Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? Voluntary control of symptoms Patient’s style of presentation Results of diagnostic testing The role of secondary gains.
Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? Narcotic analgesics for use as needed for acute pain Antidepressant medications to treat co-morbid depression Long-term use of benzodiazepines to support coping with anxiety Conventional antipsychotic medications to correct cognitive distortions.
A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably readily seek psychiatric counseling. be resistant to accepting psychiatric help. attend psychotherapy sessions without encouragement. be eager to discover the true reasons for physical symptoms. .
A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse’s planning for this patient? The patient is suppressing accurate feelings regarding the problem. The patient’s anxiety is relieved through the physical symptom. The patient’s optic nerve transmission has been impaired. The patient will not disclose genuine fears. .
A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should establish a “buddy” system with other patients who can feed the patient at each meal. expect the patient to feed self after explaining arrangement of the food on the tray. direct the patient to locate items on the tray independently and feed self. address needs of other patients in the dining room, then feed this patient. .
A patient with blindness related to conversion (functional neurological) disorder says, “All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don’t find me as interesting.” Which nursing diagnosis is most relevant? Social isolation Chronic low self-esteem Interrupted family processes Ineffective health maintenance .
To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority explain the pathophysiology of symptoms. help these patients suppress feelings of anger. shift focus from somatic symptoms to feelings. investigate each physical symptom as it is reported. .
A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, “My chest is tight, and my heart misses beats. I’m often absent from work. I don’t go out much because I need to rest.” Which health problem is most likely? Dysthymic disorder Somatic symptom disorder Antisocial personality disorder Illness anxiety disorder (hypochondriasis) .
A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient sees a relationship between symptoms and interpersonal conflicts. has little difficulty communicating emotional needs to others. rarely derives personal benefit from the symptoms. has altered comfort and activity needs. .
To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms are generally chronic. have a physiological basis. can be voluntarily controlled. provide relief from health anxiety. .
A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient’s disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will assume roles and functions of other family members. demonstrate performance of former roles and tasks. focus energy on problems occurring in the family. rely on family members to meet personal needs. .
Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? “My employer should have paid for a health club membership for me.” “My family will see me through this. It won’t be easy, but I will never be alone.” “My heart attack was no fun, but it showed me up the importance of a good diet and more exercise.” “I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily.” .
A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? “Since my father died, I’ve been short of breath and had sharp pains that go down my left arm, but I think it’s just indigestion.” “I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I’m getting seriously dehydrated.” “Sexual intercourse is painful. I pretend as if I’m asleep so I can avoid it. I think it’s starting to cause problems with my marriage.” “I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus.” .
A patient who experienced a myocardial infarction was transferred from critical care to a stepdown unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient’s needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic? “I’m wondering if you are feeling anxious about your illness and being left alone.” “The staff are concerned that you are not satisfied with the care you are receiving.” “Let’s talk about why you use your call light so frequently. It is a problem.” “You frustrate the staff by calling them so often. Why are you doing that?” .
A patient reports fears of having cervical cancer and says to the nurse, “I’ve had Pap smears by six different doctors. The results were normal, but I’m sure that’s because of errors in the laboratory.” Which disorder would the nurse suspect? Conversion (functional neurological) disorder Illness anxiety disorder (hypochondriasis) Somatic symptom disorder . Factitious disorder .
A patient diagnosed with a somatic symptom disorder says, “My pain is from an undiagnosed injury. I can’t take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much.” It is important for the nurse to assess mood. cognitive style. secondary gains. identity and memory. .
What is an essential difference between somatic symptom disorders and factitious disorders? Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization. .
A patient says, “I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day.” Which response by the nurse fosters cognitive reframing? “You do not have a brain tumor. The more you talk about it, the more it reinforces your belief.” “Let’s see if there are any other possible explanations for your vomiting.” “You seem so worried. Let’s talk about how you’re feeling.” “We need to talk about something else.” .
Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively? Flooding Response prevention Relaxation techniques Systematic desensitization .
Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder? “What are you unable to do now but were previously able to do?” “How many doctors have you seen in the last year?” “Who do you talk to when you’re upset?” “Did you experience abuse as a child?” .
A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, “Although I’m still having pain, I notice it less and am able to perform more activities.” The nurse should evaluate the treatment plan as marginally successful. minimally successful. partially successful. totally achieved. .
A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder imposed on another is suspected. Which nursing interventions are appropriate? (Select all that apply.) Increase private visiting time for the parents to improve bonding. Keep careful, detailed records of visitation and untoward events. Place mittens on the child to reduce access to ports and incisions. Encourage family members to visit in groups of two or three. Interact with the patient frequently during visiting hours.
Which assessment findings suggest the possibility of a factitious disorder, imposed on selftype? (Select all that apply.) History of multiple hospitalizations without findings of physical illness History of multiple medical procedures or exploratory surgeries Going from one doctor to another seeking the desired response Claims illness to obtain financial benefit or other incentive Difficulty describing symptoms .
A patient diagnosed with a somatic symptom disorder says, “Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear.” Which nursing diagnoses apply to this patient? (Select all that apply.) Spiritual distress Decisional conflict Adult failure to thrive Impaired social interaction Ineffective role performance.
A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? (Select all that apply.) Female Reports frequent syncope Rates pain as “1” on a scale of “10” First diagnosed with psoriasis at age 12 Reports insomnia often results from back pain .
A nurse’s neighbor says, “I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?” The nurse should respond by noting that some serious medical conditions may be complicated by emotional stress, including (Select all that apply) cancer. hip fractures. hypertension. immune disorders. cardiovascular disease. .
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? Binge eating Bulimia nervosa Anorexia nervosa Eating disorder not otherwise specified .
Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? Weight, muscle, and fat congruence with height, frame, age, and sex Calorie intake is within required parameters of treatment plan Weight reaches established normal range for the patient Patient expresses satisfaction with body appearance .
A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: “Do you often feel fat?” “Who plans the family meals?” “What do you eat in a typical day?” “What do you think about your present weight?” .
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, “Describe what you think about your present weight and how you look.” Which response by the patient is most consistent with the diagnosis? “I am fat and ugly.” “What I think about myself is my business.” “I’m grossly underweight, but that’s what I want.” “I’m a few pounds’ overweight, but I can live with it.” .
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia .
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will weigh self accurately using balanced scales. limit exercise to less than 2 hours daily. select clothing that fits properly. gain 1 to 2 pounds. .
Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? Assess for depression and anxiety. Observe for adverse effects of refeeding. Communicate empathy for the patient’s feelings. Help the patient balance energy expenditures with caloric intake. .
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care. Because of increased risk of physical problems with refeeding, the patient’s permission is needed. A team approach to planning the diet ensures that physical and emotional needs will be met. .
The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention “monitor for complications of refeeding.” Which system should a nurse closely monitor for dysfunction? Renal Endocrine Integumentary Cardiovascular .
A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? “What are your feelings about not eating foods that you prepare?” “You seem to feel much better about yourself when you eat something.” “It must be difficult to talk about private matters to someone you just met.” “Being thin doesn’t seem to solve your problems. You are thin now but still unhappy.” .
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to eat a small meal after purging. not to skip meals or restrict food. to increase oral intake after 4 PM daily. the value of reading journal entries aloud to others. .
A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? The nurse interacts with the patient in a protective fashion. The nurse’s comments to the patient are compassionate and nonjudgmental. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. The nurse refers the patient to a self-help group for individuals with eating disorders. .
A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will appropriately express angry feelings. verbalize two positive things about self. verbalize the importance of eating a balanced diet. identify two alternative methods of coping with loneliness. .
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? Assist the patient to identify triggers to binge eating. Provide corrective consequences for weight loss. Assess for signs of impulsive eating. Explore needs for health teaching.
One bed is available on the inpatient eating-disorder unit. Which patient should be admitted to this bed? The patient whose weight decreased from 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg .
A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to self-monitoring of daily food and fluid intake. establishing the desired daily weight gain. how to recognize hypokalemia. self-esteem maintenance.
As a patient admitted to the eating-disorder unit undresses, a nurse observes that the patient’s body is covered by fine, downy hair. The patient weighs 70 pounds and is 5'4" tall. Which term should be documented? Amenorrhea Alopecia Lanugo Stupor .
A patient being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5'4". The patient says, “I won’t eat until I look thin.” Select the priority initial nursing diagnosis. Anxiety related to fear of weight gain Disturbed body image related to weight loss Ineffective coping related to lack of conflict resolution skills Imbalanced nutrition: less than body requirements related to self-starvation .
A nurse conducting group therapy on the eating-disorder unit schedules the sessions immediately after meals for the primary purpose of maintaining patients’ concentration and attention. shifting the patients’ focus from food to psychotherapy. promoting processing of anxiety associated with eating. focusing on weight control mechanisms and food preparation. .
Physical assessment of a patient diagnosed with bulimia often reveals prominent parotid glands. peripheral edema. thin, brittle hair. 25% underweight. .
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? Carefree flexibility Rigidity, perfectionism Open displays of emotion High spirits and optimism .
Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? Urine output 40 mL/hour Pulse rate 58 beats/min Serum potassium 3.4 mEq/L Systolic blood pressure 62 mm Hg .
A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? “You and I will have to sit down and discuss this problem.” “It bothers me to see you exercising. I am afraid you will lose more weight.” “Let’s discuss the relationship between exercise, weight loss, and the effects on your body.” d. “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.” “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.” .
Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? Powerlessness Ineffective coping Disturbed body image Imbalanced nutrition: less than body requirements .
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should assess lung sounds and extremities. suggest use of an aerobic exercise program. positively reinforce the patient for the weight gain. establish a higher goal for weight gain the next week. .
The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a patient diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? The patient’s history of poly-substance abuse The patient’s preference for homeopathic remedies The patient’s family history of autoimmune disorders The patient’s comorbid diagnosis of a learning disability .
A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? The child frequently eats newspapers and magazines. The child refuses to eat peanut butter and jelly sandwiches. The child often rechews and reswallows foods at mealtimes. The parents feed the child clay because of concerns about anemia. .
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) Peripheral edema Parotid swelling Constipation Hypotension Dental caries Lanugo .
A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.) Flexible mealtimes Unscheduled weight checks Adherence to a selected menu Observation during and after meals Monitoring during bathroom trips Privileges correlated with emotional expression .
A nurse cares for these four patients. Which patient has the highest risk for problems with sleep physiology? Retiree who volunteers twice a week at Habitat for Humanity Corporate accountant who travels frequently Parent with three teenagers Lawn care worker .
Which comment is most likely from a patient with chronic sleep deprivation? “I turn on the television every night to get to sleep. I set the timer so it goes off in 30 minutes.” “I have diarrhea frequently and not much energy, so I stay at home most of the time.” “I only sleep about 7 hours a night, but I know I should sleep 8 or 9 hours.” “When my alarm clock goes off every morning, it seems like I am dreaming.” .
The nurse provides health education for an adult experiencing sleep deprivation. Which instruction has the highest priority? “It’s important to limit your driving to short periods. Sleep deprivation increases your risks for serious accidents.” “Sleep deprivation is usually self-limiting. See your health care provider if it lasts more than a year.” “Turn the radio on with a soft volume as you prepare for bed each evening. It will
help you relax.” “Three glasses of wine each evening helps many patients who suffer from sleep deprivation.” .
A nurse provides health education for an adult with sleep deprivation. It is most important for the nurse to encourage caution when the patient engages in using a vacuum cleaner. cooking a meal. driving a car. bathing. .
A patient needs diagnostic evaluation of sleep problems. Which test will evaluate the patient for possible sleep-related problems? Skull x-rays Electroencephalogram (EEG) Positron emission tomography (PET) Single photon emission computed tomography (SPECT) .
A patient says, “It takes me about 15 minutes to go to sleep each night.” This comment describes delta sleep. parasomnia. sleep latency. REM sleep. .
A person says, “I often feel like I have been dreaming just before I awake in the morning.” Which rationale correctly explains the comment? Sleep architecture changes during the sleep period, resulting in increased slowwave sleep at the end of the cycle. Cycles of REM sleep increase in the second half of sleep and occupy longer periods. Dreams occur more frequently when a person is experiencing unresolved conflicts or depression. Dream content relates directly to developmental tasks. The person is likely feeling autonomous. .
Which person would be most likely to experience sleep fragmentation? An obese adult A toddler who attends day care A person diagnosed with mild osteoarthritis An adolescent diagnosed with anorexia nervosa .
A person is prescribed lorazepam 2 mg PO bid as needed for anxiety. When the person takes this medication, which change in sleep is anticipated? The patient will have fewer dreams. have less slow-wave sleep. experience extended sleep latency. enter sleep through REM sleep. .
A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have more dreams. excessive sleepiness. less slow-wave sleep. less REM sleep. .
Which season would be most associated with increased periods of wakefulness in the general population? Summer Winter Spring Fall .
Normally, most people sleep at night. What is the physiological rationale? The master biological clock responds to darkness with sleep. Darkness stimulates histamine release, which promotes sleep. Cooler environmental temperatures stimulate retinal messages. Stimulation of the sympathetic nervous system promotes sleep. .
A nurse counsels a patient on ways to determine the person’s total sleep requirement. Which instruction would produce the most accurate results? “For 1 full week, record what you remember about your dream content and related feelings as soon as you wake up. Bring the record to your next appointment.” “While off work for 1 week, go to bed at your usual time and wake up without an alarm. Record how many hours you sleep and then average the findings.” “For 2 full weeks, record how much time you sleep each night and rate your daytime alertness on a scale of 1 to 10. Calculate your average alertness score.” “All adults need 7 or 8 hours of sleep to function properly. Let’s design ways to help you reach that goal.” .
A home care nurse assesses a very demanding patient with chronic obstructive pulmonary disease (COPD). Afterward, the nurse talks with the spouse who has provided this patient’s care for 6 years. The spouse says, “I don’t need much sleep anymore. I might need to help him during the night.” Select the nurse’s most therapeutic response. “It sounds like you are very devoted to your spouse.” “I noticed you fell asleep while I was assessing your spouse. I’m concerned about you.” “Your spouse is lucky to have you to provide care rather than being placed in a nursing home.” “If you keep going like this, your health will be impaired also. Then who will take care of both of you?” .
A patient with rheumatoid arthritis reports, “For the past month I’ve had trouble falling asleep. When I finally get to sleep, I wake up several times during the night.” Which information should the nurse seek initially? “What have you done to try to improve your sleep?” “What would be a good sleep pattern for you?” “How much exercise are you getting?” “Do you have pain at night?.
A 76-year-old man tells the nurse at the sleep disorder clinic, “I awaken almost nightly in the midst of violent dreams in which I am defending myself against multiple attackers. Then I realize I have been hitting and kicking my wife. She has bruises.” Which health problem is most likely? Sleep paralysis Night terror disorder Sleep-related bruxism REM Sleep Behavior Disorder .
A patient reports, “Nearly every night I awaken feeling frightened after a bad dream. The dream usually involves being hunted by people trying to hurt me. It usually happens between 4 and 5 AM.” The nurse assesses this disorder as most consistent with criteria for which problem? Sleep deprivation Nightmare disorder Night terror disorder REM sleep behavior disorder .
A nurse who works night shift says, “I am exhausted most of the time. I sleep through my alarm. Sometimes my brain does not seem to work right. I am worried that I might make a practice error.” Which question should the nursing supervisor ask first? “What stress are you experiencing in your life?” “How much sleep do you get in a 24-hour period?” “Would it help if you do some exercises just before going to bed?” “Have you considered using a hypnotic medication to help you sleep?” .
A patient reports, “The medicine prescribed to help me get to sleep worked well for about a month, but I don’t have any more of those pills. Now my insomnia is worse than ever. I had nightmares the last 2 nights.” Which type of medication did the health care provider most likely prescribe? Benzodiazepine Tricyclic antidepressant Conventional antipsychotic Central nervous system (CNS) stimulant .
A patient experiencing primary insomnia asks the nurse, “I take a nap during the day. Doesn’t that make up for a lost night’s sleep?” Select the nurse’s best reply. “Circadian drives give daytime naps a structure different from nighttime sleep.” “The body clock operates on a 24-hour cycle, making nap effectiveness
unpredictable.” “It is a matter of habit and expectation. We expect to be more refreshed from a night’s sleep.” “Sleep restores homeostasis but works more efficiently when aided by melatonin secreted at night.” .
A patient tells the nurse, “Everyone says we should sleep 8 hours a night. I can only sleep 6 hours, no matter how hard I try. Am I doing harm to my body?” Select the nurse’s best response. “Tell me about strategies you have tried to increase your total sleep hours.” “Lack of sleep acts as a stressor on the body and can cause physical changes.” “If you have really tried to sleep more, maybe you should consult your health care provider.” “If you function well with 6 hours of sleep, you are a short sleeper. That’s normal for some people.” .
A patient says, “I have trouble falling asleep at night and might lie awake until 3 or 4 AM before falling sleep.” Which medication would the nurse expect a health care provider to prescribe for this patient? zolpidem flurazepam risperidone methylphenidate .
A young adult says to the nurse, “I go to sleep without any problem, but I often wake up during the night because it feels like there are rubber bands in my legs.” Which assessment question should the nurse ask to assess for restless legs syndrome (RLS)? “What type of birth control do you use?” “How much caffeine do you use every day?” “How much exercise do you get in a typical day?” “Does anyone else in your family have this problem?” .
Which neurotransmitters are most responsible for wakefulness? (Select all that apply.) γ-aminobutyric acid (GABA) Norepinephrine Acetylcholine Dopamine Galanin.
A night shift worker reports, “I’m having trouble getting to sleep after a night’s work. I have a hearty breakfast with coffee, read the paper, do my exercises, and then go to bed. However, I just lie awake until it is nearly time to get up to be with my family for dinner.” What changes should the nurse suggest? (Select all that apply.) Drink juice with breakfast rather than coffee. Exercise after awakening rather than before. Turn on the television when going to bed. Do not read the paper. Eat a light breakfast. .
A new patient at the sleep disorders clinic tells the nurse, “I have not slept well in a year, so I never feel good. I do not expect things will ever improve or be any different.” Interventions the nurse should consider include (Select all that apply) suggesting use of alcohol as a sedative. providing instruction in relaxation techniques. counseling the patient to address cognitive distortions. health teaching regarding factors that influence sleep. teaching fatigue-producing activities to become overtired. encouraging long daytime naps to compensate for sleep deprivation. .
A new staff nurse tells the clinical nurse specialist, “I am unsure about my role when patients bring up sexual problems.” The clinical nurse specialist should give clarification by saying, “All nurses qualify as sexual counselors. Nurses have knowledge about the biopsychosocial aspects of sexuality throughout the life cycle.” should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths.” should defer questions about sex to other health care professionals because of their limited knowledge of sexuality.” who are interested in sexual dysfunction can provide sex therapy for individuals and couples.” .
An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, “I haven’t had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don’t know if my heart is strong enough.” Which nursing diagnosis applies? Deficient knowledge related to faulty perception of health status Disturbed self-concept related to required lifestyle changes Disturbed body image related to treatment side effects Sexual dysfunction related to self-esteem disturbance .
A nurse is performing an assessment for a 59-year-old man with a long history of hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? Sexual dysfunction may result from use of prescription medications for management of hypertension. Such questions are an indirect way of learning about the patient’s medication adherence. These questions ease the transition to questions about sexual practices in general. Sexual dysfunction can cause stress and contribute to increased blood pressure. .
Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should develop an understanding of human sexual response. assess the patient’s sexual functioning and needs. develop an understanding of human sexual response. b. assess the patient’s sexual functioning and needs. c. acquire knowledge of the patient’s sexual roles. d. clarify own personal values about sexuality. clarify own personal values about sexuality. .
A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, “Without the red teddies, I am not interested in sex.” The nurse can assess this as consistent with exhibitionism. voyeurism. frotteurism. fetishism. .
While performing an assessment, the nurse says to a patient, “While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?” The purpose of this question is to identify areas of sexual dysfunction for treatment. determine possible homosexual urges. introduce the topic of masturbation. identify sexual misinformation. .
A woman tells the nurse, “My partner is frustrated with me. I don’t have any natural lubrication when we have sex.” What type of sexual disorder is evident? Genito-pelvic pain/penetration disorder Female sexual interest/arousal disorder Hypoactive sexual desire disorder Female orgasmic disorder .
The male manager of a health club placed a hidden video camera in the women’s locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is homosexuality. exhibitionism. pedophilia. voyeurism. .
A woman consults the nurse practitioner because she has not achieved orgasm for 2 years, despite having been sexually active. This is an example of Paraphilic disorder. Female orgasmic disorder. Genito-pelvic pain/penetration disorder. Female sexual interest/arousal disorder. .
An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? Defensive coping Sexual dysfunction Ineffective sexuality pattern Disturbed sensory perception, tactile .
An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful? “No complaints related to sexual function; to return next week.” “Patient reports achieving orgasm last week; seems very happy.” “Reports satisfaction with sexual encounters; feels partner is supportive.” “Reports achieving orgasm occasionally; relationship with partner is adequate.” .
Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? Homosexual Ritualistic behaviors Seeks access to children Self-confident professional .
A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patient’s sexual practices? “Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?” “Sexual health can reflect a number of medical problems, so I’d like to ask if you have any sexual problems you think we should know about.” “It’s your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please?” “I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment.” .
A man says, “I enjoy watching women when I am out in public. I like to go to places where I can observe women crossing their legs in hopes of seeing something good.” Which statement about this behavior is most accurate? It is a sexual disorder. The behavior is socially atypical. It could disrupt relationships and could be insulting to others. It is not a sexual disorder. These events occur in public, where those he observes do not have a reasonable expectation of privacy. It is not a sexual disorder. Because it occurs in public areas, this behavior does not hurt others or involve intrusion into the personal space of those observed. An action is or is not a sexual disorder depending on applicable local laws, so whether this meets the definition of a sexual disorder depends on the location. .
A parent who is very concerned about a 3-year-old son says, “He likes to play with girls’ toys. Do you think he is homosexual or mentally ill?” Which response by the nurse most professionally describes the current understanding of gender identity? “A child’s interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood.” “It’s difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult.” “The research is incomplete, but many boys play with girls’ toys and turn out normal as adults.” “I am sure that whatever happens, he will be a loving son, and you will be a proud parent.” .
Which statement about paraphilic disorders is accurate? Paraphilic behavior is controllable by willpower, but most persons with these disorders fail to do so. Persons with paraphilic disorders rarely experience shame and are not distressed by their acts. . Persons with paraphilic disorders prey primarily on female children between the ages of 12 and 15 years. Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon. .
A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach’s arrest? Determine the nature and extent of the coach’s sexual disorder. Assess the coach’s potential for suicide or other self-harm. Assess the coach’s self-perception of problem and needs. Determine whether other children were harmed. .
An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult consistently avoids schools and shops at malls only during school hours. indicates sexual drive and enjoyment from sex have decreased. reports an active and satisfying sex life with an adult partner. volunteers to become a scout troop leader. .
A patient’s medical record documents sexual masochism. This patient derives sexual pleasur from inanimate objects. by inflicting pain on a partner. when sexually humiliated by a partner. from touching a nonconsenting person. .
A man with hypospadias tells the nurse, “Intercourse with my new bride is painful.” Which term applies to the patient’s complaint? Delayed ejaculation Erectile dysfunction Premature ejaculation Genito-pelvic pain/penetration disorder .
A man who regularly experiences premature ejaculation tells the nurse, “I feel like such a failure. It’s so awful for both me and my partner.” Select the nurse’s most therapeutic response. “I sense you are feeling frustrated and upset.” “Tell me more about feeling like a failure.” “You are too hard on yourself.” “What do you mean by awful?” .
A man who reports frequently experiencing premature ejaculation tells the nurse, “I feel like such a failure. It’s so awful for both me and my partner. Can you help me?” Select the nurse’s best response. “Have you discussed this problem with your partner?” “I can refer you to a practitioner who can help you with this problem.” “Have you asked your health care provider for prescription medication?” “There are several techniques described in this pamphlet that might be helpful.” .
A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect? Having tea parties with dolls A compromised sexual response cycle Identifying with boys who are athletic Intense urges to watch his parents have sex.
A patient approaches the nurse in the clinic waiting room and says, “I want to talk to you about a sexual matter.” The nurse can best facilitate the discussion by saying, “Let’s go my office.” responding, “I want to help. Go ahead; I’m listening.” telling the patient, “Let’s schedule another appointment.” offering to sit in a corner of the waiting room with the patient. .
A nurse assesses a patient diagnosed with a paraphilic disorder. Which findings are most likely? (Select all that apply.) Childhood history of attention deficit hyperactivity disorder (ADHD) A poorly managed endocrine disorder History of brain injury Cognitive distortions Grandiosity.
A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. The adolescent identifies friends in the home community who are a positive influence. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. The adolescent experiences no anger and frustration for 1 week. .
A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, “We can’t manage our teenager.” The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent’s behavior? Attention deficit hyperactivity disorder (ADHD)
Posttraumatic stress disorder (PTSD) Intermittent explosive disorder CD .
A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic? Planned ignoring Establish firm limits Neutrally permit refusals Coaxing to gain compliance .
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which type of therapy might promote the greatest change in the adolescent’s behavior? Family therapy Bibliotherapy Play therapy Art therapy .
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which nursing diagnosis is most applicable? Disturbed personal identity related to acting out as evidenced by prostitution Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another .
A 12-year-old has engaged in bullying for several years. The parents say, “We can’t believe anything our child says.” Recently this child shot a dog with a pellet gun and set fire to a neighbor’s trash bin. The child’s behaviors support the diagnosis of ADHD.
intermittent explosive disorder. oppositional defiant disorder (ODD).
CD. .
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. Ignore the child’s behavior. Send the child to time-out for 2 hours. Take the child to the gym and engage in an activity. Role-play a more appropriate behavior with the child.
An adolescent acts out in disruptive ways. When this adolescent threatens to throw a heavy pool ball at another adolescent, which comment by the nurse would set appropriate limits? “Attention everyone: we are all going to the craft room. “You will be taken to seclusion if you throw that ball.” “Do not throw the ball. Put it back on the pool table.” “Please do not lose control of your emotions.” .
The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child’s plan of care will be provided by an advanced practice nurse rather than a staff nurse? Leading an activity group Providing positive feedback Formulating nursing diagnoses Dialectical behavioral therapy (DBT) .
Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, “I’d rather stay in my room and listen to music. It’s easier than thinking about what is happening in my family.” Which nursing diagnosis is most applicable? Chronic low self-esteem related to role within the family Decisional conflict related to compliance with school requirements c Defensive coping related to adjustment to changes in family relationships Disturbed personal identity related to self-perceptions of changing family dynamics .
A child known as the neighborhood bully says, “Nobody can tell me what to do.” After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher’s computer. These behaviors support a diagnosis of CD.
ODD. intermittent explosive disorder.
ADHD. .
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurse’s initial action to defuse the situation? Say to the child, “Tell me how you’re feeling right now.” Take the child swimming at the facility’s pool. Establish a behavioral contract with the child. Administer an anxiolytic medication. .
Parents of an adolescent diagnosed with a CD say, “We don’t know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?” Which therapy is likely to be helpful for these parents? Parent–child interaction therapy (PCIT) Behavior modification therapy Multi-systemic therapy (MST) Pharmacotherapy .
An adolescent diagnosed with an impulse control disorder says, “I want to die. I spend my time getting even with people who hurt me.” When asked about a suicide plan, the adolescent replies, “I’ll jump from a bridge near my home. My father threw kittens off that bridge and they died.” Rate the suicide risk. Absent
Low
Moderate High .
An adolescent diagnosed with CD has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication? Second-generation antipsychotic bAntianxiety medication Calcium channel blocker β-blocker .
An adolescent was recently diagnosed with ODD. The parents say to the nurse, “Isn’t there some medication that will help with this problem?” Select the nurse’s best response. “There are no medications to treat this problem. This diagnosis is behavioral in
nature.” “It’s a common misconception that there is a medication available to treat every health problem.” “Medication is usually not prescribed for this problem. Let’s discuss some behavioral strategies you can use.” “There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you.”.
An adolescent diagnosed with a CD stole and wrecked a neighbor’s motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent’s reaction? Serotonin dysregulation and increased testosterone activity impair one’s capacity for remorse. Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior. .
Which assessment findings support a diagnosis of ODD? Negative, hostile, and spiteful toward parents. Blames others for misbehavior. Exhibits involuntary facial twitching and blinking; makes barking sounds. Violates others’ rights; cruelty toward people or animals; steals; truancy. Displays poor academic performance and reports frequent nightmares.
A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient’s history support the suspected diagnosis? (Select all that apply.) Family history of mental illness Allergies to multiple antibiotics Long history of severe facial acne Father with history of alcohol abuse History of an abusive relationship with one parent .
What are the primary distinguishing factors between the behavior of persons diagnosed with ODD and those with CD? The person diagnosed with (Select all that apply) ODD relives traumatic events by acting them out. ODD tests limits and disobeys authority figures. ODD has difficulty separating from loved ones. CD uses stereotypical or repetitive language. CD often violates the rights of others. .
A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because (Select all that apply) it is a vital component of implementing a behavior modification program. a therapeutic alliance is the first step in a nurse’s therapeutic use of self. the adolescent has demonstrated resistance to other authority figures. acceptance and trust convey feelings of security for the adolescent. adolescents usually relate better to authority figures than peers. .
A patient diagnosed with alcohol use disorder asks, “How will Alcoholics Anonymous (AA) help me?” Select the nurse’s best response. “The goal of AA is for members to learn controlled drinking with the support of a higher power.” “An individual is supported by peers while striving for abstinence one day at a time.” “You must make a commitment to permanently abstain from alcohol and other drugs.” “You will be assigned a sponsor who will plan your treatment program.” .
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/minute 0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse’s priority action? Force fluids. Begin the detox protocol. Obtain a clean-catch urine sample. Place the patient in a vest-type restraint.
3. A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority? Cardiovascular
Respiratory Neurological Hepatic .
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/minute. 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 is attempting to obtain attention by manipulating staff. may have sustained a head injury before admission. has symptoms of alcohol withdrawal delirium. is having an acute psychosis. .
A patient admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? Disturbed sensory perception Ineffective coping Ineffective denial Risk for injury .
A hospitalized patient diagnosed with alcohol use 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) narcotic analgesic, such as hydromorphone. sedative, such as lorazepam or chlordiazepoxide. cantipsychotic, such as olanzapine or thioridazine. monoamine oxidase inhibitor antidepressant, such as phenelzine.
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