Sample Chapter

INSTANT DOWNLOAD

 

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

 

Chapter 3: Theories and Therapies

 

MULTIPLE CHOICE

 

  1. A 26-month-old child displays negative behaviors. The parent says, “My child refuses toilet training and shouts, ‘No!’ when given direction. What do you think is wrong?” Select the nurse’s best reply.
a. “This is normal for your child’s age. The child is striving for independence.”
b. “The child needs firmer control. Punish the child for disobedience and say, ‘No.’”
c. “There may be developmental problems. Most children are toilet trained by age 2 years.”
d. “Some undesirable attitudes are developing. A child psychologist can help you develop a remedial plan.”

 

 

ANS:  A

These negative behaviors are typical of a child around the age of 2 years whose developmental task is to develop autonomy. The remaining options indicate the child’s behavior is abnormal.

 

DIF:    Cognitive Level: Application          REF:   Pages: 28-30

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

 

  1. A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, “No!” when given directions. Using Freud’s stages of psychosexual development, a nurse would assess the child’s behavior is based on which stage?
a. Oral
b. Anal
c. Phallic
d. Genital

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 28-30

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

 

  1. A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, “No!” when given direction. The nurse’s counseling with the parent should be based on the premise that the child is engaged in which of Erikson’s psychosocial crises?
a. Trust versus Mistrust
b. Initiative versus Guilt
c. Industry versus Inferiority
d. Autonomy versus Shame and Doubt

 

 

ANS:  D

The crisis of Autonomy versus Shame and Doubt is related to the developmental task of gaining control of self and environment, as exemplified by toilet training. This psychosocial crisis occurs during the period of early childhood. Trust versus Mistrust is the crisis of the infant, Initiative versus Guilt is the crisis of the preschool and early school-aged child, and Industry versus Inferiority is the crisis of the 6- to 12-year-old child.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 28-30

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

 

  1. A 4-year-old child grabs toys from siblings, saying, “I want that toy now!” The siblings cry, and the child’s parent becomes upset with the behavior. Using the Freudian theory, a nurse can interpret the child’s behavior as a product of impulses originating in the:
a. id.
b. ego.
c. superego.
d. preconscious.

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 28-30

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

 

  1. The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. A nurse supports the use of praise because according to the Freudian theory, these qualities will likely be internalized and become part of the child’s:
a. id.
b. ego.
c. superego.
d. preconscious.

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 26-30

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

 

  1. A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which feeling will most likely result?
a. Guilt
b. Anxiety
c. Loneliness
d. Self-esteem

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 26-30

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

 

  1. A patient comments, “I never know the right answer” and “My opinion is not important.” Using Erikson’s theory, which psychosocial crisis did the patient have difficulty resolving?
a. Initiative versus Guilt
b. Trust versus Mistrust
c. Autonomy versus Shame and Doubt
d. Generativity versus Self-Absorption

 

 

ANS:  C

These statements show severe self-doubt, indicating that the crisis of gaining control over the environment is not being successfully met. Unsuccessful resolution of the crisis of Initiative versus Guilt results in feelings of guilt. Unsuccessful resolution of the crisis of Trust versus Mistrust results in poor interpersonal relationships and suspicion of others. Unsuccessful resolution of the crisis of Generativity versus Self-Absorption results in self-absorption that limits the ability to grow as a person.

 

DIF:    Cognitive Level: Application          REF:   Pages: 28-30

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

 

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

 

 

ANS:  B

According to Erikson, the developmental task of infancy is the development of trust. The patient’s statement that he or she is afraid of becoming acquainted with others clearly shows a lack of ability to trust other people. Having warm and close friendships suggests the developmental task of infancy was successfully completed. The third option suggests rigidity rather than mistrust. The fourth option suggests failure to resolve the crisis of Initiative versus Guilt.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 28-30|Page: 35

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

 

  1. A nurse assesses that a patient is suspicious and frequently manipulates others. Using the Freudian theory, these traits are related to which psychosexual stage?
a. Oral
b. Anal
c. Phallic
d. Genital

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 27-30

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

 

  1. An adult expresses the wish to be taken care of and often behaves in a helpless fashion. This adult has needs related to which of Freud’s stages of psychosexual development?
a. Latency
b. Phallic
c. Anal
d. Oral

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 27-30

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

 

  1. A nurse listens to a group of recent retirees. One says, “I volunteer with Meals on Wheels, coach teen sports, and do church visitation.” Another laughs and says, “I’m too busy taking care of myself to volunteer. I don’t have time to help others.” These comments contrast which developmental tasks?
a. Trust versus Mistrust
b. Industry versus Inferiority
c. Intimacy versus Isolation
d. Generativity versus Self-Absorption

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 28-30

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

 

  1. Cognitive therapy was provided for a patient who frequently said, “I’m stupid.” Which statement by the patient indicates the therapy was effective?
a. “I’m disappointed in my lack of ability.”
b. “I always fail when I try new things.”
c. “Things always go wrong for me.”
d. “Sometimes I do stupid things.”

 

 

ANS:  D

“I’m stupid” is an irrational thought. A more rational thought is, “Sometimes I do stupid things.” The latter thinking promotes emotional self-control. The incorrect options reflect irrational thinking.

 

DIF:    Cognitive Level: Application          REF:   Page: 32         TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Psychosocial Integrity

 

  1. A student nurse tells the instructor, “I don’t need to interact with my patients. I learn what I need to know by observation.” The instructor can best interpret the nursing implications of Sullivan’s theory to the student by responding:
a. “nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills.”
b. “observing patient interactions can help you formulate priority nursing diagnoses and appropriate interventions.”
c. “I wonder how accurate your assessment of the patient’s needs can be if you do not interact with the patient.”
d. “noting patient behavioral changes is important because these signify changes in personality.”

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Application          REF:   Page: 26|Pages: 37-38

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

 

  1. A psychiatric technician says, “Little of what takes place on the behavioral health unit seems to be theory based.” A nurse educates the technician by identifying which common use of Sullivan’s theory?
a. Structure of the therapeutic milieu of most behavioral health units
b. Frequent use of restraint and seclusion as behavior management tools
c. Assessment tools based on age-appropriate versus arrested behaviors
d. Method nurses use to determine the best sequence for nursing actions

 

 

ANS:  A

The structure of the therapeutic environment has, as its foci, an accepting atmosphere and provision of opportunities for practicing interpersonal skills. Both constructs are directly attributable to Sullivan’s theory of interpersonal relationships. Sullivan’s interpersonal theory did not specifically consider the use of restraint or seclusion. Assessment based on the developmental level is more the result of Erikson’s theories. Sequencing nursing actions based on the priority of patient needs is related to Maslow’s hierarchy of needs.

 

DIF:    Cognitive Level: Application          REF:   Page: 26|Pages: 37-38

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

 

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

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 31-32  TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Operant conditioning will be used to encourage speech in a child who is nearly mute. Which technique would a nurse include in the treatment plan?
a. Ignore the child for using silence.
b. Have the child observe others talking.
c. Give the child a small treat for speaking.
d. Teach the child relaxation techniques, then coax speech.

 

 

ANS:  C

Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards to reinforce speech. Ignoring the child will not change the behavior. Having the child observe others describes modeling. Teaching relaxation techniques and then coaxing speech is an example of systematic desensitization.

 

DIF:    Cognitive Level: Application          REF:   Page: 31         TOP:   Nursing Process: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. The parent of a child who has schizophrenia tearfully asks a nurse, “What could I have done differently to prevent this illness?” Select the nurse’s most caring response.
a. “Although schizophrenia is caused by impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance.”
b. “Most of the damage is done, but there is still hope. Changing your parenting style can help your child learn to cope more effectively with the environment.”
c. “Schizophrenia is a biological illness with similarities to diabetes and heart disease. You are not to blame for your child’s illness.”
d. “Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting.”

 

 

ANS:  C

Patients and families need reassurance that the major mental disorders are biological in origin and are not the “fault” of parents. Knowing the biological nature of the disorder relieves feelings of guilt over being responsible for the illness. The incorrect responses are neither wholly accurate nor reassuring; they fall short of being reassuring and place the burden of having faulty genes on the shoulders of the parents.

 

DIF:    Cognitive Level: Application          REF:   Page: 26|Page: 36

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

 

  1. A nurse uses Peplau’s interpersonal therapy while working with an anxious, withdrawn patient. Interventions should focus on:
a. changing the patient’s perceptions about self
b. improving the patient’s interactional skills
c. using medications to relieve anxiety
d. reinforcing specific behaviors

 

 

ANS:  B

The nurse-patient relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others. Changing the patient’s perceptions about his- or herself would be appropriate for cognitive therapy. Reinforcing specific behaviors would be used in behavioral therapy. Using medications would be the focus of biological therapy.

 

DIF:    Cognitive Level: Application          REF:   Page: 33|Pages: 37-38

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

 

  1. A patient underwent psychotherapy weekly for 3 years. The therapist used free association, dream analysis, and facilitated transference to help the patient understand unconscious processes and foster personality changes. Which type of therapy was used?
a. Short-term dynamic psychotherapy
b. Transactional analysis
c. Cognitive therapy
d. Psychoanalysis

 

 

ANS:  D

The therapy described is traditional psychoanalysis. Short-term dynamic psychotherapy would last less than 1 year. Neither transactional analysis nor cognitive therapy makes use of the techniques described.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 26-27

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

 

  1. An advanced practice nurse determines a group of patients would benefit from therapy in which peers and interdisciplinary staff all have a voice in determining the level of the patients’ privileges. The nurse would arrange for:
a. milieu therapy
b. cognitive therapy
c. short-term dynamic therapy
d. systematic desensitization

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 42         TOP:   Nursing Process: Planning

MSC:  NCLEX: Psychosocial Integrity

 

  1. A nurse psychotherapist works with an anxious, dependent patient. The therapeutic strategy most consistent with the framework of psychoanalytic psychotherapy is:
a. emphasizing medication compliance
b. identifying the patient’s strengths and assets
c. offering psychoeducational materials and groups
d. focusing on feelings developed by the patient toward the nurse

 

 

ANS:  D

Positive or negative feelings of the patient toward the nurse or therapist represent transference. Transference is a psychoanalytic concept that can be used to explore previously unresolved conflicts. Emphasizing medication compliance is more related to biological therapy. Identifying patient strengths and assets would be consistent with supportive psychotherapy. The use of psychoeducational materials is a common “homework” assignment used in cognitive therapy.

 

DIF:    Cognitive Level: Application          REF:   Page: 21

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

 

  1. A person tells a nurse, “I was the only survivor in a small plane crash, but three business associates died. I got anxious and depressed and saw a counselor three times a week for a month. We talked about my feelings related to being a survivor, and now I’m fine, back to my old self.” Which type of therapy was used?
a. Milieu therapy
b. Psychoanalysis
c. Behavior modification
d. Interpersonal therapy

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 27

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

 

  1. A cognitive strategy a nurse could use to assist a very dependent patient would be to help the patient:
a. reveal dream content.
b. take prescribed medications.
c. examine thoughts about being independent.
d. role model ways to ask for help from others.

 

 

ANS:  C

Cognitive theory suggests that one’s thought processes are the basis of emotions and behavior. Changing faulty learning makes the development of new adaptive behaviors possible. Revealing dream content would be used in psychoanalytical therapy. Taking prescribed medications is an intervention associated with biological therapy. A dependent patient needs to develop independence.

 

DIF:    Cognitive Level: Application          REF:   Pages: 31-32

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

 

  1. A single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away several weeks ago. The parent seeks the help of a therapist specializing in cognitive therapy. The psychotherapist who uses cognitive therapy will treat the patient by:
a. discussing ego states
b. focusing on unconscious mental processes
c. negatively reinforcing an undesirable behavior
d. helping the patient identify and change faulty thinking

 

 

ANS:  D

Cognitive therapy emphasizes the importance of changing erroneous ways people think about themselves. Once faulty thinking changes, the individual’s behavior changes. Focusing on unconscious mental processes is a psychoanalytic approach. Negatively reinforcing undesirable behaviors is behavior modification, and discussing ego states relates to transactional analysis.

 

DIF:    Cognitive Level: Application          REF:   Pages: 31-32

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

 

  1. A person received an invitation to be in the wedding of a friend who lives across the country. The individual is afraid of flying. What type of therapy should the nurse recommend?
a. Psychoanalysis
b. Milieu therapy
c. Systematic desensitization
d. Short-term dynamic therapy

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Analysis               REF:   Page: 31         TOP:   Nursing Process: Planning

MSC:  NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A basic level registered nurse works with patients in a community setting. Which groups should this nurse expect to lead? Select all that apply.
a. Symptom management
b. Medication education
c. Family therapy
d. Psychotherapy
e. Self-care

 

 

ANS:  A, B, E

Symptom management, medication education, and self-care groups represent psychoeducation, a service provided by the basic level registered nurse. Advanced practice registered nurses provide family therapy and psychotherapy.

 

DIF:    Cognitive Level: Application          REF:   Pages: 40-42

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

 

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

 

 

ANS:  A, B, D

Cognitive therapists are active rather than passive during therapy sessions because they help patients to reality test their thinking. Homework assignments are given and completed outside the therapy sessions. Homework is usually discussed at the next therapy session. The goals of cognitive therapy are to assist the patient to identify inaccurate cognitions, to reality test their thinking, and to formulate new, accurate cognitions. Dream describing applies to psychoanalysis, not cognitive behavioral therapy. The desired outcome of cognitive therapy is to assist patients in increasing their objectivity, not subjectivity, about the cognitions that influence behavior.

 

DIF:    Cognitive Level: Application          REF:   Pages: 32-33|Pages: 37-38

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

 

Chapter 11: Anxiety, Anxiety Disorders, and Obsessive-Compulsive Disorders

Test Bank

 

MULTIPLE CHOICE

 

  1. A nurse wishes to teach alternative coping strategies to a patient who is experiencing severe anxiety. The nurse will first need to:
a. Lower the patient’s current anxiety level.
b. Verify the patient’s learning style.
c. Create outcomes and a teaching plan.
d. Assess how the patient uses defense mechanisms.

 

 

ANS:  A

A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient’s anxiety level. Using defense mechanisms does not apply.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 167-168

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

 

  1. A patient approaches the nurse and impatiently blurts out, “You’ve got to help me! Something terrible is happening. My heart is pounding.” The nurse responds, “It’s almost time for visiting hours. Let’s get your hair combed.” Which approach has the nurse used?
a. Distracting technique to lower anxiety
b. Bringing up an irrelevant topic
c. Responding to physical needs
d. Addressing false cognitions

 

 

ANS:  B

The nurse has closed off patient-centered communication. The introduction of an irrelevant topic makes the nurse feel better. The nurse is uncomfortable dealing with the patient’s severe anxiety.

 

DIF:    Cognitive Level: Application          REF:   Page: 167

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

 

  1. A patient who is experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be:
a. “Why do you suppose you are feeling anxious?”
b. “What would you like me to do to help you?”
c. “I’m not sure I understand. Give me an example.”
d. “You must get your feelings under control before we can continue.”

 

 

ANS:  C

Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.

 

DIF:    Cognitive Level: Application          REF:   Page: 167

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

 

  1. A patient with a high level of motor activity runs from chair to chair and cries, “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:
a. provide for patient safety.
b. increase environmental stimuli.
c. respect the patient’s personal space.
d. encourage the clarification of feelings.

 

 

ANS:  A

Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non–goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient’s personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 167-168

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

 

  1. A patient with a high level of motor activity runs from chair to chair and cries, “They’re coming! They’re coming!” The patient is unable to follow staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority?
a. Risk for injury
b. Self-care deficit
c. Disturbed energy field
d. Disturbed thought processes

 

 

ANS:  A

A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non–goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 179

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, “I’ve been working on other things.” When asked 4 hours later, the worker says, “Someone else was using the copier, so I couldn’t finish it.” The worker’s behavior demonstrates:
a. acting out.
b. projection.
c. rationalization.
d. passive aggression.

 

 

ANS:  D

A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks.

 

DIF:    Cognitive Level: Application          REF:   Pages: 170-171

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

 

  1. A patient is undergoing diagnostic tests. The patient says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports that the patient smokes, coughs daily, has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
a. Displacement
b. Regression
c. Projection
d. Denial

 

 

ANS:  D

Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one’s own unacceptable thoughts or feelings to another.

 

DIF:    Cognitive Level: Application          REF:   Pages: 171-172

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

 

  1. A patient with a mass in the left upper lobe of the lung 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 a tremulous voice, respirations at 28 breaths per minute, and a pulse rate at 110 beats per minute. What is the patient’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic

 

 

ANS:  B

Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

 

DIF:    Cognitive Level: Application          REF:   Pages: 165-167

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

 

  1. A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate?
a. Reassure the patient that all nurses are skilled in providing postoperative care.
b. Describe the procedure again in a calm manner using simple language.
c. Tell the patient that the staff is prepared to promote recovery.
d. Encourage the patient to express feelings to his or her family.

 

 

ANS:  B

Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the remaining options will further scatter the patient’s attention.

 

DIF:    Cognitive Level: Application          REF:   Pages: 167-168|Pages: 178-179

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

 

  1. A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention?
a. Offering hope allays and defuses the patient’s anxiety.
b. Concerns stated aloud become less overwhelming and help problem solving to begin.
c. Anxiety is reduced by focusing on and validating what is occurring in the environment.
d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

 

 

ANS:  B

All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin.

 

DIF:    Cognitive Level: Application          REF:   Page: 168

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

 

  1. Which assessment question would be most appropriate to ask a patient who has possible generalized anxiety disorder?
a. “Have you been a victim of a crime or seen someone badly injured or killed?”
b. “Do you feel especially uncomfortable in social situations involving people?”
c. “Do you repeatedly do certain things over and over again?”
d. “Do you find it difficult to control your worrying?”

 

 

ANS:  D

Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 176-177|Pages: 182-183

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

 

  1. A patient in the emergency department exhibits disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient?
a. Interview room furnished with a desk and two chairs
b. Small, empty storage room with no windows or furniture
c. Room with an examining table, instrument cabinets, desk, and chair
d. Nurse’s office, furnished with chairs, files, magazines, and bookcases

 

 

ANS:  A

Individuals who are experiencing a severe-to-panic level of anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse’s office or a room with an examining table and instrument cabinets may be overstimulating and unsafe.

 

DIF:    Cognitive Level: Application          REF:   Page: 169

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

 

  1. A person has minor physical injuries after an automobile 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 this person’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic

 

 

ANS:  C

The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in a panic level of anxiety demonstrates significantly disturbed behavior and may lose touch with reality.

 

DIF:    Cognitive Level: Application          REF:   Pages: 166-167

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

 

  1. 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?
a. Introjection
b. Conversion
c. Projection
d. Splitting

 

 

ANS:  C

Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

 

DIF:    Cognitive Level: Application          REF:   Pages: 171-172

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

 

  1. A patient tells a nurse, “My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can’t find a single flaw.” This patient is demonstrating:
a. denial.
b. projection.
c. idealization.
d. compensation.

 

 

ANS:  C

Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

 

DIF:    Cognitive Level: Application          REF:   Pages: 171-172

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

 

  1. A patient experiences an episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to administer as an as-needed (prn) anxiolytic medication?
a. buspirone (BuSpar)
b. lorazepam (Ativan)
c. amitriptyline (Elavil)
d. desipramine (Norpramin)

 

 

ANS:  B

Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

 

DIF:    Cognitive Level: Application          REF:   Pages: 184-185

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

 

  1. 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?
a. Altruism
b. Sublimation
c. Suppression
d. Passive aggression

 

 

ANS:  A

Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurse’s reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others.

 

DIF:    Cognitive Level: Application          REF:   Pages: 168-169

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

 

  1. A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of:
a. Repression
b. Devaluation
c. Identification
d. Compensation

 

 

ANS:  D

Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.

 

DIF:    Cognitive Level: Application          REF:   Page: 172

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

 

  1. A person who is speaking about a rival for a significant other’s affection says in a gushy, syrupy voice, “What a lovely person. That’s someone I simply adore.” The individual is demonstrating:
a. Reaction formation
b. Repression
c. Projection
d. Denial

 

 

ANS:  A

Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

 

DIF:    Cognitive Level: Application          REF:   Pages: 169-170|Page: 172|Page: 176

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

 

  1. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?
a. Rationalization
b. Compensation
c. Introjection
d. Regression

 

 

ANS:  A

Rationalization involves unconsciously making excuses for one’s behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

 

DIF:    Cognitive Level: Application          REF:   Pages: 170-172

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

 

  1. A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” The nurse can correctly assess the student’s experience as:
a. Culturally influenced
b. Displacement
c. Trait anxiety
d. Mild anxiety

 

 

ANS:  D

Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.

 

DIF:    Cognitive Level: Application          REF:   Pages: 165-166

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

 

  1. A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” The nursing intervention most suitable for assisting the student is to:
a. Explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects.
b. Advise the student to discuss this experience with a health care provider.
c. Encourage the student to begin antioxidant vitamin supplements.
d. Listen without comment.

 

 

ANS:  A

Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.

 

DIF:    Cognitive Level: Application          REF:   Pages: 165-168

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

 

  1. If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person?
a. “I don’t know why it happens.”
b. “I have poor impulse control.”
c. “That person shouldn’t have provoked me.”
d. “I’m really a coward who is afraid of being hurt.”

 

 

ANS:  C

Rationalization consists of justifying one’s unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person.

 

DIF:    Cognitive Level: Application          REF:   Pages: 170-172

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

 

  1. A patient with severe anxiety suddenly begins running and shouting, “I’m going to explode!” The nurse should:
a. Ask, “I’m not sure what you mean. Give me an example.”
b. Chase after the patient, and give instructions to stop running.
c. Capture the patient in a basket-hold to increase feelings of control.
d. Assemble several staff members and state, “We will help you regain control.”

 

 

ANS:  D

The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient’s anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly.

 

DIF:    Cognitive Level: Application          REF:   Pages: 167-169

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

 

  1. 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?
a. Teach the person to use positive self-talk.
b. Assist the person to apply for disability benefits.
c. Ask the person to explain why the fear is so disabling.
d. Advise the person to accept the situation and use a companion.

 

 

ANS:  A

This intervention, a form of cognitive restructuring, replaces negative thoughts such as “I can’t leave my apartment” with positive thoughts such as “I can control my anxiety.” This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.

 

DIF:    Cognitive Level: Application          REF:   Page: 183

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

 

  1. Which comment by a person who is experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?
a. “I check where my car keys are eight times.”
b. “My legs often feel weak and spastic.”
c. “I’m embarrassed to go out in public.”
d. “I keep reliving the car accident.”

 

 

ANS:  A

Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, “My legs feel weak most of the time,” is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.

 

DIF:    Cognitive Level: Application          REF:   Pages: 176-177

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

 

  1. When alprazolam (Xanax) is prescribed for acute anxiety, health teaching should include instructions to:
a. Report drowsiness.
b. Eat a tyramine-free diet.
c. Avoid alcoholic beverages.
d. Adjust dose and frequency based on anxiety level.

 

 

ANS:  C

Drinking alcohol or taking other anxiolytic medications along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.

 

DIF:    Cognitive Level: Application          REF:   Page: 187       TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which statement is mostly likely to be made by a patient with agoraphobia?
a. “Being afraid to go out seems ridiculous, but I can’t go out the door.”
b. “I’m sure I’ll get over not wanting to leave home soon. It takes time.”
c. “When I have a good incentive to go out, I can do it.”
d. “My family says they like it now that I stay home.”

 

 

ANS:  A

Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 175-176

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

 

  1. A patient has the nursing diagnosis: Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis?
a. Ensuring the health of household members
b. Attempting to avoid interactions with others
c. Having persistent thoughts about bacteria, germs, and dirt
d. Needing approval for cleanliness from friends and family

 

 

ANS:  C

Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relief anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 176-177

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies?
a. Allow the patient to set a hand-washing schedule.
b. Encourage the patient to participate in social activities.
c. Encourage the patient to discuss hand-washing routines.
d. Focus on the patient’s symptoms rather than on the patient.

 

 

ANS:  B

Because patients with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patient’s coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 176-177

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

 

  1. For a patient experiencing panic, which nursing intervention should be first?
a. Teach relaxation techniques.
b. Administer an anxiolytic medication.
c. Provide calm, brief, directive communication.
d. Gather a show of force in preparation for gaining physical control.

 

 

ANS:  C

Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.

 

DIF:    Cognitive Level: Application          REF:   Page: 169

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

 

  1. Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient:
a. Asks, “What’s the matter with me?”
b. Stays in a room alone and paces rapidly.
c. Can concentrate on what the nurse is saying.
d. States, “I don’t want anything to eat. My stomach is upset.”

 

 

ANS:  C

The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, “What’s the matter with me?” Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.

 

DIF:    Cognitive Level: Application          REF:   Page: 166       TOP:   Nursing Process: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient tells the nurse, “I don’t go to restaurants because people might laugh at the way I eat or I could spill food and be laughed at.” The nurse assesses this behavior as consistent with:
a. Acrophobia
b. Agoraphobia
c. Social phobia
d. Posttraumatic stress disorder

 

 

ANS:  C

The fear of a potentially embarrassing situation represents a social phobia. Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Posttraumatic stress disorder is associated with a major traumatic event.

 

DIF:    Cognitive Level: Application          REF:   Page: 175

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

 

  1. 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 that a house fire is not likely. This counseling demonstrates the principles of:
a. Flooding
b. Desensitization
c. Relaxation technique
d. Cognitive restructuring

 

 

ANS:  D

Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves a graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of undesirable stimuli in an effort to extinguish the anxiety response.

 

DIF:    Cognitive Level: Application          REF:   Page: 186

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

 

  1. A patient has a fear of public speaking. The nurse should be aware that social phobias are often treated with which type of medication?
a. (beta)-blockers.
b. Antipsychotic medications.
c. Tricyclic antidepressant agents.
d. Monoamine oxidase inhibitors.

 

 

ANS:  A

Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 173-175|Page: 186

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

 

  1. A patient tells the nurse, “I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?” The nurse’s reply should be based on the knowledge that buspirone:
a. Does not produce blood dyscrasias.
b. Does not cause dependence.
c. Can be administered as needed.
d. Is faster acting than diazepam.

 

 

ANS:  B

Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 185

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

 

MULTIPLE RESPONSE

 

  1. A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply.
a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.

 

 

ANS:  A, B, E

The child can be hypothesized to have moderate-to-severe trait (chronic) anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns.

 

DIF:    Cognitive Level: Application          REF:   Page: 168|Pages: 179-183

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

 

  1. A nurse plans health teaching for a patient with generalized anxiety disorder who takes lorazepam (Ativan). What information should be included? Select all that apply.
a. Use caution when operating machinery.
b. Allowed tyramine-free foods in diet.
c. Understand the importance of caffeine restriction.
d. Avoid alcohol and other sedatives.
e. Take the medication on an empty stomach.

 

 

ANS:  A, C, D

Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.

 

DIF:    Cognitive Level: Application          REF:   Page: 187       TOP:   Nursing Process: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply.
a. “Have you been a victim of a crime or seen someone badly injured or killed?”
b. “Are there certain social situations that cause you to feel especially uncomfortable?”
c. “Do you have to do things in a certain way to feel comfortable?”
d. “Is it difficult to keep certain thoughts out of awareness?”
e. “Do you do certain things over and over again?”

 

 

ANS:  C, D, E

The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 176-177

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

 

Chapter 19: Addictions and Compulsions

Test Bank

 

MULTIPLE CHOICE

 

  1. An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
c. About 0200 on hospital day 3 (72 hours after drinking stopped)
d. About 0200 on hospital day 4 (96 hours after drinking stopped)

 

 

ANS:  B

Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

 

DIF:    Cognitive Level: Application          REF:   Pages: 336-367

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

 

  1. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is:
a. jaundiced
b. dependent on alcohol
c. healthy but underweight
d. microcephalic and cognitively impaired

 

 

ANS:  D

Fetal alcohol syndrome is the result of alcohol’s inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distracters.

 

DIF:    Cognitive Level: Application          REF:   Page: 363

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

 

  1. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, “Somebody tied me up with ropes.” The patient is experiencing:
a. illusion
b. delusion
c. hallucinations
d. hypnagogic phenomenon

 

 

ANS:  A

The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 367

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

 

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

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 366-368

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

 

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

 

 

ANS:  D

The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety is the nurse’s priority. The scenario does not provide data to support the other diagnoses.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 372-373

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Physiological Integrity

 

  1. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine

 

 

ANS:  C

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

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 379-380

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

 

  1. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit.

 

 

ANS:  C

One-on-one supervision is necessary to promote physical safety until sedation reduces the patient’s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 372-373|Pages: 379-380

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

 

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

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 365-366|Pages: 373-375

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

 

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

 

 

ANS:  A

AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 372-373|Pages: 378-379

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

 

  1. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has recently ingested both alcohol and sedative drugs.

 

 

ANS:  B

A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient’s body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 368

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

 

  1. A patient admitted to an alcoholism rehabilitation program says, “I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening.” Which defense mechanism is evident?
a. Rationalization
b. Introjection
c. Projection
d. Denial

 

 

ANS:  D

Minimizing one’s drinking is a form of denial of alcoholism. The patient’s own description indicates that “social drinking” is not an accurate name for the behavior. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one’s own system.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 363-366|Pages: 375-377

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. A new patient in an alcoholism rehabilitation program says, “I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening.” Which response by the nurse will help the patient view the drinking more honestly?
a. “I see,” and use interested silence.
b. “I think you may be drinking more than you report.”
c. “Being a social drinker involves having a drink or two once or twice a week.”
d. “You describe drinking steadily throughout the day and evening. Am I correct?”

 

 

ANS:  D

The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 375-377

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

 

  1. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, “After discharge, I’m sure everything will be just fine.” Which remark by the nurse will be most helpful to the spouse?
a. “It is good that you’re supportive of your spouse’s sobriety and want to help maintain it.”
b. “Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol.”
c. “It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection.”
d. “Remember that alcoholism is a disease of self-destruction. You will need to observe your spouse’s behavior carefully.”

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 364-365|Pages: 375-379

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

 

  1. The treatment team plans care for a person diagnosed with paranoid schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?
a. Consider each diagnosis primary and provide simultaneous treatment.
b. The person will benefit from treatment in a residential treatment facility.
c. Withdraw the person from cannabis, and then treat the symptoms of schizophrenia.
d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

 

 

ANS:  A

Dual diagnoses clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 359-360

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

 

  1. When working with a patient beginning treatment for alcohol dependence, what is the nurse’s most therapeutic approach?
a. Empathetic, supportive
b. Strong, confrontational
c. Skeptical, guarded
d. Cool, distant

 

 

ANS:  A

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 373-375|Pages: 378-379

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

 

  1. A patient comes to an outpatient appointment obviously intoxicated. The nurse should:
a. explore the patient’s reasons for drinking today.
b. arrange admission to an inpatient psychiatric unit.
c. coordinate emergency admission to a detoxification unit.
d. tell the patient, “We cannot see you today because you’ve been drinking.”

 

 

ANS:  D

One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment.

 

DIF:    Cognitive Level: Application          REF:   Pages: 377-378

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

 

  1. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur?
a. The alcohol is less potent.
b. Tolerance develops.
c. Antagonistic effects occur.
d. Hypomagnesemia develops.

 

 

ANS:  B

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

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 362-364|Pages: 367-368

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

 

  1. Which statement most accurately describes substance dependence?
a. It is a lack of control over use. Tolerance and withdrawal symptoms occur when intake is reduced or stopped.
b. It occurs when psychoactive drug use interferes with the work of competing neurotransmitters.
c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects.
d. It involves taking a combination of substances to weaken or inhibit the effect of another drug.

 

 

ANS:  A

Psychoactive substance dependence involves a lack of control over use, as well as tolerance and withdrawal symptoms when intake is reduced or stopped.

 

DIF:    Cognitive Level: Knowledge          REF:   Pages: 357-358

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

 

  1. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, “I feel terrible.” Which analysis is correct?
a. The patient is exhibiting a prodromal symptom of seizures.
b. An idiosyncratic reaction to naloxone is occurring.
c. Symptoms of opiate withdrawal are present.
d. The patient is experiencing a relapse.

 

 

ANS:  C

The symptoms given in the question are consistent with narcotic withdrawal. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 365-368|Page: 370|Page: 377

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

 

  1. In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department.
c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
d. The patient will identify two community resources for the treatment of substance abuse by discharge.

 

 

ANS:  A

Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distracters are desired outcomes later in the plan of care.

 

DIF:    Cognitive Level: Application          REF:   Page: 359|Pages: 365-370

TOP:   Nursing Process: Outcomes Identification

MSC:  NCLEX: Physiological Integrity

 

  1. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient with an opiate overdose.
a. Monitor the airway and vital signs every 15 minutes.
b. Insert a nasogastric tube and test gastric pH.
c. Treat hyperpyrexia with cooling measures.
d. Insert an indwelling urinary catheter.

 

 

ANS:  A

Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer span of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

 

DIF:    Cognitive Level: Application          REF:   Page: 365|Page: 370|Page: 377

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

 

  1. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse’s drug use was evident?
a. Accepting responsibility for medication errors.
b. Seeking to be assigned as the medication nurse.
c. Frequent complaints of physical pain.
d. High sociability with peers.

 

 

ANS:  B

The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers and seeks access to medications. Usually, the person’s appearance will deteriorate, and he or she will blame errors on others.

 

DIF:    Cognitive Level: Application          REF:   Pages: 363-364

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

 

  1. A nurse with a history of narcotic dependence is found unconscious in the hospital locker room after overdosing. The nurse is transferred to the inpatient chemical dependence unit for care. Which attitudes or behaviors by nursing staff may be enabling?
a. Conveying understanding that pressures associated with nursing practice underlie substance use.
b. Pointing out that work problems are the result, but not the cause, of substance dependence.
c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing.
d. Providing health teaching about stress management.

 

 

ANS:  A

Enabling denies the seriousness of the patient’s problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

 

DIF:    Cognitive Level: Application          REF:   Pages: 363-364

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

 

  1. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed?
a. One-week detoxification program
b. Long-term outpatient therapy
c. Twelve-step self-help program
d. Residential program

 

 

ANS:  D

Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

 

DIF:    Cognitive Level: Application          REF:   Page: 379       TOP:   Nursing Process: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis?
a. Powerlessness
b. Disturbed thought processes
c. Ineffective thermoregulation
d. Impaired oral mucous membrane

 

 

ANS:  B

Both types of patients commonly experience paranoid delusions; thus the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 369

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
a. Make physical contact by frequently touching the patient.
b. Offer intellectual activities requiring concentration.
c. Avoid manipulation by denying the patient’s requests.
d. Observe for depression and suicidal ideation.

 

 

ANS:  D

Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

 

DIF:    Cognitive Level: Application          REF:   Pages: 369-370

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

 

  1. Which assessment findings best correlate to the withdrawal from central nervous system depressants?
a. Dilated pupils, tachycardia, elevated blood pressure, elation
b. Labile mood, lack of coordination, fever, drowsiness
c. Nausea, vomiting, diaphoresis, anxiety, tremors
d. Excessive eating, constipation, headache

 

 

ANS:  C

The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 367-370

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

 

  1. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
a. Substance abuse
b. Substance intoxication
c. Substance dependence
d. Recreational use of a social drug

 

 

ANS:  C

Nicotine meets the criteria for a substance, the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 357-358|Page: 369

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

 

  1. Which assessment findings will the nurse expect in an individual who has just injected heroin?
a. Anxiety, restlessness, paranoid delusions
b. Heightened sexuality, insomnia, euphoria
c. Muscle aching, dilated pupils, tachycardia
d. Drowsiness, constricted pupils, slurred speech

 

 

ANS:  D

Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

 

DIF:    Cognitive Level: Application          REF:   Pages: 369-370

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

 

  1. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for:
a. slurred speech, excessive drowsiness, and bradycardia
b. paranoid delusions, tactile hallucinations, and panic
c. runny nose, yawning, insomnia, and chills
d. anxiety, agitation, and aggression

 

 

ANS:  C

Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, minus the temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

 

DIF:    Cognitive Level: Application          REF:   Pages: 369-370

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

 

  1. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse’s first action?
a. Test reflexes
b. Check pupils
c. Initiate vomiting
d. Establish a patent airway

 

 

ANS:  D

Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

 

DIF:    Cognitive Level: Application          REF:   Pages: 366-367

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

 

  1. An adult in the emergency department states, “I feel restless. Everything I look at wavers. Sometimes I’m outside my body looking at myself. I hear colors. I think I’m losing my mind.” Vital signs are slightly elevated. The nurse should suspect a(n):
a. schizophrenic episode
b. cocaine overdose
c. phencyclidine (PCP) intoxication
d. D-lysergic acid diethylamide (LSD) ingestion

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 370-372

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

 

  1. In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)?
a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided.
b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained.
c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided.
d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

 

 

ANS:  A

Patients who have ingested LSD respond well to being “talked down” by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

 

DIF:    Cognitive Level: Analysis               REF:   Pages: 370-372

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

 

  1. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect:
a. acrophobia
b. hypothermia
c. hallucinations
d. anterograde amnesia

 

 

ANS:  D

Flunitrazepam is also known as the date rape drug; it produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

 

DIF:    Cognitive Level: Comprehension   REF:   Page: 359|Page: 372

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

 

  1. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, “Often my friend drinks, along with taking more of the drug than is ordered.” What is the effect of the use of alcohol with this drug?
a. The drug’s metabolism is stimulated.
b. The drug’s effect is diminished.
c. A synergistic effect occurs.
d. There is no effect.

 

 

ANS:  C

Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages: 364-365

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

 

  1. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction?
a. methadone (Dolophine)
b. bromocriptine (Parlodel)
c. disulfiram (Antabuse)
d. naltrexone (Revia)

 

 

ANS:  D

Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids; because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

 

DIF:    Cognitive Level: Application          REF:   Page: 370|Pages: 380-381

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

 

  1. Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, the patient will
a. use rationalization in healthy ways.
b. state, “I see the need for ongoing treatment.”
c. identify constructive outlets for expression of anger.
d. develop a trusting relationship with one staff member.

 

 

ANS:  B

The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 373|Pages: 377-379

TOP:   Nursing Process: Outcomes Identification

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
a. “Have you ever had blackouts?”
b. “When did you have your last drink?”
c. “Has drinking caused you any problems?”
d. “When did you decide to seek treatment?”

 

 

ANS:  B

Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority.

 

DIF:    Cognitive Level: Application          REF:   Pages: 366-367

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

 

  1. A patient in an alcohol rehabilitation program says, “I have been a loser all my life. I’m so ashamed of what I have put my family through. Now, I’m not even sure I can succeed at staying sober.” Which nursing diagnosis applies?
a. Chronic low self-esteem
b. Situational low self-esteem
c. Disturbed personal identity
d. Ineffective health maintenance

 

 

ANS:  A

Low self-esteem is present when a patient sees him- or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.

 

DIF:    Cognitive Level: Application          REF:   Pages: 362-363|Page: 374

TOP:   Nursing Process: Diagnosis| Nursing Process: Analysis

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which documentation indicates that the treatment plan for a patient in an alcohol rehabilitation program was effective?
a. Is abstinent for 10 days and states, “I can maintain sobriety 1 day at a time.” Spoke with employer, who is willing to allow the patient to return to work in 3 weeks.
b. Is abstinent for 15 days and states, “My problems are under control.” Plans to seek a new job where co-workers will not know history.
c. Attends AA daily; states many of the members are “real” alcoholics and states, “I may be able to help some of them find jobs at my company.”
d. Is abstinent for 21 days and says, “I know I can’t handle more than one or two drinks in a social setting.”

 

 

ANS:  A

The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.

 

DIF:    Cognitive Level: Analysis               REF:   Page: 373|Pages: 377-379

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

 

  1. Which assessment findings support a nurse’s suspicion that a patient has been using inhalants?
a. Perforated nasal septum and hypertension
b. Drowsiness, euphoria, and constipation
c. Pinpoint pupils and respiratory rate of 12 breaths per minute
d. Confusion, mouth ulcers, and ataxia

 

 

ANS:  D

Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid use.

 

DIF:    Cognitive Level: Application          REF:   Pages: 370-372

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

 

MULTIPLE RESPONSE

 

  1. A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply.
a. Avoid aged cheeses.
b. Read labels of all liquid medications.
c. Wear sunscreen and avoid bright sunlight.
d. Maintain an adequate dietary intake of sodium.
e. Avoid breathing fumes of paints, stains, and stripping compounds.

 

 

ANS:  B, E

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

 

DIF:    Cognitive Level: Application          REF:   Pages: 380-381

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

 

  1. A nurse can assist a patient and family in which aspects of substance abuse relapse prevention? Select all that apply.
a. Rehearsing techniques to handle anticipated stressful situations
b. Advising the patient to accept residential treatment if relapse occurs
c. Assisting the patient to identify life skills needed for effective coping
d. Isolating self from significant others and social situations until sobriety is established
e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances

 

 

ANS:  A, C, E

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

 

DIF:    Cognitive Level: Application          REF:   Page: 373|Pages: 377-379

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

 

  1. While caring for a patient with a methamphetamine overdose, which tasks are the priority focuses of care? Select all that apply.
a. Administration of naloxone (Narcan)
b. Vitamin B12 and folate supplements
c. Restoring nutritional integrity
d. Prevention of seizures
e. Reduction of fever

 

 

ANS:  D, E

Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

 

DIF:    Cognitive Level: Application          REF:   Page: 362|Page: 369

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