Chapter 26 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 26

Question 1

Type: MCSA

The nurse utilizes a sound theoretical knowledge base about adolescent growth and development to:

1. Integrate truth and fiction.

2. Differentiate between normal and abnormal.

3. Assess cognitive abilities.

4. Incorporate good and evil.

Correct Answer: 2

Rationale 1: A sound theoretic knowledge base is needed to assist with differentiating between the normal and abnormal, or the usual and unusual, behaviors of adolescents. This knowledge base does not include integrating truth and fiction, incorporating good and evil, and assessing cognitive abilities.

Rationale 2: A sound theoretic knowledge base is needed to assist with differentiating between the normal and abnormal, or the usual and unusual, behaviors of adolescents. This knowledge base does not include integrating truth and fiction, incorporating good and evil, and assessing cognitive abilities.

Rationale 3: A sound theoretic knowledge base is needed to assist with differentiating between the normal and abnormal, or the usual and unusual, behaviors of adolescents. This knowledge base does not include integrating truth and fiction, incorporating good and evil, and assessing cognitive abilities.

Rationale 4: A sound theoretic knowledge base is needed to assist with differentiating between the normal and abnormal, or the usual and unusual, behaviors of adolescents. This knowledge base does not include integrating truth and fiction, incorporating good and evil, and assessing cognitive abilities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the biopsychosocial theories important to understanding adolescents.

Question 2

Type: MCSA

During group, the adolescents are asked to identify their role models. One of the teens responds, My parents. The nurse recognizes this response as:

1. Developmentally appropriate.

2. Grammatically incorrect.

3. Regressive behavior.

4. Inappropriate for the situation.

Correct Answer: 1

Rationale 1: The development of an adolescents sense of identity entails a preoccupation with self-image. It also entails a connection between future role and past experiences. In this case, the teen is drawing from positive experiences with the past, which is developmentally appropriate. The teens response did not indicate regressive behavior. The response was grammatically correct and is appropriate for the situation.

Rationale 2: The development of an adolescents sense of identity entails a preoccupation with self-image. It also entails a connection between future role and past experiences. In this case, the teen is drawing from positive experiences with the past, which is developmentally appropriate. The teens response did not indicate regressive behavior. The response was grammatically correct and is appropriate for the situation.

Rationale 3: The development of an adolescents sense of identity entails a preoccupation with self-image. It also entails a connection between future role and past experiences. In this case, the teen is drawing from positive experiences with the past, which is developmentally appropriate. The teens response did not indicate regressive behavior. The response was grammatically correct and is appropriate for the situation.

Rationale 4: The development of an adolescents sense of identity entails a preoccupation with self-image. It also entails a connection between future role and past experiences. In this case, the teen is drawing from positive experiences with the past, which is developmentally appropriate. The teens response did not indicate regressive behavior. The response was grammatically correct and is appropriate for the situation.

Global Rationale:

Cognitive Level: Creating

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Compare and contrast the biopsychosocial theories important to understanding adolescents.

Question 3

Type: MCSA

The nurse plans to use a group approach when conducting a teaching session for adolescents about dealing with stress. A group approach works well with adolescents because:

1. Problem-solving is less focused in groups.

2. Peer support and values are important elements to an adolescent.

3. Confidentiality is not an issue.

4. The nurse therapist is the authority figure for the group.

Correct Answer: 2

Rationale 1: It is usually more effective to work with adolescents in a group. Because the values, acceptance, and recognition of peers are so important during adolescence, the group can provide support for dealing with problem-solving and affecting change. Client confidentiality is always an issue. The role of the nurse is that of a facilitator, not an authority figure.

Rationale 2: It is usually more effective to work with adolescents in a group. Because the values, acceptance, and recognition of peers are so important during adolescence, the group can provide support for dealing with problem-solving and affecting change. Client confidentiality is always an issue. The role of the nurse is that of a facilitator, not an authority figure.

Rationale 3: It is usually more effective to work with adolescents in a group. Because the values, acceptance, and recognition of peers are so important during adolescence, the group can provide support for dealing with problem-solving and affecting change. Client confidentiality is always an issue. The role of the nurse is that of a facilitator, not an authority figure.

Rationale 4: It is usually more effective to work with adolescents in a group. Because the values, acceptance, and recognition of peers are so important during adolescence, the group can provide support for dealing with problem-solving and affecting change. Client confidentiality is always an issue. The role of the nurse is that of a facilitator, not an authority figure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the biopsychosocial theories important to understanding adolescents.

Question 4

Type: MCSA

The nurse observes that an adolescent admitted to the inpatient unit for failed outpatient treatment for depression is very shy about interacting with peers. In planning care for this client, the nurse will integrate which of the following to help the client become more comfortable in the milieu?

1. Limit choices

2. Establish a trusting relationship

3. Establish concrete boundaries

4. Provide physical activity

Correct Answer: 2

Rationale 1: According to Erikson, these crisis periods or stages are reviews of the adolescents sense of trust, autonomy, initiative, and industry, in that order. In this situation, the client is regressing and needs to feel safe within the milieu. Establishing boundaries, limiting choices, and physical activity are not the priority actions for this client.

Rationale 2: According to Erikson, these crisis periods or stages are reviews of the adolescents sense of trust, autonomy, initiative, and industry, in that order. In this situation, the client is regressing and needs to feel safe within the milieu. Establishing boundaries, limiting choices, and physical activity are not the priority actions for this client.

Rationale 3: According to Erikson, these crisis periods or stages are reviews of the adolescents sense of trust, autonomy, initiative, and industry, in that order. In this situation, the client is regressing and needs to feel safe within the milieu. Establishing boundaries, limiting choices, and physical activity are not the priority actions for this client.

Rationale 4: According to Erikson, these crisis periods or stages are reviews of the adolescents sense of trust, autonomy, initiative, and industry, in that order. In this situation, the client is regressing and needs to feel safe within the milieu. Establishing boundaries, limiting choices, and physical activity are not the priority actions for this client.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Learning Outcome 26-2: [

Question 5

Type: MCSA

During an admission assessment of an adolescent client, the nurse inquires about friends or peer groups. The adolescent smiles and jokingly tells the nurse that I consider myself a loner and I dont need any friends. The nurses next action is to:

1. Ask the client how he/she gets along in school.

2. Ask the client to explain why he/she feels this way.

3. Document this in the admission assessment.

4. Encourage exploration of feelings.

Correct Answer: 4

Rationale 1: To avoid the possibility that this statement is a symptom characteristic of a further problem, the nurse utilizes therapeutic communication to explore the adolescents perception of self, as adolescents have a need for peer acceptance. Isolation could be symptomatic of an underlying problem. The findings should be documented and shared with the treatment team, but this is not the priority action at this time. Asking the client about getting along in school is not therapeutic and is an example of changing the subject. Asking the client to explain feelings is not therapeutic.

Rationale 2: To avoid the possibility that this statement is a symptom characteristic of a further problem, the nurse utilizes therapeutic communication to explore the adolescents perception of self, as adolescents have a need for peer acceptance. Isolation could be symptomatic of an underlying problem. The findings should be documented and shared with the treatment team, but this is not the priority action at this time. Asking the client about getting along in school is not therapeutic and is an example of changing the subject. Asking the client to explain feelings is not therapeutic.

Rationale 3: To avoid the possibility that this statement is a symptom characteristic of a further problem, the nurse utilizes therapeutic communication to explore the adolescents perception of self, as adolescents have a need for peer acceptance. Isolation could be symptomatic of an underlying problem. The findings should be documented and shared with the treatment team, but this is not the priority action at this time. Asking the client about getting along in school is not therapeutic and is an example of changing the subject. Asking the client to explain feelings is not therapeutic.

Rationale 4: To avoid the possibility that this statement is a symptom characteristic of a further problem, the nurse utilizes therapeutic communication to explore the adolescents perception of self, as adolescents have a need for peer acceptance. Isolation could be symptomatic of an underlying problem. The findings should be documented and shared with the treatment team, but this is not the priority action at this time. Asking the client about getting along in school is not therapeutic and is an example of changing the subject. Asking the client to explain feelings is not therapeutic.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Learning Outcome 26-2: [

Question 6

Type: MCSA

A parent brings an adolescent child to the doctors office. The nurse will be assessing both physical and psychosocial concerns. Which of the following actions by the nurse demonstrates a developmental approach to interviewing the adolescent?

1. Interview the adolescent in private.

2. Refer the psychosocial assessment to the mental health counselor at school.

3. Ask the parent to wait for the doctor in the next room.

4. Include the parent in the interview.

Correct Answer: 1

Rationale 1: A developmental approach to assessing adolescents is to respect their privacy and conduct the assessment in private. There are several ways to approach this and there will be times when having privacy with the adolescent will not be possible; however, the ideal is to assess the adolescent alone. Referring the psychosocial assessment is not an option as there may be issues that require immediate attention. Asking the parent to wait in another room may be a means of providing privacy for the adolescent.

Rationale 2: A developmental approach to assessing adolescents is to respect their privacy and conduct the assessment in private. There are several ways to approach this and there will be times when having privacy with the adolescent will not be possible; however, the ideal is to assess the adolescent alone. Referring the psychosocial assessment is not an option as there may be issues that require immediate attention. Asking the parent to wait in another room may be a means of providing privacy for the adolescent.

Rationale 3: A developmental approach to assessing adolescents is to respect their privacy and conduct the assessment in private. There are several ways to approach this and there will be times when having privacy with the adolescent will not be possible; however, the ideal is to assess the adolescent alone. Referring the psychosocial assessment is not an option as there may be issues that require immediate attention. Asking the parent to wait in another room may be a means of providing privacy for the adolescent.

Rationale 4: A developmental approach to assessing adolescents is to respect their privacy and conduct the assessment in private. There are several ways to approach this and there will be times when having privacy with the adolescent will not be possible; however, the ideal is to assess the adolescent alone. Referring the psychosocial assessment is not an option as there may be issues that require immediate attention. Asking the parent to wait in another room may be a means of providing privacy for the adolescent.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Learning Outcome 26-2: [

Question 7

Type: MCSA

The nurse is conducting an assessment of an adolescent client. Which of the following information will the nurse obtain from the parents rather than the client?

1. Academic achievement

2. The adolescents perception of the reason for seeking care

3. The age at which developmental milestones occurred

4. Dietary food preferences and allergies

Correct Answer: 3

Rationale 1: The parents, rather than the adolescent, are more likely to recall the age at which each developmental milestone occurred. It is expected that an adolescent can provide information regarding academic achievements, dietary food preferences, and allergies. The nurse can ask the parents about what they think is the adolescents perception of the reason for seeking care, but the client is the only one who can address the actual perception.

Rationale 2: The parents, rather than the adolescent, are more likely to recall the age at which each developmental milestone occurred. It is expected that an adolescent can provide information regarding academic achievements, dietary food preferences, and allergies. The nurse can ask the parents about what they think is the adolescents perception of the reason for seeking care, but the client is the only one who can address the actual perception.

Rationale 3: The parents, rather than the adolescent, are more likely to recall the age at which each developmental milestone occurred. It is expected that an adolescent can provide information regarding academic achievements, dietary food preferences, and allergies. The nurse can ask the parents about what they think is the adolescents perception of the reason for seeking care, but the client is the only one who can address the actual perception.

Rationale 4: The parents, rather than the adolescent, are more likely to recall the age at which each developmental milestone occurred. It is expected that an adolescent can provide information regarding academic achievements, dietary food preferences, and allergies. The nurse can ask the parents about what they think is the adolescents perception of the reason for seeking care, but the client is the only one who can address the actual perception.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Learning Outcome 26-2: [

Question 8

Type: MCSA

The nurse completing an assessment for an adolescent from a humanisticinteractionist perspective will include which of the following assessments? Choose the best response.

1. Developmental and psychosocial

2. Spiritual only

3. Psychosocial and physiological

4. Physiological and spiritual

Correct Answer: 3

Rationale 1: A psychiatricmental health nurse needs knowledge about developmental theories and psychobiology. The nurse assesses both psychosocial and physiological systems of an adolescent when assessing from an interactionist perspective. Both the developmental and spiritual are included in the psychosocial component.

Rationale 2: A psychiatricmental health nurse needs knowledge about developmental theories and psychobiology. The nurse assesses both psychosocial and physiological systems of an adolescent when assessing from an interactionist perspective. Both the developmental and spiritual are included in the psychosocial component.

Rationale 3: A psychiatricmental health nurse needs knowledge about developmental theories and psychobiology. The nurse assesses both psychosocial and physiological systems of an adolescent when assessing from an interactionist perspective. Both the developmental and spiritual are included in the psychosocial component.

Rationale 4: A psychiatricmental health nurse needs knowledge about developmental theories and psychobiology. The nurse assesses both psychosocial and physiological systems of an adolescent when assessing from an interactionist perspective. Both the developmental and spiritual are included in the psychosocial component.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Illustrate how a humanisticinteractionist perspective contributes to a comprehensive assessment of adolescent problems.

Question 9

Type: MCMA

An anxious parent reports feeling his adolescent child is depressed because when the adolescent is at home he/she would sleep all the time if not woken up. Which of the following would the nurse say when conducting a comprehensive assessment about the adolescents mental health?

Standard Text: Select all that apply.

1. What has happened that might have lead to him/her becoming depressed?

2. Perhaps your anxiety is affecting your adolescent child.

3. Are there other behaviors you are concerned about?

4. I see you are anxious.

5. Is there a history of depression in the family?

Correct Answer: 3,5

Rationale 1: What has happened that might have lead to his becoming depressed? is related to collecting situational data.

Rationale 2: Perhaps your anxiety is affecting your adolescent child. is not related to collecting data about the adolescents mental health.

Rationale 3: Are there other behaviors you are concerned about? is related to the parents perspective of the adolescents overall functioning and is related to collecting data about the adolescents mental health.

Rationale 4: I see you are anxious. is not related to collecting data about the adolescents mental health.

Rationale 5: Is there a history of depression in the family? is related to the mental health of the adolescent.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Illustrate how a humanisticinteractionist perspective contributes to a comprehensive assessment of adolescent problems.

Question 10

Type: MCSA

During an admission to the inpatient adolescent unit, a client tells the nurse that his foster parents punish him too severely. The appropriate response of the nurse is to:

1. Inform the psychiatrist.

2. Notify the authorities.

3. Gather data from the foster parents regarding their disciplinary practices.

4. Tell the parents they need to be more therapeutic, not punitive.

Correct Answer: 3

Rationale 1: It is insufficient to base the nursing response to the adolescents needs and dilemmas solely on behaviors without a more comprehensive evaluation of other factors. Part of the assessment will include gathering data regarding the foster parents disciplinary practices. Telling them they need to be more therapeutic, not punitive, is inappropriate and nontherapeutic. Part of being therapeutic is holding the child accountable for his actions, which may result in punitive consequences. The nurse will not notify the authorities unless there is evidence to suggest the adolescent is being harmed by his parents disciplinary actions. The nurse will provide the information to the psychiatrist, but not until the assessment data is complete.

Rationale 2: It is insufficient to base the nursing response to the adolescents needs and dilemmas solely on behaviors without a more comprehensive evaluation of other factors. Part of the assessment will include gathering data regarding the foster parents disciplinary practices. Telling them they need to be more therapeutic, not punitive, is inappropriate and nontherapeutic. Part of being therapeutic is holding the child accountable for his actions, which may result in punitive consequences. The nurse will not notify the authorities unless there is evidence to suggest the adolescent is being harmed by his parents disciplinary actions. The nurse will provide the information to the psychiatrist, but not until the assessment data is complete.

Rationale 3: It is insufficient to base the nursing response to the adolescents needs and dilemmas solely on behaviors without a more comprehensive evaluation of other factors. Part of the assessment will include gathering data regarding the foster parents disciplinary practices. Telling them they need to be more therapeutic, not punitive, is inappropriate and nontherapeutic. Part of being therapeutic is holding the child accountable for his actions, which may result in punitive consequences. The nurse will not notify the authorities unless there is evidence to suggest the adolescent is being harmed by his parents disciplinary actions. The nurse will provide the information to the psychiatrist, but not until the assessment data is complete.

Rationale 4: It is insufficient to base the nursing response to the adolescents needs and dilemmas solely on behaviors without a more comprehensive evaluation of other factors. Part of the assessment will include gathering data regarding the foster parents disciplinary practices. Telling them they need to be more therapeutic, not punitive, is inappropriate and nontherapeutic. Part of being therapeutic is holding the child accountable for his actions, which may result in punitive consequences. The nurse will not notify the authorities unless there is evidence to suggest the adolescent is being harmed by his parents disciplinary actions. The nurse will provide the information to the psychiatrist, but not until the assessment data is complete.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Explain the importance of a humanisticinteractionist perspective in a comprehensive assessment of adolescent problems.

Question 11

Type: MCSA

Following a difficult family session, an adolescent client in the inpatient psychiatricmental health unit has become combative. Prior to communicating with this client, the nurse must consider:

1. The childs emotional state.

2. The number of points to take away.

3. Which consequences to use for punishment.

4. The developmental age of the client.

Correct Answer: 1

Rationale 1: Prior to communicating with this client, the nurse recognizes the client is acting out. Adolescents tend to act out feelings and conflicts rather than verbalize them. The other choices relate to how the nurse may deal with the childs behavior. It is important that the nurse recognize the feelings and help the child to be held accountable for behavior.

Rationale 2: Prior to communicating with this client, the nurse recognizes the client is acting out. Adolescents tend to act out feelings and conflicts rather than verbalize them. The other choices relate to how the nurse may deal with the childs behavior. It is important that the nurse recognize the feelings and help the child to be held accountable for behavior.

Rationale 3: Prior to communicating with this client, the nurse recognizes the client is acting out. Adolescents tend to act out feelings and conflicts rather than verbalize them. The other choices relate to how the nurse may deal with the childs behavior. It is important that the nurse recognize the feelings and help the child to be held accountable for behavior.

Rationale 4: Prior to communicating with this client, the nurse recognizes the client is acting out. Adolescents tend to act out feelings and conflicts rather than verbalize them. The other choices relate to how the nurse may deal with the childs behavior. It is important that the nurse recognize the feelings and help the child to be held accountable for behavior.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Design intervention strategies for adolescent clients who act out.

Question 12

Type: MCSA

The staff observes that a young male manifests oppositional behavior when he interacts with male staff. He has recently been placed in the custody of his father, since his mother has been deployed in the military. The client told the nurse that his mother relied on him a lot when he lived with her. He tells the nurse that his father is always on his case, never speaks to him without yelling, and tells him he cant do anything right. Identify the appropriate intervention for the client when he feels oppositional toward the staff.

1. Provide opportunities for the client to get to know the staff.

2. Encourage the client to take five to revive.

3. Have the client chose the consequences for his behavior.

4. Ask the client if he is upset.

Correct Answer: 2

Rationale 1: This is a component of a clients life script; the client is recreating his situation at home by his reaction to the male staff. The purpose of having the client take five to revive is to help him substitute a healthier way of dealing with his feelings. When the client is engaging in oppositional behavior, asking him if he is upset may further aggravate the situation. Providing opportunities for the client to get to know the staff will not help him deal with his feelings toward the staff. Having the client choose the consequences for his behavior is not an intervention designed to help him learn how to deal with his feelings.

Rationale 2: This is a component of a clients life script; the client is recreating his situation at home by his reaction to the male staff. The purpose of having the client take five to revive is to help him substitute a healthier way of dealing with his feelings. When the client is engaging in oppositional behavior, asking him if he is upset may further aggravate the situation. Providing opportunities for the client to get to know the staff will not help him deal with his feelings toward the staff. Having the client choose the consequences for his behavior is not an intervention designed to help him learn how to deal with his feelings.

Rationale 3: This is a component of a clients life script; the client is recreating his situation at home by his reaction to the male staff. The purpose of having the client take five to revive is to help him substitute a healthier way of dealing with his feelings. When the client is engaging in oppositional behavior, asking him if he is upset may further aggravate the situation. Providing opportunities for the client to get to know the staff will not help him deal with his feelings toward the staff. Having the client choose the consequences for his behavior is not an intervention designed to help him learn how to deal with his feelings.

Rationale 4: This is a component of a clients life script; the client is recreating his situation at home by his reaction to the male staff. The purpose of having the client take five to revive is to help him substitute a healthier way of dealing with his feelings. When the client is engaging in oppositional behavior, asking him if he is upset may further aggravate the situation. Providing opportunities for the client to get to know the staff will not help him deal with his feelings toward the staff. Having the client choose the consequences for his behavior is not an intervention designed to help him learn how to deal with his feelings.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Design intervention strategies for adolescent clients who act out.

Question 13

Type: MCSA

The nurse observes that an adolescent client relates, reacts, and consistently behaves with one of the male staff in an inappropriate manner. Based on the adolescents history, the nurse is concerned this client may be:

1. Manifesting manic behavior.

2. Experiencing a side effect from the medication.

3. Acting out a life script.

4. Afraid of being alone.

Correct Answer: 3

Rationale 1: The way the client relates, reacts, and behaves are all components of what is commonly called the clients life script. It is not likely that the client is experiencing a side effect from medication, manifesting manic behavior, or exhibiting fear of being alone since the behavior is not directed at all staff.

Rationale 2: The way the client relates, reacts, and behaves are all components of what is commonly called the clients life script. It is not likely that the client is experiencing a side effect from medication, manifesting manic behavior, or exhibiting fear of being alone since the behavior is not directed at all staff.

Rationale 3: The way the client relates, reacts, and behaves are all components of what is commonly called the clients life script. It is not likely that the client is experiencing a side effect from medication, manifesting manic behavior, or exhibiting fear of being alone since the behavior is not directed at all staff.

Rationale 4: The way the client relates, reacts, and behaves are all components of what is commonly called the clients life script. It is not likely that the client is experiencing a side effect from medication, manifesting manic behavior, or exhibiting fear of being alone since the behavior is not directed at all staff.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Design intervention strategies for adolescent clients who act out.

Question 14

Type: MCSA

An adolescent female client who had lived on the street for at least a year dresses provocatively, wears heavy make-up, and is flirtatious in her interactions with adults. The nurse:

1. Directs her to wash her face and put on appropriate clothing.

2. Recognizes the client may be acting out her life script.

3. Restricts the client to her room.

4. Encourages her to seek spiritual guidance.

Correct Answer: 2

Rationale 1: The clients behaviors are all components of what is commonly called the clients life script. The client is recreating her life experiences from the time spent on the street. The other choices are examples of nontherapeutic interactions.

Rationale 2: The clients behaviors are all components of what is commonly called the clients life script. The client is recreating her life experiences from the time spent on the street. The other choices are examples of nontherapeutic interactions.

Rationale 3: The clients behaviors are all components of what is commonly called the clients life script. The client is recreating her life experiences from the time spent on the street. The other choices are examples of nontherapeutic interactions.

Rationale 4: The clients behaviors are all components of what is commonly called the clients life script. The client is recreating her life experiences from the time spent on the street. The other choices are examples of nontherapeutic interactions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Design intervention strategies for adolescent clients who act out.

Question 15

Type: MCSA

A 14-year-old female inpatient, diagnosed with depression and self-mutilating behavior, is scheduled to be discharged in the morning.

Her parents divorced when she was 10 and she hasnt seen her father for almost a year, but for the past three months she has been looking forward to his taking her to a special concert a few days after discharge. Her father has just called to tell his daughter he will not be able to make their date because he has been detained longer than expected on a business trip. The client takes the phone receiver and begins hitting herself in the chest with it. Which of the following nursing interventions will be most therapeutic in helping the client deal with her anger?

1. Provide emotional support by telling the client she has a right to be angry.

2. Tell the client you understand how she feels.

3. Revoke the discharge and transfer the client to a more restrictive environment.

4. Suggest that the client write her father a letter telling him how she feels.

Correct Answer: 4

Rationale 1: The most therapeutic response is to encourage the client to deal with her anger in a constructive, nonphysical manner. In this instance, the client is displacing her anger onto herself. By writing a letter she will be acknowledging her feelings and directing the anger at the source, which is her father. There is no need to move the client to a more restrictive environment unless she continues to harm herself. Telling her the nurse understands how she feels or that she has a right to be angry would not be a therapeutic response to the situation.

Rationale 2: The most therapeutic response is to encourage the client to deal with her anger in a constructive, nonphysical manner. In this instance, the client is displacing her anger onto herself. By writing a letter she will be acknowledging her feelings and directing the anger at the source, which is her father. There is no need to move the client to a more restrictive environment unless she continues to harm herself. Telling her the nurse understands how she feels or that she has a right to be angry would not be a therapeutic response to the situation.

Rationale 3: The most therapeutic response is to encourage the client to deal with her anger in a constructive, nonphysical manner. In this instance, the client is displacing her anger onto herself. By writing a letter she will be acknowledging her feelings and directing the anger at the source, which is her father. There is no need to move the client to a more restrictive environment unless she continues to harm herself. Telling her the nurse understands how she feels or that she has a right to be angry would not be a therapeutic response to the situation.

Rationale 4: The most therapeutic response is to encourage the client to deal with her anger in a constructive, nonphysical manner. In this instance, the client is displacing her anger onto herself. By writing a letter she will be acknowledging her feelings and directing the anger at the source, which is her father. There is no need to move the client to a more restrictive environment unless she continues to harm herself. Telling her the nurse understands how she feels or that she has a right to be angry would not be a therapeutic response to the situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate intervention strategies for adolescents who are angry or hostile, test the staff, scapegoat others, engage in problematic sexual behaviors, or abuse substances.

Question 16

Type: MCSA

An adolescent client is being verbally abusive toward staff and is refusing to comply with the units rules. The first action is to:

1. Separate the client from other clients.

2. Administer a PRN medication.

3. Tell the client the behavior is unacceptable.

4. Ignore the client as the behavior is part of the illness.

Correct Answer: 1

Rationale 1: Expressions of anger and hostility are common on an adolescent unit. Anger expressed verbally usually takes the form of profanity. Ensuring the safety of the client and others is the primary concern. The first action would be to ensure the safety of all concerned by separating the client from the other clients. The second action would be to inform the client that the behavior, not the person, is unacceptable. The nurse must confront, not ignore, the behavior. Administering a PRN medication is not the initial action.

Rationale 2: Expressions of anger and hostility are common on an adolescent unit. Anger expressed verbally usually takes the form of profanity. Ensuring the safety of the client and others is the primary concern. The first action would be to ensure the safety of all concerned by separating the client from the other clients. The second action would be to inform the client that the behavior, not the person, is unacceptable. The nurse must confront, not ignore, the behavior. Administering a PRN medication is not the initial action.

Rationale 3: Expressions of anger and hostility are common on an adolescent unit. Anger expressed verbally usually takes the form of profanity. Ensuring the safety of the client and others is the primary concern. The first action would be to ensure the safety of all concerned by separating the client from the other clients. The second action would be to inform the client that the behavior, not the person, is unacceptable. The nurse must confront, not ignore, the behavior. Administering a PRN medication is not the initial action.

Rationale 4: Expressions of anger and hostility are common on an adolescent unit. Anger expressed verbally usually takes the form of profanity. Ensuring the safety of the client and others is the primary concern. The first action would be to ensure the safety of all concerned by separating the client from the other clients. The second action would be to inform the client that the behavior, not the person, is unacceptable. The nurse must confront, not ignore, the behavior. Administering a PRN medication is not the initial action.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate intervention strategies for adolescents who are angry or hostile, test the staff, scapegoat others, engage in problematic sexual behaviors, or abuse substances.

Question 17

Type: MCSA

An adolescent client is attempting to manipulate the nurse into giving a special privilege. The nurse recognizes the manipulation and responds by saying:

1. All the clients must follow the rules.

2. If I do it for you, I would have to do it for everyone.

3. If I granted you that privilege, Id be in trouble

4. That would not be fair to the others.

Correct Answer: 1

Rationale 1: The correct response is to state the expectations for behavior on the unit and be clear that there is no room for exceptions. Stating the rules helps to reinforce the boundaries and prevents the nurse from getting into a power struggle. The other choices (If I granted you that privilege, Id be in trouble; That would not be fair to the others; and If I do it for you I would have to do it for everyone) are an attempt to induce feelings of guilt and place the decision-making in the power of the adolescent.

Rationale 2: The correct response is to state the expectations for behavior on the unit and be clear that there is no room for exceptions. Stating the rules helps to reinforce the boundaries and prevents the nurse from getting into a power struggle. The other choices (If I granted you that privilege, Id be in trouble; That would not be fair to the others; and If I do it for you I would have to do it for everyone) are an attempt to induce feelings of guilt and place the decision-making in the power of the adolescent.

Rationale 3: The correct response is to state the expectations for behavior on the unit and be clear that there is no room for exceptions. Stating the rules helps to reinforce the boundaries and prevents the nurse from getting into a power struggle. The other choices (If I granted you that privilege, Id be in trouble; That would not be fair to the others; and If I do it for you I would have to do it for everyone) are an attempt to induce feelings of guilt and place the decision-making in the power of the adolescent.

Rationale 4: The correct response is to state the expectations for behavior on the unit and be clear that there is no room for exceptions. Stating the rules helps to reinforce the boundaries and prevents the nurse from getting into a power struggle. The other choices (If I granted you that privilege, Id be in trouble; That would not be fair to the others; and If I do it for you I would have to do it for everyone) are an attempt to induce feelings of guilt and place the decision-making in the power of the adolescent.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate intervention strategies for adolescents who are angry or hostile, test the staff, scapegoat others, engage in problematic sexual behaviors, or abuse substances.

Question 18

Type: MCSA

The parent of an adolescent tells the nurse that the adolescent used to be on the honor roll at school, but now is failing every subject, skipping school, and doesnt care about anything except a new group of friends. The nurse recognizes this adolescent may be in need of counseling related to:

1. Adolescent substance abuse.

2. Growth and development.

3. Self-esteem.

4. Independent living.

Correct Answer: 1

Rationale 1: Change in values, ideals, beliefs, and changes in friends are behaviors that are characteristic of teenaged substance abuse. Adolescents with substance abuse problems may also have issues with self-esteem, but the information relates directly to behaviors associated with adolescent substance abuse. The behaviors of the adolescent, described by the parent, are not directly related to a problem with growth and development or independent living.

Rationale 2: Change in values, ideals, beliefs, and changes in friends are behaviors that are characteristic of teenaged substance abuse. Adolescents with substance abuse problems may also have issues with self-esteem, but the information relates directly to behaviors associated with adolescent substance abuse. The behaviors of the adolescent, described by the parent, are not directly related to a problem with growth and development or independent living.

Rationale 3: Change in values, ideals, beliefs, and changes in friends are behaviors that are characteristic of teenaged substance abuse. Adolescents with substance abuse problems may also have issues with self-esteem, but the information relates directly to behaviors associated with adolescent substance abuse. The behaviors of the adolescent, described by the parent, are not directly related to a problem with growth and development or independent living.

Rationale 4: Change in values, ideals, beliefs, and changes in friends are behaviors that are characteristic of teenaged substance abuse. Adolescents with substance abuse problems may also have issues with self-esteem, but the information relates directly to behaviors associated with adolescent substance abuse. The behaviors of the adolescent, described by the parent, are not directly related to a problem with growth and development or independent living.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Formulate intervention strategies for adolescents who are angry or hostile, test the staff, scapegoat others, engage in problematic sexual behaviors, or abuse substances.

Question 19

Type: MCSA

The nurse educator is discussing manipulation that can occur when working with adolescent clients. Which nurse is most at risk for being manipulated by an adolescent client? The nurse who:

1. Avoids power struggles.

2. Rewards appropriate behavior.

3. Consistently enforces the rules.

4. Maintains an all-accepting attitude.

Correct Answer: 4

Rationale 1: In working with adolescents, there is always the risk of seduction of the nurse, that is, manipulation of the nurse by the client into relating in a nontherapeutic way. Factors contributing to the problem include: the intimate nature of the nurses involvement with the adolescent client; the narcissism inherent in this age group; and the nurses all-accepting attitude in working with the adolescent client. Measures to avoid being manipulated include consistently enforcing the rules, rewarding appropriate behavior, and avoiding power struggles.

Rationale 2: In working with adolescents, there is always the risk of seduction of the nurse, that is, manipulation of the nurse by the client into relating in a nontherapeutic way. Factors contributing to the problem include: the intimate nature of the nurses involvement with the adolescent client; the narcissism inherent in this age group; and the nurses all-accepting attitude in working with the adolescent client. Measures to avoid being manipulated include consistently enforcing the rules, rewarding appropriate behavior, and avoiding power struggles.

Rationale 3: In working with adolescents, there is always the risk of seduction of the nurse, that is, manipulation of the nurse by the client into relating in a nontherapeutic way. Factors contributing to the problem include: the intimate nature of the nurses involvement with the adolescent client; the narcissism inherent in this age group; and the nurses all-accepting attitude in working with the adolescent client. Measures to avoid being manipulated include consistently enforcing the rules, rewarding appropriate behavior, and avoiding power struggles.

Rationale 4: In working with adolescents, there is always the risk of seduction of the nurse, that is, manipulation of the nurse by the client into relating in a nontherapeutic way. Factors contributing to the problem include: the intimate nature of the nurses involvement with the adolescent client; the narcissism inherent in this age group; and the nurses all-accepting attitude in working with the adolescent client. Measures to avoid being manipulated include consistently enforcing the rules, rewarding appropriate behavior, and avoiding power struggles.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Formulate intervention strategies for adolescents who are angry or hostile, test the staff, scapegoat others, engage in problematic sexual behaviors, or abuse substances.

Question 20

Type: MCSA

The nurse is explaining the purpose of negotiating a behavioral contract to an adolescents parents. A primary reason for the contract is:

1. The contract is just between the client and nurse.

2. It is a legal document.

3. The terms cannot be changed once the contract is formed.

4. There is less room for misinterpretation.

Correct Answer: 4

Rationale 1: With most adolescents, a written contract is best since goals and expectations are less easily forgotten, the process seems more formal and serious, and there is less room for misinterpretation and manipulation. The contract is between the client and the staff, not just the nurse, and is not a legal document.

Rationale 2: With most adolescents, a written contract is best since goals and expectations are less easily forgotten, the process seems more formal and serious, and there is less room for misinterpretation and manipulation. The contract is between the client and the staff, not just the nurse, and is not a legal document.

Rationale 3: With most adolescents, a written contract is best since goals and expectations are less easily forgotten, the process seems more formal and serious, and there is less room for misinterpretation and manipulation. The contract is between the client and the staff, not just the nurse, and is not a legal document.

Rationale 4: With most adolescents, a written contract is best since goals and expectations are less easily forgotten, the process seems more formal and serious, and there is less room for misinterpretation and manipulation. The contract is between the client and the staff, not just the nurse, and is not a legal document.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Construct a client contract for use with an adolescent in treatment.

Question 21

Type: MCMA

When negotiating a behavior contract with adolescents, the nurse ensures that:

Standard Text: Select all that apply.

1. The expectations for behavior are clear.

2. The contract is oral.

3. There is no room to renegotiate.

4. Consequences outlined in the contract will be administered consistently.

5. The terms are rigid.

Correct Answer: 1,4

Rationale 1: The expectations for behavior are clear. The expectations for behavior must be clearly articulated; using a behavioral contract without understanding the underlying reasons or factors contributing to the adolescents problems will result in a superficial approach with an equally superficial evaluation.

Rationale 2: The contract is oral. A contract can be oral or written.

Rationale 3: There is no room to renegotiate. The contract terms should be realistic and renegotiated when necessary or as needed, according to the clients behavior.

Rationale 4: Consequences outlined in the contract will be administered consistently. If the consequences or the contract are not administered consistently the contract will not be effective.

Rationale 5: The terms are rigid. The terms should not be so rigid or inflexible that they prevent renegotiation as the clients behavior changes.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Construct a client contract for use with an adolescent in treatment.

Question 22

Type: MCSA

A therapeutic contract with a client will be renegotiated:

1. Daily.

2. As needed.

3. During the treatment team meeting.

4. At the beginning of each shift.

Correct Answer: 2

Rationale 1: The contract is renegotiated at regular intervals (hourly, daily, or weekly), depending on the goals, the severity of the symptoms, and the degree of adherence to the agreement. The form of the contract is less important than the way the nurse and the client jointly set the goals and expectations, carry out the contract, set limits, and renegotiate changes, and evaluate the final outcome.

Rationale 2: The contract is renegotiated at regular intervals (hourly, daily, or weekly), depending on the goals, the severity of the symptoms, and the degree of adherence to the agreement. The form of the contract is less important than the way the nurse and the client jointly set the goals and expectations, carry out the contract, set limits, and renegotiate changes, and evaluate the final outcome.

Rationale 3: The contract is renegotiated at regular intervals (hourly, daily, or weekly), depending on the goals, the severity of the symptoms, and the degree of adherence to the agreement. The form of the contract is less important than the way the nurse and the client jointly set the goals and expectations, carry out the contract, set limits, and renegotiate changes, and evaluate the final outcome.

Rationale 4: The contract is renegotiated at regular intervals (hourly, daily, or weekly), depending on the goals, the severity of the symptoms, and the degree of adherence to the agreement. The form of the contract is less important than the way the nurse and the client jointly set the goals and expectations, carry out the contract, set limits, and renegotiate changes, and evaluate the final outcome.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Construct a client contract for use with an adolescent in treatment.

Question 23

Type: MCMA

A nurse making rounds hears sounds coming from an adolescents room. When checking on the client, the nurse hears noises coming from the bathroom, and suspects that the client is masturbating. Which are the most appropriate actions in this situation?

Standard Text: Select all that apply.

1. Wait until the client comes out of the bathroom.

2. Pretend she did not hear anything.

3. Discuss the inappropriate behavior.

4. Examine his/her personal feelings about what might be happening.

5. Knock on the door before entering the bathroom.

Correct Answer: 4,5

Rationale 1: Wait until the client comes out of the bathroom. Waiting for the client to come out of the bathroom is not necessary; the nurse needs to verify the clients well-being.

Rationale 2: Pretend she did not hear anything. It would not be prudent to pretend she didnt hear anything; she needs to verify the clients well-being.

Rationale 3: Discuss the inappropriate behavior. Masturbation is a normal sexual activity for people of all ages from the beginning of sexual awareness to senescence, it is not considered inappropriate if he is in a private place.

Rationale 4: Examine his/her personal feelings about what might be happening. The nurse must examine his/her own feelings about the behavior as masturbation is a normal sexual activity for people of all ages from the beginning of sexual awareness to senescence.

Rationale 5: Knock on the door before entering the bathroom. The client is in a private place. It is appropriate for the nurse to knock on the door before entering. This communicates respect for the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Analyze personal feelings and attitudes or unresolved issues about adolescence that may affect professional practice when caring for adolescent clients.

Question 24

Type: MCSA

Prior to intervening with an adolescent projecting anger on the nurse, the nurse should:

1. Encourage the adolescent to engage in reflection.

2. Engage in introspection to examine how he/she reacts to others when they are angry.

3. Organize the rapid response team due to the aggressive action.

4. Enlist an adolescent peer to intervene with the adolescent.

Correct Answer: 2

Rationale 1: Before responding to the adolescent, the nurse must be aware of how he/she reacts to others when they are angry. At this point the adolescent is projecting anger and is not aggressive; therefore, it is not necessary to notify the rapid response team. It would not be appropriate for the nurse to ask another peer to intervene. Encouraging the adolescent to reflect is an appropriate interaction to attempt after the adolescent has cooled down and is ready to process the event.

Rationale 2: Before responding to the adolescent, the nurse must be aware of how he/she reacts to others when they are angry. At this point the adolescent is projecting anger and is not aggressive; therefore, it is not necessary to notify the rapid response team. It would not be appropriate for the nurse to ask another peer to intervene. Encouraging the adolescent to reflect is an appropriate interaction to attempt after the adolescent has cooled down and is ready to process the event.

Rationale 3: Before responding to the adolescent, the nurse must be aware of how he/she reacts to others when they are angry. At this point the adolescent is projecting anger and is not aggressive; therefore, it is not necessary to notify the rapid response team. It would not be appropriate for the nurse to ask another peer to intervene. Encouraging the adolescent to reflect is an appropriate interaction to attempt after the adolescent has cooled down and is ready to process the event.

Rationale 4: Before responding to the adolescent, the nurse must be aware of how he/she reacts to others when they are angry. At this point the adolescent is projecting anger and is not aggressive; therefore, it is not necessary to notify the rapid response team. It would not be appropriate for the nurse to ask another peer to intervene. Encouraging the adolescent to reflect is an appropriate interaction to attempt after the adolescent has cooled down and is ready to process the event.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Analyze personal feelings and attitudes or unresolved issues about adolescence that may affect professional practice when caring for adolescent clients.

Question 25

Type: MCSA

A nurse has been offered a transfer to an adolescent substance abuse treatment center. Which of the following will assist the nurse in deciding whether to accept or decline the assignment?

1. Assess his/her self-awareness related to working with substance abusers

2. Make a list of the benefits of accepting the position

3. Review his/her experience to determine if this will be a worthwhile endeavor

4. Examine the repercussions for declining the transfer

Correct Answer: 1

Rationale 1: The nurse working with substance abuse will benefit from self-awareness and an understanding of the feelings that working with substance abusers can evoke. The nurse who feels angry and punitive with clients who abuse drugs, or who over identifies with these clients and finds adventure in the clients drug stories, will not be able to establish a therapeutic relationship with this client population. The other answer choices may be considerations, but do not take priority over self-awareness.

Rationale 2: The nurse working with substance abuse will benefit from self-awareness and an understanding of the feelings that working with substance abusers can evoke. The nurse who feels angry and punitive with clients who abuse drugs, or who over identifies with these clients and finds adventure in the clients drug stories, will not be able to establish a therapeutic relationship with this client population. The other answer choices may be considerations, but do not take priority over self-awareness.

Rationale 3: The nurse working with substance abuse will benefit from self-awareness and an understanding of the feelings that working with substance abusers can evoke. The nurse who feels angry and punitive with clients who abuse drugs, or who over identifies with these clients and finds adventure in the clients drug stories, will not be able to establish a therapeutic relationship with this client population. The other answer choices may be considerations, but do not take priority over self-awareness.

Rationale 4: The nurse working with substance abuse will benefit from self-awareness and an understanding of the feelings that working with substance abusers can evoke. The nurse who feels angry and punitive with clients who abuse drugs, or who over identifies with these clients and finds adventure in the clients drug stories, will not be able to establish a therapeutic relationship with this client population. The other answer choices may be considerations, but do not take priority over self-awareness.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Analyze personal feelings and attitudes or unresolved issues about adolescence that may affect professional practice when caring for adolescent clients.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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