Answer Options:
a. A child loses a beloved family pet.
b. A single male prepares to take a 1-week vacation to a tropical island with a group of close friends.
c. A couple receives a bank notice there were insufficient funds in their account for a recent rent payment.
d. A married female receives notification that their current employer is experiencing financial problems and some workers will be terminated.
Answer: B. A single male prepares to take a 1-week vacation to a tropical island with a group of close friends.
Question: To assist a patient diagnosed with a somatic system disorder, which nursing intervention is of highest priority?
Answer Options:
a. Analyzing the causes of the physical symptoms.
b. Helping the patient suppress feelings of anger.
c. Shifting the focus from somatic symptoms to feelings.
d. Investigating each physical symptom as soon as it is reported.
Answer: C. Shifting the focus from somatic symptoms to feelings.
Question: When assessing a 2-year-old diagnosed with autism spectrum disorder, what should a nurse expects?
Answer Options:
a. Hyperactivity and attention deficits
b. Failure to develop interpersonal social skills
c. History of disobedience and destructive acts
d. High levels of anxiety when separated from a parent
Answer: b. Failure to develop interpersonal social skills
Question: A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” What nursing intervention is most helpful for assisting the student?
Answer Options:
a. Explaining that the symptoms are the result of mild anxiety and discussing the helpful aspects
b. Advising the student to discuss this experience with a health care provider
c. Encouraging the student to begin antioxidant vitamin supplements
d. Listening without comment
Answer: A. Explaining that the symptoms are the result of mild anxiety and discussing the helpful aspects
Question: A patient diagnosed with somatic symptom disorder has been in treatment for 4 weeks. The patient says, “Although I’m still having pain, I notice it less and am able to perform more activities.” The nurse should evaluate the treatment plan using which statement as a measure of success?
Answer Options:
a. Personal preoccupation with symptoms is gone.
b. Identifying personal coping patterns that are proving to be ineffective.
c. Decreased preoccupation with symptoms and an increased ability to perform activities of daily living suggest partial success of the treatment plan.
d. The treatment plan is not successful until all symptoms are totally achieved.
Answer: C. Decreased preoccupation with symptoms and an increased ability to perform activities of daily living suggest partial success of the treatment plan.
Question: For a patient diagnosed with somatic symptom disorder, what statement would effectively complete the long-term outcome of “Within 4 weeks, the patient will demonstrate an ability to”?
Answer Options:
a. Verbalize feelings of peace and emotional safety.”
b. Function independently on a basic level.”
c. Regularly attend prescribed diversional activity groups.”
d. Identifying personal coping patterns that are proving to be ineffective.”
Answer: B. Function independently on a basic level.”
Question: A patient experiencing severe anxiety suddenly begins running and shouting, “I’m going to explode!” The nurse should implement which intervention to best maximize the patient’s safety?
Answer Options:
a. State, “I’m not sure what you mean. Give me an example.”
b. Chase after the patient while giving instructions to stop running.
c. Restrain the patient in a basket-hold to increase feelings of control.
d. Assemble several staff members and state, “We will help you regain control.”
Answer: D. Assemble several staff members and state, “We will help you regain control.”
Question: A patient diagnosed with somatic symptom disorder says, “Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear.” Which nursing diagnoses apply to this patient? (Select all that apply.)
Answer Options:
a. Spiritual distress
b. Decisional conflict
c. Adult failure to thrive
d. Impaired social interaction
e. Ineffective role performance
Answer: A. Spiritual distress
E. Ineffective role performance
Question: 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?
Answer Options:
a. Displacement
b. Regression
c. Projection
d. Denial
Answer: D. Denial
Question: As a nurse escorts a patient being discharged after treatment for panic disorder, the patient gives the nurse a gold necklace with a heart pendant and says, “Thank you for helping mend my broken heart.” Which is the nurse’s best response?
Answer Options:
a. “Accepting gifts violates the policies and procedures of the facility.”
b. “I’m glad you feel so much better now. Thank you for the beautiful necklace.”
c. “I’m glad I could help you, but I can’t accept the gift. My reward is seeing you renewed sense of hope.”
d. “Helping people is what nursing is all about. It’s rewarding to me when patients recognize how hard we work.”
Answer: C. “I’m glad I could help you, but I can’t accept the gift. My reward is seeing you renewed sense of hope.”
Question: Which assessment finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild?
Answer Options:
a. Patient asks, “What’s the matter with me?”
b. Patient stays in a room alone and paces rapidly.
c. Patient successfully concentrates on what the nurse is saying.
d. Patient states, “I don’t want anything to eat. My stomach is upset.”
Answer: C. Patient successfully concentrates on what the nurse is saying.
Question: A 12-year-old child has been the neighborhood bully for several years. The parents say, “We can’t believe anything our child says.” Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child’s behaviors are most consistent with which disorder?
Answer Options:
a. Conduct disorder (CD)
b. Defiance of authority
c. Anxiety over separation from a parent
d. Attention-deficit/hyperactivity disorder (ADHD)
Answer: a. Conduct disorder (CD)
Question: A patient reports fears of having cervical cancer and says to the nurse, “I’ve had Pap smears by six different doctors. The results are normal, but I’m sure that’s because of errors in the laboratory.” Which disorder would the nurse suspect?
Answer Options:
a. Functional neurological (conversion) disorder
b. Illness anxiety disorder (hypochondriasis)
c. Derealization disorder
d. Dissociative amnesia with fugue
Answer: B. Illness anxiety disorder (hypochondriasis)
Question: A patient diagnosed with somatic symptom disorder says, “I have pain from an undiagnosed injury. I can’t take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much.” It is important for the nurse to conduct what focused assessment?
Answer Options:
a. Mood
b. Cognitive style
c. Secondary gains
d. Identity and memory
Answer: C. Secondary gains
Question: Which client statement most supports a diagnosis of agoraphobia?
Answer Options:
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.”
Answer: A. “Being afraid to go out seems ridiculous, but I can’t go out the door.”
Question: A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient’s disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. What is an appropriate outcome for this patient?
Answer Options:
a. Assumes roles and functions of the other family members.
b. Demonstrates a resumption of former roles and tasks.
c. Focuses energy on problems occurring in the family.
d. Relies on family members to meet personal needs.
Answer: B. Demonstrates a resumption of former roles and tasks.
Question: A patient diagnosed with severe and persistent mental illness who recently moved to a homeless shelter says, “My life is out of control. I’m like a leaf at the mercy of the wind.” The nurse formulates the diagnosis Powerlessness. Outcomes will focus on which goal?
Answer Options:
a. Instilling hope
b. Controlling anxiety
c. Planning social activities
d. Developing personal autonomy
Answer: d. Developing personal autonomy