Adults

MULTIPLE CHOICE

1. Health maintenance and promotion efforts for patients diagnosed with severe and persistent mental illness should include education about the importance of regular:
a. home safety inspections.
b. monitoring of self-care abilities.
c. screening for cancer, hypertension, and diabetes.
d. determination of adequacy of a patient’s support system.
ANS: C
Individuals diagnosed with severe and persistent mental illness have an increased prevalence of medical disorders. Patients should be taught the importance of regular visits to a primary care physician for screening for these illnesses. Home safety inspections are more often suggested for patients with physical impairments. Caregivers and family members usually evaluate self-care abilities, rather than the patient. Assessment of a patient’s support system is not usually considered part of health promotion and maintenance.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 517-518
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

2. Severe and persistent mental illness is characterized as a:
a. mental illness with longer than 2 weeks’ duration.
b. major ongoing mental illness marked by significant functional impairments.
c. mental illness accompanied by physical impairment and severe social problems.
d. major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.
ANS: B
“Severe and persistent mental illness” has replaced the phrase “chronic mental illness.” Global impairments in function are evident, including social skills. Physical impairments may be present. Severe mental illness can be treated, but remissions and exacerbations are part of the course of the illness.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 516
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

3. A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says, “That girl looked like she was 19 years old.” Which defense mechanism is this patient using?
a. Denial
b. Identification
c. Displacement
d. Rationalization
ANS: D
Rationalization is used to justify upsetting behaviors by creating reasons that would allow the individual to believe that the behaviors were warranted or appropriate. The patient is rationalizing molestation of a minor. Denial is used to avoid dealing with the problems and responsibilities related to one’s behaviors. Identification is incorporating the image of an emulated person and then acting, thinking, and feeling like that person. Displacement is the discharge of pent-up feelings onto something or someone else in the environment that is less threatening than the original source of the feelings.

DIF: Cognitive Level: Application (Applying) REF: Pages: 527-530
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

4. Which nursing diagnosis is likely to apply to a homeless individual diagnosed with severe and persistent mental illness?
a. Insomnia
b. Substance abuse
c. Chronic low self-esteem
d. Impaired environmental interpretation syndrome
ANS: C
Many individuals with severe mental illness do not live with their families and are homeless. Life on the street or in a shelter has a negative influence on the individual’s self-esteem, making this nursing diagnosis one that should be considered. Insomnia may be noted in some patients but is not a universal problem. Substance abuse is not an approved North American Nursing Diagnosis Association International (NANDA-I) diagnosis. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not observed in a majority of the homeless population.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 517-520
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

5. A patient diagnosed with schizophrenia tells the community mental health nurse, “I threw away my pills because they interfere with God’s voice.” The nurse identifies the cause of the patient’s ineffective management of the medication regimen as:
a. inadequate discharge planning.
b. poor therapeutic alliance with clinicians.
c. impaired reasoning secondary to schizophrenia.
d. dislike of the side effects of antipsychotic medications.
ANS: C
The patient’s ineffective management of the medication regimen is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears God’s voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest that any of the other factors often relate to medication nonadherence.

DIF: Cognitive Level: Application (Applying) REF: Pages: 517-518
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

6. A patient diagnosed with severe and persistent mental illness lives independently. This patient has command hallucinations and shouts warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, “You can’t come back here. You cause too much trouble.” What problem is the patient experiencing?
a. Grief
b. Stigma
c. Recidivism
d. Lack of insurance parity
ANS: B
The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as the patient’s problem. Recidivism refers to repetition of a previous offense. Insurance parity is not relevant to this scenario.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 517
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

7. A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse’s initial priority?
a. Develop a relationship
b. Find supported employment
c. Administer prescribed medication
d. Teach appropriate health care practices
ANS: A
Basic psychosocial needs do not change because a person is homeless. The nurse’s initial priority should be establishing rapport. Once a trusting relationship is established, then the nurse can pursue other interventions.

DIF: Cognitive Level: Application (Applying) REF: Pages: 519-520
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

8. A patient diagnosed with severe and persistent mentally illness lives in a homeless shelter. The priority nursing diagnosis for this patient is Powerlessness. Which intervention should be included in the plan of care?
a. Encourage mutual goal setting.
b. Verbally communicate empathy.
c. Reinforce participation in activities.
d. Demonstrate an accepting attitude.
ANS: A
Mutual goal setting is an intervention designed to promote feelings of personal autonomy and dispel feelings of powerlessness. Although it might be easier and faster for the nurse to establish a plan and outcomes, this action contributes to the patient’s sense of powerlessness. Involving the patient in decision making empowers the patient and reduces feelings of powerlessness.

DIF: Cognitive Level: Application (Applying) REF: Pages: 519-520
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

9. A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement?
a. “I am feeling safe and comfortable here. Nobody bothers me.”
b. “They will not let me drink. They have many rules in the shelter.”
c. “Those guys are always watching me. I think someone stole my shoes.”
d. “That shot made my arm sore. I’m not going to take any more of them.”
ANS: A
Evaluation of a patient’s progress is made based on patient satisfaction with the new health status and the health care team’s estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being “bothered” by others denotes an improvement in the patient’s condition. The other options suggest that the patient is in danger of relapse.

DIF: Cognitive Level: Application (Applying) REF: Pages: 518-520
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

10. For patients diagnosed with severe and persistent mental illness, what is the major advantage of case management? A case manager can:
a. modify traditional psychotherapy.
b. efficiently access and use resources.
c. focus on social skills training and self-esteem building.
d. bring groups of patients together to discuss common problems.
ANS: B
The case manager not only provides entrance into the system of care, but he or she also coordinates the multiple referrals that so often confuse the patient who is severely and persistently mentally ill and the patient’s family. Case management promotes the efficient use of services. The other options are lesser advantages or may be irrelevant.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 517-520
TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

11. The father of a child diagnosed with schizophrenia says, “I lost my job, so we have no health insurance.” The mother says, “I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture.” The sibling says, “My parents don’t pay very much attention to me.” These comments signify:
a. life-cycle stressors.
b. psychobiologic issues.
c. family burden of mental illness.
d. stigma associated with mental illness.
ANS: C
Family burden refers to the meaning that the experience of living with a person who is mentally ill has for families. The stressors mentioned are not related to live-cycle issues. The stressors described are psychosocial. Stigma refers to shame and ridicule associated with mental illness.

DIF: Cognitive Level: Application (Applying) REF: Page: 516
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

12. The parent of an adult diagnosed with severe and persistent mental illness asks the nurse, “Why are you making a referral to that vocational rehabilitation program? My child won’t ever be able to hold a job.” Which is the nurse’s best reply?
a. “We make this referral to continue eligibility for federal funding.”
b. “Are you concerned that we’re trying to make your child too independent?”
c. “If you think the program would be detrimental, we can postpone it for a time.”
d. “Most patients are capable of employment at some level, competitive or supported.”
ANS: D
Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment; also they demonstrate significant improvement in assertiveness and work behaviors, as well as decreased depression.

DIF: Cognitive Level: Application (Applying) REF: Pages: 519-521
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

13. An adult says, “When I was a child, I took medication because I couldn’t follow my teachers’ directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job.” Which disorder is most likely?
a. Stress intolerance disorder
b. Generalized anxiety disorder (GAD)
c. Borderline personality disorder
d. Adult attention deficit hyperactivity disorder (ADHD)
ANS: D
Adult ADHD is usually diagnosed in early life and treated until adolescence. Treatment is often stopped because professionals think the disorder resolves itself because the hyperactive impulsive behaviors may diminish; the inattentive and disorganized behaviors tend to persist, however. Stress intolerance disorder is not found in the DSM-5. The scenario description is inconsistent with generalized anxiety disorder and borderline personality disorder.

DIF: Cognitive Level: Application (Applying) REF: Pages: 530-533
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

14. A patient says, “I often make careless mistakes and have trouble staying focused. Sometimes it’s hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment.” Which problem should the nurse document?
a. Inattention
b. Impulsivity
c. Hyperactivity
d. Social impairment
ANS: A
Inattention refers to the failure to stay focused. A number of the other problems are the result of failure to pay attention, which contributes to problems with organization. Impulsivity refers to acting without thinking through the consequences. Hyperactivity refers to excessive motor activity. Social impairment refers to the failure to use appropriate social skills.

DIF: Cognitive Level: Application (Applying) REF: Pages: 530-532
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

15. A nurse prepares for an initial interview with a patient with suspected adult attention deficit hyperactivity disorder (ADHD). Questions should be focused to elicit information about which problem?
a. Headaches
b. Inattention
c. Sexual impulses
d. Trichotillomania
ANS: B
Inattention usually persists from childhood into adult ADHD, although hyperactivity, impulsivity, and social impairments may also be present. Headaches would not be expected. Sexual impulses may be affected by adult ADHD, but this area is assessed later. Trichotillomania refers to pulling out one’s hair as a tension-relieving behavior.

DIF: Cognitive Level: Application (Applying) REF: Pages: 530-532
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

16. A nurse prepares a plan of care for a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which intervention should be included?
a. Remind the patient of priorities and deadlines.
b. Teach work-related skills such as basic computer literacy.
c. Establish penalties for failing to organize and prioritize tasks.
d. Give encouragement and strategies for managing and organizing.
ANS: D
The nurse’s major responsibilities lie with encouraging the patient to learn and use necessary skills, assisting the patient to stay on task. The nurse is not an ever-present taskmaster or disciplinarian. The nurse does not teach work-related skills; vocational staff members assume those types of tasks.

DIF: Cognitive Level: Application (Applying) REF: Pages: 532-533
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. The treatment team believes medication will help a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which class of medications does the nurse expect will be prescribed?
a. Benzodiazepines
b. Psychostimulants
c. Antipsychotics
d. Anxiolytics
ANS: B
Psychostimulants, such as methylphenidate and amphetamines, provide the basis for treatment of both adult and childhood ADHD. They are the most commonly used medications; therefore the nurse could expect the health care provider to prescribe a drug in this class. None of the other drugs listed as options have proved useful in the treatment of ADHD.

DIF: Cognitive Level: Application (Applying) REF: Pages: 532-533
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

18. An adult diagnosed with attention deficit hyperactivity disorder (ADHD) says, “I’ve always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I can’t keep a job.” The nurse managing care should consider:
a. aversive therapy to extinguish negative behaviors.
b. cognitive therapy to help address internalized beliefs.
c. group therapy to allow comparison of feelings with others.
d. vocational counseling to identify needed occupational skills.
ANS: B
Cognitive therapy and knowledge of ADHD will make it possible for the patient to reframe the past and present in a more positive and realistic light and to challenge internalized false beliefs about self. Aversive therapy would not be useful for the patient. Group therapy may be valuable later to allow for the testing of new coping behaviors in a safe environment. Vocational counseling can help the patient explore suitable career options while pursuing treatment.

DIF: Cognitive Level: Application (Applying) REF: Page: 533
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

19. A new staff nurse tells the clinical nurse specialist, “I’m unsure about my role when patients bring up sexual problems.” Which information should the clinical nurse specialist provide? All nurses:
a. qualify as sexual counselors. Each has knowledge about the biopsychosocial aspects of sexuality throughout the life cycle.
b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths.
c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality.
d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples.
ANS: B
The basic education of nurses provides information sufficient to qualify as a generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy require additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors; additional education is necessary. The registered nurse may provide basic information about sexual function, but complex questions may require referral.

DIF: Cognitive Level: Application (Applying) REF: Pages: 528-529
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

20. Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning?
a. Acquire knowledge of the patient’s sexual roles and preferences
b. Develop an understanding of human sexual responses
c. Assess the patient’s sexual functioning
d. Clarify the nurse’s own personal values
ANS: D
Before a nurse can be helpful to patients with sexual dysfunction, he or she must be aware of and comfortable with his or her own feelings about sex and sexuality. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure.

DIF: Cognitive Level: Application (Applying) REF: Pages: 528-529
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

21. A patient tells the nurse, “My sexual functioning is normal when my partner wears lace. Without it, I’m not interested in sex.” This comment evidences:
a. exhibitionism.
b. voyeurism.
c. pedophilia.
d. fetishism.
ANS: D
A person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality, to be sexually satisfied. Exhibitionism refers to exposing one’s genitalia publicly. Voyeurism refers to viewing others in intimate situations. Pedophilia refers to the preference for having sexual relations with a child.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 527
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

22. A man tells the nurse, “All my life, I have felt and acted like a woman while living in a man’s body. For the past year, I have lived and dressed as a woman. I changed jobs to protect my new identity.” Which request is the patient likely to make to the health care provider?
a. “Can you refer me for psychological testing?”
b. “Will you prescribe estrogen therapy?”
c. “Will you alter my medical records?”
d. “What should I tell my parents?”
ANS: B
Before sexual reassignment surgery, the step that follows living as a member of the other sex is hormone therapy. The patient’s decision to live as a woman makes this a natural request. Psychological testing occurs before sexual reassignment surgery, often after hormone therapy has begun. The patient has likely told his parents by this point.

DIF: Cognitive Level: Application (Applying) REF: Pages: 525-526
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

23. The manager of a health club put a hidden camera in the women’s locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident?
a. Frotteurism
b. Exhibitionism
c. Pedophilia
d. Voyeurism
ANS: D
Voyeurism is the viewing of others in intimate situations such as undressing, bathing, or having sexual relations. Voyeurs are often called “peeping Toms.” Frotteurism is touching or rubbing against a nonconsenting person to achieve sexual gratification. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with prepubescent children.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 527
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

24. Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is:
a. sympathy.
b. assertiveness training.
c. sexual self-awareness.
d. effective communication.
ANS: C
Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distractors are not prerequisites.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 528
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

25. An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior?
a. Voyeurism
b. Frotteurism
c. Exhibitionism
d. Sexual masochism
ANS: C
Exhibitionism is obtaining sexual pleasure from exposing one’s genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. Frotteurism is associated with obtaining sexual arousal by rubbing one’s genitals against an unsuspecting person. Sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 527
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

26. A nurse cares for a patient diagnosed with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors?
a. Selective serotonin reuptake inhibitor (SSRI)
b. Erectile dysfunction medication
c. Atypical antipsychotic medication
d. Mood stabilizer
ANS: A
SSRIs are reported to have a positive effect on paraphilia. The other medications are not indicated for this disorder.

DIF: Cognitive Level: Application (Applying) REF: Pages: 528-530
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

27. 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:
a. instilling hope.
b. controlling anxiety.
c. planning social activities.
d. developing personal autonomy.
ANS: D
Powerlessness is associated with feeling unable to control events in one’s life. It is often associated with low self-esteem. The goal is to increase one’s sense of autonomy. The scenario does not indicate hopelessness or anxiety. Socialization is not the primary need.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 516-521
TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. Which information should a nurse include in health teaching for adults diagnosed with attention deficit hyperactivity disorder (ADHD) and their significant others? Select all that apply.
a. Tendency for genetic transmission
b. Prevention strategies related to substance abuse
c. Negative reinforcement strategies to help modify behaviors
d. Selective serotonin reuptake inhibitors (SSRIs) are usually prescribed for hyperactivity
e. Cognitive therapy may help resolve internalized negative beliefs about self
ANS: A, B, E
Evidence suggests that ADHD has a biological basis. This fact can help adults with the disorder to cope with low self-esteem. Cognitive therapy is helpful in reframing negative beliefs about self. Adults diagnosed with ADHD have a higher incidence of substance abuse problems. Psychostimulant medications, rather than SSRIs, are usually prescribed.

DIF: Cognitive Level: Application (Applying) REF: Pages: 530-533
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

2. An adult patient tells the case manager, “I don’t have bipolar disorder anymore, so I don’t need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I’m bored and don’t have any friends.” Which resources should the nurse suggest for the patient? Select all that apply.
a. Psychoeducation classes
b. Vocational rehabilitation
c. Social skills training
d. Homeless shelter
e. Crisis intervention
ANS: A, B, C
The patient does not understand the illness and the need for adhering to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. Work gives meaning and purpose to life; vocational rehabilitation can assist with this aspect of care. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with severe mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking down the skill into small verbal and nonverbal components. The patient presently has a home and does not require the services of a homeless shelter. The nurse case manager functions in the role of crisis stabilizer, so no related referral is needed.

DIF: Cognitive Level: Application (Applying) REF: Pages: 519-522
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

3. Which economic factors are most critical to the success of discharge planning for a patient diagnosed with severe and persistent mental illness? Select all that apply.
a. Access to housing
b. Individual psychotherapy
c. Income to meet basic needs
d. Availability of health insurance
e. Ongoing interdisciplinary evaluation
ANS: A, C, D
The success of discharge planning requires careful attention to the patient’s economic status. Access to housing is the first priority of the seriously mentally ill, and lack of income and health insurance is a barrier to effective treatment and rehabilitation. Although important aspects of ongoing care of the seriously mentally ill patient, ongoing interdisciplinary evaluation and individual psychotherapy are not economic factors.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 516-522
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

4. Which statements most clearly indicate that the speaker views mental illness with stigma? Select all that apply.
a. “We are all a little bit crazy.”
b. “If people with mental illness would go to church, their problems would be solved.”
c. “Many mental illnesses are genetically transmitted. It’s no one’s fault that the illness occurs.”
d. “Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people.”
e. “People with mental illness are lazy. They get government disability checks instead of working.”
ANS: A, B, E
Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame.

DIF: Cognitive Level: Application (Applying) REF: Pages: 516-518
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment