NURS 206 Mental Health 2 Questions and Answers,100% CORRECT

NURS 206 Mental Health 2 Questions and Answers Chapter 11: Anxiety, Anxiety Disorders, and Obsessive-Compulsive Disorders 1. A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to: a. Verify the patients learning style. b. Create outcomes and a teaching plan. c. Lower the patients current anxiety level. d. Assess how the patient uses defense mechanisms. ANS: C A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient’s anxiety level. Using defense mechanisms does not apply. 2. A patient approaches the nurse and impatiently blurts out, Youve got to help me! Something terrible is happening. My heart is pounding. The nurse responds, it’s almost time for visiting hours. Let’s get your hair combed. Which approach has the nurse used? a. Bringing up an irrelevant topic b. Responding to physical needs c. Addressing false cognitions d. Focusing ANS: A The patient is experiencing anxiety. The nurse has closed off patient-centered communication by changing the subject. The introduction of an irrelevant topic makes the nurse feel better. The nurse may be uncomfortable dealing with the patient’s severe anxiety. The nurse has not responded to the patients’ physical needs. There is no evidence of false cognition. Focusing is a therapeutic communication technique used to concentrate attention on a single issue. 3. A patient experiencing moderate anxiety says, I feel undone. An appropriate response for the nurse would be: a. Why do you suppose you are feeling anxious? b. What would you like me to do to help you? c. I’m not sure I understand. Give me an example. d. You must get your feelings under control before we can continue. ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish. 4. A patient with a high level of motor activity runs from chair to chair and cries, they’re coming! They’re coming! The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patients personal space. d. encourages the clarification of feelings. ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for self- injury related to an increase in nongoal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient’s personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered. 5. A patient with a high level of motor activity runs from chair to chair and cries, they’re coming! They’re coming! The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processes ANS: A A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in nongoal- directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority. 6. A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, I’ve been working on other things. When asked 4 hours later, the worker says, someone else was using the copier, so I couldn’t finish it. The workers behavior demonstrates: a. acting out. b. projection. c. suppression. d. passive aggression. ANS: D A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks. Acting out refers to behavioral expression of conflict. Projection is a form of blaming. Suppression is the conscious denial of a disturbing situation or feeling. 7. A patient is undergoing diagnostic tests. The patient says nothing is wrong with me except a stubborn chest cold. The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one’s own unacceptable thoughts or feelings to another. 8. A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurses’ comments and asks, what are they going to do? Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patient’s level of anxiety? a. Mild b. Moderate c. Severe d. Panic ANS: B Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior. 9. A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner, using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family. ANS: B Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the incorrect options will further scatter the patient’s attention. 10. A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient’s anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety. ANS: B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin. 11. Which assessment question would be most appropriate for the nurse to ask a patient who has possible generalized anxiety disorder (GAD)? a. Have you been a victim of a crime or seen someone badly injured or killed? b. Do you feel especially uncomfortable in social situations involving people? c. Do you repeatedly do certain things over and over again? d. Do you find it difficult to control your worrying? ANS: D Patients with GAD frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event. 12. A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurse’s office, furnished with chairs, files, magazines, and bookcases ANS: A Individuals who are experiencing severe to panic-level anxiety require a safe environment that is quiet, no stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse’s office or a room with an examining table and instrument cabinets may be overstimulating and unsafe. 13. A person has minor physical injuries after an automobile accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person’s level of anxiety? a. Mild b. Moderate c. Severe d. Panic ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic-level anxiety demonstrates significantly disturbed behavior and may lose touch with reality. 14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, the nurse manager had a headache the day I was interviewed. Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting ANS: C Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. 15. A patient tells a nurse, my new friend is the most perfect person one could imagine kind, considerate, and good looking. I can’t find a single flaw. This patient is demonstrating a. denial. b. projection. c. idealization. d. compensation. ANS: C Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point. 16. A patient experiences an episode of severe anxiety. Of these medications in the patients’ medical record, which is most appropriate to administer as an as-needed (PRN) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin) ANS: B Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents. 17. Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse’s response? a. Altruism b. Sublimation c. Suppression d. Passive aggression ANS: A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurse’s reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others. 18. A person who feels unattractive repeatedly says, Although I’m not beautiful, I am smart. This is an example of: a. repression. b. devaluation. c. identification. d. compensation. ANS: D Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others. 19. A person who is speaking about a contender for a significant others affection says in a gushy, syrupy voice, What a lovely person. That’s someone I simply adore. The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial. ANS: A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety- producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness. 20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression ANS: A Rationalization involves unconsciously making excuses for one’s behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person. 21. A student says, before taking a test, I feel a heightened sense of awareness and restlessness. The nurse can correctly assess the students experience as: a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety. ANS: D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. 22. A student says, before taking a test, I feel a heightened sense of awareness and restlessness. The nursing intervention most suitable for assisting the student is to: a. explain that the symptoms are the result of mild anxiety and discuss the helpful aspects. b. advise the student to discuss this experience with a health care provider. c. encourage the student to begin antioxidant vitamin supplements. d. listen without comment. ANS: A Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario. 23. If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. I don’t know why it happens. b. I have always had poor impulse control. c. That person should not have provoked me. d. Inside I am a coward who is afraid of being hurt. ANS: C Rationalization consists of justifying one’s unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. 24. A patient experiencing severe anxiety suddenly begins running and shouting, I’m going to explode! The nurse should: a. says, I’m not sure what you mean. Give me an example. b. chase after the patient and give instructions to stop running. c. capture the patient in a basket-hold to increase feelings of control. d. assemble several staff members and state, we will help you regain control. ANS: D The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient’s anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile, a patient in panic processes information poorly. 25. A person who has been unable to leave home for more than a week because of severe anxiety says, I know it does not make sense, but I just can’t bring myself to leave my apartment alone. Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion. ANS: A This intervention, a form of cognitive restructuring, replaces negative thoughts such as I can’t leave my apartment with positive thoughts such as I can control my anxiety. This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role. 26. Which comment by a person experiencing severe anxiety indicates the possibility of obsessive- compulsive disorder? a. I check where my car keys are eight times. b. My legs often feel weak and spastic. c. I’m embarrassed to go out in public. d. I keep reliving the car accident. ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, my legs feel weak most of the time, is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with post- traumatic stress disorder. 27. Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to: a. report drowsiness. b. eats a tyramine-free diet. c. avoids alcoholic beverages. d. adjusts dose and frequency based on anxiety level. ANS: C Drinking alcohol or taking other anxiolytic medications along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration. 28. Which statement is mostly likely to be made by a patient diagnosed with agoraphobia? a. Being afraid to go out seems ridiculous, but I can’t go out the door. b. I’m sure I’ll get over not wanting to leave home soon. It takes time. c. When I have a good incentive to go out, I can do it. d. My family says they like it now that I stay home. ANS: A Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house. 29. A patient has the nursing diagnosis Anxiety, related to , as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. ensuring the health of household members b. attempting to avoid interactions with others c. having persistent thoughts about bacteria, germs, and dirt d. needing approval for cleanliness from friends and family ANS: C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relief anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior. 30. A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patients’ symptoms rather than on the patient. ANS: B Because patients diagnosed with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patients coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom. 31. For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control. ANS: C Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other, less-restrictive measures are proven ineffective. 32. Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. asks, What’s the matter with me? b. stays in a room alone and paces rapidly. c. can concentrate on what the nurse is saying. d. states, I dent want anything to eat. My stomach is upset. ANS: C The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, What’s the matter with me? Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety. 33. A patient tells the nurse, I don’t go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at. The nurse assesses this behavior as consistent with: a. acrophobia. b. agoraphobia. c. social anxiety disorder (social phobia). d. post-traumatic stress disorder (PTSD). ANS: C The fear of a potentially embarrassing situation represents social anxiety disorder (social phobia). Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Post-traumatic stress disorder is associated with a major traumatic event. 34. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring. ANS: D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves a graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of undesirable stimuli in an effort to extinguish the anxiety response. 35. A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication? a. Beta-blockers b. Antipsychotic medications c. Tricyclic antidepressant agents d. Monoamine oxidase inhibitors ANS: A Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required. 36. A patient tells the nurse, I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why? The nurses reply should be based on the knowledge that buspirone: a. does not produce blood dyscrasias. b. does not cause dependence. c. can be administered as needed. d. is faster acting than diazepam. ANS: B Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone. SELECT ALL THAT APPLY 1. A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions. ANS:A,B,E The child can be hypothesized to have moderate-to-severe anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns. 2. A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder (GAD) who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allow only tyramine-free foods in diet. c. Restrict intake of caffeine. d. Avoid using alcohol and other sedatives. e. Take the medication on an empty stomach. ANS:A,C,D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication. 3. Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. Have you been a victim of a crime or seen someone badly injured or killed? b. Are there certain social situations that cause you to feel especially uncomfortable? c. Do you have to do things in a certain way to feel comfortable? d. Is it difficult to keep certain thoughts out of awareness? e. Do you do certain things over and over again? ANS:C,D,E The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected post-traumatic stress disorder or with suspected social anxiety disorder (social phobia). Chapter 13: Personality Disorders 1. A therapist recently convicted of multiple counts of Medicare fraud says, Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too. These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings. ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patients remarks cannot be assessed as shameful. Lack of trust or concern that other are determined to cause harm is not evident. 2. Which intervention is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer the patients requests and questions to the case manager. b. Explore the patients’ feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior. ANS: A Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority. 3. As a nurse prepares to administer a medication to a patient diagnosed with a borderline personality disorder, the patient says, just leave it on the table. I’ll take it when I finish combing my hair. What is the nurses best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, I’m worried that you might not take it. I will come back later. c. Say to the patient, I must watch you take the medication. Please take it now. d. Ask the patient, why don’t you want to take your medication now? ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient’s safety, as well as to prevent splitting other staff members. Why questions are not therapeutic. 4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identifies when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledges manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately. ANS: C Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. Ideally, the patient will use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control. 5. Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: You’re a better nurse than the day shift nurse said you were Another nurse said you don’t do your job right; You think you’re perfect, but I’ve seen you make three mistakes. Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt producing. ANS: C Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments. 6. 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? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling ANS: C Limits must be set in areas in which the patients behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters. 7. 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? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic ANS: A SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not Test Bank: Essentials of Psychiatric Mental Health Nursing (3rd Edition by Varcarolis) 96 supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive. 8. 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? a. I have a quick temper, but I can usually keep it under control. b. I’ve done some stupid things in my life, but I’ve learned a lesson. c. I’m feeling terrible about the way my behavior has hurt my family. d. I hit because I’m tired of being nagged. My spouse deserved the beating. ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common. 9. 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? a. Disturbed sensory perception auditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping ANS: B Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority. 10. 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? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient’s wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient’s behavior. ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately. 11. 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, I’m feeling empty and want to cut myself. The nurse should: a. arranges for emergency inpatient hospitalization. b. sends the patient to the crisis intervention unit for 8 to 12 hours. c. assists the patient to identify the trigger situation and choose a coping strategy. d. advises the patient to take an antianxiety medication to decrease the anxiety level. ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for coaching during crises. The nurse can assist the patient to choose an alternative to self- mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patient’s ability to weigh alternatives to mutilating behavior. 12. The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy. ANS: C Maintaining consistent limits is by far the most difficult intervention because of the patients’ superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques. 13. The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action. ANS: D The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity. 14. A patient tells a nurse; I sometimes get into trouble because I make quick decisions and act on them. A therapeutic response would be: a. Let’s consider the advantages of being able to stop and think before acting. b. It sounds as though you’ve developed some insight into your situation. c. I’ll bet you have some interesting stories to share about overreacting. d. It’s good that you’re showing readiness for behavioral change. ANS: A the patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental. 15. 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? a. Risk for self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient diagnosed with borderline personality disorder. 16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. I think you are the best nurse on the unit. b. I’m never going to get high on drugs again. c. I hate my doctor for not giving me what I ask for. d. I felt empty and wanted to cut myself, so I called you. ANS: D Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking. 17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionism. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisiveness, submissiveness. d. grandiosity, attention seeking, and arrogance. ANS: D According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the characteristics of grandiosity, attention seeking, and arrogance are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients diagnosed with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals diagnosed with obsessive- compulsive personality disorder. Patients diagnosed with dependent personality disorder often express difficulty being alone and are indecisive and submissive. 18. For which behavior would limit setting be most essential? The patient: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares. ANS: D The correct option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance. 19. 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? a. Histrionic b. Dependent c. Narcissistic d. Borderline ANS: B The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting. 20. 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? a. Avoidant b. Dependent c. Histrionic d. Paranoid ANS: A Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame. 21. What is the priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder? a. Respect the patients need for periods of social isolation. b. Prevent the patient from violating the nurses’ rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing. ANS: A Patients diagnosed with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients diagnosed with schizotypal personality disorder rarely engage in behaviors that violate the nurses’ rights or exploit the nurse. 22. 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: a. inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence. ANS: D Fear of abandonment is a central theme for most patients diagnosed with borderline personality disorder. This fear is often exacerbated when patients diagnosed with borderline personality disorder experience success or growth. The incorrect options are not associated with self-mutilation. 23. 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: a. encourages the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patients’ feelings about cutting. ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self- mutilation. The goal of providing emotional consistency is supported by this approach. The incorrect options provide positive reinforcement of the behavior. 24. 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. You’re terrible. This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies. ANS: B Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver. 25. Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships ANS: C Frequent team meetings are held to counteract the effects of the patients attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. 26. Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms. ANS: B Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress. SELECT ALL THAT APPLY 1. A nurse plans the care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety ANS: B, D Individuals diagnosed with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals diagnosed with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals diagnosed with antisocial personality disorders are more likely to be impulsive than to be perfectionists. 2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Dependent d. Schizotypal e. Narcissistic ANS:A,B,D Some personality disorders have evidence of genetic links; therefore the family history would show other family members with similar traits. Heredity plays a role in schizotypal and antisocial problems, as well as obsessive- compulsive personality disorder. Chapter 14: Eating Disorders 1. 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 weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating disorder b. Anorexia nervosa c. Bulimia nervosa d. Pica ANS: B Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. Pica refers to eating nonfood items. 2. Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance. ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis. 3. A patient who is referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient’s oral intake, the nurse should ask: a. Do you often feel fat? b. Who plans the family meals? c. What do you eat in a typical day? d. What do you think about your present weight? ANS: C Although all the questions might be appropriate to ask, only What do you eat in a typical day? focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patients’ thoughts on present weight explores the patients’ feelings about weight. 4. 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? a. I am fat and ugly. b. What I think about myself is my business. c. I am grossly underweight, but that’s what I want. d. I am a few pounds overweight, but I can live with it. ANS: A Patients diagnosed with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually disclose perceptions about self to others. The patient with anorexia will persist in trying to lose more weight. 5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient’s current serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia ANS: D The patient’s history and laboratory results support the correct nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia. 6. 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: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds. ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority. 7. Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of re-feeding. c. Communicate empathy for the patients’ feelings. d. Help the patient balance energy expenditure and caloric intake. ANS: B The nursing intervention of observing for adverse effects of re-feeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention. 8. 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? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs of the patient are met. d. Because of increased risk for physical problems with re-feeding, obtaining patient permission is required. ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that the patients’ needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment. 9. 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? a. Renal b. Endocrine c. Central nervous d. Cardiovascular ANS: D Re-feeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the re-feeding syndrome. 10. 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? a. What are your feelings about not eating the food that you prepare? b. You seem to feel much better about yourself when you eat something. c. It must be difficult to talk about private matters to someone you just met. d. Being thin does not seem to solve your problems. You are thin now but still unhappy. ANS: D The correct response is the only strategy that attempts to question the patients distorted thinking. 11. An appropriate intervention for a patient diagnosed with bulimia nervosa who binges, and purges is to teach the patient to: a. eats a small meal after purging. b. avoids skipping meals or restricting food. c. concentrates oral intake after 4 PM daily. d. understands the value of reading journal entries aloud to others. ANS: B One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private. 12. What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? a. The nurses’ comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders. ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patients’ feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention. 13. 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: a. appropriately express angry feelings. b. verbalizes two positive things about self. c. verbalizes the importance of eating a balanced diet. d. identifies two alternative methods of coping with loneliness. ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable. 14. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Explore patient needs for health teaching. d. Assess for signs of impulsive eating. ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority. The question calls for an intervention rather than an assessment. 15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 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 b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36 C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature, 36.5 C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7 C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg ANS: A Physical criterion for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36 C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg. 16. While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance. ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia. 17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient’s body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which condition should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered. 18. 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 won’t eat until I look thin. What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation ANS: D The physical as