Ramont2e Rev TIF Ch49

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test BankChapter 49Question 1Type: MCSA

The nurse is leading a discussion group when a client asks who determines what is mentally healthy and what is not. The nurse's best response explains that mental health and mental illness are defined:

1. Essentially the same throughout the world.

2. Differently as culture and society change attitudes.

3. According to whatever the client believes is right.

4. According to the definition in the dictionary.

Correct Answer: 2

Rationale 1: While there are certain characteristics common to the mentally healthy individual, mental illness is often defined differently in different cultures, and is based on societal beliefs of what is right and wrong.




Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: Explain key concepts about mental disorders, including why they are difficult to diagnose and treat.

Question 2Type: MCSA

The nurse assesses the client's thinking to determine if it is concrete or abstract by:Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank

Copyright 2012 by Pearson Education, Inc.

1. Giving the client a familiar proverb to interpret.

2. Asking the client to subtract nines backwards from 100.

3. Giving the client five objects to recall in five minutes' time.

4. Asking the client to draw either a circle or a square.

Correct Answer: 1

Rationale 1: Asking the client to interpret a proverb helps the nurse determine if he can think abstractly. If he interprets the proverb literally, it indicates concrete thinking.




Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: Describe the nurse's role in promoting mental health.


Which of the following activities performed by the nurse would be considered secondary prevention of a mental disorder or disorders?

1. Providing drug abuse prevention lectures in the school

2. Teaching money management to clients with mental disorders

3. Performing depression screenings at the local mall

4. Administering medications to relieve extrapyramidal side effects

Correct Answer: 3

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank


Rationale 1: Performing screenings for existing depression is secondary prevention. Drug abuse lectures are primary prevention aimed at keeping students from beginning to use illegal substances. Teaching money management is a rehabilitation or tertiary care act, as is medication administration to relieve side effects.




Global Rationale:

Cognitive Level: ApplyingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: Describe the nurse's role in promoting mental health.


The nurse assesses the client with schizophrenia and determines that which of the following demonstrates negative symptoms of the disorder?

1. The client says she is Jesus, and is preaching and baptizing.

2. Her speech is coherent, and the content is appropriate.

3. The client has a flat or very blunted affect most of the time.

4. Speech pattern is loose, moving from one idea to another.

Correct Answer: 3

Rationale 1: Negative symptoms of schizophrenia involve a deficit or decrease of normal function, such as a blunted or flat affect. Positive symptoms are an excess or distortion of normal functioning, such as delusions, hallucinations, or rapid speech pattern producing a word salad that has little meaning to the listener.






Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: Identify diagnostic criteria, treatment, and nursing care for clients with schizophrenia.


The nurse is working on an inpatient psychiatric unit that uses milieu therapy. The nurse's role in this form of therapy is to:

1. Avoid caring for the same client every day.

2. Model normal behavior for the clients.

3. Provide verbal rewards for good behavior.

4. Provide negative reinforcement for bad behavior.

Correct Answer: 2

Rationale 1: In milieu therapy, the nurse acts as a role model of normal behavior in the hopes the client will model the behavior. Negative reinforcement is never indicated.






Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: List three major types of treatment used for clients with major mental health disorders.


The nurse, screening for tardive dyskinesia symptoms, identifies which of the following?

1. Tongue protrusion during sleep

2. Rocking back and forth

3. Involuntary staring without blinking

4. Involuntary lip smacking

Correct Answer: 4

Rationale 1: Lip smacking is indicative of tardive dyskinesia, which includes repetitive movements.




Global Rationale:

Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: List three major types of treatment used for clients with major mental health disorders.




The nurse is following up with a client who was begun on antipsychotic medication last week to treat schizophrenia symptoms. The client says, "That medicine makes my mouth dry, and it's not helping me at all, so I want to stop taking it." The nurse's best response is:

1. "You should need talk with the doctor before stopping the medication."

2. "You have the right to refuse your medication if you think that is best."

3. "You need to take this medicine for at least 3-6 weeks before it will be effective."

4. "You should not stop this medication suddenly, or it can have negative effects."

Correct Answer: 3

Rationale 1: The nurse should explain that antipsychotic medications do not begin to work immediately but must establish a blood level over 3-6 weeks before effects will be seen, and then encourage the client not to give up, and provide options for coping with side effects.




Global Rationale:

Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: Identify diagnostic criteria, treatment, and nursing care for clients with schizophrenia.


The nurse hears the client on the psychiatric inpatient unit tell another client, "They'll all be sorry when I'm gone." The nurse's priority action is to:

1. Ask the client, "Are you thinking about killing or hurting yourself?"



2. Leave a note for the physician giving the details of her suspicions.

3. Call the client's family or significant other and ask them to visit and report conversations.

4. Ask the client what was meant by the overheard comment.

Correct Answer: 1

Rationale 1: This comment indicates the client is considering a world without him, and might be planning suicide. It is important for the nurse to question the client directly by asking if he is considering killing or hurting himself. Leaving a note for the physician would delay assessment of the client, and could have a negative outcome if the client is in imminent danger. The family is not the best source of information. The nurse should question the client very specifically, and not ask for an interpretation of the comment.




Global Rationale:

Cognitive Level: AnalyzingClient Need: Safe Effective Care EnvironmentClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: Name several types of mood disorders and describe treatments and nursing care for them.

Question 9Type: MCMA

The nurse working with a group of clients assesses which of the following as being mentally healthy? Select all that apply.



Standard Text: Select all that apply.

1. The client who believes her dead mother is in heaven watching what she does

2. The client who lives with his mother, drinks beer all day, and has never held a job

3. The client who is extremely angry at his ex-wife, and avoids contact with her when the children are around

4. The client who works as a nurse and washes his hands frequently to prevent the spread of infection

5. The client who says he dislikes people and prefers to be alone rather than socializing with others

Correct Answer: 1,3,5

Rationale 1: It is not unusual for people from some cultural or religious backgrounds to believe their dead relatives can see them from heaven, and it often motivates them to follow societal rules. The client who is angry is able to control his emotions enough to avoid exposing his children to the bad feelings between him and his wife. The nurse who washes his hands frequently comes from a culture that promotes the importance of this behavior. These clients would be considered mentally healthy. The client who drinks beer all day most likely has a substance abuse problem, and the client who prefers to be alone does not have the ability to relate to others, so these two clients would be suspected of a mental disorder, but more information would be required in order to determine this definitively.



Rationale 4: It is not unusual for people from some cultural or religious backgrounds to believe their dead relatives can see them from heaven, and it often motivates them to follow societal rules. The client who is angry is able to control his emotions enough to avoid exposing his children to the bad feelings between him and his wife. The nurse who washes his hands frequently comes from a culture that promotes the importance of this behavior. These clients would be considered mentally healthy. The client who drinks beer all day most likely has a substance abuse problem, and the client who prefers to be alone does not have the ability to relate to others, so



these two clients would be suspected of a mental disorder, but more information would be required in order to determine this definitively.


Global Rationale:

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: Identify characteristics of a mentally healthy person.


The nurse screens all children for early symptoms of mental health disorders because:

1. Untreated mental disorders can lead to move severe, difficult-to-treat, and debilitating mental disorders in later life.

2. People with mental disorders in childhood are more likely to become violent in later life.

3. Symptoms are more obvious and easy to see in children because children are so honest about their feelings.

4. Disorders that are caught early are easier to cure.

Correct Answer: 1

Rationale 1: Mental disorders often begin in childhood, and if left untreated, they tend to become move severe mental disorders in adulthood that are harder to treat. Early intervention can make a big difference in the life of the child.






Global Rationale:

Cognitive Level: ApplyingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: Discuss mental health and mental health disorders in children.


The nurse working in a pediatrician's office admits an 8-year-old child whose growth was within the 50th percentile until the past year, when his weight failed to increase. He is now in the 10th percentile for growth. The child's mother reports that he sleeps all the time and all he wants to do when he is awake is play on the computer. His grades have been slipping, and his mother reports he claims he doesn't feel well and can't go to school at least 2-3 times per week. The nurse assesses the child and asks him:

1. "What is school like this year?"

2. "Are you feeling depressed?"

3. "Do you like school?"

4. "Sounds like you're not doing well in school. Why is that?"

Correct Answer: 1

Rationale 1: Asking an open-ended question like "What is school like this year?" does not place an expectation for a specific answer on the wording, and requires more information than a simple yes or no. While this child most likely is experiencing depression, asking him if he is depressed is unlikely to yield useful information; he might not really understand the meaning of the term, and it is a question that can be answered in one word. Putting emphasis on poor school performance is liable to make the child defensive, and will not improve nurse-client rapport.

Rationale 2: Asking an open-ended question like "What is school like this year?" does not place an expectation for a specific answer on the wording, and requires more information than a simple yes or no. While this child most likely is experiencing depression, asking him if he is depressed is unlikely to yield useful information; he might not really understand the meaning of the term, and it is a question that can be answered in one word. Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank


Putting emphasis on poor school performance is liable to make the child defensive, and will not improve nurse-client rapport.



Global Rationale:

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: Name several types of mood disorders and describe treatments and nursing care for them.


The nurse is caring for a client with major depressive disorder who was recently placed on a high-potency neuroleptic (antipsychotic) medication. The client has not been eating well, is starting to get dehydrated, and has a temperature of 101°F. The physician orders antibiotics. Six hours later, the nurse notice that the client's temperature has risen to 103°F, and the client has muscle rigidity, and a fluctuating blood pressure. The priority of action for the nurse is to:

1. Discontinue neuroleptic and report symptoms to physician immediately.

2. Chart the assessment findings and report them to the primary nurse at change of shift.

3. Discontinue the neuroleptic and document assessment findings as cause for the action.

4. Continue the medications and perform more frequent assessments of the client.

Correct Answer: 1



Rationale 1: These symptoms are indicative of neuroleptic malignant syndrome, a potentially fatal idiopathic response to high-potency neuroleptic medications. The medication should be discontinued, and the physician notified immediately.




Global Rationale:

Cognitive Level: ApplyingClient Need: Safe Effective Care EnvironmentClient Need Sub: Nursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: Name several types of mood disorders and describe treatments and nursing care for them.

Question 13Type: MCMA

The nurse working on an inpatient psychiatric unit admits a client diagnosed with antisocial personality disorder. After obtaining admission data from the client, the nurse plans care to include: (Select all that apply.)

Standard Text: Select all that apply.

1. Careful monitoring of the new client's interaction with others on the unit.

2. Consistency in staff assigned to care for this client.

3. Strict limit-setting, with the rules carefully explained and written for the client.

4. Involvement in group therapy.

5. Encouraging socialization with other clients on the unit

Correct Answer: 1,2,3

Rationale 1: Clients with antisocial personality disorder often are manipulative, so it is important to carefully monitor interactions with other clients, because they can be very upsetting to the unit as they manipulate other



clients to do their bidding. There should be consistency in staff assignments because the client often will play one staff member against another. Further, consistent staffing is most effective in setting limits and consistently maintaining them.

Rationale 2: Clients with antisocial personality disorder often are manipulative, so it is important to carefully monitor interactions with other clients, because they can be very upsetting to the unit as they manipulate other clients to do their bidding. There should be consistency in staff assignments because the client often will play one staff member against another. Further, consistent staffing is most effective in setting limits and consistently maintaining them.




Global Rationale:

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: Identify key aspects of personality disorders and describe nursing care for clients with this disorder.


The nurse is caring for a client who has difficulty making decisions, frequently saying "I'm so stupid. What do you think I should do?" The client's actions lead the nurse to suspect the possibility of what personality disorder?

1. Paranoid

2. Schizoid



3. Dependent

4. Avoidant

Correct Answer: 3

Rationale 1: The client with dependent personality disorder needs to be taken care of, has difficulty making decisions, takes no initiative, and displays powerlessness, often referring to herself as stupid or incompetent so others will help her.




Global Rationale:

Cognitive Level: AnalyzingClient Need: Psychosocial IntegrityClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: Identify key aspects of personality disorders and describe nursing care for clients with this disorder.



Ramont2e Rev TIF Ch49

Documents

Transcript of Ramont2e Rev TIF Ch49