COMPLETE M3381 PSYCH EXAM 3 STUDY GUIDE – QUESTIONS ANSWERED AND EXPLAINED

1. A child diagnosed with attention deficit hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? - ANSWER Central nervous system stimulants 2. Shortly after an adolescents parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, If my parents loved me, then they would work out their problems. What nursing diagnosis is most applicable? - ANSWER Ineffective coping 3. Shortly after a 15-year-olds parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, andavoids former friends. The adolescent says, All the other kids have families. If my parents loved me, then they would stay together. Which nursing intervention is most appropriate? - ANSWER Assist the adolescent to differentiate reality from perceptions. 4. When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9-year-old in a group that uses: - ANSWER play then talk about the play activity. 5. When assessing a 2-year-old diagnosed with autism spectrum disorder, a nurse expects: - ANSWER failure to develop interpersonal skills. 6. A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, What should we do? What is the nurses best recommendation? - ANSWER Talk with your health care provider about a referral to a mental health professional. 7. A 15-year- old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, We cant manage our teenager. The adolescent is physically abusive to the mother and defiant with the father. The adolescents problem is most consistent with criteria for: - ANSWER conduct disorder (CD). 8. A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? - ANSWER Establish firm limits 9. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all their attention on my brother, whos perfect in their eyes. Which type of therapy might promote the greatest change in this adolescents behavior? - ANSWER Family therapy 10 . An adolescent is arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all their attention on my brother, whos perfect in their eyes. Which nursing diagnosis is most applicable? - ANSWER Ineffective impulse control, related to seeking parental attention as evidenced by acting out 11 Which assessment finding would cause the nurse to consider an 8 year-old child to be most at risk for the development of a psychiatric disorder? - ANSWER Being raised by a parent with chronic major depressive disorder 12 Which child shows behaviors indicative of mental illness? - ANSWER 3-year-old who is mute, passive toward adults, and twirls while walking 13 The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: - ANSWER autism spectrum disorder (ASD). 14 A 12-year- old child has been the neighborhood bully for several years. The parents say, We cant believe anything our child says. Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The childs behaviors are most consistent with: - ANSWER conduct disorder (CD). 15 The parent of a child diagnosed with Tourettes disorder says to the nurse, I think my child is faking the tics because they come and go. Which response by the nurse is accurate? - ANSWER Tics often change frequency or severity. That does not mean they arent real. 16 An 11-year- old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. - ANSWER Assign the child to a short time-out. 17 When a 5-year-old child is disruptive, the nurse says, You must take a time-out. The expectation is that the child will: - ANSWER sit on the edge of the activity until able to regain self-control. 18 Child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: - ANSWER impulsivity. 19 A parent diagnosed with schizophrenia and her 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a shelter volunteer. The child says, My three friends and I got an A on our school science project. The nurse can assess that the child: - ANSWER displays resiliency. 20 A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, I have three good friends at school. We talk and sit together at lunch. What is the nurses best suggestion to the treatment team? - ANSWER Foster healthy characteristics and existing environmental supports. 21 Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? The child: - ANSWER holds the parents hand while walking. 22 Health maintenance and promotion efforts for patients diagnosed with severe and persistent mental illness should include education about the importance of regular: - ANSWER screening for cancer, hypertension, and diabetes. 23 Severe and persistent mental illness is characterized as a: - ANSWER major ongoing mental illness marked by significant functional impairments. 24 A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says, That girl looked like she was 19 years old. Which defense mechanism is this patient using? - ANSWER Rationalization 25 Which nursing diagnosis is likely to apply to a homeless individual diagnosed with severe and persistent mental illness? - ANSWER Chronic low self-esteem 26 A patient diagnosed with schizophrenia tells the community mental health nurse, I threw away my pills because they interfere with Gods voice. The nurse identifies the cause of the patients ineffective management of the medication regimen as: - ANSWER impaired reasoning secondary to schizophrenia. 27 A patient diagnosed with severe and persistent mental illness lives independently. This patient has command hallucinations and shouts warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, You cant come back here. You cause too much trouble. What problem is the patient experiencing? - ANSWER Stigma 28 A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority? - ANSWER Develop a relationship 29 A patient diagnosed with severe and persistent mentally illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care? - ANSWER Encourage mutual goal setting. 30 A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? - ANSWER I am feeling safe and comfortable here. Nobody bothers me. 31 For patients diagnosed with severe and persistent mental illness, what is the major advantage of case management? A case manager can: - ANSWER efficiently access and use resources. 32 The father of a child diagnosed with schizophrenia says, I lost my job, so we have no health insurance. The mother says, I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture. The sibling says, My parents dont pay very much attention to me. These comments signify: - ANSWER family burden of mental illness. 33 The parent of an adult diagnosed with severe and persistent mental illness asks the nurse, Why are you making a referral to that vocational rehabilitation program? My child wont ever be able to hold a job. Which is the nurses best reply? - ANSWER Most patients are capable of employment at some level, competitive or supported. 34 An adult says, When I was a child, I took medication because I couldnt follow my teachers directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job. Which disorder is most likely? - ANSWER Adult attention deficit hyperactivity disorder (ADHD) 35 A patient says, I often make careless mistakes and have trouble staying focused. Sometimes its hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment. Which problem should the nurse document? - ANSWER Inattention 36 A nurse prepares for an initial interview with a patient with suspected adult attention deficit hyperactivity disorder (ADHD). Questions should be focused to elicit information about which problem? - ANSWER Inattention 37 A nurse prepares a plan of care for a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which intervention should be included? - ANSWER Give encouragement and strategies for managing and organizing. 38 The treatment team believes medication will help a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which class of medications does the nurse expect will be prescribed? - ANSWER Psychostimulants 39 An adult diagnosed with attention deficit hyperactivity disorder (ADHD) says, Ive always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I cant keep a job. The nurse managing care should consider: - ANSWER cognitive therapy to help address internalized beliefs. 40 A new staff nurse tells the clinical nurse specialist, Im unsure about my role when patients bring up sexual problems. Which information should the clinical nurse specialist provide? All nurses: - ANSWER should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. 41 Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? - ANSWER Clarify the nurses own personal values 42 A patient tells the nurse, My sexual functioning is normal when my partner wears lace. Without it, Im not interested in sex. This comment evidences: - ANSWER fetishism. 43 A man tells the nurse, All my life, I have felt and acted like a woman while living in a mans body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity. Which request is the patient likely to make to the health care provider? - ANSWER Will you prescribe estrogen therapy? 44 The manager of a health club put a hidden camera in the womens locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? - ANSWER Voyeurism 45 Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is: - ANSWER sexual self-awareness. 46 An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior? - ANSWER Exhibitionism 47 A nurse cares for a patient diagnosed with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors? - ANSWER Selective serotonin reuptake inhibitor (SSRI) 48 A patient diagnosed with severe and persistent mental illness who recently moved to a 49 homeless shelter says, My life is out of control. Im like a leaf at the mercy of the wind. The nurse formulates the diagnosis Powerlessness. Outcomes will focus on: - ANSWER developing personal autonomy. 50 A person comes to the clinic reporting, I wear a scarf across my lower face when I go out but because of my ugly appearance. Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? - ANSWER Body dysmorphic disorder 51 A nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is: - ANSWER risk for self-harm 52 A patient says, I feel detached and weird all the time, like Im looking at life through a cloudy window. - ANSWER Depersonalization 53 A patient reports fears of having cervical cancer and says to the nurse, Ive had Pap smears by six different doctors. The results are normal, but Im sure thats because of errors in the laboratory. Which disorder would the nurse suspect? - ANSWER Illness anxiety disorder (hypochondriasis) 54 A patient diagnosed with somatic symptom disorder says, I have pain from an undiagnosed injury. I cant take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much. It is important for the nurse to assess: - ANSWER secondary gains 55 The causes of somatic system disorders may be related to: - ANSWER faulty perceptions of body sensations. 56 What is the primary difference between somatic system disorders and dissociative disorders? - ANSWER Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychological stress through somatic symptoms. 57 A patient says, I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day. Which response by the nurse fosters cognitive restructuring? - ANSWER Lets see whether any other explanations for your vomiting are possible 58 Which treatment modality should a nurse recommend to help a patient diagnosed with somatic symptom disorder cope more effectively? - ANSWER Relaxation 59 A patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. The nurse should help the patient by: - ANSWER helping the patient focus on the here and now 60 A patient diagnosed with somatic symptom disorder has been in treatment for 4 weeks. The patient says, Although Im still having pain, I notice it less and am able to perform more activities. The nurse should evaluate the treatment plan as: - ANSWER partially successful 61 A therapist recently convicted of multiple counts of Medicare fraud says, SureI overbilled. Why not? Everyone takes advantage of the government, so I did too. These statements show: - ANSWER lack of guilt feelings. 62 Which intervention is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others? - ANSWER Refer the patients requests and questions to the case manager. 63 As a nurse prepares to administer a medication to a patient diagnosed with a borderline 64 personality disorder, the patient says, Just leave it on the table. Ill take it when I finish combing my hair. What is the nurses best response? - ANSWER Say to the patient, I must watch you take the medication. Please take it now. 65 What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: - ANSWER acknowledge manipulative behavior when it is called to his or her attention. 66 Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: Youre a better nurse than the day shift nurse said you were; Another nurse said you dont do your job right; You think youre perfect, but Ive seen you make three mistakes. Collectively, these interactions can be assessed as: - ANSWER manipulative. 67 A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? - ANSWER Verbal abuse of another patient 68 A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? - ANSWER Selective serotonin reuptake inhibitor (SSRI) 69 A persons spouse filed charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests an antisocial personality disorder? - ANSWER I hit because Im tired of being nagged. My spouse deserved the beating. 70 What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? - ANSWER Risk for other-directed violence 71 A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? - ANSWER External controls are necessary while internal controls are developed. 72 A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, Im feeling empty and want to cut myself. The nurse should: - ANSWER assist the patient to identify the trigger situation and choose a coping strategy. 73 The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: - ANSWER maintaining consistent limits. 74 The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: - ANSWER little time elapsed between thought and action. 75 A patient tells a nurse, I sometimes get into trouble because I make quick decisions and act on them. A therapeutic response would be: - ANSWER Lets consider the advantages of being able to stop and think before acting. 76 A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? - ANSWER Risk for self-mutilation 77 Which statement made by a patient diagnosed with borderline personalitydisorder indicates the treatment plan is effective? - ANSWER I felt empty and wanted to cut myself, so I called you. 78 When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: - ANSWER grandiosity, attention seeking, and arrogance. 79 For which behavior would limit setting be most essential? The patient: - ANSWER urges a suspicious patient to hit anyone who stares. 80 A nurse in the emergency department tells an adult, Your mother had a severe stroke. The adult tearfully says, Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious. Which term best describes this behavior? - ANSWER Dependent 81 Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day and never comes out for breaks or lunch. Which term best describes this behavior? - ANSWER Avoidant 82 What is the priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder? - ANSWER Respect the patients need for periods of social isolation. 83 A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: - ANSWER fear of abandonment associated with progress toward autonomy and independence. 84 A patient diagnosed with borderline personality disorder has self inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: - ANSWER provide care in a matter-of-fact manner. 85 A nurse set limits for a patient diagnosed with a borderline personality disorder. The patient tells the nurse, You used to care about me. I thought you were wonderful. Now I can see I was mistaken. Youre terrible. This outburst can be assessed as: - ANSWER splitting. 86 Which characteristic of individuals diagnosed with personality disorders makes itmost necessary for staff to schedule frequent meetings? - ANSWER Ability to evoke interpersonal conflict 87 Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: - ANSWER has self-esteem issues, despite his or her outward presentation. 88 Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. She wears layered, loose clothing and now has amenorrhea. Her current weightis 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? - ANSWER Anorexia nervosa 89 Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? - ANSWER Patient expresses satisfaction with body appearance. 90 A patient who is referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patients oral intake, the nurse should ask: - ANSWER What do you eat in a typical day? 91 A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, Describe what you think about your present weight and how you look. Which response by the patient is most consistent with the diagnosis? - ANSWER I am fat and ugly. 92 A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 93 months ago and has lost 25% of body weight. The patients current serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? - ANSWER Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia 94 Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: - ANSWER gain 1 to 2 pounds. 95 Which nursing intervention has priority as a patient diagnosed with anorexianervosa begins to gain weight? - ANSWER Observe for adverse effects of re-feeding. 96 A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? - ANSWER Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. 97 The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention Monitor for complications of re-feeding. Which body system should a nurse closely monitor for dysfunction? - ANSWER Cardiovascular 98 A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? - ANSWER Being thin does not seem to solve your problems. You are thin now but still unhappy. 99 An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to: - ANSWER avoid skipping meals or restricting food. 100 What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? - ANSWER The nurse uses an authoritarian manner when interacting with the patient. 101 A nursing diagnosis for a patient diagnosed with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, Within 2 weeks the patient will: - ANSWER identify two alternative methods of coping with loneliness. 102 Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? - ANSWER Assist the patient to identify triggers to binge eating. 103 One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: - ANSWER 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9 C; pulse,38 beats/min; blood pressure, 60/40 mm Hg 104 While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: - ANSWER recognizing symptoms of hypokalemia. 105 As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which condition should be documented? - ANSWER Lanugo 106 A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, I wont eat until I look thin. What is the priority initial nursing diagnosis? - ANSWER Imbalanced nutrition:less than body requirements, related to self-starvation 107 A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: - ANSWER processing the heightened anxiety associated with eating. 108 Physical assessment of a patient diagnosed with bulimia nervosa often reveals: - ANSWER prominent parotid glands. 109 Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? - ANSWER Rigidity, perfectionism 110 Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization? - ANSWER Systolic blood pressure: 62 mm Hg 111 Which statement is a nurse most likely to hear from a patient diagnosed with anorexia nervosa? - ANSWER I would be happy if I could lose 20 more pounds. 112 Which nursing diagnosis is more applicable for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? - ANSWER Imbalanced nutrition: less than body requirements 113 An outpatient diagnosed with anorexia nervosa has begun re feeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: - ANSWER assess lung sounds and extremities. 114 When a nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: - ANSWER According to our agreement, no exercising is permitted until you have gained a specific amount of weight. 115 A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? - ANSWER Cachexia 116 An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurredspeech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: - ANSWER delirium. 117 A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, Bugs are crawling on my legs! Get them off! Which problem is the patient experiencing? - ANSWER Tactile hallucinations 118 A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, Someone get these bugs off me. What is the nurses best response? - ANSWER I dont see any bugs, but I know you are frightened so I will stay with you. 119 What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? - ANSWER Risk for injury, related to altered cerebral function, misperception of theenvironment, and unsteady gait 120 What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? - ANSWER Careful observation and supervision 121 Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? - ANSWER Provide a well-lit room without glare or shadows. Limit noise and stimulation. 122 Which description best applies to a hallucination? A patient: - ANSWER states, I feel bugs crawling on my legs and biting me. 123 Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems? - ANSWER Dementia 124 When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N methyl-D-aspartate (NMDA) channels rather than cholinesterase? - ANSWER memantine (Namenda) 125 An older adult was stopped by police for driving through a red light. When asked for a drivers license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? - ANSWER Agnosia 126 An older adult drove to a nearby store but was unable to remember how to get home or state an address. 127 When police took the person home, the spouse reported frequent wandering into neighbors homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident? - ANSWER 2 (moderate) 128 Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? - ANSWER Alzheimer disease 129 A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. 130 Which nursing diagnosis applies at this time? - ANSWER Impaired memory 131 A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? - ANSWER Assist the patient to perform simple tasks by giving step-by-step directions. 132 Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, Move along, youre blocking the road. The other patient turns, shakes a fist, and shouts, I know what youre up to; youre trying to steal my car. What is the nurses best action? - ANSWER Separate and distract the patients. Take one to the day room and the other to an activities area. 133 An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? - ANSWER Use the patients glasses and hearing aids. 134 A patient diagnosed with stage 2 Alzheimer disease calls the police saying, An intruder is in my home. 135 Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: - ANSWER agnosia. 136 During morning care, a nursing assistant asks a patient diagnosed with dementia, How was your night? The patient replies, It was lovely. I went out to dinner and a movie with my friend. Which term applies to the patients response? - ANSWER Confabulation 137 A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? - ANSWER Place locks at the tops of doors. 138 Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on: - ANSWER returning to premorbid levels of function. 139 An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patients family? - ANSWER Label the bathroom door. 140 A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit.What is the nurses best reply? - ANSWER It is disappointing when someone you love no longer recognizes you. 141 A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? - ANSWER Focus interaction on familiar topics. 142 What is the priority need for a patient diagnosed with late-stage dementia? - ANSWER Maintenance of nutrition and hydration 143 Which intervention is appropriate to use for patients diagnosed with either delirium or dementia? - ANSWER Reintroduce the health care worker at each contact. 144 A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: - ANSWER remain safe in the environment. 145 A patient with a history of daily alcohol abuse was hospitalized at 0200 today.When would the nurse expect withdrawal symptoms to peak? - ANSWER Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) 146 A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: - ANSWER microcephalic and cognitively impaired. 147 A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Bucks traction and screams, Somebody tied me up with ropes. The patient is experiencing: - ANSWER an illusion. 148 A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. Ive got to get out of here. What is the most accurate assessment of the situation? The patient: - ANSWER has symptoms of alcohol withdrawal delirium. 149 A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are 150 crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? - ANSWER Risk for injury 151 A patient admitted yesterday for injuries sustained while intoxicated believes the windowblinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? - ANSWER Benzodiazepine, such as lorazepam (Ativan) 152 A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in 153 the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? - ANSWER Provide one-on-one supervision. 154 A patient with a history of daily alcohol abuse says, Drinking helps me cope with being a single parent. 155 Which response by the nurse would help the individual conceptualize the drinking more objectively? - ANSWER Tell me what happened the last time you drank. 156 A patient asks for information about Alcoholics Anonymous (AA). Which is the nurses best response? - ANSWER It is a self-help group with the goal of sobriety. 157 Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: - ANSWER has a high tolerance to alcohol. 158 A patient admitted to an alcoholism rehabilitation program says, Im just a social drinker. I usually 159 have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening. 160 The patient is using which defense mechanism? - ANSWER Denial 161 A new patient in an alcoholism rehabilitation program says, Im just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening. Which response by the nurse will help the patient view the drinking more honestly? - ANSWER You describe drinking steadily throughout the day and evening. Am I correct? 162 During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, After discharge, Im sure everything will be just fine. Which remark by the nurse will be most helpful to the spouse? - ANSWER Although sobriety solves some problems, new ones may emerge as one adjusts toliving without alcohol. 163 The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? - ANSWER Consider each disorder primary and provide simultaneous treatment. 164 When working with a patient beginning treatment for alcohol abuse, what is the nurses most therapeutic approach? - ANSWER Empathetic, supportive 165 A patient comes to an outpatient appointment obviously intoxicated. The nurse should: - ANSWER tell the patient, We cannot see you today because youve been drinking. 166 When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? - ANSWER Tolerance develops. 167 Which statement most accurately describes substance addiction? - ANSWER It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occurwhen intake is reduced or stopped. 168 A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, I feel terrible. Which analysis is correct? - ANSWER Symptoms of opiate withdrawal are present. 169 In the emergency department, a patients vital signs are: blood pressure (BP), 66/40 mm Hg;pulse (P), 140 170 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. - ANSWER Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 171 bpm, and respirations at or above 12 breaths per minute. 172 Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. - ANSWER Monitor the airway and vital signs every 15 minutes. 173 A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurses drug use was evident? - ANSWER Seeking to be assigned as a medication nurse. 174 A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. 175 The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? - ANSWER Conveying understanding that pressures associated with nursing practiceunderlie substance abuse. 176 Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? - ANSWER Residential program 177 Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? - ANSWER Disturbed thought processes 178 Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? - ANSWER Observe for depression and suicidal ideation. 179 Which assessment findings best correlate to the withdrawal from central nervous system depressants? - ANSWER Nausea, vomiting, diaphoresis, anxiety, tremors 180 A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? - ANSWER Substance addiction 181 Which assessment findings will the nurse expect in an individual who has just injected heroin? - ANSWER Drowsiness, constricted pupils, slurred speech 182 A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: - ANSWER runny nose, yawning, insomnia, and chills. 183 A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurses first action? - ANSWER Establish a patent airway 184 An adult in the emergency department states, I feel restless. Everything I look at wavers. Sometimes Im outside my body looking at myself. I hear colors. I think Im losing my mind. Vital signs are slightly elevated. 185 The nurse should suspect a: - ANSWER D-lysergic acid diethylamide (LSD) ingestion. 186 In what significant ways is the therapeutic environment different for a patient who has ingested D- lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? - ANSWER For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. 187 When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: - ANSWER anterograde amnesia. 188 A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, Often my friend drinks, along with taking more of the drug than is prescribed. What is the effect of the use of alcohol with this drug? - ANSWER A synergistic effect occurs. 189 Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? - ANSWER naltrexone (Revia) 190 Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will - ANSWER state, I see the need for ongoing treatment. 191 Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? - ANSWER When did you have your last drink? 192 A patient in an alcohol treatment program says, I have been a loser all my life. Im so ashamed of what I have put my family through. Now, Im not even sure I can succeed at staying sober. Which nursing diagnosis applies? - ANSWER Chronic low self-esteem 193 Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? - ANSWER Is abstinent for 10 days and states, I can maintain sobriety one day at a time. Spoke with employer, who is willing to allow the patient to return to work in three weeks. 194 Which assessment findings support a nurses suspicion that a patient has been using inhalants? - ANSWER Confusion, mouth ulcers, and ataxia 195 A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, I want to go to school, but we cant afford a babysitter. It doesnt matter; Im too dumb to learn. What preliminary assessment is evident? - ANSWER Child and siblings are experiencing neglect. 196 An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, My parents dont like me. They call me stupid and say I never do anything right. Which type of abuse is likely? - ANSWER Emotional 197 What feelings are most commonly experienced by nurses working with abusive families? - ANSWER Sympathy for the victim and anger toward the abuser 198 Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? - ANSWER Strong negative feelings interfere with assessment and judgment. 199 A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. 200 The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? - ANSWER Have the patient complete an abuse assessment screen. 201 A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? - ANSWER Risk of intimate partner violence 202 What is a nurses legal responsibility if child abuse or neglect is suspected? - ANSWER Report the suspected abuse or neglect according to state regulations. 203 Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: - ANSWER bite marks. 204 An 11-year-old child says, My parents dont like me. They call me stupid and say Inever do anything right, but it doesnt matter. Im too dumb to learn. Which nursing diagnosis applies to this child? - ANSWER Chronic low self-esteem, related to negative feedback from parents 205 An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority assessment? - ANSWER Physical injuries 206 An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority question? - ANSWER How did this happen to you? 207 An employee has recently been absent from work on several occasions. Each time, this employee returns to work wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurses interview, the employee says, My partner beat me, but it was because there are problems at work. What should the nurses next action be? - ANSWER Document injuries with a body map. 208 A patient tells the nurse, My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me. What risk factor was most predictive for the husband to become abusive? - ANSWER History of family violence 209 An adult tells the nurse, My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. Ive considered leaving but havent been able to bring myself to actually do it. Which phase in the cycle of violence prevents the patient from leaving? - ANSWER Honeymoon 210 After treatment for a detached retina, a victim of intimate partner violence says, My partner only abuses me when intoxicated. Ive considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me. Which nursing diagnosis applies? - ANSWER Risk for injury, related to partners physical abuse when intoxicated 211 A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, You stay together, no matter what happens. Which outcome should be met before the patient leaves the emergency department? The patient will: - ANSWER name two community resources that can be contacted. 212 An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? - ANSWER Physical 213 An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? - ANSWER Dementia 214 An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adults daughter, who becomes defensive and says, My mother often wanders at night. Last night she fell down the stairs. Which nursing diagnosis has priority? - ANSWER Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision 215 An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patients adult child. This caregiver becomes defensive and says, It takes all my time and energy to care for my mother. Shes awake all night. I never get any sleep. Which nursing intervention has priority? - ANSWER Secure additional resources for the mothers evening and night care. 216 A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: - ANSWER expresses frustration verbally instead of physically. 217 Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? - ANSWER Womens shelter 218 Which family scenario presents the greatest risk for family violence? - ANSWER An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child 219 A nurse works with a person who was raped four years ago. This person says, It took a long time for me to recover from that horrible experience. Which term should the nurse use when referring to this person? - ANSWER Survivor 220 A personwas abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the persons level of anxiety? - ANSWER Severe 221 A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? - ANSWER Confusion and disbelief 222 A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, I cant talk about it. Nothing happened. I have to forget! What is the persons present coping strategy? - ANSWER Denial 223 A child was abducted and raped. Which personal reaction by the nurse could interfere with the childs care? - ANSWER Anger 224 A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? - ANSWER I gave her what she wanted. 225 A rape victim asks an emergency department nurse, Maybe I did something to cause this - ANSWER Support the victim to separate issues of vulnerability fromblame. 226 A rape victim tells the nurse, I should not have been out on the street alone. Which is the nurses most therapeutic response? - ANSWER You believe this would not have happened if you had not been alone? 227 The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patients discharge? - ANSWER Patient agrees to keep a follow-up appointment with the rape crisis center. 228 The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? - ANSWER Use accepting, nurturing, and empathetic communication techniques. 229 What is the primary motivator for most rapists? - ANSWER Desire to humiliate or control others 230 A nurse working a rape telephone hotline should focus communication with callers to: - ANSWER explain immediate steps that a victim of rape should take. 231 A rape victim tells the emergency department nurse, I feel so dirty. Please let me take a shower before the doctor examines me. The nurse should: - ANSWER explain that washing would destroy evidence. 232 Which situation constitutes consensual sex rather than rape? - ANSWER A persons lover pleads to have oral sex. The person gives in but then regrets thedecision. 233 When a victim of sexual assault is discharged from the emergency department, the nurse should: - ANSWER provide referral information verbally and in writing. 234 A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, I cant believe Ive been raped. This behavior is characteristic of which phase of the rape trauma syndrome? - ANSWER Acute phase 235 survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: - ANSWER plans coping strategies for fearful situations. 236 A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: - ANSWER provide written information concerning the physical and emotional reactions that may be experienced. 237 An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the persons underclothes. The priority actions of staff members should focus on: - ANSWER maintaining the airway. 238 A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, I will never be the same again. I cant face my friends. There is no sense of trying to go on. Select the nurses most important response. - ANSWER Are you thinking of suicide? 239 A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for: - ANSWER respiratory depression. 240 When working with rape victims, immediate care focuses first on: - ANSWER helping the victim feel safe. 241 A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this childs most likely problem? - ANSWER Attention deficit hyperactivity disorder (ADHD) 242 A child diagnosed with attention deficit hyperactivity disorder (ADHD) has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: - ANSWER improved ability to participate in play with other children. 243 A 5-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurses best action? - ANSWER Take the child into another room with toys to act out feelings. 244 A 16-year-old adolescent diagnosed with conduct disorder (CD) has been in a residential program for three months. Which outcome should occur before discharge? - ANSWER The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. 245 A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably: - ANSWER be resistant to accepting psychiatric help. 246 A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurses planning for this patient? The patient is: - ANSWER relieving anxiety through the physical symptom. 247 A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should: - ANSWER expect the patient to feed himself or herself after explaining the arrangement of the food on the tray 248 A patient with blindness related to a functional neurological (conversion) disorder says, All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital dont find me interesting. Which nursing diagnosis is most relevant? - ANSWER Chronic low self-esteem 249 To assist a patient diagnosed with a somatic system disorder, a nursing intervention of high priority is to: - ANSWER shift the focus from somatic symptoms to feelings. 250 A patient who fears serious heart disease was referred to the mental health center by a cardiologist after diagnostic evaluation showed no physical illness. The patient says, My heart misses beats. Im frequently absent from work. I dont go out much because I need to rest. Which health problem is most likely? - ANSWER Illness anxiety disorder (hypochondriasis) 251 A nurse assessing a patient diagnosed with a somatic system disorder is most likely to note that the patient: - ANSWER has unmet needs related to comfort and activity. 252 To plan effective care for patients diagnosed with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: - ANSWER provide relief from health anxiety. 253 A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patients disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: - ANSWER demonstrate a resumption of former roles and tasks 254 A woman wears a size 7 shoe. She says, My feet are huge. Ive asked three orthopedists to surgically reduce my feet. The patient tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? - ANSWER Body dysmorphic disorder 255 Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states: - ANSWER I cannot recall why Im living in this town 256 A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later, and then sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? - ANSWER Dissociative identity disorder 257 A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? - ANSWER Since my father died, Ive been short of breath and had sharp pains that go down my left arm, but I think its justindigestion. 258 A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? - ANSWER Risk for suicide 259 Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder: Disturbed personal identity, related to: - ANSWER cognitive distortions associated with unresolved childhood abuse issues 260 For a patient diagnosed with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: - ANSWER describing previously forgotten experiences