Chapter 21: Impulse Control Disorders My Nursing Test Banks

Chapter 21: Impulse Control Disorders

MULTIPLE CHOICE

1. A 16-year-old diagnosed with a conduct disorder has been in a residential program for 3 months. Which outcome should occur before discharge?

a.

The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences.

b.

The adolescent identifies friends in the home community who are a positive influence.

c.

Temporary placement is arranged with a foster family until the parents complete a parenting skills class.

d.

The adolescent experiences no anger and frustration for 1 week.

ANS: A

The adolescent and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The adolescent will continue to experience anger and frustration. The adolescent and parents must continue with family therapy to work on boundary and communication issues. It is not necessary to separate the adolescent from the family to work on these issues. Separation is detrimental to the healing process. While it is helpful for the adolescent to identify peers who are a positive influence, its more important for behavior to be managed for an adolescent diagnosed with a conduct disorder.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 406 (Table 21-2) | Page 408 (Box 21-1) | Page 409

TOP: Nursing Process: Outcomes Identification

MSC: Client Needs: Psychosocial Integrity

2. A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the court, We cant manage our teenager. The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescents behavior?

a.

Attention deficit hyperactivity disorder (ADHD)

b.

Posttraumatic stress disorder (PTSD)

c.

Intermittent explosive disorder

d.

Conduct disorder

ANS: D

Conduct disorders are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. Criteria for ADHD and PTSD are not met in the scenario.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 402-403 (Table 21-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

3. A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic?

a.

Planned ignoring

c.

Neutrally permit refusals

b.

Establish firm limits

d.

Coaxing to gain compliance

ANS: B

Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teens thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, ignoring, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 406-408 (Box 21-1) | Page 409 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

4. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all attention on my brother, whos perfect in their eyes. Which type of therapy might promote the greatest change in the adolescents behavior?

a.

Family therapy

c.

Play therapy

b.

Bibliotherapy

d.

Art therapy

ANS: A

Family therapy focuses on problematic family relationships and interactions. The patient has identified problems within the family. Play therapy is more appropriate for younger patients. Art therapy and bibliotherapy would not focus specifically on the identified problem.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 407 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

5. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, I hate my parents. They focus all attention on my brother, whos perfect in their eyes. Which nursing diagnosis is most applicable?

a.

Disturbed personal identity related to acting out as evidenced by prostitution

b.

Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents

c.

Ineffective coping related to inappropriate methods of seeking parental attention as evidenced by acting out

d.

Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another

ANS: C

The patient demonstrates a failure to follow age-appropriate social norms and an inability to problem solve by using adaptive behaviors to meet lifes demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient never mentioned hopelessness or disturbed personal identity. The problem relates to the patients perceptions of parental behavior rather than the actual behavior.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 406 TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity

6. A 12-year-old has engaged in bullying for several years. The parents say, We cant believe anything our child says. Recently this child shot a dog with a pellet gun and set fire to a neighbors trash bin. The childs behaviors support the diagnosis of:

a.

attention deficit hyperactivity disorder.

b.

intermittent explosive disorder.

c.

defiance of authority.

d.

conduct disorder.

ANS: D

The behaviors mentioned are most consistent with criteria for conduct disorder, for example, aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. The behaviors are not consistent with attention deficit and are more pervasive than defiance of authority. See related audience response question.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 401-403 (Table 21-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

7. An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation.

a.

Ignore the childs behavior.

b.

Send the child to time-out.

c.

Accompany the child to the gym and shoot baskets.

d.

Role-play a more appropriate behavior with the child.

ANS: C

The childs behavior warrants an active response. Redirecting the expression of feelings into nondestructive age-appropriate behaviors, such as a physical activity, helps defuse the situation here and now. This response helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to a more restrictive measure. Role-playing is appropriate after the childs anger is defused.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 406-408 (Box 21-1) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

8. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a pool ball at another adolescent, which comment by the nurse would set appropriate limits?

a.

Attention everyone: we are all going to the craft room.

b.

You will be taken to seclusion if you throw that ball.

c.

Do not throw the ball. Put it back on the pool table.

d.

Please do not lose control of your emotions.

ANS: C

Setting limits uses clear, sharp statements about prohibited behavior and guidance for performing a behavior that is expected. The incorrect options represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the childs developing self-control that may be ineffective.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 406-408 (Box 21-1) | Page 409

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

9. The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the childs plan of care will be provided by an advanced practice nurse rather than a staff nurse?

a.

Leading an activity group

c.

Formulating nursing diagnoses

b.

Providing positive feedback

d.

Dialectical behavioral therapy (DBT)

ANS: D

The advanced practice nurse role includes individual, group, and family psychotherapist; educator of nurses, other professions, and the community; clinical supervisor; consultant to professional and nonprofessional groups; and researcher. Dialectical behavioral therapy (DBT) is an aspect of psychotherapy. The distracters describe actions of a nurse generalist.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 408-409 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

10. Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, Id rather stay in my room and listen to music. Its easier than thinking about what is happening in my family. Which nursing diagnosis is most applicable?

a.

Chronic low self-esteem related to role within the family

b.

Decisional conflict related to compliance with school requirements

c.

Ineffective coping related to adjustment to changes in family relationships

d.

Disturbed personal identity related to self-perceptions of changing family dynamics

ANS: C

Depression is often associated with impulse control disorder. The correct nursing diagnosis refers to the patients dysfunctional management of feelings associated with upcoming changes to the family. The teen displays self-imposed isolation. The distracters are not supported by data in the scenario.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 403-404 TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity

11. A child known as the neighborhood bully says, Nobody can tell me what to do. After receiving a poor grade on a science project, this child secretly loaded a virus on the teachers computer. These behaviors support a diagnosis of:

a.

conduct disorder.

b.

oppositional defiant disorder.

c.

intermittent explosive disorder.

d.

attention deficit hyperactivity disorder.

ANS: B

Oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Loading a virus is a vindictive behavior in retribution for a poor grade. Persons with conduct disorder are aggressive against people and animals; destroy property; are deceitful; violate rules; and have impaired social, academic, or occupational functioning. There is no evidence of explosiveness or distractibility.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 401 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

12. An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurses initial action to defuse the situation?

a.

Say to the child, Tell me how youre feeling right now.

b.

Take the child swimming at the programs pool.

c.

Establish a behavioral contract with the child.

d.

Administer an anxiolytic medication.

ANS: B

Redirecting the expression of feelings into nondestructive, age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to measures that are more restrictive. A shouting child will not likely engage in a discussion about feelings. A behavioral contract could be considered later, but first the situation must be defused.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 407-408 (Box 21-1) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

13. Parents of an adolescent diagnosed with a conduct disorder say, We dont know how to respond when our child breaks the rules in our house. Is there any treatment that might help us? Which therapy is likely to be helpful for these parents?

a.

Parent-child interaction therapy (PCIT)

b.

Behavior modification therapy

c.

Multi-systemic therapy (MST)

d.

Pharmacotherapy

ANS: A

In parent-child interaction therapy (PCIT), the therapist sits behind one-way mirrors and coaches parents through an ear audio device while they interact with their children. The therapist can suggest strategies that reinforce positive behavior in the adolescent. The goal is to improve parenting strategies and thereby reduce problematic behavior. Behavior modification therapy may help the adolescent, but the parents are seeking help for themselves. Multi-systemic therapy is much broader and does not target the parents need.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 409 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

14. An adolescent diagnosed with an impulse control disorder said, I just want to die. I spend all my time getting even with people who have done wrong to me. When asked about a suicide plan, the adolescent replied, Ill jump from the bridge near my home. My father threw kittens off that bridge, and they died because they couldnt swim. Rate the suicide risk.

a.

Absent

c.

Moderate

b.

Low

d.

High

ANS: D

The suicide risk is high. The child is experiencing feelings of hopelessness and helplessness. The method described is lethal, and the means to carry out the plan are available.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 404-405 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

15. An adolescent diagnosed with conduct disorder has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication?

a.

Second-generation antipsychotic

c.

Calcium channel blocker

b.

Anti-anxiety medication

d.

Beta-blocker

ANS: A

Medications for conduct disorder are directed at problematic behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms. Second-generation antipsychotics are likely to be prescribed. Beta-blocking medications may help to calm individuals with intermittent explosive disorder by slowing the heart rate and reducing blood pressure. Calcium channel blockers reduce blood pressure but are not used for persons with impulse control problems. An anti-anxiety medication will not assist with impulse control.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 407-408 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

16. An adolescent was recently diagnosed with oppositional defiant disorder. The parents say to the nurse, Isnt there some medication that will help with this problem? Select the nurses best response.

a.

There are no medications to treat this problem. This diagnosis is behavioral in nature.

b.

Its a common misconception that there is a medication available to treat every health problem.

c.

Medication is usually not prescribed for this problem. Lets discuss some behavioral strategies you can use.

d.

There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you.

ANS: C

The parents are seeking a quick solution. Medications are generally not indicated for oppositional defiant disorder. Comorbid conditions that increase defiant symptoms, such as attention deficit hyperactivity disorder, should be managed with medication, but no comorbid problem is identified in the question. The nurse should give information on helpful strategies to manage the adolescents behavior.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 407-409 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

17. An adolescent diagnosed with a conduct disorder stole and wrecked a neighbors motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescents reaction?

a.

Serotonin dysregulation and increased testosterone activity impair ones capacity for remorse.

b.

Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules.

c.

Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy.

d.

Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.

ANS: C

Adolescents with conduct disorder have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the amygdala. This reduction may be related to aggressive behavior and deficits of empathy. The less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. People with intermittent explosive disorder may have differences in serotonin regulation in the brain and higher levels of testosterone. Neuron destruction in the hippocampus is associated with memory deficits. The occipital lobe is involved with visual stimuli but not the processing of emotions.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 404 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

18. Which assessment findings support a diagnosis of oppositional defiant disorder?

a.

Negative, hostile, and spiteful toward parents. Blames others for misbehavior.

b.

Exhibits involuntary facial twitching and blinking; makes barking sounds.

c.

Violates others rights; cruelty toward people or animals; steals; truancy.

d.

Displays poor academic performance and reports frequent nightmares.

ANS: A

Oppositional defiant disorder is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. The distracters identify findings associated with conduct disorder, anxiety disorder, and Tourettes syndrome.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 401-402 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1. A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patients history support the suspected diagnosis? Select all that apply.

a.

Family history of mental illness

b.

Allergies to multiple antibiotics

c.

Long history of severe facial acne

d.

Father with history of alcohol abuse

e.

History of an abusive relationship with one parent

ANS: A, D, E

Parents who are abusive, rejecting, or overly controlling cause a child to suffer detrimental effects. Other stressors associated with impulse control disorders can include major disruptions such as placement in foster care, severe marital discord, or a separation of parents. Substance abuse by a parent is common. Acne and allergies are not aspects of the history that relate to the behavior.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 403-405 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

2. What are the primary distinguishing factors between the behavior of persons diagnosed with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? Select all that apply. The person diagnosed with:

a.

ODD relives traumatic events by acting them out.

b.

ODD tests limits and disobeys authority figures.

c.

ODD has difficulty separating from loved ones.

d.

CD uses stereotypical or repetitive language.

e.

CD often violates the rights of others.

ANS: B, E

Persons diagnosed with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas persons with conduct disorder frequently behave in ways that do violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are seen in persons with autism spectrum disorders.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 401-403 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

3. A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because: (select all that apply)

a.

it is a vital component of implementing a behavior modification program.

b.

a therapeutic alliance is the first step in a nurses therapeutic use of self.

c.

the adolescent has demonstrated resistance to other authority figures.

d.

acceptance and trust convey feelings of security for the adolescent.

e.

adolescents usually relate better to authority figures than peers.

ANS: B, D

Trust is frequently an issue because the adolescent may never have had a trusting relationship with an adult. Trust promotes feelings of security and is the basis of the nurses therapeutic use of self. Adolescents value peer relationships over those related to authority. Rewards for appropriate behavior are the main component of behavior modification programs.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 406-409 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

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