but now they’re just another day.” The nurse documents this report as an example of dysthymia. anhedonia. euphoria. anergia.
A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1
week ago. Today the patient says, “I don’t think I can keep taking these pills. They make me
so dizzy, especially when I stand up.” The nurse will limit the patient’s activities to those that can be performed in a sitting position. withhold the drug, force oral fluids, and notify the health care provider. teach the patient strategies to manage postural hypotension. update the patient’s mental status examination.
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs.
Which assessment finding would prompt the nurse to collaborate with the health care provider
regarding potentially hazardous side effects of this drug? Dry mouth Blurred vision Nasal congestion Urinary retention.
A patient diagnosed with major depressive disorder tells the nurse, “Bad things that happen
are always my fault.” Which response by the nurse will best assist the patient to reframe this
overgeneralization? “I really doubt that one person can be blamed for all the bad things that happen.” “Let’s look at one bad thing that happened to see if another explanation exists.” You are being extremely hard on yourself. Try to have a positive focus.” “Are you saying that you don’t have any good things happen?”.
A nurse worked with a patient diagnosed with major depressive disorder, severe withdrawal,
and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at
risk for feelings of guilt and despair. over-involvement. interest and pleasure. ineffectiveness and frustration.
A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor
(SSRI) antidepressant therapy. The nurse should provide information to the patient and family
about restricting sodium intake to 1 gram daily. minimizing exposure to bright sunlight. reporting increased suicidal thoughts. maintaining a tyramine-free diet.
A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the
nurse approve? Macaroni and cheese, hot dogs, banana bread, caffeinated coffee Mashed potatoes, ground beef patty, corn, green beans, apple pie Avocado salad, ham, creamed potatoes, asparagus, chocolate cake Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls.
What is the focus of priority nursing interventions for the period immediately after
electroconvulsive therapy (ECT) treatment? Nutrition and hydration Supporting physiological stability Reducing disorientation and confusion Assisting the patient to identify and test negative thoughts.
A nurse provided medication education for a patient diagnosed with major depressive disorder
who began a new prescription for phenelzine (Nardil). Which behavior indicates effective
learning? The patient monitors sodium intake and weight daily. wears support stockings and elevates the legs when sitting. can identify foods with high selenium content that should be avoided. confers with a pharmacist when selecting over-the-counter medications.
Major depressive disorder resulted after a patient’s employment was terminated. The patient
now says to the nurse, “I’m not worth the time you spend with me. I am the most useless
person in the world.” Which nursing diagnosis applies? Powerlessness Defensive coping Situational low self-esteem Disturbed personal identity.
A patient diagnosed with major depressive disorder does not interact with others except when
addressed, and then only in monosyllables. The nurse wants to show nonjudgmental
acceptance and support for the patient. Which communication technique will be effective? Make observations. Ask the patient direct questions. Phrase questions to require yes or no answers. Frequently reassure the patient to reduce guilt feelings.
A patient being treated for depression has taken sertraline daily for a year. The patient calls
the clinic nurse and says, “I stopped taking my antidepressant 2 days ago. Now I am having
nausea, nervous feelings, and I can’t sleep.” The nurse will advise the patient to: “Go to the nearest emergency department immediately.” “Do not to be alarmed. Take two aspirin and drink plenty of fluids.” “Take a dose of your antidepressant now and come to the clinic to see the health
care provider.” “Resume taking your antidepressants for 2 more weeks and then discontinue them
again.”.
Which documentation for a patient diagnosed with major depressive disorder indicates the
treatment plan was effective? Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing
grandchild. Slept 10 hours uninterrupted. Attended craft group; stated “project was a failure,
just like me.” Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance.
Weight loss of 1 pound. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, “I
feel tired all the time.”.
A patient was diagnosed with seasonal affective disorder (SAD). During which month would
this patient’s symptoms be most acute? January April June September.
A patient diagnosed with major depressive disorder repeatedly tells staff, “I have cancer. It’s
my punishment for being a bad person.” Diagnostic tests reveal no cancer. Select the priority
nursing diagnosis. Powerlessness Risk for suicide Stress overload Stress overload.
A patient diagnosed with major depressive disorder refuses solid foods. In order to meet
nutritional needs, which beverage will the nurse offer to this patient? Tomato juice Orange juice Hot tea Milk.
During a psychiatric assessment, the nurse observes a patient’s facial expression is without
emotion. The patient says, “Life feels so hopeless to me. I’ve been feeling sad for several
months.” How will the nurse document the patient’s affect and mood? Affect depressed; mood flat Affect flat; mood depressed Affect labile; mood euphoric Affect and mood are incongruent.
A disheveled patient in the acute phase of major depressive disorder is withdrawn, has
psychomotor retardation, and has not showered for several days. The nurse will bring up the issue at the community meeting. calmly tell the patient, “You must bathe daily.” make observations about the patient’s poor personal hygiene. firmly and neutrally assist the patient with showering.
A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago.
The patient now says, “This medicine isn’t working.” The nurse’s best intervention would be
to discuss with the health care provider the need to increase the dose. reassure the patient that the medication will be effective soon. explain the time lag before antidepressants relieve symptoms. critically assess the patient for symptoms of improvement.
A patient is experiencing psychomotor agitation associated with major depressive disorder.
Which observation would the nurse associate with this symptom? The patient paces aimlessly around the room. asks the nurse to repeat instructions. complains of prickly skin sensations. demonstrates slowed verbal responses.
A patient diagnosed with major depressive disorder received six ECT sessions and aggressive
doses of antidepressant medication. The patient owns a small business and was counseled not
to make major decisions for a month. Select the correct rationale for this counseling. Antidepressant medications alter catecholamine levels, which impairs decisionmaking
abilities. Antidepressant medications may cause confusion related to limitation of tyramine
in the diet. Temporary memory impairments and confusion may occur with ECT. The patient needs time to readjust to a pressured work schedule.
A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase
(MAO) to avoid certain foods and drugs because of the risk of hypotensive shock. hypertensive crisis. cardiac dysrhythmia. cardiogenic shock.
Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major
depressive disorder. Which comment by the patient indicates teaching about the procedure
was effective? “They will put me to sleep during the procedure so I won’t know what is
happening.” “I might be a little dizzy or have a mild headache after each procedure.” “I will be unable to care for my children for about 2 months.” “I will avoid eating foods that contain tyramine.”.
The admission note indicates a patient diagnosed with major depressive disorder has anergia
and anhedonia. For which measures should the nurse plan? (Select all that apply.) Channeling excessive energy Reducing guilty ruminations Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation.
A nurse caring for a patient diagnosed with major depressive disorder reads in the patient’s
medical record, “This patient shows vegetative signs of depression.” Which nursing diagnoses
most clearly relate to this documentation? (Select all that apply.) Imbalanced nutrition: less than body requirements Chronic low self-esteem Sexual dysfunction Self-care deficit Powerlessness Insomnia.
A patient diagnosed with major depressive disorder shows vegetative signs of depression.
Which nursing actions should be implemented? (Select all that apply.) Offer laxatives if needed. Monitor food and fluid intake. Provide a quiet sleep environment. Eliminate all daily caffeine intake. Restrict intake of processed foods.
A patient being treated with paroxetine 50 mg po daily reports to the clinic nurse, “I took a
few extra tablets earlier today and now I feel bad.” Which assessments are most critical?
(Select all that apply.) Vital signs Urinary frequency Psychomotor retardation Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness.
A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety.
Which action should the nurse perform first? Verify the patient’s learning style. Lower the patient’s current anxiety. Create outcomes and a teaching plan. Assess how the patient uses defense mechanisms.
A woman is 5'7", 160 lbs. and wears a size 8 shoe. She says, “My feet are huge. I’ve asked
three orthopedists to surgically reduce my feet.” This person tries to buy shoes to make her
feet look smaller and, in social settings, conceals both feet under a table or chair. Which
health problem is likely? Social anxiety disorder Body dysmorphic disorder Separation anxiety disorder Obsessive-compulsive disorder due to a medical condition.
A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for
the nurse would be: “What would you like me to do to help you?” “Why do you suppose you are feeling anxious?” “I’m not sure I understand. Give me an example.” “You must get your feelings under control before we can continue.”.
A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The
patient does not follow the staff’s directions or respond to verbal interventions. The initial
nursing intervention of highest priority is to provide for the patient’s safety. encourage clarification of feelings. respect the patient’s personal space. offer an outlet for the patient’s energy.
A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The
patient does not follow the staff’s directions or respond to verbal interventions. Which nursing
diagnosis has the highest priority? Fear Risk for injury Self-care deficit Disturbed thought processes.
A patient checks and rechecks electrical cords related to an obsessive thought that the house
may burn down. The nurse and patient explore the likelihood of an actual fire. The patient
states this event is not likely. This counseling demonstrates principles of flooding. desensitization. relaxation technique. cognitive restructuring.
A patient undergoing diagnostic tests says, “Nothing is wrong with me except a stubborn
chest cold.” The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily
fatigued. Which defense mechanism is the patient using? Displacement Regression Projection Denial.
A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty
understanding the nurse’s comments and asks, “What do you mean? What are they going to
do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the
patient’s level of anxiety? Mild Moderate Severe Panic.
A patient preparing for surgery has moderate anxiety and is unable to understand preoperative
information. Which nursing intervention is most appropriate? Reassure the patient that all nurses are skilled in providing postoperative care. Present the information again in a calm manner using simple language. Tell the patient that staff is prepared to promote recovery. Encourage the patient to express feelings to family.
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about
feelings and concerns. What is the rationale for this intervention? Offering hope allays and defuses the patient’s anxiety. Concerns stated aloud become less overwhelming and help problem solving begin. Anxiety is reduced by focusing on and validating what is occurring in the
environment. Encouraging patients to explore alternatives increases the sense of control and
lessens anxiety.
A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which
question would be most appropriate for the nurse to ask? “Have you been a victim of a crime or seen someone badly injured or killed?” “Do you feel especially uncomfortable in social situations involving people?” Do you repeatedly do certain things over and over again?” “Do you find it difficult to control your worrying?”.
A patient in the emergency department shows disorganized behavior and incoherence after a
friend suggested a homosexual encounter. In which room should the nurse place the patient? An interview room furnished with a desk and two chairs A small, empty storage room with no windows or furniture A room with an examining table, instrument cabinets, desk, and chair The nurse’s office, furnished with chairs, files, magazines, and bookcases.
A person has minor physical injuries after an auto accident. The person is unable to focus and
says, “I feel like something awful is going to happen.” This person has nausea, dizziness,
tachycardia, and hyperventilation. What is the person’s level of anxiety? Mild Moderate Severe Panic.
Two staff nurses applied for a charge nurse position. After the promotion was announced, the
nurse who was not promoted said, “The nurse manager had a headache the day I was
interviewed.” Which defense mechanism is evident? Splitting Conversion Projection Splitting.
A patient tells a nurse, “My best friend is a perfect person. She is kind, considerate, goodlooking,
and successful with every task. I could have been like her if I had the opportunities,
luck, and money she’s had.” This patient is demonstrating denial. projection. rationalization. compensation.
A patient experiences a sudden episode of severe anxiety. Of these medications in the
patient’s medical record, which is most appropriate to give as a prn anxiolytic? buspirone lorazepam amitriptyline desipramine.
Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially
had feelings of loss but then became supportive of the new manager by helping make the
transition smooth and encouraging others. Which term best describes the nurse’s response? Altruism Suppression Intellectualization Reaction formation.
A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.”
This is an example of repression. devaluation. identification.. compensation.
A person speaking about a rival for a significant other’s affection says in an emotional, syrupy
voice, “What a lovely person. That’s someone I simply adore.” The individual is
demonstrating reaction formation. repression. projection. denial.
An individual experiences sexual dysfunction and blames it on a partner by calling the person
unattractive and unromantic. Which defense mechanism is evident? Rationalization Compensation Introjection Regression.
A student says, “Before taking a test, I feel very alert and a little restless.” The nurse can
correctly assess the student’s experience as culturally influenced. displacement. trait anxiety. mild anxiety.
A student says, “Before taking a test, I feel very alert and a little restless.” Which nursing
intervention is most appropriate to assist the student? Explain that the symptoms result from mild anxiety and discuss the helpful
aspects. Advise the student to discuss this experience with a health care provider. Encourage the student to begin antioxidant vitamin supplements. Listen attentively, using silence in a therapeutic way.
A cruel and abusive person often uses rationalization to explain the behavior. Which comment
demonstrates use of this defense mechanism? “I don’t know why I do mean things.” “I have always had poor impulse control.” “That person should not have provoked me.” “I’m really a coward who is afraid of being hurt.”.
A patient experiencing panic suddenly began running and shouting, “I’m going to explode!”
Select the nurse’s best action. Ask, “I’m not sure what you mean. Give me an example.” Capture the patient in a basket-hold to increase feelings of control. Tell the patient, “Stop running and take a deep breath. I will help you.” Assemble several staff members and say, “We will take you to seclusion to help
you regain control.”.
A person who has been unable to leave home for more than a week because of severe anxiety
says, “I know it does not make sense, but I just can’t bring myself to leave my apartment
alone.” Which nursing intervention is appropriate? Help the person use online video calls to provide interaction with others. Advise the person to accept the situation and use a companion. Ask the person to explain why the fear is so disabling. Teach the person to use positive self-talk techniques.
A nurse assesses an individual who commonly experiences anxiety. Which comment by this
person indicates the possibility of obsessive-compulsive disorder? “I check where my car keys are eight times.” “My legs often feel weak and spastic.” “I’m embarrassed to go out in public.” “I keep reliving a car accident.”.
When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching
should include instructions to report drowsiness. eat a tyramine-free diet. avoid alcoholic beverages. adjust dose and frequency based on anxiety level.
The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which
statement by the patient is mostly likely if this patient also has agoraphobia? “I’m sure I will get over not wanting to leave home soon. It takes time.” “Being afraid to go out seems ridiculous, but I can’t go out the door.” “My family says they like it now that I stay home most of the time.” “When I have a good incentive to go out, I can do it.”.
A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety
related to __________ as evidenced by inability to control compulsive cleaning. Which
phrase correctly completes the etiological portion of the diagnosis? feelings of responsibility for the health of family members approval-seeking behavior from friends and family persistent thoughts about bacteria, germs, and dirt needs to avoid interactions with others.
A patient performs ritualistic hand washing. Which action should the nurse implement to help
the patient develop more effective coping? Allow the patient to set a hand-washing schedule. Encourage the patient to participate in social activities. Encourage the patient to discuss hand-washing routines. Focus on the patient’s symptoms rather than on the patient.
For a patient experiencing panic, which nursing intervention should be implemented first? Teach relaxation techniques. Administer an anxiolytic medication. Prepare to implement physical controls.. Provide calm, brief, directive communication.
A child was placed in a foster home after being removed from abusive parents. The child is
apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to
help the child. Which interventions should the nurse suggest? (Select all that apply.) Use a calm manner and low voice. Maintain simplicity in the environment. Avoid repetition in what is said to the child. Minimize opportunities for exercise and play Explain and reinforce reality to avoid distortions.
A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who
begins a new prescription for lorazepam. What information should be included? (Select all
that apply.) Caution in use of machinery Foods allowed on a tyramine-free diet The importance of caffeine restriction Avoidance of alcohol and other sedatives Take the medication on an empty stomach.
Which assessment questions would be most appropriate for the nurse to ask a patient with
possible obsessive-compulsive disorder? (Select all that apply.) “Are there certain social situations that cause you to feel especially
uncomfortable?” “Are there others in your family who must do things in a certain way to feel
comfortable?” “Have you been a victim of a crime or seen someone badly injured or killed?” “Is it difficult to keep certain thoughts out of your awareness?” “Do you do certain things over and over again?”.
The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses
most likely apply to this individual? (Select all that apply.) Ineffective home maintenance Situational low self-esteem Chronic low self-esteem Disturbed body image Risk for injury.
A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has
frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be
included in the plan of care? Trigger flashbacks intentionally in order to help the patient learn to cope with
them. Explain that the physical symptoms are related to the psychological state. Encourage repression of memories associated with the traumatic event. Support “numbing” as a temporary way to manage intolerable feelings.
Four teenagers died in an automobile accident. One week later, which behavior by the parents
of these teenagers most clearly demonstrates resilience? The parents who visit their teenager’s grave daily. return immediately to employment. discuss the accident within the family only. create a scholarship fund at their child’s high school.
After the sudden death of his wife, a man says, “I can’t live without her … she was my whole
life.” Select the nurse’s most therapeutic reply. “Each day will get a little better.” “Her death is a terrible loss for you.” “It’s important to recognize that she is no longer suffering.” “Your friends will help you cope with this change in your life.”.
A woman just received notification that her husband died. She approaches the nurse who
cared for him during his last hours and says angrily, “If you had given him your undivided
attention, he would still be alive.” How should the nurse analyze this behavior? The comment suggests potential allegations of malpractice. In some cultures, grief is expressed solely through anger. Anger is an expected emotion in an adjustment disorder. The patient had ambivalent feelings about her husband.
A wife received news that her husband died of heart failure and called her family to come to
the hospital. She angrily tells the nurse who cared for him, “He would still be alive if you had
given him your undivided attention.” Select the nurse’s best intervention. Say to the wife, “I understand you are feeling upset. I will stay with you until your
family comes.” Say to the wife, “Your husband’s heart was so severely damaged that it could no
longer pump.” Say to the wife, “I will call the health care provider to discuss this matter with
you.” Hold the wife’s hand in silence until the family arrives.
A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the
child’s parents have adapted to their loss? The parents visit their child’s grave daily. maintain their child’s room as the child left it 2 years ago. keep a place set for the dead child at the family dinner table throw flowers on the lake at each anniversary date of the accident.
A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of
schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse’s
most therapeutic response. “Are you taking your medications the way they are prescribed?” “This loss is harder to accept because of your mental illness. Do you think you
should be hospitalized?” “I’m worried about how much you are crying. Your grief over your husband’s
death has gone on too long.” d. “The unexpected death of your husband is very painful. I’m glad you are able to
talk about your feelings.”.
Which scenario demonstrates a dissociative fugue? After being caught in an extramarital affair, a man disappeared but then reappeared
months later with no memory of what occurred while he was missing. A man is extremely anxious about his problems and sometimes experiences dazed
periods of several minutes passing without conscious awareness of them. A woman finds unfamiliar clothes in her closet, is recognized when she goes to
new restaurants, and complains of “blackouts” despite not drinking. A woman reports that when she feels tired or stressed, it seems like her body is not
real and is somehow growing smaller.
The nurse who is counseling a patient with dissociative identity disorder should understand
that the assessment of highest priority is risk for self-harm. cognitive function. memory impairment. condition of self-esteem.
A patient states, “I feel detached and weird all the time. It is as though I am looking at life
through a cloudy window. Everything seems unreal. It really messes up things at work and
school.” This scenario is most suggestive of which health problem? Acute stress disorder Dissociative amnesia Depersonalization disorder Disinhibited social engagement disorder.
The unlicensed assistive personnel (UAP) says to the nurse, “That patient with amnesia looks
fine, but when I talk to her, she seems vague. What should I be doing for her?” Select the
nurse’s best reply. “Spend as much time with her as you can and ask questions about her life.” “Use short, simple sentences and keep the environment calm and protective.” “Provide more information about her past to reduce the mysteries that are causing
anxiety.”
“Structure her time with activities to keep her busy, stimulated, and regaining
concentration.”.
A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel
as though I’m going to float away.” Which intervention would be most appropriate at this
point? Notify the health care provider of this change in the patient’s behavior.
Engage the patient in a physical activity such as exercise.
Isolate the patient until the sensation has diminished.
Administer a prn dose of antianxiety medication.
A person runs from a crowded nightclub after a pyrotechnics show causes the building to
catch fire. Which division of the autonomic nervous system will be stimulated in response to
this experience? Limbic system Peripheral nervous system
Sympathetic nervous system
Parasympathetic nervous system.
The gas pedal on a person’s car became stuck on a busy interstate highway, causing the car to
accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after
this experience, afterward, which assessment finding would the nurse expect? Weight gain
Flashbacks Headache Diuresis.
A soldier returns to the United States from active duty in a combat zone. The soldier is
diagnosed with PTSD. The nurse’s highest priority is to screen this soldier for bipolar disorder. schizophrenia. depression. dementia.
Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The
soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse’s
immediate attention? “It’s good to be home. I missed my home, family, and friends.” “I saw my best friend get killed by a roadside bomb. I don’t understand why it
wasn’t me.” “Sometimes I think I hear bombs exploding, but it’s just the noise of traffic in my
hometown.” “I want to continue my education, but I’m not sure how I will fit in with other
college students.”.
A soldier returned home from active duty in a combat zone and was diagnosed with PTSD.
The soldier says, “If there’s a loud noise at night, I get under my bed because I think we’re
getting bombed.” What type of experience has the soldier described? Illusion Flashback Nightmare Auditory hallucination.
A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which
social event would be most disturbing for this soldier? Halloween festival with neighborhood children Singing carols around a Christmas tree A family outing to the seashore Fireworks display on July 4th.
Which comment by the parents of young children best demonstrates support of development
of resilience and effective stress management? “Our children will be stronger if they make their own decisions.” “We spend daily family time talking about experiences and feelings.”
“We use three different babysitters. All of them have college degrees.” “Our parenting strategies are different from those our own parents used.”.
A soldier in a combat zone tells the nurse, “I saw a child get blown up over a year ago, and I
still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my
mind.” Which phenomenon associated with PTSD is the soldier describing? Reexperiencing Hyperarousal Avoidance Psychosis.
A soldier who served in a combat zone returned to the United States. The soldier’s spouse
complains to the nurse, “We had planned to start a family, but now he won’t talk about it. He
won’t even look at children.” The spouse is describing which symptom associated with
PTSD? Reexperiencing Hyperarousal Avoidance Psychosis.
A soldier returned home last year after deployment to a war zone. The soldier’s spouse
complains, “We were going to start a family, but now he won’t talk about it. He will not look
at children. I wonder if we’re going to make it as a couple.” Select the nurse’s best response. “Posttraumatic stress disorder (PTSD) often changes a person’s sexual
functioning.” “I encourage you to continue to participate in social activities where children are
present.” “Have you talked with your spouse about these reactions? Sometimes we just need
to confront behavior.” “Posttraumatic stress disorder often strains relationships. Here are some
community resources for help and support.”.
Which assessment finding best supports dissociative fugue? The patient states “I cannot recall why I’m living in this town.” “I feel as if I’m living in a fuzzy dream state.” “I feel like different parts of my body are at war. “I feel very anxious and worried about my problems.”.
After major reconstructive surgery, a patient’s wounds dehisced. Extensive wound care was
required for 6 months, causing the patient to miss work and social activities. Which
physiological response would be expected for this patient? Vital signs return to normal. Release of endogenous opioids would cease. Pulse and blood pressure readings are elevated. Psychomotor abilities of the right brain become limited.
Relaxation techniques help patients who have experienced major traumas because they engage the parasympathetic nervous system. increase sympathetic stimulation. increase the metabolic rate. release hormones.
Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with
dissociative identity disorder. Disturbed personal identity related to obsessive fears of harming self or others. poor impulse control and lack of self-confidence. depressed mood secondary to nightmares and intrusive thoughts. cognitive distortions associated with unresolved childhood abuse issues.
A young adult says, “I was sexually abused by my older brother. During those assaults, I went
somewhere else in my mind. I don’t remember the details. Now, I often feel numb or unreal in
romantic relationships, so I just avoid them.” Which disorders should the nurse suspect based
on this history? (Select all that apply.) Acute stress disorder Depersonalization disorder Generalized anxiety disorder PTSD Reactive attachment disorder Disinhibited social engagement disorder.
A 10-year-old child was placed in a foster home after being removed from parental contact
because of abuse. The child has apprehension, tremulousness, and impaired concentration.
The foster parent also reports the child has an upset stomach, urinates frequently, and does not
understand what has happened. What helpful measures should the nurse suggest to the foster
parents? The nurse should recommend (Select all that apply) conveying empathy and acknowledging the child’s distress. explaining and reinforcing reality to avoid distortions using a calm manner and low, comforting voice. avoiding repetition in what is said to the child. staying with the child until the anxiety decreases. minimizing opportunities for exercise and play.
The nurse interviewing a patient with suspected PTSD should be alert to findings indicating
the patient (Select all that apply) avoids people and places that arouse painful memories experiences flashbacks or re-experiences the trauma. experiences symptoms suggestive of a heart attack. feels compelled to repeat selected ritualistic behaviors. demonstrates hypervigilance or distrusts others. feels detached, estranged, or empty inside.
Which experiences are most likely to precipitate PTSD? (Select all that apply). A young adult bungee jumped from a bridge with a best friend. An 8-year-old child watched an R-rated movie with both parents An adolescent was kidnapped and held for 2 years in the home of a sexual
predator. A passenger was in a bus that overturned on a sharp curve and tumbled down an
embankment. An adult was trapped for 3 hours at an angle in an elevator after a portion of the
supporting cable breaks.
The admission note indicates a patient diagnosed with major depressive disorder has anergia
and anhedonia. For which measures should the nurse plan? (Select all that apply.) Channeling excessive energy Reducing guilty ruminations Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation.
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