RNSG 1538 EXAMS 2 ANSWERS AND QUESTIONS
SET A+
✔✔Which of the following statements about the assessment of persons with anxiety and
anxiety disorders is most accurate?
A) When an elder person has an onset of anxiety for the first time in his or her life, it is
possible that the anxiety is associated with another condition.
B) Panic attacks are the most common late-life anxiety disorders.
C) An elder person with anxiety may be experiencing ruminative thoughts.
D) Agoraphobia that occurs in late life may be related to trauma experienced or
anticipated. - ✔✔A) When an elder person has an onset of anxiety for the first time in
his or her life, it is possible that the anxiety is associated with another condition.
✔✔What is the treatment of choice for ANXIETY in the ELDERLY? - ✔✔SSRI
ANTIDEPRESSANTS
✔✔A 15-year-old female is admitted for treatment of anorexia nervosa. Which is
characteristic of anorexia nervosa?
A) Body weight less than normal for age, height, and overall physical health
B) Amenorrhea for at least two cycles
C) Absence of hunger feelings
D) Erosion of dental enamel - ✔✔A) Body weight less than normal for age, height, and
overall physical health
✔✔The nurse is assessing a client with bulimia nervosa. Which of the following
symptoms would the nurse expect to find? Select all that apply.
A) Cold intolerance
B) Normal weight for height
C) Dental erosion
D) Hypotension
E) Metabolic alkalosis - ✔✔B) Normal weight for height
C) Dental erosion
E) Metabolic alkalosis
,✔✔The nurse understands that before a client with an eating disorder can accept their
body image, he or she must first learn effective coping skills. Which statement best
describes the relationship between body image and coping skills?
A) Coping skills are dependent on a supportive upbringing.
B) When body image is positive, the client will develop better coping skills.
C) Being able to cope in healthy ways improves the ability to accept a realistic body
image.
D) Neurotransmitters that are deficient in clients with eating disorders prohibit the
development of effective coping skills. - ✔✔C) Being able to cope in healthy ways
improves the ability to accept a realistic body image.
✔✔What is the primary difference between anorexia nervosa and bulimia nervosa?
A) Anorexia has a psychological basis, whereas the cause of bulimia is biologic.
B) Clients who are anorexic are proud of their control over eating, and clients with
bulimia are ashamed of their behavior.
C) Bulimia can be life threatening, whereas anorexia is seldom so.
D) There is no real difference between these two types of disorders. - ✔✔B) Clients who
are anorexic are proud of their control over eating, and clients with bulimia are ashamed
of their behavior.
✔✔Which individual is at highest risk for committing suicide?
A) A 71-year-old male, alcohol user, independent minded
B) A 16-year-old female, diabetic, two best friends
C) A 47-year-old male, schizophrenic, unemployed
D) A 57-year-old female, depression, active in church - ✔✔A) A 71-year-old male,
alcohol user, independent minded
✔✔A client who just went through an upsetting divorce is threatening to commit suicide
with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing
diagnosis has the highest priority?
A) Hopelessness related to recent divorce
B) Ineffective coping related to inadequate stress management
C) Spiritual distress related to conflicting thoughts about suicide and sin
D) Risk for suicide related to a highly lethal plan - ✔✔D) Risk for suicide related to a
highly lethal plan
✔✔In planning for a client's discharge, the nurse must know that the most serious risk
for the client taking a tricyclic antidepressant is which of the following?
A) Hypotension
B) Narrow-angle glaucoma
C) Seizures
D) Suicide by overdose - ✔✔D) Suicide by overdose
-Treatment with antidepressants and spring increase in sunlight and energy may give a
person with suicidal ideation the energy to act on it.
,✔✔Tricyclic antidepressants can cause what? - ✔✔-Serious risk for suicide by overdose
(tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal
therapeutic benefit)
✔✔The nurse is assessing for negative symptoms of schizophrenia in a newly admitted
client. The nurse would note which behavior as indicative of a negative symptom?
A) Difficulty staying on subject when responding to assessment questions
B) Belief of owning a transportation device allowing for travel to the center of the Earth
C) Hesitant to answer the nurse's questions during the assessment interview
D) Mimicking the postural changes made by the nurse during the assessment interview
- ✔✔C) Hesitant to answer the nurse's questions during the assessment interview
-A negative symptom of schizophrenia is alogia, or the tendency to speak very little or to
convey little substance of meaning (poverty of content). Associative looseness
(fragmented or poorly related thoughts and ideas), delusions (fixed false beliefs that
have no basis in reality), and echopraxia (imitation of the movements and gestures of
another person whom the client is observing) are all positive symptoms.
✔✔All of the following are nursing diagnoses identified for a client with schizophrenia.
The student nurse correctly anticipates which diagnosis will resolve when the client's
negative symptoms improve?
A) Impaired verbal communication
B) Risk for other-directed violence
C) Disturbed thought processes
D) Social isolation - ✔✔D) Social isolation
✔✔positive symptoms of schizophrenia - ✔✔DELUSIONS of reference, delusions of
persecution, delusions of grandeur, thought broadcasting, though insertion,
HALLUCINATIONS, disorganized thought, disorganized behaviour, catatonia
✔✔All of the following are included in the plan of care for a client with schizophrenia.
Which nursing intervention should the nurse perform first when caring for this client?
A) Observe for signs of fear or agitation
B) Maintain reality through frequent contact
C) Encourage to participate in the treatment milieu
D) Assess community support systems - ✔✔A) Observe for signs of fear or agitation
✔✔A pt is talking out loud and then stops and turns what is the nurse best response? -
✔✔Who are you talking to?
✔✔The client with schizophrenia believes the student nurses are there to spy on the
clients. The client is suffering from which of the following symptoms?
A) Hallucinations
B) Delusions
C) Anhedonia
, D) Ideas of reference - ✔✔B) Delusion
Delusions are fixed false beliefs that have no basis in reality. Hallucinations are false
sensory perceptions or perceptual experiences that do not exist in reality. Ideas of
reference are false impressions that external events have special meaning for the
person. Anhedonia is feeling no joy or pleasure from life or any activities or
relationships.
✔✔A client with schizophrenia reads the advice column in the newspaper daily. When
asked why the client is so interested in the advice column, the client replies, "This
person is my guide and tells me what I must do every day." The nurse would best
describe this type of thinking as which of the following?
A) Referential delusion
B) Grandiose delusion
C) Thought insertion
D) Personalization - ✔✔A) Referential delusion
✔✔The client may report that the president is speaking directly to him on a news
broadcast of that special message are sent through the newspaper articles. This is an
example of... - ✔✔Referential delusion
✔✔A patient has high blood pressure and penile erectile dysfunction. He asks the nurse
if he could try tadalafil (Cialis) after seeing an advertisement on television. What
medications, if taken by the patient, would the nurse recognize as increasing the risk
associated with taking tadalafil?
A. Beta-blockers (-lol)
B. Angiotensin-converting enzyme (ACE) inhibitors (-pril)
C. Alpha-adrenergic blockers
D. Calcium channel blockers - ✔✔C. Alpha-adrenergic blockers
✔✔A nurse reviews the history of a man with erectile dysfunction before teaching him
about the use of tadalafil (Cialis). Which of the following medications would be
contraindicated with the use of tadalafil (Cialis)? - ✔✔-Nitroglycerin (nitro - dur)
-Do not take if you are taking nitrate medications such as nitroglycerin (e.g., Nitro-Bid)
or isosorbide mononitrate (e.g., Imdur).
✔✔A man comes to the clinic complaining that he is having difficulty obtaining an
erection. When reviewing the patient's history, what might the nurse note that
contributes to erectile dysfunction?
A) The patient has been treated for a UTI twice in the past year.
B) The patient has a history of hypertension.
C) The patient is 66 years old.
D) The patient leads a sedentary lifestyle. - ✔✔B) The patient has history of
hypertension
SET A+
✔✔Which of the following statements about the assessment of persons with anxiety and
anxiety disorders is most accurate?
A) When an elder person has an onset of anxiety for the first time in his or her life, it is
possible that the anxiety is associated with another condition.
B) Panic attacks are the most common late-life anxiety disorders.
C) An elder person with anxiety may be experiencing ruminative thoughts.
D) Agoraphobia that occurs in late life may be related to trauma experienced or
anticipated. - ✔✔A) When an elder person has an onset of anxiety for the first time in
his or her life, it is possible that the anxiety is associated with another condition.
✔✔What is the treatment of choice for ANXIETY in the ELDERLY? - ✔✔SSRI
ANTIDEPRESSANTS
✔✔A 15-year-old female is admitted for treatment of anorexia nervosa. Which is
characteristic of anorexia nervosa?
A) Body weight less than normal for age, height, and overall physical health
B) Amenorrhea for at least two cycles
C) Absence of hunger feelings
D) Erosion of dental enamel - ✔✔A) Body weight less than normal for age, height, and
overall physical health
✔✔The nurse is assessing a client with bulimia nervosa. Which of the following
symptoms would the nurse expect to find? Select all that apply.
A) Cold intolerance
B) Normal weight for height
C) Dental erosion
D) Hypotension
E) Metabolic alkalosis - ✔✔B) Normal weight for height
C) Dental erosion
E) Metabolic alkalosis
,✔✔The nurse understands that before a client with an eating disorder can accept their
body image, he or she must first learn effective coping skills. Which statement best
describes the relationship between body image and coping skills?
A) Coping skills are dependent on a supportive upbringing.
B) When body image is positive, the client will develop better coping skills.
C) Being able to cope in healthy ways improves the ability to accept a realistic body
image.
D) Neurotransmitters that are deficient in clients with eating disorders prohibit the
development of effective coping skills. - ✔✔C) Being able to cope in healthy ways
improves the ability to accept a realistic body image.
✔✔What is the primary difference between anorexia nervosa and bulimia nervosa?
A) Anorexia has a psychological basis, whereas the cause of bulimia is biologic.
B) Clients who are anorexic are proud of their control over eating, and clients with
bulimia are ashamed of their behavior.
C) Bulimia can be life threatening, whereas anorexia is seldom so.
D) There is no real difference between these two types of disorders. - ✔✔B) Clients who
are anorexic are proud of their control over eating, and clients with bulimia are ashamed
of their behavior.
✔✔Which individual is at highest risk for committing suicide?
A) A 71-year-old male, alcohol user, independent minded
B) A 16-year-old female, diabetic, two best friends
C) A 47-year-old male, schizophrenic, unemployed
D) A 57-year-old female, depression, active in church - ✔✔A) A 71-year-old male,
alcohol user, independent minded
✔✔A client who just went through an upsetting divorce is threatening to commit suicide
with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing
diagnosis has the highest priority?
A) Hopelessness related to recent divorce
B) Ineffective coping related to inadequate stress management
C) Spiritual distress related to conflicting thoughts about suicide and sin
D) Risk for suicide related to a highly lethal plan - ✔✔D) Risk for suicide related to a
highly lethal plan
✔✔In planning for a client's discharge, the nurse must know that the most serious risk
for the client taking a tricyclic antidepressant is which of the following?
A) Hypotension
B) Narrow-angle glaucoma
C) Seizures
D) Suicide by overdose - ✔✔D) Suicide by overdose
-Treatment with antidepressants and spring increase in sunlight and energy may give a
person with suicidal ideation the energy to act on it.
,✔✔Tricyclic antidepressants can cause what? - ✔✔-Serious risk for suicide by overdose
(tricyclic antidepressants can require 4 to 6 weeks before the client experiences optimal
therapeutic benefit)
✔✔The nurse is assessing for negative symptoms of schizophrenia in a newly admitted
client. The nurse would note which behavior as indicative of a negative symptom?
A) Difficulty staying on subject when responding to assessment questions
B) Belief of owning a transportation device allowing for travel to the center of the Earth
C) Hesitant to answer the nurse's questions during the assessment interview
D) Mimicking the postural changes made by the nurse during the assessment interview
- ✔✔C) Hesitant to answer the nurse's questions during the assessment interview
-A negative symptom of schizophrenia is alogia, or the tendency to speak very little or to
convey little substance of meaning (poverty of content). Associative looseness
(fragmented or poorly related thoughts and ideas), delusions (fixed false beliefs that
have no basis in reality), and echopraxia (imitation of the movements and gestures of
another person whom the client is observing) are all positive symptoms.
✔✔All of the following are nursing diagnoses identified for a client with schizophrenia.
The student nurse correctly anticipates which diagnosis will resolve when the client's
negative symptoms improve?
A) Impaired verbal communication
B) Risk for other-directed violence
C) Disturbed thought processes
D) Social isolation - ✔✔D) Social isolation
✔✔positive symptoms of schizophrenia - ✔✔DELUSIONS of reference, delusions of
persecution, delusions of grandeur, thought broadcasting, though insertion,
HALLUCINATIONS, disorganized thought, disorganized behaviour, catatonia
✔✔All of the following are included in the plan of care for a client with schizophrenia.
Which nursing intervention should the nurse perform first when caring for this client?
A) Observe for signs of fear or agitation
B) Maintain reality through frequent contact
C) Encourage to participate in the treatment milieu
D) Assess community support systems - ✔✔A) Observe for signs of fear or agitation
✔✔A pt is talking out loud and then stops and turns what is the nurse best response? -
✔✔Who are you talking to?
✔✔The client with schizophrenia believes the student nurses are there to spy on the
clients. The client is suffering from which of the following symptoms?
A) Hallucinations
B) Delusions
C) Anhedonia
, D) Ideas of reference - ✔✔B) Delusion
Delusions are fixed false beliefs that have no basis in reality. Hallucinations are false
sensory perceptions or perceptual experiences that do not exist in reality. Ideas of
reference are false impressions that external events have special meaning for the
person. Anhedonia is feeling no joy or pleasure from life or any activities or
relationships.
✔✔A client with schizophrenia reads the advice column in the newspaper daily. When
asked why the client is so interested in the advice column, the client replies, "This
person is my guide and tells me what I must do every day." The nurse would best
describe this type of thinking as which of the following?
A) Referential delusion
B) Grandiose delusion
C) Thought insertion
D) Personalization - ✔✔A) Referential delusion
✔✔The client may report that the president is speaking directly to him on a news
broadcast of that special message are sent through the newspaper articles. This is an
example of... - ✔✔Referential delusion
✔✔A patient has high blood pressure and penile erectile dysfunction. He asks the nurse
if he could try tadalafil (Cialis) after seeing an advertisement on television. What
medications, if taken by the patient, would the nurse recognize as increasing the risk
associated with taking tadalafil?
A. Beta-blockers (-lol)
B. Angiotensin-converting enzyme (ACE) inhibitors (-pril)
C. Alpha-adrenergic blockers
D. Calcium channel blockers - ✔✔C. Alpha-adrenergic blockers
✔✔A nurse reviews the history of a man with erectile dysfunction before teaching him
about the use of tadalafil (Cialis). Which of the following medications would be
contraindicated with the use of tadalafil (Cialis)? - ✔✔-Nitroglycerin (nitro - dur)
-Do not take if you are taking nitrate medications such as nitroglycerin (e.g., Nitro-Bid)
or isosorbide mononitrate (e.g., Imdur).
✔✔A man comes to the clinic complaining that he is having difficulty obtaining an
erection. When reviewing the patient's history, what might the nurse note that
contributes to erectile dysfunction?
A) The patient has been treated for a UTI twice in the past year.
B) The patient has a history of hypertension.
C) The patient is 66 years old.
D) The patient leads a sedentary lifestyle. - ✔✔B) The patient has history of
hypertension
