Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City

Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

PSYCHIATRIC NURSING FINAL EXAMINATION 2nd Semester, SY 2012-2013 Rationale: 1. Answer: B - The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship, but not in a therapeutic one. The nurse needs to be honest with the client that a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses. 2. Answer: A A nurse is required to maintain confidentiality regarding the client and the clients care. Confidentiality is basic to the therapeutic relationship and is a clients right. The most appropriate response to the neighbor is Option A. Option B is a blunt statement and does not acknowledge the issue that the nurse cannot reveal if the named person is or was a client. Options C and D identify statements that do not maintain client confidentiality. Option A is the most direct and correct. 3. Answer: D Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. Options A, B, and C are incorrect. 4. Answer: D - Cognitive therapy frequently is used for clients with depression. This type of therapy is based on exploring the clients subjective experience the clients subjective experience. Cognitive therapy includes examining the clients thoughts and feelings about situations and how these thoughts and feelings contribute to and perpetuate the clients difficulties and mood. 5. Answer: D Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Exposure is gradually increased until the anxiety about or fear of the object or situation has ceased. Options A, B, and C are incorrect. 6. Answer: A The sponsor of a self-help group is an experienced member of the group. A nurse or psychiatrist may be asked by the group to serve as a resource, but would not be the leader of the group. Options B, C, and D are characteristics of self-help group. 7. Answer: D If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although option C may be a direct response, Option D is a more specific and direct statement. Options A and B are inappropriate. 8. Answer: D It is most therapeutic for the nurse to empathize with the clients experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. 9. Answer: B Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise including radio and television may add to the confusion and disorientation. Moving the client next to the nurses station is not the initial action. 10. Answer: D. A client with depression often has a depressed mood and is withdrawn. The client also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feeling of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Options A, B, and C are too restrictive and offer little or no structure and stimulation. 11. Answer: B Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

12. Answer: A Agoraphobia is a fear of open spaces and the fear of being trapped in a situation where there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if an attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on specific situations such as the fear of speaking, performing or eating in public. Claustrophobia is a fear of closed spaces. Clients with hypochondriachal symptoms focus their anxiety on physical complaints and are pre-occupied with their health. 13. Answer: D Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the clients behavior. Initially asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the clients behavior further. Option C is also inappropriate initial action because it violates the clients right to receive treatment and is a threatening action. 14. Answer: C A conversion disorder is the alteration of loss of a physical function that cannot be explained by any known pathophysical mechanism. A conversion disorder is thought to be an expression of psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state on which a persons mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the persons ability to deal with lifes demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. 15. Answer: C The client is at risk for inquiry to self and others and should be escorted out of the dayroom. Option D may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is inappropriate already has been attempted by the nurse. 16. Answer: B Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger paintings are activities that minimize stimuli and provide a constructive release for tension. Competitive games should be avoided because they can stimulate aggression and increase psychomotor activity. 17. Answer: A Safety of the client and other clients is the priority. Option A is the only option that addresses the safety needs of the client and other clients. Option B addresses other clients needs only. Option C is not client-oriented. Option D addresses the clients needs only. 18. Answer: D The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. The nurse should ask the client whether he or she has intentions to hurt himself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. Options A, B, and C will aid in wellness, but are not specific interventions for hallucinations, if they occur 19. Answer: C Clients who are withdrawn may be immobile and mute and require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with one client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. 20. Answer: B Disturbed thought process related to paranoia is the clients problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious to others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. Options A, C, and D ask the client to trust on a multitude levels. These options are actions that are too intrusive for a client who is paranoid.

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

21. Answer: B Whenever the nurse carries out an assessment for a client who I dependent on drugs, it is best for the nurse to attempt to illicit information by being nonjudgmental and direct. Option A is incorrect because it is judgmental and off focus and reflects the nurses bias. Option C is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option D is incorrect because indicates passivity on the nurses part and uses rationalization to avoid the therapeutic nursing intervention. 22. Answer: B Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the clients coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group. 23. Answer: A A nurse can be charged with false imprisonment if a client is made to believe wrongfully that he/she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign relating to the clients responsibilities when the client is asked to sign relating to the clients responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against the clients will. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise. 24. Answer: D Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel and if the client has been inducing vomiting. Electrolyte imbalances are present. 25. Answer: B - Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. Options A, B, and C are inappropriate nursing actions. 26. Answer: B - The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leucopenia. Having a roommate with pneumonia would place the client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of to others or being managed by others because this may contribute to sublimation and suppression of personal hunger. 27. Answer: D - Symptoms associated with withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in level of consciousness, agitation, fever, and delusions. 28. Answer: B - The most helpful response is one that encourages the client so solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The not agree with the client, and the nurse should not request that the client provide explanations. 29. Answer: B - During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options A, C, and D are incorrect interpretations. 30. Answer: B - A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of charge of a job, death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options A, C, and D identify adventitious crisis of disaster; it is unplanned or accidental. 31. Answer: C - A nurses initial task when assessing a client in crisis to assess to the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found.

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

Option C would assist in determining data related to the precipitating event that led to the crisis. Options A and B assess situational supports. Option D assesses personal coping skills. 32. Answer: D - Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has an emotional or mental illness. 33. Answer: C - The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option A is demanding behavior that causes increased agitation in the client. Options B and D are threats to the client and are inappropriate. 34. Answer: D - Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan fro self-harm exists. Options A, B, and C are not deal directly with the clients feelings. 35. Answer: A - During the escalation period, the clients behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures is most appropriate during the crisis period 36. Answer: B - A depressed suicidal client often gives away that which of the value as a way of saying goodbye and wanting to be remembered. Options A, C, and D deal with anger and acting-out behaviors that are often typical of any adolescent. 37. Answer: C - Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the clients safety. Constant observation status (one-to-one) with a staff member who is never less than an arms length away is the best choice. Seclusion should not be the initial intervention, and the least restrictive measure should be used. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. 38. Answer: B - The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options A, C, and D, may follow after the client has been treated medically. 39. Answer: C - A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. 40. Answer: A - One-to-one suicide precautions are required for a client who has attempted suicide. Options B and C may be appropriate, but not at the present time, considering the situation. Option D also may be an appropriate nursing intervention, but the priority identified is option A. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself. 41. Answer: A - Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not appropriate action for the victim when dealing with a violent person. 42. Answer: C - Option C allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

feelings are normal and that they may express their concerns freely in a safe, caring environment. Option D places the problem solving totally on the client. Option B places the clients feelings on hold. Option A immediately blocks communication. 43. Answer: A - The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being wrong to the clients significant others (e.g. the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have episodes of wandering or sundowning. 44. Answer: C - Client with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety. 45. Answer: B - Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the clients personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the clients past accomplishments or personal successes are ways to interrupt the clients negative self-talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options A and C give advice and evaluate the clients feelings. 46. Answer: C - The initial nursing assessment of a client in a crisis state is to evaluate the physical condition of the client, the potential for self-harm, and the potential for harm to others. After this has been determined and appropriate interventions have been initiated, the nurse proceeds with the mental health interview. 47. ANS: A - Patients with personality disorders suffer lifelong inflexible and dysfunctional patterns of relating and behaving. The patient experiences subjective distress, usually based on others reactions to him or her, and functioning is impaired. More than one aspect of personality is involved: personality disorders are described as pervasive. Behaviors are complex and difficult to manage. 48. ANS: B - The characteristics mentioned in the scenario fit entirely within the description of paranoid personality disorder. Schizoid personality is characterized by shyness, withdrawal, and poor social relationships. Borderline personality is characterized by problems with identity, self-image, mood, and impulsivity. Narcissistic personality is characterized by self-importance, grandiosity, and a sense of entitlement. 49. ANS: C - Characteristic behaviors of individuals with borderline personality disorder include rapid mood shifts, impulsive acting out, and manipulation of others, as well as problems with identity, dependency, selfmutilation, and unstable, intense interpersonal relationships. 50. ANS: D - Individuals with schizoid PD do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in antisocial PD, schizotypal PD, and paranoid PD. 51. ANS: C - The group of dramatic-erratic personality disorders includes antisocial and borderline personality disorders. These patients are particularly skillful at manipulating others to get their needs met. The other options list characteristics that would not require frequent meetings. 52. ANS: B - Trust building is essential to developing a nurse-patient relationship. Firm limit setting is rarely necessary when working with a patient with schizoid PD. Involvement in activities might be difficult at first, because the patient will be highly uncomfortable around people. The patient must trust the nurse before responding to encouragement to express feelings. 53. ANS: C - The patient with schizotypal PD might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

54. ANS: C - Individuals with antisocial personality disorders have no concern for what is right or wrong or for the rights of others. They frequently violate others rights and frequently break laws in their me first thinking. These individuals exhibit no guilt or remorse, show no improvement from antipsychotics, and walk all over anyone who is not able to set firm limits. 55. ANS: C - Individuals with antisocial personality disorder have no concern for what is right or wrong or for the rights of others. They frequently violate others rights and frequently break laws in their me first thinking. These individuals exhibit no guilt or remorse. Conduct disorder is diagnosed in younger patients. Narcissistic PD is characterized by grandiosity and a sense of entitlement. Borderline BP is characterized by identity disturbances, impulsivity, self-mutilation, and affective instability. 56. ANS: D - Attempts at manipulation can be successfully handled by firmly, matter of factly reiterating unit policies and consistently adhering to them. The other responses are defensive, retaliative, or permissive. 57. ANS: C - Ordinarily, the patient would impulsively engage in self-mutilation. When he or she is able to delay the action and seek the more adaptive coping strategy of talking with the nurse, the nurse can correctly evaluate the patient as showing improvement. The other responses suggest use of idealization, manipulation, impulsive behavior, and devaluation, all symptomatic of the disorder. 58. ANS: C - There is no clear-cut cause for borderline personality disorder. It is probably multifactorial. Environmental factors include childhood neglect and abuse, and biologic theories suggest neurotransmitter dysregulation. Object loss, family history of bipolar disorder, and overindulgence as a child have not been identified as causative factors. 59. ANS: D - Patients can be helped to understand themselves and their feelings by keeping a journal. Sharing the journal with the nurse fosters greater understanding and a sense of autonomy and responsibility. The other options do not heighten self-awareness. 60. ANS: D - The individual with narcissistic PD displays grandiosity about his or her importance and achievements, does not empathize or understand the feelings of others, and exhibits a sense of entitlement and expects special treatment. The other options reflect characteristics of histrionic PD, obsessive-compulsive PD, and schizotypal personality disorder. 61. ANS: B - An individual with histrionic PD dramatizes all events and draws attention to self. The patient might use somatic complaints to avoid responsibility and support dependency. 62. ANS: A - The individual with a dependent personality disorder has a pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviors. The other options are characteristic of individuals with obsessive-compulsive PD, antisocial PD, and paranoid PD. 63. ANS: A - Dependent patients find it difficult to make even simple decisions. They often ask advice; thus, independently choosing his or her own attire is a behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable. 64. ANS: B - The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD. 65. ANS: D - When an attempt is made to play staff against one another, it is necessary to involve the two parties and the patient. Often, when this is suggested, the patient will back off and say he was just joking. The other options result in successful manipulation, buck passing to avoid making a decision, and retaliation. 66. ANS: C - Individuals with avoidant personalities desire relationships but keep their anxiety at a low level by avoiding situations in which they might experience rejection. Their timid, uncertain, withdrawn behavior can be identified as problematic. The other options describe behaviors that would not be seen in patients with avoidant PD. 67. ANS: C - Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

68. ANS: B - Any patient who is self-mutilative is at serious risk for suicide. Feelings of depression and hopelessness add to the risk. Thus, the nursing diagnosis of risk for self-directed violence should be considered. Data are not present to suggest the other nursing diagnoses. 69. ANS: C - Mood stabilizer drugs are used to reduce mood swings and emotional lability. SSRIs are prescribed to decrease impulsive behaviors. Antianxiety medication is given to reduce high levels of anxiety and antipsychotic medication is given if sensory perceptual symptoms are present. 70. ANS: B - Every patient is entitled to respectful care. The nurse must respond by teaching the UAP that what he considers a minor problem is actually a major mental health problem. Citing a statistic can bring the point home better than preaching. The other options do not capitalize on this teaching opportunity. 71. ANS: C - Paraphilias are conditions in which the sexual instinct is expressed in ways that are socially prohibited or unacceptable or are biologically undesirable. Option 3 is the best approximation of that definition. The other options characterize other sexual behaviors. 72. ANS: D - It is known that pedophiles usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilia. 73. ANS: B - Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The other options refer to fetishism, sexual sadism, and frotteurism. 74. ANS: A - In every state, nurses are mandated reporters of child abuse. The nurse is obligated legally and morally to report the incident so that proper authorities can follow up. The other actions do not fulfill the nurses ethical or legal responsibilities. 75. ANS: D - This sexual pain disorder, in which an individual feels pain in the genitals during intercourse, is called dyspareunia. Impotence refers to a sexual arousal disorder, frotteurism to a paraphilia, and vaginismus to vaginal spasms. 76. ANS: C - Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The other options are not related to the nurses ability to provide acceptance. 77. ANS: C - A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. The rationale for the correct answer explains options 1 and 2. The last option blocks communication. 78. ANS: A - Using empathy promotes trust and conveys understanding to the patient. The other options do not offer empathy. Option 2 begins to probe and option 1 offers premature reassurance. 79. ANS:B - The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurses role. 80. ANS: C - Patients who describe guilt, shame, and the idea that others would be better off without them are suicide risks. The nurse should report the data and assessment and institute suicide precautions. The other options do not fully consider the primary issue of patient safety. 81. ANS: B - Sexual acts that are forced on another are considered both morally and legally unacceptable. The other options are used less often as evaluation criteria. 82. ANS: A - An individual with gender identity disorder feels trapped in the body of the wrong gender and at odds with the roles associated with that gender. The other options are not characteristically seen in patients with gender identity disorder. 83. ANS: B - In sexual arousal disorders, the individual cannot maintain the physiologic requirements for sexual intercourse. The patients statement does not provide data to suggest one of the other options. 84. ANS: C - Exhibitionism is obtaining sexual pleasure from exposing ones genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked, dyspareunia

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

refers to painful intercourse, and sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer. 85. ANS: B - Because the individual demonstrated the exhibitionistic behavior during a period of increased stress, assigning him to a stress management group would be beneficial. The other groups would be acceptable, but would not have the relevance that the stress management group would have. 86. ANS: A - SSRIs are reported to have a positive effect on paraphilia. The other medications are not indicated for this disorder. 87. ANS: A - The only realistic short-term outcome is that the patient will discuss alternate methods for satisfying sexual needs. Taking antiandrogen medication is a decision that will take longer to reach. The other two options are not realistic, dementia is not an issue, and SSRI medication would not be prescribed unless depression is present. 88. ANS: C - Dependence is marked by a physiologic need for the substance. The other options refer to psychological need. 89. ANS: A - Tolerance refers to the need for increasing amounts of a substance to achieve the same effects. The other terms are not related to needing more drug to achieve the same effect. 90. ANS: D - A blackout is defined as a period of time in which the drinker functions socially but for which there is no memory. The other options do not accurately describe a blackout. 91. ANS: D - Fetal alcohol syndrome is the result of alcohols inhibiting fetal development in the first trimester. The fetus of a woman who has drunk that much alcohol will probably have this disorder. Alcohol use during pregnancy will not produce conditions listed in the other options. 92. ANS: A - Minor withdrawal symptoms include all the symptoms listed in the incorrect options. Delirium and seizures are considered serious withdrawal symptoms requiring immediate medical attention. 93. ANS: B - Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. 94. ANS: B - Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect. 95. ANS: D - Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help. 96. ANS: D - Acamprosate is thought to reestablish the balance between neuronal inhibition and excitation. It cannot be used until the patient is alcohol-abstinent. Disulfiram acts to increase abstinence by creating an unpleasant physical reaction to alcohol. Amobarbital is a sedative and is contraindicated as a medication to increase abstinence. Naltrexone acts as an opioid receptor antagonist. 97. ANS: B - If someone is hereditarily predisposed to developing alcoholism, the disease can be avoided if that person never drinks. The other responses are pseudotherapeutic or do not provide practical advice. 98. ANS: C - Asking when the patient had his last drink will help the nurse plan measures to deal with impending alcohol withdrawal symptoms. Drugs that have a cross dependence with alcohol should be administered to control withdrawal symptoms and then should be tapered. Asking how much the individual drinks daily is relevant, but not as much of a priority as the time of the last drink. The other two options are inappropriate when the patient is physically unwell. 99. ANS: D - Fear of weight gain is a subjective symptom because it is voiced by the patient. The other options are objective signs. 100. ANS: C - The outcome directly related to the nursing diagnosis is to restore healthy eating patterns and normalize weight. The first option is a short-term goal, the next is vague, and the last option is not directly related to the nursing diagnosis.

Easter College DEPARTMENT OF NURSING

Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483 E-mail: ndcon2011@gmail.com Website: www.eastercollege.ph

101. ANS: B - Data are consistent with the medical diagnosis of anorexia nervosa, a disorder in which intense fear of being fat leads to a body weight 15% or more below normal. Bulimic patients are usually near normal weight. Individuals who have binge-eating disorder tend to be overweight. Dissociative identity disorder refers to individuals who have multiple personalities. 102. ANS: B - A contract is formulated early in therapy to give the patient the opportunity to participate in treatment. This increases the patients sense of control. By establishing contractual behavioral limits, manipulation and power struggles can be minimized. Recommending a therapeutic group and using confrontation to attack denial are later interventions. Family members are encouraged to take part actively in the treatment of the patient. 103. ANS: C - Patients with anorexia nervosa often use strategies to hide food, spill food, or discard it to avoid eating. The nurse can best handle these behaviors with nonjudgmental confrontation and adherence to established limits. Only the correct answer is a nonjudgmental response. The other options are judgmental. 104. 105. ANS: A - Option 1 is considered a cognitive distortion, because bingeing will not cure loneliness. Loneliness is cured by companionship. The other options are not examples of distorted thinking. 106. ANS: C - Often, the individual with an eating disorder is seen as compliant, perfectionist, introverted, and having self-esteem and relationship problems. The other characteristics are rarely seen among patients with eating disorders. 107. ANS: D - Three options represent objective data, whereas option 4 reflects feelings that the patient has revealed. 108. ANS: D - Current thinking, based on a few research studies, suggests that serotonin might play a role in bulimia nervosa. 109. ANS: D - The three objectives are increasing self-esteem, increasing weight to 90% of average body weight, and reestablishing appropriate eating behavior. Thus, only option 4 can be chosen as the correct answer. 110. ANS: B - Close observation is necessary to prevent patients with eating disorders from purging during and after meals. Patients should be accompanied to the bathroom and observed while in the bathroom to prevent purging. Bargaining, lying, and judgmental confrontation are not appropriate responses. 111. ANS: B - Resistance to the urge to vomit or purge can be strengthened by reporting it to a nurse and talking about the feelings that the individual experienced before the urge and the feelings being experienced presently. Once feelings are identified, the patient can begin to work on alternate coping strategies. The other options are not helpful. 112. ANS: D - The priority diagnosis relates to a physical problem that is life-threatening. 113. ANS: D - Junior high and high school students are at particular risk for eating disorders, based on our cultures emphasis on thinness and the adolescents need for peer approval. Stress makes the adolescent more vulnerable. Times of particular stress are moving from one school to anotherthus, the need for vigilance on the part of the school nurse. Risk is lower in the other options. 114. ANS: D - Option 4 describes the only actual difference given in any of the options. The other options are incorrect. 115. ANS: C - This response is matter of fact and reinforces the established limits. The first option allows the patient to manipulate the nurse. The second option is overly controlling. The last option is bargaining. 116. ANS: D - This is the only behavior modification technique listed in the options. It makes use of positive reinforcementthat is, rewarding the patient for desired behavior. 117. ANS: B - Having the patient weighed backward prevents the patient from seeing the weight. Patients who become highly anxious are often able to tolerate weigh-ins using this method. This intervention is also useful to help redirect the patients focus from weight to other aspects of therapy. The other options are inappropriate or unnecessary.

Easter College DEPARTMENT OF NURSING

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118. 119. ANS: B - The patients statements suggest that a cognitive distortion has been unmasked. None of the other options are appropriate conclusions based on what has been verbalized. 120. ANS: B - Dental caries is often a problem for patients with bulimia because of highly acidic stomach contents eroding dental enamel during purging. Parotid swelling frequently accompanies bulimia and is also related to purging. Calloused knuckles develop on the fingers used to induce vomiting.