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Foundations of Psychiatric Mental Health Nursing A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis – Test Bank

 

Varcarolis: Foundations of Psychiatric Mental Health Nursing: A

Clinical Approach, 5th Edition

 

Test Bank

 

Chapter 5: Mental Health Nursing in Acute Care Settings

 

MULTIPLE CHOICE

 

1)   The nurse manager has the task of introducing staff to the use of clinical pathways. The nurse manager will need to explain that clinical pathways are used in managed care settings to

A. identify obstacles to effective care.
B. stabilize aggressive clients.
C. relieve nurses of planning responsibilities.
D. streamline the care process and save money.

 

ANS:   D

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

 

DIF:    Cognitive Level: Application             REF:    Text Page: 76, Text Page: 77

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

2)   Planning for clients with mental illness is facilitated by understanding that under behavioral health managed care, inpatient hospitalization is generally reserved for clients who

A. are noncompliant with medication at home.
B. present a clear danger to self or others.
C. develop new symptoms during the course of the illness.
D. have no support systems in the community.

 

ANS:   B

Hospitalization is justified when the client is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. Options A, C, and D do not necessarily describe clients who would require inhospital treatment.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 74, Text Page: 75

 

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

3)   An intervention strategy in which all psychiatric mental health nurses need to be competent and that is useful in reducing the number of clients who are admitted to psychiatric units is

A. milieu therapy.
B. utilization review.
C. use of clinical pathways.
D. community-based crisis intervention.

 

ANS:   D

Community-based crisis intervention, by a case manager or at a crisis clinic, often resolves or manages client problems so hospitalization may be averted. Options A, B, and C refer to interventions and processes that take place after admission.

 

DIF:    Cognitive Level: Comprehension       REF:    Text Page: 74, Text Page: 75

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

4)   A client who is a member of a health maintenance organization was hospitalized after a severe reaction to a psychotropic medication. He was treated for the reaction, a new medication was ordered, and he was closely observed for side effects for 24 hours. The case manager visited before the client’s discharge to give him an appointment for an outpatient visit in 2 days and learned that the client had neglected to mention that he received notice of eviction from his apartment on the day he was admitted. The most appropriate intervention for the case manager is to

A. cancel the client’s discharge from the hospital.
B. file a restraining order against the landlord who evicted the client.
C. arrange a place for the client to stay until a new apartment can be found.
D. call the health maintenance organization and obtain permission to transfer the client to a medical unit in the hospital.

 

ANS:   C

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

 

DIF:    Cognitive Level: Application             REF:    Text Page: 77

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

5)   Under managed care, how are the client and family likely to view the experience of hospitalization?

A. As an unpleasant interruption of daily life
B. Too short to produce complete wellness
C. Too restrictive to help with adjustment to the community
D. A pleasant vacation from the pressures of life in the community

 

ANS:   B

Managed care has resulted in very short hospital stays, much shorter than clients experienced in the past when discharge occurred only when the client was reasonably well suited to resume community responsibilities. Option A: Crisis situations often precede admission. Generally, both client and family are relieved. Option C: Hospitalization is currently no more restrictive or unpleasant than before the advent of managed care. Option D: Hospitalization can be guaranteed not to be long enough to be considered a vacation.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 74, Text Page: 75

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

6)   A teenage client is hospitalized after a serious suicide attempt related to feelings of hopelessness. The client comes from an upper-middle-class home in the suburbs and has never had psychiatric care before. Two hours after admission, when the nurse asks about the client’s reaction to hospitalization, the client is most likely to label the experience as

A. necessary.
B. exciting.
C. enjoyable.
D. frightening.

 

ANS:   D

Because only the most acutely ill clients are hospitalized, the client is in a milieu in which many behavioral manifestations of mental illness are apparent. The client is most likely frightened. Option A: Insight into the necessity for hospitalization only hours after making a suicide attempt is unlikely. Options B and C: Finding hospitalization enjoyable or exciting is also unlikely.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 80, Text Page: 81

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

 

 

7)   The interdisciplinary health care team meets 12 hours after a teenage client was admitted after a suicide attempt. Members of the team report assessments. What other outcome can be expected from this meeting?

A. A clinical pathway will be selected.
B. The nurse will assume the surrogate mother role.
C. The team will request a court-appointed advocate for the client.
D. Assessment of client need for placement outside the home will be undertaken.

 

ANS:   A

Clinical pathways are selected early in the course of treatment to streamline the treatment process and reduce costs. Option B would be inappropriate. Option C would rarely be required. Option D: It would be too early to determine the need for alternative postdischarge living arrangements.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 76, Text Page: 77

TOP:    Nursing Process: Planning (Outcome Identification)

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

8)   A client with a thought disorder is to be discharged home today, 4 days after having severe decompensation related to medication noncompliance. The client’s medication was restarted, and the client’s thought processes are now noted to be more logical and less interrupted by hallucinations. When the client’s husband comes to pick her up, he becomes upset and tells the nurse “She shouldn’t come home so soon. She’s still sick. You must keep her at least a month.” The nurse should

A. call the psychiatrist to come to the unit to explain discharge rationale.
B. explain that health insurance won’t pay for a longer stay for the client.
C. explain that the client will continue to improve if she takes medication regularly.
D. call security to handle the disturbance and escort the husband off the unit.

 

ANS:   C

Under managed care clients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the client’s right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. Option A will ultimately produce the same result because the physician will use the same rationale. Option B simply shifts blame but will not change the discharge. Option D is unnecessary; the nurse can handle the matter.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 82

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

 

 

9)   The nurse receives three telephone calls regarding a newly admitted client. The psychiatrist wishes to see the client for an assessment interview, the medical doctor wants to perform a physical examination, and the client’s lawyer wishes to set up an appointment to see the client. The nurse schedules the three activities for the client. This exemplifies the role of the nurse known as

A. advocate.
B. milieu manager.
C. care manager.
D. provider of care.

 

ANS:   C

Nurses on psychiatric units routinely coordinate client services as described in this scenario. Option A: The role of advocate would require the nurse to speak out on the client’s behalf. Option B: The role of milieu manager refers to maintaining a therapeutic environment. Option D: Provider of care refers to giving direct care to the client.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 78

TOP:    Nursing Process: Planning

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

10)   The nurse moves about the psychiatric unit, noting that exits are free from obstruction, no one is smoking in any area other than the smoking room, the janitor’s closet is locked, and all sharp objects are being used under supervision of staff. These observations relate to

A. management of milieu safety.
B. coordinating care of clients.
C. management of the interpersonal climate.
D. use of therapeutic intervention strategies.

 

ANS:   A

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

 

DIF:    Cognitive Level: Application             REF:    Text Page: 80

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

11)   Which aspect of direct care is the hospital psychiatric nurse most likely to provide for a client?

A. Hygiene assistance
B. Assertiveness training
C. Diversional activity
D. Assistance with job hunting

 

ANS:   B

Assertiveness training relies on the counseling and psychoeducational skills of the nurse. The other tasks are usually performed by the lowest cost staff member who can effectively perform the task. Option A: Assistance with personal hygiene would usually be accomplished by a psychiatric technician or nursing assistant. Option C: Diversional activities are usually the province of activities therapists. Option D: The client would probably be assisted in job hunting by the social worker.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 76, Text Page: 77

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Health Promotion and Maintenance

 

 

12)   The nurse writes in the client’s progress notes: “3/5/year 10 AM. Client brought to unit by ER nurse. Client’s clothing and body are dirty. In interview room, client sat with hands over face, sobbing softly. Did not acknowledge nurse and did not reply to questions. After several minutes abruptly arose and ran to window and pounded window screen, shouting, ‘Let me out of here!’ repeatedly. Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol po obtained. Medication administered with result that client stopped shouting and returned to sit wordlessly in chair. Client placed on one-to-one observation until seen by psychiatrist.” How should this documentation be evaluated?

A. Meets agency standards
B. Contains subjective material
C. Too brief to be of value
D. Excessively wordy

 

ANS:   A

This narrative note describes client appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents client response to medication. This note would probably meet agency standards. A complete nursing assessment would be in order as soon as the client is able to participate. Option B: Subjective material is absent from the note. Options C and D are inaccurate evaluations based on the explanation for option A.

 

DIF:    Cognitive Level: Evaluation              REF:    Text Page: 80

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

13)   For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of neuroleptic medication is whether

A. the client is willing to accept the medication.
B. less-restrictive alternatives have been tried without success.
C. the client’s behavior indicates possible danger to self, others, or the environment.
D. administration of the medication will make the work of the staff easier or safer.

 

ANS:   C

Although options A and B are factors to be considered, the client’s behavior is the factor of greatest importance. Option D is irrelevant.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 80, Text Page: 81

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

14)   A client was admitted after police brought him to the hospital after a fight with his roommate at a community residence. The client tells the nurse that he had been suspicious for several days, then noted his roommate was casting a spell on him by looking at him intently, so he hit the roommate with his fists. The client admits he stopped taking his antipsychotic medication a week ago when the prescription needed to be refilled. Which outcome should the nurse working in a managed behavioral health inpatient unit select for this client?

A. Symptoms will be stabilized with medication within 48 hours.
B. A trusting relationship with the nurse will be developed within 5 days.
C. A high level of ease with other clients will be reported within 1 week.
D. The client will agree to placement in a new residence within 3 weeks.

 

ANS:   A

Managed care requires the shortest possible hospital stay. Stabilization of symptoms can occur rapidly when medication is restarted. Discharge can occur shortly after stabilization. Options B, C, and D: These outcomes are inappropriate because they presume a long hospitalization.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 82

TOP:    Nursing Process: Planning (Outcome Identification)

MSC:   NCLEX: Physiologic Integrity

 

 

15)   The following clients are seen in the emergency department. The psychiatric unit has one bed. The advanced practice nurse acting as admitting officer should recommend for admission to the hospital the client who

A. is experiencing dry mouth and tremor related to haloperidol and wants his dose of haloperidol reduced.
B. is experiencing anxiety and a saddened mood after separation from her husband of 10 years.
C. argued with her boyfriend and inflicted a superficial cut on her forearm with a knife.
D. is a single parent and hears voices telling her to smother her infant son.

 

ANS:   D

Admission to the hospital would be justified by the risk of client danger to self or others. The other clients have issues that can be handled without hospitalization.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 74, Text Page: 75

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

16)   Which document pertaining to client care would a student beginning clinical experience on a psychiatric inpatient unit be justified in reading last?

A. Clients’ Bill of Rights
B. Unit Policy on Suicide Precautions
C. Unit Seclusion and Restraint Policies
D. Employee Directive on Overtime Refusal

 

ANS:   D

Because the student is not an employee, information about overtime refusal is of less relevance. Options A, B, and C: The student will be directly involved with client rights, implementing suicide precautions, and seclusion and restraint policies.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 76, Text Page: 80

TOP:    Nursing Process: N/A

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

17)   A student nurse is assigned to administer oral medications to her assigned client. The client refuses to take the medication. The student nurse should

A. tell the client that she will receive a poor grade if she doesn’t administer the medication.
B. tell the client that refusal is not permitted and staff will require him to take the medication.
C. document the client’s refusal on the medication administration record without comment.
D. ask the client’s reason for refusing and report to the coassigned nurse.

 

ANS:   D

The client has the right to refuse medication unless a court order to medicate has been obtained. The client’s reason for refusing should be ascertained, and the refusal should be reported to a unit nurse. Sometimes refusals are based on unpleasant side effects that can be ameliorated. Options A and B: Threats and manipulation are inappropriate. Option C: Medication refusal should be reported to permit appropriate intervention.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 80, Text Page: 81

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

 

 

18)   Which nursing intervention is most likely to be listed in the clinical pathway as part of a basic level psychiatric nurse’s duties to a psychiatric client on day 1 of hospitalization?

A. Provide a safe environment.
B. Assign therapeutic activities.
C. Order admission laboratory studies.
D. Educate client and family about illness and medications.

 

ANS:   A

The nurse is responsible for options A and D, but client education about illness and medications usually begins on day 2 after assessments are completed. Providing a safe environment begins at the time of admission. Option B is usually the responsibility of activities therapists. Option C would be the responsibility of a physician, physician assistant, or nurse practitioner.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 80

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

19)   The unit secretary is away from the unit desk, the phone rings, and the student nurse answers. The caller is the health insurer for one of the inpatients, seeking information about the client’s projected length of stay. How should the student nurse handle the request?

A. Obtain the information from the client’s medical record and relay it to the caller.
B. Inform the caller that information about clients is confidential.
C. Refer the request for information to the client’s case manager.
D. Refer the request to the unit psychiatrist.

 

ANS:   C

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

 

DIF:    Cognitive Level: Application             REF:    Text Page: 77

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

20)   The nurse is surveying medical records to look for violations of client rights. The finding that would signal a violation of client rights is

A. no treatment plan present in record.
B. client belongings searched at admission.
C. physical restraint used to prevent harm to self.
D. client was placed on one-to-one continuous observation.

 

ANS:   A

The client has the right to have a treatment plan. Option B: Inspecting client belongings is performed as a safety measure. Clients have the right to a safe environment. Options C and D: Clients have the right to be protected against the possible impulse to harm oneself that occurs as a result of a mental disorder.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 76

TOP:    Nursing Process: Evaluation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

21)   When responding to a client who exhibits agitated, hostile behavior during a community meeting, the initial action the nurse should take is to

A. offer prn medication.
B. follow the treatment plan.
C. place the client in seclusion.
D. permit the angry outburst if no harmful behavior is threatened.

 

ANS:   B

Consistency in response is vital to positive outcomes; hence, following the treatment plan is the correct answer. The response of staff might take different forms depending on the treatment plan.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 81

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

22)   A student nurse tells the instructor “I don’t feel as though I’m helping my assigned client. I don’t have the opportunity to engage him in formal counseling sessions. I only spend time with him as he has time between appointments.” The best reply for the instructor would be

A. “It is appropriate for beginners to progress slowly and develop skills.”
B. “It’s all new to you. By the end of your second week on the unit you will find you feel more helpful.”
C. “I’m sorry you’re feeling disappointed. Have you considered whether your goals for the experience were realistic?”
D. “In informal contacts your psychosocial communication skills help him feel listened to and supported. You provide feedback and encourage use of adaptive coping skills.”

 

ANS:   D

Nurses should be aware that informal contacts are often as significant as formal contacts because they occur during natural activities of daily and social living and are therefore based on reality.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 79

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

 

 

23)   Which of the following would the psychiatric nurse assess as a behavioral crisis? A client is

A. found crying hysterically after receiving a phone call from her boyfriend.
B. noted curled up in a corner of the bathroom with a towel wrapped around her head.
C. performing push-ups in the middle of the hall, forcing everyone to walk around him.
D. waving his fists and shouting threats at a nurse who offered him prn medication.

 

ANS:   D

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

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 81

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

24)   Which principle should be followed by psychiatric inpatient staff when addressing a behavioral crisis?

A. Resolve it with the least restrictive intervention possible.
B. Individual client rights are superseded by the rights of the majority.
C. Swift intervention is preferable to planned, structured intervention in nearly all instances of dyscontrol.
D. Allow the client the opportunity to regain control without intervention when safety of other clients is not compromised.

 

ANS:   A

The rule of using the least restrictive treatment or intervention possible to achieve the desired outcome is the client’s legal right. Option B: This is not strictly true. Option C: Planned interventions are nearly always preferable. Option D: Intervention may be necessary when the client is threatening harm to self.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 81

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

25)   When the clinical nurse leader is asked to defend the use of clinical pathways to a hospitalwide committee, which should be stated as an advantage? Clinical pathways

A. obscure resource management.
B. deter collaborative practice.
C. are generic rather than individualized.
D. make it easy to monitor treatment progression.

 

ANS:   D

When treatment and outcomes are projected on a day-to-day basis, monitoring and outcome evaluation are simplified. Exceptions are quickly noted. This is of considerable advantage to the treatment team. Option A: Pathways actually facilitate resource management, particularly in the area of staffing. Option B: Pathways support collaborative practice. Option C: Generic treatment plans are useful because they are evidence based and complete plans for a client with a specific disorder. They can easily be modified to meet individual needs.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 76, Text Page: 77

TOP:    Nursing Process: N/A

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

26)   A new client asks the nurse “So what goes on at this community meeting scheduled this afternoon?” The best reply by the nurse would be

A. “You and your therapist will discuss problems and goals for problem resolution.”
B. “You and a small group of other clients will meet to discuss common issues.”
C. “You, the staff, and the other clients will meet to discuss problems occurring on the unit.”
D. “We never know what will go on at a community meeting because clients determine the agenda.”

 

ANS:   C

Community meetings involve staff and clients. Items pertinent to the functioning of the community are topics for exploration. Ideas for activities, community problems, clarifications of unit rules, greeting new clients, and saying goodbye to clients being discharged might be included. Option A describes individual therapy. Option B describes group therapy. Option D is evasive.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 79

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

OTHER

 

1)   A group of nurses at the managed behavioral health organization have the task of revising the current admission criteria.

  1. Clear risk of client danger to self or others
  2. Dangerous decompensation of a client under long-term treatment
  3. Failure of community-based treatment demonstrating clear need for intensive, structured treatment
  4. Medical need unassociated with psychiatric treatment or associated with treatment
  5. Provision of respite for caregivers

Which, if any, of the criteria should be deleted?

  1. none
  2. 1
  3. 2
  4. 3
  5. 4
  6. 5

 

ANS:

E

Rationale: The goal of caregiver respite can be accomplished without hospitalizing the client. The other options are acceptable, evidence-based criteria for admission of a client to a managed behavioral health organization.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 74, Text Page: 75

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

2)   The psychiatric nurse should plan interventions based on the knowledge that clients may be intolerant of, or resistant to, common procedures such as vital signs, blood glucose monitoring, or insulin administration. Common reasons for resistance include (more than one answer may be correct)

  1. anxiety.
  2. obstinacy.
  3. lack of trust.
  4. thought impairment.

 

ANS:

A, C, D

Rationale: Resistance to routine procedures is rarely related to the psychiatric client being perverse or having an uncooperative personality trait. More often resistance is related to anxiety, fear, suspicion, cognitive impairment, or lack of knowledge.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 80, Text Page: 81

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

 

 

3)   A nurse performed the following actions and interventions in the course of a day while caring for a client with psychosis:

  1. Removed embroidery scissors from client’s possession
  2. Arranged for client to make an appointment with a lawyer
  3. In client’s presence, opened a package mailed to client
  4. Remained within arm’s length of client during the shift
  5. Permitted client to refuse oral psychotropic medication

Which intervention, if any, violated a right of the client?

  1. none
  2. 1
  3. 2
  4. 3
  5. 4
  6. 5

 

ANS:

A

Rationale: Actions 1 and 4 preserve the client’s right to be protected against the possible impulse to harm self or others. Action 2 preserved the client’s right to legal counsel. Action 3 preserved the client’s rights to send and receive mail and be present during package inspection. Action 5 preserved the client’s right to refuse treatment.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 76

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

4)   The nurse observes a client’s anger escalating. He begins to pace the hall and shouts “You all had better watch out. I’m going to hurt anybody who gets in my way.” Assuming each of the following interventions is appropriate, put them in the order in which they should occur. (Type answer in order from first to last.)

  1. Take the client to a seclusion room and administer medication.
  2. Have a nurse prepare prn medication.
  3. Calmly tell the client that “staff will help you control your impulse to hurt someone.”
  4. Gather a show of force.
  5. Remove clients from the area.

 

ANS:

E, C, B, D, A

Rationale: The ideal sequence provides a rapid, organized response that provides safety for the other clients and progresses from verbal limit setting to immobilization and concurrent use of medication.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 81

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

Varcarolis: Foundations of Psychiatric Mental Health Nursing:
A Clinical Approach, 5th Edition

 

Test Bank

 

Chapter 15: Somatoform and Dissociative Disorders

 

MULTIPLE CHOICE

 

1)   The medical-surgical nurse working with a client who has a somatoform disorder will find planning is facilitated by the understanding that the client will probably

A. readily seek psychiatric counseling.
B. be difficult to convince to seek psychiatric help.
C. attend psychotherapy sessions without encouragement.
D. be eager to discover the true reasons for his or her physical symptoms.

 

ANS:   B

Clients with somatoform disorders go from doctor to doctor trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling is offered, these clients reject both. Thus, options A, C, and D are incorrect.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 258, Text Page: 262

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

 

 

2)   A client has been diagnosed as having blindness related to conversion disorder. She displays indifference regarding the conversion symptom. The nurse states “I can’t understand why the client doesn’t seem more anxious about her symptom.” The understanding that should guide planning is that the

A. client is suppressing her true feelings.
B. client’s anxiety has been relieved through the physical symptom.
C. client’s needs are met during hospitalization, so she has no need to be anxious.
D. client does not wish to display her actual fear.

 

ANS:   B

Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom that is symbolically linked to an underlying conflict. Option A: Conversion, not suppression, is the operative defense mechanism in this disorder. Option C: This explanation oversimplifies the dynamics, suggesting that only dependency needs are of concern. Option D: This option suggests conscious motivation, but conversion operates unconsciously.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 259

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

 

 

 

3)   A client has blindness related to conversion disorder. To help the client eat, the nurse should

A. establish a “buddy” system with other clients who can feed the client at each meal.
B. expect the client to feed self after explaining the arrangement of the food on the tray.
C. see to the needs of other clients in the dining room, then feed this client.
D. direct the client to locate items on the tray independently and feed self unassisted.

 

ANS:   B

The client is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. Options A and C support dependency. Option D offers little support.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 262

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

 

 

4)   A client with blindness related to conversion disorder tells the nurse “I’m really popular here in the hospital. Lots of doctors and nurses stop by to check on my blindness and the other patients are really interested in it, too. Too bad people outside the hospital don’t find me so interesting.” On the basis of this statement, the nurse should continue to gather assessment data to support the nursing diagnosis of

A. social isolation.
B. chronic low self-esteem.
C. interrupted family processes.
D. ineffective health maintenance.

 

ANS:   B

The client mentions that her symptoms make her more interesting to people, inferring that she is uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in the scenario.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 256, Text Page: 257

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

5)   To best assist a client with a somatoform disorder, a nursing intervention of high priority that should be planned is

A. shift focus from somatic symptoms to feelings.
B. imply that somatic symptoms are not real.
C. help client suppress feelings of anger.
D. investigate each physical symptom as it is offered.

 

ANS:   A

Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the client as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. Option B destroys trust. Option C: A desired outcome would be that client would express feelings, including anger if it is present. Option D: Once physical symptoms have been investigated, they do not need to be reinvestigated each time the client reports them.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 263

TOP:    Nursing Process: Planning

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

6)   A client who is concerned that she may have serious heart disease seeks help at the mental health center after a referral from the internist who told her that she has no physical illness. The client reports she has had tightness in her chest and the sensation of her heart missing a beat. Because of her concern over her symptoms, she has missed much time from work over the past 2 years. Her social life has been severely restricted because she believes she must rest each evening. The client can be assessed as having symptoms consistent with

A. somatization disorder.
B. dysthymic disorder.
C. antisocial disorder.
D. hypochondriasis.

 

ANS:   D

Hypochondriasis, according to the DSM-IV-TR, involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Option A: Somatization disorder involves a variety of physical symptoms. Option B: Dysthymic disorder is a disorder of lowered mood. Option C: Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 258, Text Page: 259

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

 

 

7)   The nurse assessing a client with a somatoform disorder is most likely to note that the client

A. readily sees a relation between symptoms and interpersonal conflicts.
B. rarely derives personal benefit from the symptoms.
C. has little difficulty communicating emotional needs.
D. has altered comfort and activity needs.

 

ANS:   D

The client frequently has altered comfort and activity needs associated with the symptoms he or she displays (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and security needs may also be compromised. Option A: The client is rarely able to see a relation between symptoms and events in his or her life, which is readily discernable to health professionals. Option B: Clients with somatoform disorders often derive secondary gain from their symptoms. Option C: Clients with somatoform disorders have considerable difficulty identifying feelings and conveying emotional needs to others.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 260

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

 

 

8)   To plan effective care for clients with somatoform disorders, the nurse must understand that the clients may have difficulty giving up the symptoms because they

A. are generally ego dystonic.
B. can be voluntarily controlled.
C. provide relief of anxiety.
D. have a physiological basis.

 

ANS:   C

At the unconscious level, the client’s primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the client more psychologically comfortable and may also provide secondary gain, clients frequently fiercely cling to the symptoms. Option A: The symptoms tend to be ego syntonic. Option B: The symptoms are not under voluntary control. Option D: The symptoms are not physiologically based.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 260

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

 

 

9)   A client with somatization has an established nursing diagnosis of interrupted family processes related to client’s symptoms. The client’s spouse and children assume roles and tasks that previously belonged to the client. An appropriate outcome for the client is that the client will

A. demonstrate resumption of former roles and tasks.
B. assume roles and functions of other family members.
C. focus energy on problems occurring in the family.
D. rely on family members to meet all client needs.

 

ANS:   A

The client with somatization has typically adopted a sick role in the family, characterized by dependence. Increasing independence and resumption of former roles are necessary to change this pattern. The other options are inappropriate outcomes.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 261, Text Page: 262

TOP:    Nursing Process: Planning (Outcome Identification)

MSC:   NCLEX: Psychosocial Integrity

 

 

10)   A client who is 5 feet 7 inches tall and weighs 160 pounds believes that her size-9 feet are enormous compared with the rest of her body. She has visited orthopedic surgeons to see if surgery to reduce the length of her feet is possible. She spends hours trying to buy shoes that make her feet look smaller, and she prefers social interactions where she can sit with her feet concealed under a table. The nurse can assess that the client’s symptoms are consistent with

A. hypochondriasis.
B. somatoform pain disorder.
C. body dysmorphic disorder.
D. depersonalization disorder.

 

ANS:   C

Body dysmorphic disorder refers to preoccupation with some imagined defect in appearance in a normal-appearing person. The client’s feet are proportional to the rest of her body. Option A: Hypochondriasis involves misinterpreting physical symptoms as signs of a serious medical disorder. Option B: Somatoform pain disorder involves the presence of pain not associated with a medical disorder. Option D: Depersonalization disorder involves alteration in perception of self, such as feeling mechanical or unreal.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 259

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

 

 

11)   The data element obtained during nursing assessment that supports the presence of a fugue state is that the client states he

A. cannot recall why he is living in his present location.
B. feels as if he is living in a fuzzy dream state.
C. feels very anxious about his problems.
D. feels that different parts of him are at war.

 

ANS:   A

The client in a fugue state frequently relocates and assumes a new identity while not recalling his previous identity or where he lived in the past. Option B is more consistent with depersonalization disorder. Option C is consistent with generalized anxiety disorder. Option D is consistent with feelings experienced with dissociative identity disorder.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 266

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

 

 

12)   The client lives with her roommate in a condominium. She tells the nurse that her roommate has urged her to seek a therapist’s advice about episodes of strange behavior observed by the roommate but that the client cannot remember. The roommate has observed her leaving the condo wearing seductive clothing, quite different from her usual wardrobe, and returning 12 to 24 hours later, after which she sleeps for 8 to 12 hours. Episodes have also occurred in which the client and her roommate have argued about household matters and the client has gone to sit on the floor in the corner of the kitchen. While seated there she has spoken like a young child. The client’s problem can be assessed as being consistent with DSM-IV-TR criteria for

A. antisocial personality.
B. borderline personality.
C. dissociative identity disorder.
D. body dysmorphic disorder.

 

ANS:   C

Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. At least two of the subpersonalities take control of the person’s behavior but leave the individual unable to remember the periods of time in which the subpersonality was in control. Option A: Antisocial personality disorder features include impulsive, irresponsible behaviors, little concern for the rights of others, inability to empathize, and failure to learn from experience. Option B: Borderline personality disorder features include intense, stormy relationships, idealization/devaluation, impulsivity, self-mutilation, and fear of abandonment. Option D: Body dysmorphic disorder involves excessive concern with an imagined defect in a part of the body.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 266, Text Page: 267

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

 

 

13)   A client who lives with her roommate in a condominium seeks advice about episodes of strange behavior observed by the roommate but that the client cannot remember. The roommate has observed her leaving the condo wearing seductive clothing, quite different from her usual wardrobe, and returning 12 to 24 hours later, after which she sleeps for 8 to 12 hours. Episodes have also occurred in which the client and her roommate have argued about household matters and the client has gone to sit on the floor in the corner of the kitchen. While seated there she has spoken like a young child. The nurse should assess that the ego defense mechanism responsible for the client’s condition is most likely

A. rationalization.
B. dissociation.
C. projection.
D. symbolization.

 

ANS:   B

Dissociation involves the splitting off from awareness of an event or series of events, thus explaining the client’s inability to remember the episodes described by the roommate. Dissociated processes (memories and feelings) may take on a separate existence, becoming a subpersonality.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 266, Text Page: 267

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

 

 

14)   A client’s roommate has observed the client behaving in uncharacteristic ways, but the client cannot remember the episodes. During the assessment, which question should the nurse omit as irrelevant?

A. “Are you sexually promiscuous?”
B. “Are your memories of childhood clear and complete, or do you have many blank spots?”
C. “Have you ever found new things in your belongings that you cannot remember buying?”
D. “Have you ever found yourself someplace and did not know how you got there?”

 

ANS:   A

This question would probably produce defensiveness on the part of the client. If a subpersonality acts out sexually, the main personality is probably not aware of the behavior. All other questions would be pertinent.

 

DIF:    Cognitive Level: Application

REF:    Text Page: 266, Text Page: 267, Text Page: 268

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

 

 

15)   For a client with dissociative identity disorder, the nursing diagnosis of disturbed personal identity most likely has an etiology statement of “related to

A. poor impulse control.”
B. chronic low self-esteem.”
C. unresolved childhood abuse issues.”
D. high risk for self-directed violence.”

 

ANS:   C

Nearly all clients with multiple personality disorder resulting in disturbance of personal identity have a history of having been abused in childhood. None of the other etiology statements are relevant.

 

DIF:    Cognitive Level: Analysis

REF:    Text Page: 264, Text Page: 266, Text Page: 267

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

16)   For the client with dissociative amnesia, an appropriate indicator for the outcome of cognition (demonstrate ability to execute complex mental processes) is that the client will

A. verbalize feelings of safety.
B. function independently.
C. regularly attend diversional activities.
D. describe previously forgotten experiences.

 

ANS:   D

The ability to recall previously repressed or dissociated material is an indication that the client is integrating identity and memory. Option A: A client may verbalize feeling safe but may be disoriented and have memory deficits. Option B: A client may be able to function independently on a basic level without being able to remember significant information. Option C: Attending activities is possible without being able to remember antecedent events.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 265

TOP:    Nursing Process: Planning (Outcome Identification)

MSC:   NCLEX: Psychosocial Integrity

 

 

17)   Establishing a therapeutic relationship with a client with a dissociative disorder may be more difficult for the nurse than establishing a relationship with a psychotic client because the client with a dissociative disorder

A. seems haughty, distant, and aloof.
B. has symptoms that may seem contrived.
C. seems too needy, overwhelming the nurse.
D. seeks enormous amounts of secondary gain.

 

ANS:   B

The nurse often questions the genuineness of the behaviors of a client with dissociative disorder. They may seem sensational, exaggerated, and not authentic. Option A: The client with a dissociative disorder often appears withdrawn and vague. Options C and D are not typical of clients with dissociative disorders.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 268, Text Page: 269

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

 

 

18)   The nurse who is counseling a client with a dissociative disorder should understand that the assessment of highest priority is

A. risk for self-harm.
B. cognitive functioning.
C. identification of drug abuse.
D. readiness to reestablish identity or memory.

 

ANS:   A

Assessments that relate to client safety take priority. Clients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for hints of hopelessness, helplessness and worthlessness, low self-esteem, and impulses to self-mutilate. The other options are important assessments but rank beneath safety.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 268

TOP:    Nursing Process: Implementation

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

19)   A client states “I feel detached and weird all the time. It’s as though I’m looking at life through a cloudy window. Everything seems unreal. These feelings really get in the way of working and studying.” The nurse can assess that the client is experiencing

A. depersonalization disorder.
B. body dysmorphic disorder.
C. dissociative amnesia.
D. hypochondriasis.

 

ANS:   A

The DSM-IV-TR description of depersonalization disorder states that it involves a persistent or recurrent experience of feeling detached from and outside one’s mental processes or body. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Option B: Body dysmorphic disorder involves preoccupation with a body part the individual believes to be distorted. Option C: Dissociative amnesia involves memory loss. Option D: Hypochondriasis involves interpretation of body sensations as symptomatic of a serious illness.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 265

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

 

 

20)   The nursing assistant remarks to the nurse, “The client with amnesia looks together, but when I talk to her she seems rather vague. What should I be doing for her?” The best reply would be

A. “Give her lots of space to test her independence.”
B. “Whenever you think she needs direction, use short, simple sentences.”
C. “Spend as much time with her as you can and ask questions about her recent life.”
D. “Keep her busy and make sure she doesn’t take naps during the day.”

 

ANS:   B

Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in clients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. Option A: This option does not provide the structure or support often required by clients with amnesia. Option C: Probing is not a recommended strategy for a client with amnesia. Option D: Clients with amnesia need a balanced activity schedule that allows for rest because they often feel fatigued.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 270

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

 

 

21)   The husband of a client who has been diagnosed with severe depersonalization disorder asks the nurse if he is in any way at fault for his wife’s illness. He states their relationship is mutually supportive and no trauma has recently occurred. The nurse’s reply should be predicated on the knowledge that this disorder is thought to be related to

A. faulty learning.
B. genetic predisposition.
C. childhood emotional abuse.
D. the intentional production of symptoms.

 

ANS:   C

Depersonalization is sometimes preceded by severe stress; however, many authorities believe depersonalization disorder is associated with childhood emotional abuse. Options A, B, and D have not been implicated as causative factors.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 265

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

 

 

22)   To plan effective nursing care for a client with somatization disorder, the nurse should be aware that the etiology of somatoform disorders may be related to

A. faulty perceptions and assessments of body sensations.
B. traumatic memories of childhood events.
C. culture-bound phenomena.
D. depressive equivalents.

 

ANS:   A

Structural or functional abnormalities of the brain have been suggested to lead to the somatoform disorders, resulting in disturbed processes of perception and interpretation of bodily sensations. Furthermore, cognitive theorists believe clients misinterpret the meaning of certain bodily sensations and then become excessively alarmed by them. Option B: Traumatic childhood events are related to the dissociative disorders. Option C: Culture-bound phenomena may explain the prevalence of some symptoms but cannot explain the cause. Option D: Somatoform disorders are not seen to be another facet of depression; however, depression may coexist with a somatoform disorders.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 258

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

 

 

23)   To assess clients effectively, the nurse must understand that an essential difference between somatoform disorders and dissociative disorders is

A. symptoms of somatoform disorders are under voluntary control, whereas symptoms of dissociative disorders are unconscious and automatic.
B. symptoms of dissociative disorders are precipitated by psychological factors, whereas symptoms of somatoform disorders are related to stress.
C. dissociative disorders involve stress-related disruptions of memory, consciousness, or identity, whereas somatoform disorders involve expression of psychological stress through somatic symptoms.
D. symptoms of dissociative disorders are individually determined and related to childhood sexual abuse, whereas symptoms of somatoform disorders are culture bound.

 

ANS:   C

Option 3 is the only fully accurate statement. Option A: Somatoform symptoms are not under voluntary control. Option B points out a similarity. Option D incorrectly suggests that all somatoform symptoms are culture bound.

 

DIF:    Cognitive Level: Application             REF:    Text Pages: 252-273

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

 

 

24)   Which of the following areas would be more relevant to the assessment of a client with somatoform disorder than for a client with dissociative disorder?

A. Voluntary control of symptoms
B. Ability to perform self-care activities
C. Effect of symptoms on family processes
D. Use of alcohol, psychoactive drugs, and prescription anxiolytics

 

ANS:   B

Voluntary control of symptoms is an important feature in differentiating somatoform disorder from malingering and factitious disorder but is less relevant to the assessment of dissociative symptoms. The other options should be included in the assessment for both types of disorders.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 260

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

 

 

25)   Which assessment data would help the health care team distinguish symptoms of conversion from symptoms of hypochondriasis?

A. Results of diagnostic testing
B. Voluntary control of symptoms
C. Client’s cognitive style
D. Secondary gains

 

ANS:   C

The cognitive style of clients with hypochondriasis tends to be more anxious and displays more obsessive attention to detail, whereas the client with conversion exhibits a more dramatic style of communicating and may exhibit unconcern for the symptom.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 260

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

 

 

26)   The emotional reaction that nurses who counsel clients with somatoform disorder are most likely to experience is

A. fear and anxiety.
B. pleasure and interest.
C. frustration and resentment.
D. sympathy and desire to rescue.

 

ANS:   C

Many nurses consider it unsatisfying to work with a client with somatoform disorder. The client’s resistance makes for slow progress. Medical-surgical nurses often feel as though they are wasting their time on a client with no organic basis for his or her symptoms. The other options are less likely reactions to these difficult clients.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 260, Text Page: 261

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

 

 

27)   A client with depersonalization disorder tells the nurse “It’s starting again. I feel as though I’m going to float away.” The nurse should help the client by

A. advising her to begin meditating.
B. administering an as-needed anxiolytic.
C. helping her visualize a pleasant scene.
D. staying with her to help her focus on the here and now.

 

ANS:   D

Talking with someone who can help the client focus on reality allows the client to interrupt the stimulus to dissociate. Options A, B, and C foster detachment.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 265

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

 

 

28)   A client with somatoform pain disorder who has been in treatment for 4 weeks tells the clinic nurse that although he still has a considerable amount of pain, he notices it less and is able to perform more activities of daily living. The nurse should evaluate the treatment plan as

A. unsuccessful.
B. minimally successful.
C. partially successful.
D. totally successful.

 

ANS:   C

Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of client resistance.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 259

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

 

 

29)   Outcomes for health promotion and maintenance for clients with somatoform and dissociative disorders can be considered attained when clients

A. identify stressors associated with symptom formation.
B. keep a detailed daily journal of events and feelings.
C. make contact with a number of different health care agencies.
D. schedule regular physicals, screening tests, and dental care.

 

ANS:   D

Most health care visits by clients with somatoform and dissociative disorders are illness related. Regular dental and medical examinations and screenings are part of health promotion and maintenance. Options A and B are not relevant to health promotion. Option C suggests uncoordinated care.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: N/A

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

 

 

30)   The treatment modality the nurse should recommend to help a client with chronic pain disorder cope more effectively is

A. flooding.
B. relaxation techniques.
C. response prevention.
D. systematic desensitization.

 

ANS:   B

Pain is increased when the client has muscle tension. Relaxation can diminish the client’s perceptions of the intensity of pain. The other options are modalities useful in treating selected anxiety disorders.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 263

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

 

 

31)   A client believes she has a brain tumor despite numerous diagnostic tests that show no evidence of a tumor. She tells the nurse “People with brain tumors vomit. Yesterday I vomited all day. I know I have a brain tumor.” The approach that fosters cognitive restructuring is

A. “You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking. We’ll talk about something else.”
B. “Let’s see if there are any other possible explanations for your vomiting.”
C. “How worried you seem! Let’s talk about how you’re feeling.”
D. “What interpersonal problems have you had recently?”

 

ANS:   B

Questioning the evidence is a cognitive restructuring technique. Learning that headaches, visual disturbances, weakness, and vomiting can have causes other than the feared disease can be helpful in changing distorted perceptions. Option A does not foster questioning on the part of the client. Option C is empathetic, but does not foster restructuring. Option D queries, but not with an appropriate focus.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 264

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

 

 

32)   A client who is being counseled for somatoform pain disorder states he believes his pain is the result of an undiagnosed injury. He adds that he cannot adhere to his plan for care involving performing own activities of daily living, walking 20 minutes daily, and using pain medication only at bedtime. He states he feels “like a baby” because his wife and children must provide so much care for him. The nurse understands that it is important to assess

A. mood.
B. cognitive style.
C. secondary gain.
D. identity and memory.

 

ANS:   C

Secondary gain should be assessed. The client’s dependency needs may be being met through care from his family. When secondary gains are prominent, the client is more resistant to giving up the symptom. Option A is an important concern, but the scenario does not allude to a problem of mood. Option B: Cognitive style and identity and memory assessment (option D) are of lesser concern because the client’s diagnosis has been established.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 260

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

 

 

33)   A college senior comes to the mental health clinic with the chief complaint that “My face is so ugly I can’t go out in public.” Assessment reveals she has no actual disfigurement and is of average attractiveness. She tells the nurse that she goes to class wearing a scarf draped across her lower face but is concerned that she will be unable to interview for positions after graduation because of her ugly appearance. The client’s symptoms are consistent with the clinical picture of

A. dissociative identity disorder.
B. body dysmorphic disorder.
C. hypochondriasis.
D. malingering.

 

ANS:   B

Body dysmorphic disorder involves preoccupation with an imagined defect in appearance. Option A: Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. Option C: Hypochondriasis is defined by preoccupation with fears of having a serious disease or the idea that one has a serious disease. Option D: Malingering is defined as intentionally producing symptoms for a personal gain.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 259

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

 

 

OTHER

 

1)   The client with somatoform pain disorder reveals to the nurse that he has begun to question why God has chosen to have him lead the life of an invalid who is unable to provide for his family. He states that he believes the burden placed on his spouse and his children may be even greater than the burden he must bear. He blames God for punishing his “innocent family.” Select the nursing diagnoses that could be developed for the client. (More than one answer may be correct.)

  1. Spiritual distress
  2. Self-care deficit
  3. Decisional conflict
  4. Ineffective role performance

 

ANS:

A, D

Rationale: The client’s verbalization is consistent with spiritual distress. Moreover, his description of being unable to provide for and burdening his family suggests ineffective role performance. Data are not provided to support diagnoses of self-care deficit or decisional conflict.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 261

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

2)   A client who is being counseled for somatoform pain disorder states he believes his pain is the result of an undiagnosed injury. He adds that he cannot adhere to his plan for care involving performing own activities of daily living, walking 20 minutes daily, and using pain medication only at bedtime. Desired outcomes for the client include (more than one answer may be correct)

  1. compliance behavior.
  2. anxiety self-control.
  3. risk control—drug use.
  4. spiritual health.

 

ANS:

A, C

Rationale: The client should ideally develop compliance behaviors that allow him to adhere to his plan for care. The risk for the excessive use of pain medication must also be controlled. The other options are less directly related to the scenario.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 261, Text Page: 262

TOP:    Nursing Process: Planning (Outcome Identification)

MSC:   NCLEX: Physiologic Integrity

Varcarolis: Foundations of Psychiatric Mental Health Nursing:
A Clinical Approach, 5th Edition

 

Test Bank

 

Chapter 29: Psychological Needs of the Medically Ill

 

MULTIPLE CHOICE

 

1)   A diabetic client is to have a mid-thigh amputation of his left leg. He tells the nurse “I guess I will be called ‘Gimpy’ after the surgery. My life is really going to change when I cannot carry out my exercise program any more.” The nurse assesses that the client is at risk for the nursing diagnosis of

A. spiritual distress.
B. ineffective denial.
C. disturbed body image.
D. impaired social interaction.

 

ANS:   C

The nature of the surgery, which involves an actual change in body structure, places the client at greater risk for developing disturbed body image than any of the other diagnoses listed. The client’s statements about what he is expecting also suggest risk for this diagnosis.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 596

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

2)   A client’s breast cancer was diagnosed after a mammogram. Her doctor advised a lumpectomy, followed by radiation and chemotherapy. The client schedules consultations with the surgeon, the radiation oncologist, and the medical oncologist so that she may ask questions regarding her treatment. The coping strategy being used can be identified as

A. keeping busy and distracting oneself.
B. conforming and complying.
C. sharing concern and finding consolation.
D. seeking information and obtaining guidance.

 

ANS:   D

 

The client is coping by gathering information that will help her understand her treatment goals and the effects of treatment. Most clients who use this strategy believe knowledge reduces anxiety. Option A: Keeping busy and distracting oneself has as its goal postponing dealing with the problem. Option B: Conforming and complying would involve simply accepting the physician’s treatment plan. Option C: Sharing concern and finding consolation are usually carried out with family and friends and would not necessitate medical appointments.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 596

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

 

 

3)   Of the common client problems listed below, the one taking priority for nursing assessment and intervention is the client’s

A. fear of the unknown.
B. future plans.
C. present level of pain.
D. reaction to the illness.

 

ANS:   C

Pain is considered a physiological warning of tissue damage, and as such would take priority over the other client problems listed. Pain management begins with assessment. Once the level of pain has been assessed, appropriate intervention can occur. Intervention may be necessary before further psychosocial assessment can take place.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 594, Text Page: 595

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

 

 

4)   Which situation indicates use of a negative coping strategy by a client?

A. A client states “That heart attack was no fun, but at least it woke me up to my need for a better diet and more exercise.”
B. A client tells the nurse “I am going to do whatever my doctor advises; after all, he knows more about things than I do.”
C. The client muses “I definitely have cancer. Now I need to look at the effects of treatment and decide whether I will be able to work daily.”
D. A client states “I would not be in this position if the company had a better safety program. I blame them for not explaining the hazards of that machine.”

 

ANS:   D

Blaming someone else is not usually considered a highly adaptive coping strategy. Options A (redefinition), B (conforming), and C (confronting) are seen as more effective.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 596

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

 

 

5)   A staff nurse tells the clinical nurse leader “I feel as though I am at a total loss as to how to cope with this client. He has so many physical needs as a result of his head and neck surgery! Those needs have to be my primary focus, but sometimes it seems he must have emotional pain, too. I do not know how to help with that.” The staff nurse should be referred to

A. the psychiatric liaison nurse.
B. the psychiatrist in the crisis clinic.
C. the unit social worker.
D. the hospital chaplain.

 

ANS:   A

The psychiatric liaison nurse is a resource for the nursing staff who feel unable to intervene therapeutically with a client. The other professionals might be helpful, but problems such as these are the specialty of the liaison nurse.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 598

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

 

 

6)   Which modality would be least helpful to include in the plan of care for a client who is being treated for severe chronic low back pain?

A. Biofeedback, to promote relaxation of muscle groups and relief of tension that             aggravates pain
B. Guided imagery, as a way of deepening relaxation and desensitizing the client to pain
C. Hypnosis, to achieve a state of resting alertness and the ability to block out painful sensations
D. Psychoanalytic psychotherapy, to develop insight about the underlying psychological reasons for the symptom

 

ANS:   D

Analytic therapy has been found to be largely ineffective in helping clients cope with chronic pain. Supportive therapy, behavior therapy, cognitive therapy, and antidepressants have proved helpful, as have the modalities listed in options A, B, and C.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 596, Text Page: 597

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

 

 

7)   A client, who is recovering from a severe myocardial infarction, was moved from the cardiac intensive care unit to the cardiac step-down unit. He tells the new nurse “I will be fine once I get home. None of that ‘watch your cholesterol, watch your calories, watch your stress’ stuff is for me. Nobody has mentioned it, so it will be business as usual.” Which nursing diagnosis should the nurse consider adding to the client’s care plan?

A. Fear related to unknown aspects of hospitalization
B. Deficient knowledge related to new diagnosis of myocardial infarction
C. Health-seeking behaviors related to desire to seek a higher level of wellness
D. Powerlessness related to unmet need to remain in control

 

ANS:   B

The client may be denying the seriousness of his condition or he may simply not know about risk factors and posthospital treatment plans. By receiving health teaching regarding risk factors related to his condition and his treatment plan, denial can be diminished and knowledge can be increased. The defining characteristics are not present for any of the other diagnoses listed as options.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 592

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

8)   A client has had a total knee replacement and will need assistance for several weeks after discharge. She tells the nurse caring for her “I do not intend to assume the ‘sick role.’” The nurse knows the client is objecting to

A. coordinating various aspects of medical and nursing care.
B. giving up financial responsibility for hospital and medical care.
C. giving up independent functioning to assume a dependent role.
D. using a variety of defense mechanisms to reduce anxiety associated with hospitalization.

 

ANS:   C

Hospitalized clients give up a certain amount of independent functioning. They give up clothing, customary roles, and occasionally a name, such as when they are referred to as “the client with pneumonia in room 213.” The “sick role” usually refers to being dependent on others. Orthopedic surgery often requires the client to assume a more dependent role because of the inability to ambulate independently. The other options are not associated with the “sick role.”

 

DIF:    Cognitive Level: Application             REF:    Text Page: 593

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

 

 

9)   A client hospitalized after a myocardial infarction is restlessly moving about in bed. Her pulse, blood pressure, and respiratory rate are elevated. In a shaky voice, she tells the nurse “I think I am going to die. The pain is gone, but it could come back anytime. Where is the doctor? Why isn’t the doctor here with me?” The nurse should analyze this behavior as suggesting the nursing diagnosis of

A. spiritual distress.
B. ineffective breathing pattern.
C. noncompliance.
D. anxiety.

 

ANS:   D

The clinical picture is typical of anxiety. The client is experiencing uneasy feelings arising from a nonspecific source. Anxiety typically produces elevated vital signs. Data are not present for the other nursing diagnoses.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 590, Text Page: 592

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

10)   A client is to have a nephrostomy. A concern the nurse might anticipate relates to the client’s

A. reproductive ability.
B. ability to think rationally.
C. body image.
D. friends.

 

ANS:   C

A nephrostomy, like a colostomy, has serious implications for body image. Options A and D: Concerns with reproductive ability and acceptance by friends are less certain to occur than body image changes. Option B: The ability to think rationally should not be affected.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 596

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

 

 

11)   An elderly client’s children had always assumed they would be able to care for her until she died. However, the client had diabetes develop, had a below-the-knee amputation that is healing poorly, and recently had a cerebrovascular accident that left her paralyzed on the right side. The family has been told the client can be cared for at home if sufficient help can be obtained, or she can be placed in a nursing home. The siblings cannot make up their minds. The nursing diagnosis most appropriate would be

A. compromised family coping.
B. anticipatory grieving.
C. decisional conflict.
D. impaired verbal communication.

 

ANS:   C

Decisional conflict occurs when a state of uncertainty about a course of action exists and when the action to be taken involves a challenge to personal values. The siblings had assumed they would be competent to care for their mother and now question this assumption.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 596

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

12)   An elderly client’s children had always assumed they would be able to care for her until she died. However, the client had diabetes develop, had a below-the-knee amputation that is healing poorly, and recently had a cerebrovascular accident that left her paralyzed on the right side. The family has been told the client can be cared for at home if sufficient help can be obtained, or she can be placed in a nursing home. The siblings cannot make up their minds. The nurse could be helpful by

A. making the decision for the family.
B. encouraging the client to make the decision.
C. reporting the situation to the elder abuse hotline.
D. helping the family clarify the advantages and disadvantages of each option.

 

ANS:   D

Decision making requires accurate information and understanding of choices. The other options are inappropriate.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 596

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

 

 

13)   Which client would the nurse assess as being at greatest risk for becoming noncompliant with his or her treatment recommendations?

A. G, who has diabetic neuropathy and depression
B. H, who has had a mild stroke and arteriosclerosis
C. I, who has chronic obstructive pulmonary disease and altered role performance
D. J, who has unstable angina and type 2 diabetes

 

ANS:   A

Evidence tells us that comorbid depression creates increased risk for noncompliance with the medical regimen. The other comorbidities have not been investigated for increased risk of noncompliance.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 590

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

 

 

14)   A client with amyotrophic lateral sclerosis is becoming increasingly debilitated. Recently, he told the nurse “It bothers me that I cannot get to church anymore. Since I have not been able to get to services, I feel out of touch with God. I pray but I wonder if my prayers are heard.” The nurse should consider the nursing diagnosis of

A. powerlessness.
B. death anxiety.
C. spiritual distress.
D. disturbed thought processes.

 

ANS:   C

The client is verbalizing his concern about his relationship with God and his inability to participate in religious services. Both are defining characteristics for the nursing diagnosis of spiritual distress. Data are not present to suggest the other nursing diagnoses.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 593, Text Page: 594

TOP:    Nursing Process: Nursing Diagnosis

MSC:   NCLEX: Psychosocial Integrity

 

 

15)   A client has spastic lower limbs and bouts of severe pain. A nursing intervention useful for helping the client learn to manage the pain would be

A. teaching relaxation techniques.
B. using cognitive behavior therapy.
C. performing a holistic lifestyle assessment.
D. obtaining an overall quality-of-life assessment.

 

ANS:   A

Relaxation techniques can be helpful in diminishing pain perception and reactions to pain. Option B: Cognitive behavior therapy may be useful to the client but would not be a nursing intervention that can be independently initiated by a basic level nurse. Options C and D refer to assessments rather than intervention.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 597

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

 

 

16)   The client who would probably require long-term intervention to promote adaptation to his or her medical condition is

A. M, who has had a negative scalene node biopsy.
B. N, who has bacterial pneumonia.
C. O, who has Crohn’s disease.
D. P, who has gout.

 

ANS:   C

O has a chronic debilitating disease that may, at some point, require surgical treatment that will cause body image change. Option A: M’s surgery has provided good news. Option B: N’s illness is considered a short-term acute infection. Option D: P’s illness is chronic but is neither threatening to life nor causative of major lifestyle change.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 588

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

 

 

17)   Which client, waiting to be seen in the emergency department, is at greatest risk for stigmatization by health care personnel?

A. Q, a student who is a victim of date rape
B. R, a street addict who has cellulitis caused by dirty needles
C. S, a visitor from Canada who has acute abdominal pain of unknown origin
D. T, a housewife whose husband beat her during a domestic dispute

 

ANS:   B

The greater the client’s disenfranchisement, the greater the possibility for stigmatization. The lifestyle of street addicts is seen by medical staff as undesirable, hence they are often stigmatized as “bad.” At best, they are labeled as psychiatric clients, misfits, or losers. The are apt to be avoided and receive less-than-optimal care. The other clients described in the options would receive adequate responses from the health care team.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 597, Text Page: 598

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

 

 

18)   An unconscious client is brought to the emergency department by ambulance for trauma treatment. The client is wearing a cocktail dress, high heels, and a wig, but on close inspection has facial and body hair consistent with being male. Further inspection determines that the client is male. Several staff laugh and make remarks about transvestism as they stabilize the client. The most appropriate action for the nurse is to say

A. “Your focus should be treatment, not ridicule.”
B. “Each client deserves our respect.”
C. “Your behavior constitutes client abuse.”
D. “Grow up, you have seen this before.”

 

ANS:   B

The scenario is an example of a stigmatization of a medically ill client. The nurse should advocate for the client in this situation. Option B is a simple, straightforward reminder of the need to respect the dignity of each individual. Remembering that clients who are unconscious may still be able to hear should cause the nurse to attempt to immediately put an end to the negative comments being made without being argumentative or accusative.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 597, Text Page: 598

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

 

 

19)   During the psychosocial assessment the nurse determines that a client who is HIV positive believes his family is “burned out” and has little energy left to provide care for him as his condition worsens. He mentions that they maintain communication with him and express concern for him but find it difficult to listen as he speaks of his anxieties and concerns regarding dying. The nurse should assess family support as

A. rarely demonstrated.
B. sometimes demonstrated.
C. often demonstrated.
D. consistently demonstrated.

 

ANS:   B

Maintaining communication and expressing concern suggest that the support is sometimes demonstrated. Other needs such as providing physical care and bearing painful feelings are not met; thus options C and D are not appropriate choices.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 594, Text Page: 595

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

 

 

20)   A client who has been diagnosed with polymyalgia rheumatica has muscle pain and weakness and has curtailed physical and social activities to accommodate her condition. She tells the nurse “I cannot do anything. I have to depend on other people to help me. I do not enjoy much of anything any more; even food does not taste good. I cannot see that my situation will change, so I feel pretty hopeless.” The priority action the nurse should take is to

A. point out positive aspects of the client’s situation.
B. discuss the importance of physical exercise.
C. inquire about her social support system.
D. assess for depression.

 

ANS:   D

The client has given several indications that she may be depressed. A thorough assessment for depression should be completed. Depression that goes unrecognized and untreated is often responsible for worsening the medical condition and diminishing functional abilities. Depression also presents a risk factor for nonadherence to the treatment plan. The other options do not address the leads the client has given.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 590

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

 

 

21)   A client who has been diagnosed with breast cancer has many questions related to surgery, radiation therapy, and chemotherapy. The nurse provides education about the disease and treatments but perceives that the client has further questions about coping with day-to-day situations. The action of greatest benefit to the client would be

A. suggesting cognitive-behavioral therapy.
B. teaching her to monitor her stress level.
C. suggesting she enroll in a pain management program.
D. referring her to a support group for individuals with breast cancer.

 

ANS:   D

Clients with breast cancer are often helped by the support and knowledge shared in support group meetings. Techniques for coping can be learned from women who have had similar experiences. Option A: There is no indication that the client is demonstrating negative cognitions. Option B: Monitoring stress level is insufficient. The client would also need to be taught stress management techniques. Option C: Pain management is not currently indicated.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 596

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

 

 

22)   A client being treated for a myocardial infarction has been transferred to a step-down unit from the intensive care unit. She uses the call bell as often as every 15 minutes. She makes a seemingly small request or complains each time a staff member is summoned. Several staff tell the primary nurse that the client is “obnoxious” and that they feel inadequate because they can never seem to satisfy her needs. The primary nurse can be most helpful by

A. explaining that the client’s anxiety is being demonstrated by demanding behaviors.
B. “laying down the law” to the client and saying she may use the call light once hourly.
C. rotating caregivers each day to give staff a much-needed respite from her complaints.
D. offering to co-assign an agency temporary nurse to the client to share the burden.

 

ANS:   A

Teaching staff the probable basis for the behavior will change their perspective. They will realize the problem is anxiety expressed as self-centeredness, rather than perversity, and that they are not inadequate to the task of lowering the client’s anxiety. They must address the anxiety rather than the complaints. Option B will only increase the client’s anxiety. Options C and D do not address the client’s real need for anxiety reduction.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 590, Text Page: 592

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

 

 

23)   A client being treated for a myocardial infarction has been transferred from the intensive care unit to a step-down unit. She uses the call bell as often as every 15 minutes. She makes a seemingly small request or complains each time a staff member is summoned. Several staff tell the primary nurse that the client is “obnoxious” and that they feel inadequate because they can never seem to satisfy her needs. The primary nurse decides to intervene directly with the client. The most appropriate way to begin problem solving would be to say

A. “I am wondering if you are feeling anxious about your condition and being left alone.”
B. “The staff are concerned that you are not satisfied with the care you are receiving.”
C. “Let’s talk about why you use your call light so frequently.”
D. “I think you are giving staff a negative message.”

 

ANS:   A

This opening conveys the nurse’s willingness to listen to the client’s feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. Verbalization is an effective outlet for anxiety. Also, knowing that staff understand her anxiety and will meet her needs without being summoned so frequently can reduce the client’s anxiety level from severe to moderate or lower.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 590, Text Page: 592

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

 

 

24)   A client being treated for a myocardial infarction has been transferred from the intensive care unit to a step-down unit. She uses the call bell as often as every 15 minutes and makes a seemingly small request or complains each time the staff member enters the room. Several staff tell the primary nurse that the client is “obnoxious” and that they feel inadequate because they can never seem to satisfy her needs. The best indicator to monitor for the outcome of anxiety self-control is that the client will

A. monitor duration of episodes of anxiety.
B. maintain adequate sleep of 7 hours nightly.
C. maintain social relationships and role performance.
D. control anxiety response by using call bell appropriately.

 

ANS:   D

This indicator is directly related to the behavior described in the scenario. The other indicators are not as indicative of improvement in self-control in the area identified in the scenario.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 590, Text Page: 592

TOP:    Nursing Process: Planning (Outcome Identification)

MSC:   NCLEX: Psychosocial Integrity

 

 

25)  A client with diabetes and coronary artery disease asks health care staff and family what they think she should do each time a decision is to be made. She often fails to follow therapeutic advice after seeking professional opinions. On the basis of this information, the information that would be found on axis III of the DSM-IV-TR would be

A. diabetes and coronary artery disease.
B. dependent personality.
C. maladaptive health behaviors: high-fat diet, lack of exercise.
D. persistent failure to follow professional advice of health care staff.

 

ANS:   C

This option identifies maladaptive health behaviors in which the client engages that have an impact on the medical conditions identified on axis I. Option A: This information would be found on axis I. Option B: This information would be found on axis II. Option D is not an appropriate statement for axis III.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 588

TOP:    Nursing Process: Assessment

MSC:   NCLEX: Safe, Effective Care Environment;

 

 

26)   The nurse sees a client with coronary artery disease 3 months after stenting. The client states he is doing “great.” He indicates he has read of the benefits of alcohol on coronary artery disease and has incorporated this theory into his lifestyle. When asked describe his lifestyle, he mentions he arises at 9 AM, has a bloody Mary, works at his computer until lunch and again after lunch, enjoys “a couple of Manhattans” before dinner, has a good dinner with some red wine and then finishes the bottle of wine during the evening. The nurse can make the assessment that the client is

A. at risk for substance abuse disorder.
B. grieving for lost abilities.
C. self-medicating for anxiety.
D. using protective denial.

 

ANS:   A

The client is drinking excessively and is at risk for developing alcoholism. The scenario does not provide data to suggest that any of the other options is correct.

 

DIF:    Cognitive Level: Analysis                  REF:    Text Page: 592

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

 

 

OTHER

 

1)   In planning client education relating to coping with stents inserted to treat coronary disease, the nurse should include (more than one answer may be correct)

  1. specific information about the client’s condition.
  2. caution to keep a tight rein on expression of emotions.
  3. the need to self-monitor for anxiety and depression.
  4. the need to adhere to good general health practices.

 

ANS:

A, C, D

Rationale: Option A: Knowledge reduces anxiety and allows the client to understand options and make appropriate decisions. Option C: Self-assessment of mood and emotions allows the client to seek help if depression or anxiety occur. Option D: Good health practices promote general health, a sense of well-being, and a healthy immune system. Option B: Expressing feelings by sharing them with a supportive person or writing a journal should be encouraged in the teaching sessions.

 

DIF:    Cognitive Level: Application             REF:    Text Page: 597

TOP:    Nursing Process: Planning

MSC:   NCLEX: Health Promotion and Maintenance