Exam 4 Mental Health Nursing

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1

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client's home environment should a nurse associate with the development of anorexia nervosa?
1. The home environment maintains loose personal boundaries.
2. The home environment places an overemphasis on food.
3. The home environment is overprotective and demands perfection.
4. The home environment condones corporal punishment.

3. The home environment is overprotective and demands perfection.

2

A client's altered body image is evidenced by claims of "feeling fat," even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem?
1. The client will consume adequate calories to sustain normal weight.
2. The client will cease strenuous exercise programs.
3. The client will perceive personal ideal body weight and shape as normal.
4. The client will not express a preoccupation with food.

3. The client will perceive personal ideal body weight and shape as normal.

3

A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide?
1. The emesis produced during purging is acidic and corrodes the tooth enamel.
2. Purging causes the depletion of dietary calcium.
3. Food is rapidly ingested without proper mastication.
4. Poor dental and oral hygiene leads to dental caries

1. The emesis produced during purging is acidic and corrodes the tooth enamel.

4

A nurse is teaching a client diagnosed with an eating disorder about behavior-modification programs. Why is this intervention the treatment of choice?
1. It helps the client correct a distorted body image.
2. It addresses the underlying client anger.
3. It manages the client's uncontrollable behaviors.
4. It allows clients to maintain control

4. It allows clients to maintain control

5

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder?
1. "Skaters need to be thin to improve their daily performance."
2. "All the skaters on the team are following an approved 1200-calorie diet."
3. "The exercise of skating reduces my appetite but improves my energy level."
4. "I am angry at my mother. I can only get her approval when I win competitions."

4. "I am angry at my mother. I can only get her approval when I win competitions."

6

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response?
1. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions."
2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."
3. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support."
4. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."

7

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?
1. The client gained two pounds in one week.
2. The client focused conversations on nutritious food.
3. The client demonstrated healthy coping mechanisms that decreased anxiety.
4. The client verbalized an understanding of the etiology of the disorder

3. The client demonstrated healthy coping mechanisms that decreased anxiety.

8

A morbidly obese client is prescribed an anorexiant medication. The nurse should expect to teach the client about which medication?
1. Phentermine (Mirapront)
2. Dexfenfluramine (Redux)
3. Sibutramine (Meridia)
4. Pemoline (Cylert)

1. Phentermine (Mirapront)

9

A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders?
1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.
2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not.
4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not

1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.

10

A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, "My parents watch me like a hawk and never let me out of their sight." Which nursing diagnosis would take priority at this time?
1. Altered nutrition less than body requirements
2. Altered social interaction
3. Impaired verbal communication
4. Altered family processes

4. Altered family processes

11

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.)
1. Binge eating with a diagnosis of obesity
2. Bingeing and purging with a diagnosis of bulimia nervosa
3. Weight loss with a diagnosis of anorexia nervosa
4. Amenorrhea with a diagnosis of anorexia nervosa
5. Emaciation with a diagnosis of bulimia nervosa

1. Binge eating with a diagnosis of obesity
2. Bingeing and purging with a diagnosis of bulimia nervosa

12

A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (Select all that apply.)
1. "In this disorder, binge eating occurs exclusively during the course of bulimia nervosa."
2. "In this disorder, binge eating occurs, on average, at least once a week for three months."
3. "In this disorder, binge eating occurs, on average, at least two days a week for six months."
4. "In this disorder, distress regarding binge eating is present."
5. "In this disorder, distress regarding binge eating is absent."

1. "In this disorder, binge eating occurs exclusively during the course of bulimia nervosa."

3. "In this disorder, binge eating occurs, on average, at least two days a week for six months."

5. "In this disorder, distress regarding binge eating is absent."

13

Which of the following would contribute to a client's excessive weight gain? (Select all that apply.)
1. A hypothalamus lesion
2. Hyperthyroidism
3. Diabetes mellitus
4. Cushing's disease
5. Low levels of serotonin

1. A hypothalamus lesion

3. Diabetes mellitus

4. Cushing's disease

14

The diagnosis of __________________ ___________________includes the symptoms of gross distortion of body image, preoccupation with food, and refusal to eat

anorexia nervosa

15

The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time is termed ________________________.

bingeing

16

To rid the body of excessive calories, a client diagnosed with bulimia nervosa may engage in ______________________ behaviors, which include self-induced vomiting, or the misuse of laxatives, diuretics, or enemas

purging

17

1. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response to this behavior?
1. "You are very disrespectful. You need to learn to control yourself."
2. "I understand that you are angry, but this behavior will not be tolerated."
3. "What behaviors could you modify to improve this situation?"
4. "What anti-personality disorder medications have helped you in the past?"

2. "I understand that you are angry, but this behavior will not be tolerated."

18

2. At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate?
1. "Go ahead and use the phone. I know this pending divorce is stressful."
2. "You know better than to break the rules. I'm surprised at you."
3. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow."
4. "A divorce shouldn't be considered until you have had a good night's sleep."

3. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow."

19

3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?
1. Provide objective evidence that reasons for violence are unwarranted.
2. Initially restrain the client to maintain safety.
3. Use clear, calm statements and a confident physical stance.
4. Empathize with the client's paranoid perceptions.

3. Use clear, calm statements and a confident physical stance.

20

4. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?
1. Allow the clients to apply the democratic process when developing unit rules.
2. Maintain consistency of care by open communication to avoid staff manipulation.
3. Allow the client spokesman to verbalize concerns during a unit staff meeting.
4. Maintain unit order by the application of autocratic leadership.

2. Maintain consistency of care by open communication to avoid staff manipulation.

21

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?
1. Being firm, consistent, and empathic, while addressing specific client behaviors
2. Promoting client self-expression by implementing laissez-faire leadership
3. Using authoritative leadership to help clients learn to conform to society norms
4. Overlooking inappropriate behaviors to avoid providing secondary gains

1. Being firm, consistent, and empathic, while addressing specific client behaviors

22

6. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder?
1. A physically healthy client who is dependent on meeting social needs by contact with 15 cat
2. A physically healthy client who has a history of depending on intense relationships to meet basic needs
3. A physically healthy client who lives with parents and depends on public transportation
4. A physically healthy client who is serious, inflexible, perfectionistic, lacks spontaneity, and depends on rules to provide security

3. A physically healthy client who lives with parents and depends on public transportation

23

A client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of "suffering" in silence. Which statement best explains the etiology of this client's personality disorder?
1. Childhood nurturance was provided from many sources, and independent behaviors were encouraged.
2. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged.
3. Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged.
4. Childhood nurturance was provided from many sources, and independent behaviors were discouraged.

2. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged.

24

Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response?
1. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone.
2. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not.
3. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant.
4. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

1. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone.

25

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder?
1. Altered thought processes R/T increased stress
2. Risk for suicide R/T loneliness
3. Risk for violence: directed toward others R/T paranoid thinking
4. Social isolation R/T inability to relate to others

4. Social isolation R/T inability to relate to others

26

Looking at a slightly bleeding paper cut, the client screams, "Somebody help me quick! I'm bleeding. Call 911!" A nurse should identify this behavior as characteristic of which personality disorder?
1. Schizoid personality disorder
2. Obsessive-compulsive personality disorder
3. Histrionic personality disorder
4. Paranoid personality disorder

3. Histrionic personality disorder

27

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit?
1. The use of highly lethal methods to commit suicide
2. The use of suicidal gestures to elicit a rescue response from others
3. The use of isolation and starvation as suicidal methods
4. The use of self-mutilation to decrease endorphins in the body

2. The use of suicidal gestures to elicit a rescue response from others

28

A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder?
1. "You really don't have to go by that schedule. I'd just stay home sick."
2. "There has got to be a hidden agenda behind this schedule change."
3. "Who do you think you are? I expect to interact with the same nurse every Saturday."
4. "You can't make these kinds of changes! Isn't there a rule that governs this decision?"

4. "You can't make these kinds of changes! Isn't there a rule that governs this decision?"

29

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder?
1. Interpreting the compliment as a secret code used to increase personal power
2. Feeling the compliment was well deserved
3. Being grateful for the compliment but fearing later rejection and humiliation
4. Wondering what deep meaning and purpose is attached to the compliment

3. Being grateful for the compliment but fearing later rejection and humiliation

30

Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder?
1. Clients diagnosed with social phobia are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications.
2. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with social phobia experience generalized anxiety.
3. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis.
4. Clients diagnosed with schizoid personality disorder avoid attending birthday parties, whereas clients diagnosed with social phobia would isolate self on a continual basis.

3. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis.

31

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder?
1. The client experiences unwanted, intrusive, and persistent thoughts.
2. The client experiences unwanted, repetitive behavior patterns.
3. The client experiences inflexibility and lack of spontaneity when dealing with others.
4. The client experiences obsessive thoughts that are externally imposed.

3. The client experiences inflexibility and lack of spontaneity when dealing with others.

32

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors?
1. A client diagnosed with antisocial personality disorder
2. A client diagnosed with borderline personality disorder
3. A client diagnosed with schizoid personality disorder
4. A client diagnosed with paranoid personality disorder

2. A client diagnosed with borderline personality disorder

33

When planning care for clients diagnosed with personality disorders, what should be the goal of treatment?
1. To stabilize the client's pathology by using the correct combination of psychotropic medications
2. To change the characteristics of the dysfunctional personality
3. To reduce personality trait inflexibility that interferes with functioning and relationships
4. To decrease the prevalence of neurotransmitters at receptor sites

3. To reduce personality trait inflexibility that interferes with functioning and relationships

34

Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder?
1. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse's arm and whispers, "The night nurse is evil. You have to stay."
2. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me."
3. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here."
4. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

4. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

35

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder?
1. Risk for violence: directed toward others R/T paranoid thinking
2. Risk for suicide R/T altered thought
3. Altered sensory perception R/T increased levels of anxiety
4. Social isolation R/T inability to relate to others

1. Risk for violence: directed toward others R/T paranoid thinking

36

From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder?
1. Seclude the client when inappropriate behaviors are exhibited.
2. Contract with the client to reinforce positive behaviors with unit privileges.
3. Teach the purpose of anti-anxiety medications to improve medication compliance.
4. Encourage the client to journal feelings to improve awareness of abandonment issues.

2. Contract with the client to reinforce positive behaviors with unit privileges.

37

A highly emotional client presents at an outpatient clinic appointment and states, "My dead husband returned to me during a séance." Which personality disorder should a nurse associate with this behavior?
1. Obsessive-compulsive personality disorder
2. Schizotypal personality disorder
3. Narcissistic personality disorder
4. Borderline personality disorder

2. Schizotypal personality disorder

38

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred?
1. "Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling."
2. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs."
3. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection."
4. "They pay particular attention to details, which can interfere with the development of relationships."

2. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs."

39

During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder?
1. "I don't have a problem. My family is inflexible, and relatives are out to get me."
2. "I am so excited about working with you. Have you noticed my new nail polish, 'Ruby Red Roses'?"
3. "I spend all my time tending my bees. I know a whole lot of information about bees."
4. "I am getting a message from the beyond that we have been involved with each other in a previous life."

4. "I am getting a message from the beyond that we have been involved with each other in a previous life."

40

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder?
1. Risk for violence: directed toward others R/T paranoid thinking
2. Risk for suicide R/T altered thought
3. Altered sensory perception R/T increased levels of anxiety
4. Social isolation R/T inability to relate to others

4. Social isolation R/T inability to relate to others

41

A nurse is admitting a client with a new diagnosis of a personality disorder. Which of the following would make the nurse question this diagnosis? (Select all that apply.)
1. The client has been diagnosed with sickle cell anemia.
2. The client has an inflated self-appraisal and feels a sense of entitlement.
3. The client has a history of a substance use disorder.
4. The client is odd and eccentric but not delusional.
5. The client has an intellectual developmental disorder.

1. The client has been diagnosed with sickle cell anemia.

3. The client has a history of a substance use disorder.

5. The client has an intellectual developmental disorder.

42

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.)
1. The client will relate one empathetic statement to another client in group by day two.
2. The client will identify one personal limitation by day one.
3. The client will acknowledge one strength that another client possesses by day two.
4. The client will list four personal strengths by day three.
5. The client will list two lifetime achievements by discharge.

1. The client will relate one empathetic statement to another client in group by day two.
2. The client will identify one personal limitation by day one.
3. The client will acknowledge one strength that another client possesses by day two.

43

A nurse is caring for a client diagnosed with antisocial personality disorder. Which factors should the nurse consider when planning this client's care? (Select all that apply.)
1. This client has personality traits that are deeply ingrained and difficult to modify.
2. This client needs medication to treat the underlying physiological pathology.
3. This client uses manipulation, making the implementation of treatment problematic.
4. This client has poor impulse control that hinders compliance with a plan of care.
5. This client is likely to have secondary diagnoses of substance abuse and depression.

1. This client has personality traits that are deeply ingrained and difficult to modify.

3. This client uses manipulation, making the implementation of treatment problematic.
4. This client has poor impulse control that hinders compliance with a plan of care.
5. This client is likely to have secondary diagnoses of substance abuse and depression.

44

A client is being assessed for antisocial personality disorder. According to the DSM-5, which of the following symptoms must the client meet in order to be assigned this diagnosis? (Select all that apply.)
1. Ego-centrism and goal setting based on personal gratification.
2. Incapacity for mutually intimate relationships.
3. Frequent feelings of being down miserable and/or hopeless.
4. Disregard for and failure to honor financial and other obligations.
5, Intense feelings of nervousness, tenseness, or panic.

1. Ego-centrism and goal setting based on personal gratification.
2. Incapacity for mutually intimate relationships.

4. Disregard for and failure to honor financial and other obligations.

45

Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual developmental disorder (IDD)?
1. The client can perform some self-care activities independently.
2. The client has more advanced speech development.
3. Other than possible coordination problems, the client's psychomotor skills are not affected.
4. The client communicates wants and needs by "acting out" behaviors.

4. The client communicates wants and needs by "acting out" behaviors.

46

Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate IDD?
1. Meeting all of the client's self-care needs to avoid injury to the client
2. Providing simple directions and praising client's independent self-care efforts
3. Avoid interfering with the client's self-care efforts in order to promote autonomy
4. Encouraging family to meet the client's self-care needs to promote bonding

2. Providing simple directions and praising client's independent self-care efforts

47

A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate?
1. "Researchers really don't know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored."
2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control."
3. "Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father."
4. "Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?"

2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control."

48

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome?
1. The client will communicate all needs verbally by discharge.
2. The client will participate with peers in a team sport by day four.
3. The client will establish trust with at least one caregiver by day five.
4. The client will perform most self-care tasks independently.

3. The client will establish trust with at least one caregiver by day five.

49

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss?
1. The pharmacological action of Ritalin causes a decrease in appetite.
2. Hyperactivity seen in ADHD causes increased caloric expenditure.
3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased.
4. Increased ability to concentrate allows the client to focus on activities rather than food.

1. The pharmacological action of Ritalin causes a decrease in appetite.

50

A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data?
1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood.
2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood.
3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely.
4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood.

51

Which finding should a nurse expect when assessing a child diagnosed with separation anxiety disorder?
1. The child has a history of antisocial behaviors.
2. The child's mother is diagnosed with an anxiety disorder.
3. The child previously had an extroverted temperament.
4. The child's mother and father have an inconsistent parenting style.

2. The child's mother is diagnosed with an anxiety disorder.

52

A child has been recently diagnosed with mild IDD. What information about this diagnosis should the nurse include when teaching the child's mother?
1. Children with mild IDD need constant supervision.
2. Children with mild IDD develop academic skills up to a sixth-grade level.
3. Children with mild IDD appear different from their peers.
4. Children with mild IDD have significant sensory-motor impairment.

2. Children with mild IDD develop academic skills up to a sixth-grade level.

53

A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual developmental disorder (IDD). Which student statement indicates that further instruction is needed?
1. "These clients can work in a sheltered workshop setting."
2. "These clients can perform some personal care activities."
3. "These clients may have difficulties relating to peers."
4. "These clients can successfully complete elementary school."

4. "These clients can successfully complete elementary school."

54

A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care?
1. Encourage and reward peer contact.
2. Provide consistent caregivers.
3. Provide a variety of safe daily activities.
4. Maintain close physical contact throughout the day.

2. Provide consistent caregivers.

55

A preschool child diagnosed with autistic spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate?
1. Place client in restraints until the aggression subsides.
2. Sedate the client with neuroleptic medications.
3. Hold client's head steady and apply a helmet.
4. Distract the client with a variety of games and puzzles.

3. Hold client's head steady and apply a helmet.

56

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome?
1. Neuroleptic medications
2. Anti-manic medications
3. Tricyclic antidepressant medications
4. Monoamine oxidase inhibitor medications

1. Neuroleptic medications

57

Which behavioral approach should a nurse use when caring for children diagnosed with disruptive behavior disorders?
1. Involving parents in designing and implementing the treatment process
2. Reinforcing positive actions to encourage repetition of desirable behaviors
3. Providing opportunities to learn appropriate peer interactions
4. Administering psychotropic medications to improve quality of life

2. Reinforcing positive actions to encourage repetition of desirable behaviors

58

A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis?
1. The client will name own body parts as separate from others by day five.
2. The client will establish a means of communicating personal needs by discharge.
3. The client will initiate social interactions with caregivers by day four.
4. The client will not harm self or others by discharge.

1. The client will name own body parts as separate from others by day five.

59

A nursing instructor presents a case study in which a three-year-old child is in constant motion and is unable to sit still during story time. She asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation?
1. "This child's behavior must be evaluated according to developmental norms."
2. "This child has symptoms of attention deficit-hyperactivity disorder."
3. "This child has symptoms of the early stages of autistic disorder."
4. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

1. "This child's behavior must be evaluated according to developmental norms."

60

A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of IDD?
1. Risk for injury R/T self-mutilation
2. Altered social interaction R/T non-adherence to social convention
3. Altered verbal communication R/T delusional thinking
4. Social isolation R/T severely decreased gross motor skills

2. Altered social interaction R/T non-adherence to social convention

61

A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents?
1. If one dose of Ritalin is missed, double the next dose.
2. Administer Ritalin to the child after breakfast.
3. Administer Ritalin to the child just prior to bedtime.
4. A side effect of Ritalin is decreased ability to learn.

2. Administer Ritalin to the child after breakfast.

62

Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder?
1. Modify environment to decrease stimulation and provide opportunities for quiet reflection.
2. Convey unconditional acceptance and positive regard.
3. Recognize escalating aggressive behavior and intervene before violence occurs.
4. Provide immediate positive feedback for appropriate behaviors.

3. Recognize escalating aggressive behavior and intervene before violence occurs.

63

A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's ADHD. Which nursing response best addresses the mother's concern?
1. "The physician will probably switch from Ritalin to a central nervous system stimulant."
2. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness."
3. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage."
4. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

3. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage."

64

After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed symptom would a student nurse recognize?
1. Arguing and annoying older sibling over the past year
2. Angry and resentful behavior over a three-month period
3. Initiating physical fights for more than 18 months
4. Arguing with authority figures for more than six months

4. Arguing with authority figures for more than six months

65

Which of the following risk factors, if noted during a family history assessment, should a nurse associate with the development of IDD? (Select all that apply.)
1. A family history of Tay-Sachs disease
2. Childhood meningococcal infection
3. Deprivation of nurturance and social contact
4. History of maternal multiple motor and verbal tics
5. A diagnosis of maternal major depressive disorder

1. A family history of Tay-Sachs disease
2. Childhood meningococcal infection
3. Deprivation of nurturance and social contact

66

Which of the following findings should a nurse identify that would contribute to a client's development of ADHD? (Select all that apply.)
1. The client's father was a smoker.
2. The client was born 7 weeks premature.
3. The client is lactose intolerant.
4. The client has a sibling diagnosed with ADHD.
5. The client has been diagnosed with dyslexia.

2. The client was born 7 weeks premature.

4. The client has a sibling diagnosed with ADHD.