Test Bank for Psychiatric Mental Health Nursing 5th Ed By Fortinash

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Test Bank for Psychiatric Mental Health Nursing 5th Ed By Fortinash

 

 

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Fortinash: Psychiatric Mental Health Nursing, 5th Edition

 

Chapter 06: Neurobiology in Mental Health and Mental Disorder

 

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient with depression mentions to the nurse, “My mother says depression is a chemical disorder. What does she mean?” The nurse’s response is based on the theory that depression primarily involves which of the following neurotransmitters?
a. Cortisol and GABA
b. COMT and glutamate
c. Monamine and glycine
d. Serotonin and norepinephrine

 

ANS: D

One possible cause of depression is thought to involve one or more neurotransmitters. Serotonin and norepinephrine have been found to be important in the regulation of depression. There is no research to support that the other options play a significant role in the development of depression.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 104

TOP:  Nursing Process: Assessment        MSC: NCLEX: Physiological Integrity

 

  1. A patient has experienced a stroke (cerebral vascular accident) that has resulted in damage to the Broca area. Which evaluation does the nurse conduct to reinforce this diagnosis?
a. Observing the patient pick up a spoon
b. Asking the patient to recite the alphabet
c. Monitoring the patient’s blood pressure
d. Comparing the patient’s grip strength in both hands

 

ANS: B

Accidents or strokes that damage Broca’s area may result in the inability to speak (i.e., motor aphasia). Fine motor skills, blood pressure control, and muscle strength are not controlled by the Broca area of the left frontal lobe.

 

DIF:   Cognitive Level: Application        REF:  Page 100

TOP:  Nursing Process: Implementation  MSC: NCLEX: Physiological Integrity

 

  1. The patient diagnosed with schizophrenia asks why psychotropic medications are always prescribed by the doctor. The nurse’s answer will be based on information that the therapeutic action of psychotropic drugs is the result of their effect on:
a. The temporal lobe; especially Wernicke’s area
b. Dendrites and their ability to transmit electrical impulses
c. The regulation of neurotransmitters especially dopamine
d. The peripheral nervous system sensitivity to the psychotropic medications

 

ANS: C

Medications used to treat psychiatric disorders operate in and around the synaptic cleft and have action at the neurotransmitter level, especially in the case of schizophrenia, on dopamine. The Wernicke’s area, dendrite function, or the sensitivity of the peripheral nervous system are not relevant to either schizophrenia or psychotropic medications.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 104

TOP:  Nursing Process: Assessment        MSC: NCLEX: Physiological Integrity

 

  1. A student nurse mutters that it seems entirely unnecessary to have to struggle with understanding the anatomy and physiology of the neurologic system. The mentor would base a response on the understanding that it is:
a. Necessary but generally for psychiatric nurses who focus primarily on behavioral interventions
b. A complex undertaking that advance practice psychiatric nurses frequently use in their practice
c. Important primarily for the nursing assessment of patients with brain trauma–caused cognitive symptoms
d. Necessary for planning psychiatric care for all patients especially those experiencing psychiatric disorders

 

ANS: D

Nurses must understand that many symptoms of psychiatric disorders have a neurologic basis, although the symptoms are manifested behaviorally. This understanding facilitates effective care planning. The foundation of knowledge is not used exclusively by advanced practice psychiatric nurses nor is it relevant for only behavior therapies or brain trauma since dealing with the results of normal and abnormal brain function is a responsibility of all nurses providing all types of care to the psychiatric patient.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 98          TOP:  Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

 

  1. A patient asks the nurse, “My wife has breast cancer. Could it be caused by her chronic depression?” Which response is supported by research data?
a. “Too much stress has been proven to cause all kinds of cancer.”
b. “There have been no research studies done on stress and disease yet.”
c. “Stress does cause the release of factors that suppress the immune system.”
d. “There appears to be little connection between stress and diseases of the body”

 

ANS: C

Research indicates that stress causes a release of corticotropin-releasing factors that suppress the immune system. Studies indicate that psychiatric disorders such as mood disorders are sometimes associated with decreased functioning of the immune system. Research does not support a connection between many cancers and stress. There is a significant amount of research about stress and the body. Research has shown that there are some connections between stress and physical disease.

 

DIF:   Cognitive Level: Application        REF:  Page 107

TOP:  Nursing Process: Implementation (Teaching and Learning)

MSC: NCLEX: Psychosocial Integrity; Physiological Integrity

 

  1. A patient who has a parietal lobe injury is being evaluated for psychiatric rehabilitation needs. Of the aspects of functioning listed, which will the nurse identify as a focus of nursing intervention?
a. Expression of emotion
b. Detecting auditory stimuli
c. Receiving visual images
d. Processing associations

 

ANS: D

The parietal lobe is responsible for associating and processing sensory information that allows for functions such as following directions on a map, reading a clock, dressing self, keeping appointments, and distinguishing right from left. Emotional expression is associated with frontal lobe function. Detecting auditory stimuli is a temporal lobe function. Receiving visual images is related to occipital lobe function.

 

DIF:   Cognitive Level: Application        REF:  Page 101        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

  1. At admission, the nurse learns that some time ago the patient had an infarct in the right cerebral cortex. During assessment, the nurse would expect to find that the patient:
a. Demonstrates major deficiencies in speech
b. Is unable to effectively hold a spoon in the left hand
c. Has difficulty explaining how to go about using the telephone
d. Cannot use his right hand to shave himself or comb his own hair

 

ANS: B

The cerebral hemispheres are responsible for functions such as control of muscles. The right hemisphere mainly controls the motor and sensory functions on the left side of the body. Damage to the right side would result in impaired function on the left side of the body. The motor cortex controls voluntary motor activity. Broca’s area controls motor speech. Cognitive functions are attributed to the association cortex. The right side of the body’s motor activity is controlled by the left cerebral cortex.

 

DIF:   Cognitive Level: Application        REF:  Page 99

TOP:  Nursing Process: Assessment        MSC: NCLEX: Physiological Integrity

 

  1. A patient with chronic schizophrenia had a stroke involving the hippocampus. The patient will be discharged on low doses of haloperidol. The nurse will need to individualize the patient’s medication teaching by:
a. Including the patient’s caregiver in the education
b. Being careful to stress the importance of taking the medication as prescribed
c. Providing the education at a time when the patient is emotionally calm and relaxed
d. Encouraging the patient to crush or dissolve the medication to help with swallowing

 

ANS: A

The hippocampus plays a major role in short-term memory and, hence, in learning. Taking the medication as prescribed and providing the education at a time when the patient is calm and relaxed is information or considerations that all patients should be given. The medication does not necessarily need to be crushed or dissolved since the stroke would not have caused difficulty with swallowing.

 

DIF:   Cognitive Level: Application        REF:  Page 102        TOP:  Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

 

  1. The physician tells the nurse, “The medication I’m prescribing for the patient enhances the g-aminobutyric acid (GABA) system.” Which patient behavior will provide evidence that the medication therapy is successful?
a. The patient is actively involved in playing cards with other patients.
b. The patient reports that, “I don’t feel as anxious as I did a couple of days ago.”
c. The patient reports that both auditory and visual hallucinations have decreased.
d. The patient says that, “I am much happier than before I came to the hospital.”

 

ANS: B

GABA is the principle inhibitory neurotransmitter. The medication should provide an antianxiety effect. Alertness, psychotic behaviors, and mood elevation are not generally affected by g-aminobutyric acid.

 

DIF:   Cognitive Level: Application        REF:  Page 105        TOP:  Nursing Process: Evaluation

MSC: NCLEX: Psychosocial Integrity

 

  1. The patient’s family asks whether a diagnosis of Parkinson’s disease creates an increased risk for any mental health issues. What question would the nurse ask to assess for such a comorbid condition?
a. “Has your father exhibited any signs of depression?”
b. “Does your father seem to experience mood swings?”
c. “Have you noticed your father talking about seeing things you can’t see?”
d. “Is your dad preoccupied with behaviors that he needs to repeat over and over?”

 

ANS: A

Serotonin and its close chemical relatives, dopamine and norepinephrine, are the neurotransmitters that are most widely involved in various forms of depression. Most researchers agree that the immediate cause of parkinsonism is a deficiency of dopamine and so a patient with Parkinson’s disease should be monitored for depression, The other mental health disorders (bipolar disorder, hallucinations, and obsessive compulsive disorder) have not been connected to Parkinson’s disease.

 

DIF:   Cognitive Level: Analysis             REF:  Pages 106-107

TOP:  Nursing Process: Assessment

MSC: NCLEX: Psychosocial Integrity; Physiological Integrity

 

  1. Which explanation for the prescription of donepezil (Aricept) would the nurse provide for a patient in the early stage of Alzheimer’s disease?
a. It will increase the metabolism of excess GABA.
b. Excess dopamine will be prevented from attaching to receptor sites.
c. Serotonin deficiency will be managed through a prolonged reuptake period.
d. The acetylcholine deficiency will be managed by inhibiting cholinesterase.

 

ANS: D

Decreased levels of acetylcholine are thought to produce many of the behavioral symptoms of Alzheimer’s disease. The inhibiting action the drug has on cholinesterase will slow down the breakdown of acetylcholine and so delay the onset of symptoms. The other neurotransmitters (GABA, dopamine, and serotonin) are not currently believed to play a role in Alzheimer’s disease.

 

DIF:   Cognitive Level: Application        REF:  Page 107

TOP:  Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity; Psychosocial Integrity

 

  1. There remains a stigma attached to psychiatric illnesses. The psychiatric nurse makes the greatest impact on this sociological problem when:
a. Providing educational programming for patients and the public
b. Arranging for adequate and appropriate social support for the patient
c. Assisting the patient to achieve the maximum level of independent functioning
d. Regularly praising the patient for seeking and complying with appropriate treatment

 

ANS: A

Much of the stigma attached to psychiatric illness is due to a lack of understanding of the biologic basis of these disorders. Therefore, effective patient, family, and public teaching is an important function of the role of the psychiatric mental health nurse. While the remaining options are appropriate, they are not directed towards eliminating social stigma but rather empowering the patient.

 

DIF:   Cognitive Level: Comprehension  REF:  Page 112        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

 

  1. The wife of a patient with paranoid schizophrenia tells the nurse, “I’ve learned that my husband has several close relatives with the same disorder. Does this problem run in families?” The response based on recent discoveries in the field of genetics would be:
a. “Your children should be monitored closely for the disorder.”
b. “Research tends to support a familiar tendency to schizophrenia.”
c. “There is no concrete evidence; it is just as likely a coincidence.”
d. “Only bipolar disorder has been identified to have a genetic component.”

 

ANS: B

Familial tendencies appear with several psychiatric disorders including schizophrenia. To insinuate that the children are at such risk would not be supported by research.

 

DIF:   Cognitive Level: Application        REF:  Page 108

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

  1. A patient whose symptoms of mild depression have been managed with antidepressants is concerned about the affect of accepting a promotion that will require working the night shift. What will be the basis of the response the nurse gives to address the patient’s concern?
a. The connection between a new job and possible depression does exist.
b. The medication can be adjusted to manage any increase in depression.
c. The interruption in normal wake-sleep patterns can influence mood disorders.
d. The change in sleep routine can be managed with a healthy sleep hygiene routine.

 

ANS: C

Many psychiatric and medical disorders occur more frequently or are exacerbated when sleep patterns and biologic rhythms are disrupted. While the remaining options contain true information regarding the management of depression that is a result of sleep disruption, they do not effectively address the patient’s concern.

 

DIF:   Cognitive Level: Application        REF:  Page 108        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity; Physiological Integrity

 

  1. The nurse is discouraged because the patient exhibiting negative symptoms of schizophrenia has shown no improvement with the planned interventions to reduce the symptoms. The mentor’s remark that helps place the problem in perspective is:
a. “You aren’t responsible for the behavior of any other person.”
b. “Patients can be perverse and cling to symptoms despite our efforts.”
c. “Negative symptoms have been associated with genetic pathology.”
d. “It will take several ‘trail and error’ attempts to get the right combination care.”

 

ANS: C

A complex disorder, such as schizophrenia, most likely has multiple contributing factors, including genetic predisposition, prenatal development, and the environment. Nurse frustration can be alleviated by helping the nurse realize that negative symptoms may be the result of actual brain dysfunction, rather than psychologically determined behaviors; thus the remaining options are not appropriate since they do not address the complexity of the problem.

 

DIF:   Cognitive Level: Application        REF:  Page 106

TOP:  Nursing Process: Implementation  MSC: NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. What assessment data would reinforce the diagnosis of temporal lobe injury in patient who experienced head trauma? Select all that apply.
a. Inability to balance a checkbook
b. Uncharacteristically aggressive
c. Affect fluctuates dramatically
d. Increased interest in sexual behaviors
e. Difficulty remembering the names of family members

 

ANS: C, D, E

The temporal lobe is involved with memory as well as increased sexual focus and altered emotional responses. Personality and intellectual function is not centered in the temporal lobe.

 

DIF:   Cognitive Level: Application        REF:  Page 101

TOP:  Nursing Process: Assessment        MSC: NCLEX: Physiological Integrity

 

  1. A patient has begun experiencing dysfunction of the hypothalamus. What nursing interventions will the nurse include in the patient’s plan of care? Select all that apply.
a. Reinforcing clear physical boundaries
b. Assisting the patient with completing daily menus
c. Learning about healthy sleep hygiene habits
d. Monitoring and recording temperature every 4 hours
e. Monitoring and recording blood pressure every 4 hours

 

ANS: B, C, D

The hypothalamus is responsible for regulation of sleep-rest patterns, body temperature, and physical drives of hunger. Social appropriateness and blood pressure is not controlled by the hypothalamus.

 

DIF:   Cognitive Level: Analysis             REF:  Page 102        TOP:  Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

 

  1. The nurse is preparing a patient for a positron emission tomography (PET) scan. Which instructions will the nurse include? Select all that apply.
a. There will likely be a 30 to 45 minute wait between the injection and the beginning of the scan.
b. A blindfold and earplugs may be used to help decrease reaction to the environment during the scan.
c. Make every attempt to lie still during the scan because movement will affect the imaging produced.
d. No food or fluids are to be ingested for at least 8 full hours before the scan and none during the scan.
e. Staying awake during the scan is important since the results are altered when the patient is in any phase of the sleep state.

 

ANS: A, B, C, E

Appropriate patient preparation for a PET scan would include information regarding the time interval between injection of the isotope and the actual scan, the fact that steps will be taken to minimize the effects of sights and sounds during the scan, lying still is critical to achieving a quality image, and that being asleep during the scan will alter the results. It is not necessary to fast before or during the scan.

 

DIF:   Cognitive Level: Application        REF:  Page 110

TOP:  Nursing Process: Implementation  MSC: NCLEX: Physiological Integrity

 

  1. A patient with schizophrenia is described as “having difficulty with executive functions.” What patient dysfunction can the nurse expect to assess behaviorally? Select all that apply.
a. Invades the personal space of others frequently
b. Consistently fails to bring money when going to buy snacks
c. Cannot remember the names of staff who often provide care
d. Requires repeated reinforcement on how to make a sandwich
e. Frequently speaks of hurting himself or of hurting other patients

 

ANS: A, B, D

Executive functions include reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgment, focusing on tasks, responding to social cues, and attending in appropriate ways to incoming stimuli. Memory is not considered an executive function and risk for harm to self and others is not generally a diagnosis appropriate for such a patient.

 

DIF:   Cognitive Level: Application        REF:  Page 100

TOP:  Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

 

 

 

  1. The unit physicians have ordered magnetic resonance imaging (MRI) tests for the following patients. For which patients would the nurse decline to make test arrangements without further discussion with the physician? Select all that apply.
a. A patient who is claustrophobic
b. A patient who is breastfeeding
c. A patient who has an allergy to iodine
d. A patient who had a total knee replacement
e. A patient who is taking a neuroleptic medication

 

ANS: A, D

Patients with claustrophobia are often unable to complete this type of study, because the MRI machine is enclosed, and patients are required to remain motionless. Metal implants are contraindications for MRIs since metal affects the scan. Breastfeeding, iodine sensitivity, and neuroleptic medication therapy are not contraindications for an MRI.

 

DIF:   Cognitive Level: Application        REF:  Page 111

TOP:  Nursing Process: Assessment        MSC: NCLEX: Physiological Integrity

 

Fortinash: Psychiatric Mental Health Nursing, 5th Edition

 

Chapter 07: Human Development Across the Life Span

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse leading parent education classes bases instruction on Erikson’s developmental stages. It follows that the nurse will plan to instruct the parents that a helpful strategy to foster a child’s initiative would be to:
a. Offer several different options for dressing and encourage the child to select one of them.
b. Allow the child to help wash the unbreakable dishes used to serve breakfast.
c. Provide one-on-one parent–child time each evening before bed.
d. Enroll the child in a weekend, age-appropriate sports program.

 

ANS: B

This strategy will allow the child to demonstrate initiative by washing dishes without worrying about breakage. Making clothes selections is a strategy related to development of autonomy. Providing one-on-one time promotes trust. Age appropriate sports program is related to competence.

 

DIF:   Cognitive Level: Application        REF:  Page 117        TOP:  Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

 

  1. Which of the following responses would the nurse expect from a 12-year-old regarding stealing?
a. “You are never allowed to steal.”
b. “You go to jail is you steal someone else’s things.”
c. “My parents would punish me if I was caught stealing.”
d. “Stealing food when you don’t have anything to eat is alright.”

 

ANS: D

Before the ages of 10 or 11 years, children consider moral dilemmas differently from older children. For younger children, rules are absolute and come from an authority figure. Older children learn that rules are changeable in certain situations. According to Piaget, younger children base moral judgment on consequences, whereas older children base judgment on motives.

 

DIF:   Cognitive Level: Application        REF:  Page 121

TOP:  Nursing Process: Assessment

MSC: NCLEX: Health Promotion and Maintenance, Health Promotion and Maintenance

 

 

  1. A nursing diagnosis of hopelessness would be considered for an individual who:
a. Was consistently overprotected by family members
b. Was raised by parents who were strict disciplinarians
c. Had inconsistent, unpredictable physical care as an infant
d. As a teenager always felt unaccepted by his social peers

 

ANS: C

A sense of hope is the outcome of Erikson’s stage of trust versus mistrust. Inconsistent, unpredictable, and discontinuous care would lead to hopelessness and to a mistrust of self and the world. No data are given to support any of the other diagnoses.

 

DIF:   Cognitive Level: Application        REF:  Page 117

TOP:  Nursing Process: Nursing Diagnosis

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. An adolescent has been a consistently, poor academic student due to a learning disorder. Which statement overheard by the nurse would support the possibility of a problem with the developmental stage competence versus inferiority?
a. “It’s too hard to get good grades.”
b. “I’ll never be able to get into a good college.”
c. “My parents are disappointed that I do so poorly in school.”
d. “I don’t want people to know I can barely read or write.”

 

ANS: B

According to Erikson and the stage of competence versus inferiority, during school years (6 to 12 years of age), children gain new knowledge, learn new skills, and grow more competent. If they lack successes in learning or productivity, children may develop a sense of inferiority. The other options reflect problems with autonomy and guilt.

 

DIF:   Cognitive Level: Application        REF:  Page 117

TOP:  Nursing Process: Assessment

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. A parent is concerned with the interpersonal skills of her 12-year-old son. Based on interpersonal theory, the nurse asks:
a. “Does your son belong to team or club with friends or classmates?”
b. “Does he feel bad when he does something he knows he shouldn’t do?”
c. “How does he tend to act when he doesn’t get exactly what he wants?”
d. “How confident is he in situations that are generally unfamiliar for him?”

 

ANS: A

According to Sullivan, the expected development of the preadolescent permits him or her to work with peers toward a common goal and to develop a sense of “oneness.” Development of a social conscience is not related to interpersonal skill development. Coping with frustration develops in late adolescence. Confidence is suggested as a developmental issue of 12- to 18-year-olds in Erikson’s model.

 

DIF:   Cognitive Level: Application        REF:  Page 118

TOP:  Nursing Process: Outcome Identification

MSC: NCLEX: Health Promotion and Maintenance

 

  1. The parents of an 8-year-old are attempting to help their child comprehend new information. Which intervention suggested by the nurse shows an understanding of the cognitive development theory for this age group?
a. The use of drawing and illustrations
b. Comparing the child’s experiences to the new material
c. Encouraging the child to talk about this new information
d. Asking the child to give a reason for how they feel about new information

 

ANS: B

Comparing a known to an unknown will help this age group understand new information. Drawings and illustration as well as talking about new information are effective methods for the younger aged child. Providing rationales is too advanced for this age group.

 

DIF:   Cognitive Level: Application        REF:  Page 119        TOP:  Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

 

  1. According to Piaget, which of the following would the nurse consider normal when assessing a 6-year-old?
a. Playing with an “imaginary friend”
b. Talking about their “best friend”
c. Enjoying putting puzzles together
d. Knowing its wrong to tell a lie

 

ANS: A

Preoperational stage (2-7 years) children begin to exhibit pretend play. The need to make friends and the development of a conscious are observed in the concrete operations stage (7-11 years). The ability to problem solve is seen in the formal operations stage (11-16 years).

 

DIF:   Cognitive Level: Application        REF:  Page 118

TOP:  Nursing Process: Assessment        MSC: NCLEX: Health Promotion and Maintenance

 

  1. Which developmental level would be characterized by a child being able to focus, to coordinate, and to imagine a series of events?
a. Preoperational
b. Concrete operational
c. Formal operational
d. Postoperational

 

ANS: B

In the concrete operational level, the child can focus and coordinate and imagine a series of events. In the preoperational stage, the child is unable to relate two classifications at one time and is present-oriented. At the formal operations level, the child can think abstractly and in future orientation. Postoperational is not a stage of cognitive development.

 

DIF:   Cognitive Level: Application        REF:  Page 118

TOP:  Nursing Process: Assessment        MSC: NCLEX: Health Promotion and Maintenance

 

  1. Which strategy will the nurse include in the plan of care for a 6-year-old child for whom operant conditioning has been recommended?
a. Periodically asking the child to attempt to solve increasingly difficult puzzles
b. Consistently offering praise when the child puts his dirty clothes in the hamper
c. Expecting the child to rinse and to place his dirty dishes in the sink
d. Conditioning the child to expect punishment when he misbehaves

 

ANS: B

A 6-year-old can learn to comply with requests when adults reinforce compliance with positive reinforcement. The remaining options do not reinforce compliance but rather state expectations.

 

DIF:   Cognitive Level: Application        REF:  Page 120        TOP:  Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. A child who has been physically abused becomes emotionally distorted when told that the parent will no longer be allowed to visit. Which principle of social learning theory is most likely for the child’s response?
a. The child views the abuse to be more desirable than the parent leaving.
b. The parent has fostered a fear in the child that increases when they are apart.
c. The child believes that he is responsible for the parent now being punished.
d. The parent has likely told the child that he deserved the abuse as a punishment.

 

ANS: A

Social theory states that reinforcement value is subjective and influenced by past experiences. For most children, parental punishment is a negative outcome with low reinforcement value. However, for some children who suffer from parental abuse, the abuse has a high reinforcement value, because it is more desirable than abandonment. The remaining options are not supported by the social theory.

 

DIF:   Cognitive Level: Application        REF:  Page 120

TOP:  Nursing Process: Assessment

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

 

 

  1. Which nursing intervention supports the principles on which the cross-links theory of aging is based?
a. Applying an elastin sustaining moisturizer to an adult patient’s skin
b. Assessing a patient’s family history for genetic diseases and disorders
c. Questioning a patient regarding long-term exposure to environmental toxins
d. Assisting an adult patient is selecting foods that are high in vitamins A, C, and E

 

ANS: A

Cross-links form in elastin in connective tissue. Elastin is similar to collagen in that it maintains tissue flexibility and permeability. The effects of cross-linking in elastin fibers are most pronounced in the changes that occur in facial skin with aging. Skin becomes brittle, dry, and saggy, and it appears translucent. Applying appropriate moisturizes helps minimize the effects. Genetic history is relevant to the genetic theory of aging. Exposure to environmental toxics applies to the biological theory of aging. Vitamin A, C, and E consumption related to the free-radical theory of aging.

 

DIF:   Cognitive Level: Application        REF:  Page 128        TOP:  Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance

 

  1. The nurse determines that a patient is showing a decline in explicit memory. Which characterizes such a deficiency?
a. Inability to remember how to operate a common kitchen appliance
b. Difficulty remembering the name of a place visited 20 years ago
c. Being unsuccessful at retaining new information
d. Forgetting the ingredients of a favorite recipe

 

ANS: B

Explicit memory, which is the ability to recall a specific name or place, tends to decline with aging. Working memory, which is the type of memory that is needed to perform daily activities, does not show an aging decline.

 

DIF:   Cognitive Level: Analysis             REF:  Page 133

TOP:  Nursing Process: Assessment        MSC: NCLEX: Psychosocial Integrity

 

  1. A patient is experiencing distress with midlife transition. Which statement provides support that the patient is successfully managing this stressor?
a. “I won’t give up on my dream to be rich.”
b. “Being rich doesn’t necessarily make a person happy.”
c. “I’ll never be rich but I can save enough to live comfortably.”
d. “I wasn’t being realistic when I set being rich as my life’s goal.”

 

ANS: C

The midlife transition occurs between the ages of 40 and 45 years. Individuals face the realization that the failure to accomplish all of life’s goals leads first to disappointment and then to the reformulation of earlier goals. The remaining options do not show a reforming of original goals.

 

DIF:   Cognitive Level: Application        REF:  Page 124        TOP:  Nursing Process: Evaluation

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. According to Maslow’s hierarchy of needs, the nursing strategies a psychiatric nurse would use to assist in meeting self-esteem needs of elderly patients would include:
a. Providing privacy when spouses are visiting
b. Arranging for the spouses to dine with the patients when visiting
c. Including both the patients and spouses in all educational sessions
d. Attending to patient hygiene and dress in preparation for spousal visits

 

ANS: D

Promoting an attractive physical appearance will assist patients in meeting the need for self-esteem. Patients receive positive feedback when appearance is attractive. The remaining options are not directly focused on self-esteem but rather belonging and safety.

 

DIF:   Cognitive Level: Application        REF:  Page 124

TOP:  Nursing Process: Implementation  MSC: NCLEX: Health Promotion and Maintenance

 

  1. A patient is involved in a smoking cessation program that encourages self-control therapy interventions. Which intervention would the nurse suggest to this patient?
a. Limiting the act of smoking to certain times of the day
b. Keeping a behavioral diary that tracks when the patient smokes
c. Identifying the factors that initially encouraged the patient to start smoking
d. Making plans that involve spending the money saved when the smoking stops

 

ANS: B

Self-control therapy is based on self-regulation concepts, for example, keeping track of one’s smoking behaviors with the use of a behavioral diary helps to identify cues associated with the habit. Taking steps to then remove or avoid some of the cues is a way to alter the environment. The remaining options are more reflective of behavior modification therapy.

 

DIF:   Cognitive Level: Application        REF:  Page 121        TOP:  Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. A 70-year-old male has the nursing diagnosis situational low self-esteem related to forced retirement. Using Maslow’s hierarchy of human needs, the nurse is confident the patient is meeting the outcome of experiencing self-worth when the patient:
a. Moves to a secure apartment building
b. Exercises regularly with friends at the gym
c. Attends his grandchildren’s school functions
d. Volunteers at the local homeless shelter each week

 

ANS: C

Feelings of worth, self-confidence, and adequacy are desired outcomes for a patient with low self-esteem. Security is associated with Maslow’s need for safety and security and would be an appropriate outcome for a patient experiencing fear. Self-fulfillment is related to self-actualization needs and might be associated with a wellness diagnosis. Acceptance is related to love and belonging needs and could be associated with a social isolation diagnosis.

 

DIF:   Cognitive Level: Application        REF:  Page 124        TOP:  Nursing Process: Evaluation

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. The spouse of a patient recently diagnosed with early stage Alzheimer’s disease asks, “

Is there anything I can do to help delay the progression of this disease?” Which strategy has the greatest potential for preserving the protective abilities of immune cells related to the disease?

a. Minimize contact with the public during cold and flu season.
b. Enroll the patient in an exercise program that meets regularly.
c. Provide supplements to enhance the patient’s immune system.
d. Identify creative ways to keep the patient mentally challenged.

 

ANS: D

Research has demonstrated links between creative activities and the consequential positive feelings with the increased production of protective immune cells. Creativity is also possibly linked to delaying the onset of Alzheimer’s disease. Continually challenging oneself mentally is a way to build up reserves of neurologic structures and connections. The remaining options, although related to the immune system, are more directly focused on the physical affects rather than the cognitive ones.

 

DIF:   Cognitive Level: Application        REF:  Page 138        TOP:  Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. A nurse is using Piaget’s model to assess a child’s developmental stage. Which behaviors would determine that a child is successfully achieving the skills required of the formal operations level of development? Select all that apply.
a. Becomes sad when the family pet dies
b. Plans a trip to attend a basketball game
c. Identifies two different bowls that hold 1 cup
d. Selects the appropriate clothing for a ski trip
e. Enjoys solving “what if” types of word problems

 

ANS: B, D, E

The formal operations level includes the ability for future thinking and for problem-solving complex issues. The remaining options reflect concrete operations level abilities.

 

DIF:   Cognitive Level: Analysis             REF:  Page 119        TOP:  Nursing Process: Evaluation

MSC: NCLEX: Health Promotion and Maintenance

 

  1. The nurse is assessing a child according to Kohlberg’s developmental theory. Which statement would support the belief the child is showing appropriate behaviors of the pre-conventional state? Select all that apply.
a. “If I pick up my toys, can I get an ice cream cone?”
b. “I can’t watch cartoons when I don’t pick up my toys.”
c. “I always pick up my toys because mommy needs my help.”
d. “When I pick up all of my toys I make mommy very happy.”
e. “If I don’t pick up my toys, mommy could trip on them and fall.”

 

ANS: A, B, E

The pre-conventional stage (4-10 years) involves a punishment-obedience orientation as well as an instrumental relativist orientation. The remaining options are reflective of a higher level of development.

 

DIF:   Cognitive Level: Analysis             REF:  Page 121

TOP:  Nursing Process: Assessment        MSC: NCLEX: Health Promotion and Maintenance

 

  1. Which activities should the nurse evaluate in an assessment of an older patient’s functional status? Select all that apply.
a. Possessing the ability to prepare nutritious meals independently
b. Having the financial resources available to live independently
c. Performing regular, simple maintenance on their primary residence
d. Effectively toileting themselves for both bowel and bladder elimination
e. Safely moving around their residence without an increased risk for falls

 

ANS: A, D, E

Functional assessment usually consists of evaluating two areas. The first area, ADLs, includes categories of personal care such as bathing, grooming, toileting, and transferring. The second area, IADLs, addresses activities that are important for the individual to be able to function in the community. IADLs include shopping, preparing meals, and getting around. Financial resources and maintenance skills are not included in such an assessment.

 

DIF:   Cognitive Level: Application        REF:  Page 131

TOP:  Nursing Process: Assessment

MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance

 

 

  1. Which older adult patient’s medical conditions appear to support the hypothesis upon which the immunologic theory of aging is based? Select all that apply.
a. Has, at age 64, been diagnosed with type 2 diabetes
b. Has been treated for multiple sclerosis since age 30
c. Is managing a 36-year history of chronic Graves’ disease
d. Has begun to experience symptoms of rheumatoid arthritis
e. Is experiencing a flare up of celiac disease, which was diagnosed at age 26

 

ANS: A, D

Immune function significantly declines with aging. Rheumatoid arthritis and mature-onset diabetes are two diseases that are commonly experienced during older age that are caused by alterations to the immune system. Although the remaining options reflect disease processes associated with the immune system, they manifested in early adulthood.

 

DIF:   Cognitive Level: Application        REF:  Page 128

TOP:  Nursing Process: Assessment

MSC: NCLEX: Psychosocial Integrity, Health Promotion and Maintenance

 

  1. The nurse manages the care for several older adult patients. Which strategies shows an understanding of the effects of aging on cognitive function? Select all that apply.
a. Allowing ample time for completion of patient activities
b. Breaking complicated patient activities into single tasks
c. Planning patient activities that can be completed rather quickly
d. Excluding complex problem-solving patient activities in the daily routine
e. Planning for complex patient activities to be introduced early in the day

 

ANS: A, B, C

With aging, the ability to maintain the attention span through the completion of complex tasks diminishes. Another segment of attention that shows some decrements with aging is vigilance, which is the ability to sustain attention over longer periods of time. Increased reaction time that results in decreased speed of performance is an obvious change that occurs with normal aging. Problem-solving ability is a higher cognitive function. There is little knowledge regarding normal changes in higher cognitive functioning during aging and so the remaining options are not based on evidenced-based practice.

 

DIF:   Cognitive Level: Analysis             REF:  Page 133        TOP:  Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance, Psychosocial Integrity

 

  1. According to most biological theories of aging, predisposing factors create the affects seen in aging. Which behaviors are considered predisposing factors regarding aging? Select all that apply.
a. Diagnosis of a chronic genetic disease
b. Lack of healthy diet and regular exercise
c. Family history of several different cancers
d. Occupation that involved working with toxins
e. Radiation exposure from numerous diagnostic studies

 

ANS: A, C, D, E

One method of classifying biologic theories of aging relates to categorizing predisposing factors as intrinsic or extrinsic to the organism. Intrinsic or genetic theories focus on the process of aging as internal to the organism. Certain genetic diseases, including several types of cancers and high-cholesterol syndromes that lead to heart disease, have a negative impact on life expectancy. Extrinsic or nongenetic theories propose that aging occurs as a result of environmental factors that act on the organism, such as radiation, ozone, drugs, and toxic substances which, researchers have theorized, damage cellular structures, thereby leading to aging and death. Diet and exercise are not considered either intrinsic or extrinsic factors to biological theories of aging.

 

DIF:   Cognitive Level: Application        REF:  Page 128

TOP:  Nursing Process: Assessment

MSC: NCLEX: Health Promotion and Maintenance, Physiological Integrity: Physiological Adaptation

 

  1. The nurse is preparing to educate a group of middle-aged adults on longevity strategies. Which behaviors would the nurse stress? Select all that apply.
a. Having warm and caring people in your life
b. Engaging in age-appropriate exercise on a regular basis
c. Accepting the fact that aging negatively impacts your life
d. Seeking help if changes of aging cause depression or anxiety
e. Avoiding retirement for as long as possible in order to keep active

 

ANS: A, B, D

A Harvard study identified factors of middle adulthood that promote longevity and include experiencing a warm and caring relationships, having effective adaptive or coping strategies, and getting adequate exercise. Aging does not necessarily affect life negatively and there are numerous ways to remain both physical and mentally active after retirement.

 

DIF:   Cognitive Level: Application        REF:  Pages 124-125

TOP:  Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation , Health Promotion and Maintenance

 

  1. A nurse is working with a group of older adults attending a seminar on the physical and emotional effects of aging. Which patient statements are good predictors of positive well being and perceived mortality? Select all that apply.
a. Being “satisfied with growing older”
b. Feeling “younger than my birthdays say I should”
c. Retirement “gives me time to do the things I’ve put off doing.”
d. Not having “to deal with the stress of any major chronic illnesses”
e. “At least I don’t have to worry about having enough money to retire.”

 

ANS: A, B, C

A research study of more than 400 older adults between the ages of 70 and 100 examined how satisfaction with aging is an indicator of positive well-being and possible predictor of death. Researchers found that feeling older and being dissatisfied with how one is aging are related to an increased mortality risk over time. Persons who were satisfied with their aging or who felt “younger than their years” generally had longer survival. Self-perception of aging predicted mortality even after controlling for known mortality predictors such as illness, old age, gender, and socioeconomic status.

 

DIF:   Cognitive Level: Application        REF:  Page 125

TOP:  Nursing Process: Assessment

MSC: NCLEX: Health Promotion and Maintenance, Physiological Adaptation