Chapter 36: Adolescent Psychiatric Nursing My Nursing Test Banks

Chapter 36: Adolescent Psychiatric Nursing

Test Bank

MULTIPLE CHOICE

1. An adolescent relates a mutual masturbatory experience to a nurse and says, I think Im a homosexual. Which statement by the nurse with respect to the patients development stage is most appropriate?

a.

Adolescence is the common time for sexual experimentation.

b.

Its important to be happy with your sexuality, whatever it may be.

c.

You might be bisexual. Tell me about your sexual behavior in detail.

d.

Its believed that many homosexual people begin to experiment at your age.

ANS: A

The most therapeutic nursing intervention is the one that provides the information that adolescence is a time when sexual identity and sexual behavior vary.

DIF: Cognitive Level: Application REF: Text Page: 695

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

2. Which intervention by the nurse would be the most therapeutic when a student reports witnessing a depressed teenager put a gun into a locker?

a.

Call the principal and request a locker search without breaching confidentiality.

b.

Accompany the witness to the principals office to further discuss what was seen.

c.

Call the police immediately and report that there is a student in school with a gun.

d.

Call the parents of the depressed teen and ask them to come and talk with their child.

ANS: B

The nurse must report any violent threats to the schools administration immediately. The best approach is to encourage the witness to tell school authorities exactly what was seen.

DIF: Cognitive Level: Application REF: Text Pages: 702-703

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. Which intervention would be the most therapeutic for the school nurse on the 1-year anniversary of a shooting that killed three of the schools adolescent students?

a.

Plan a convocation for students, family, and teachers to revisit the deaths and loss.

b.

Recommend that the principal cancel school for private observances around the town.

c.

Plan a forum of commemoration for faculty, students, and family with grief counselors and experts on violence prevention.

d.

Suggest to the principal that no specific acknowledgement be made in order to avoid reinforcing attention to the violence that occurred.

ANS: C

The occurrence of school shootings has caused experts to look more closely at lethality among adolescents. Providing a forum that will allow everyone involved to express grief and will educate them on strategies they can take to prevent further outbreaks would help to reduce feelings of powerlessness.

DIF: Cognitive Level: Analysis REF: Text Page: 703 | Text Page: 709

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

4. Which behavior would indicate to the nurse that an adolescent has entered the third stage of substance abuse? The adolescent:

a.

is abusing alcohol on the weekends.

b.

has been caught smoking hash in the school bathroom.

c.

admits to being curious about the alcohol in the family liquor cabinet.

d.

has begun selling drugs at school to support a serious drug addiction.

ANS: B

The third stage of substance abuse (regular use) is characterized by progression to midweek use of substances to get high; excitement followed by guilt over use; and regular use progressing from tobacco, alcohol, and marijuana to other substances such as hash oil, tranquilizers, sedatives, and amphetamines.

DIF: Cognitive Level: Analysis REF: Text Page: 705

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

5. Which nursing intervention would be most effective when assisting an adolescent who is in stage three of substance abuse?

a.

Recommend a drug-free self-help group and family therapy.

b.

Provide drug education and drug-free activities for the adolescent.

c.

Recommend hospitalization at a drug abuse center to facilitate withdrawal.

d.

Provide anticipatory guidance to help the adolescent develop healthy coping skills.

ANS: A

Stage three of substance abuse (regular use) indicates that the adolescent has progressed to midweek use to get high and will benefit from participation in drug-free self-help groups and family therapy. Family intervention is also an important part of treatment, because the issues surrounding the problem of adolescent use must be addressed for the whole family affected. The remaining options are demonstrating interventions that the client has either progressed past or has yet arrived at the stage where they could be effective.

DIF: Cognitive Level: Analysis REF: Text Page: 705

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

6. A parent shares with a nurse a concern that an adolescent constantly reads about Hitler and watches history television programs that show concentration camp footage. Which statement would be the most therapeutic response?

a.

Are there any other behavior changes that concern you?

b.

Being interested in Hitler isnt necessarily something to be worried about.

c.

Have you ever talked with your child about how this interest in Hitler concerns you?

d.

Ill be happy to talk with your child, but anything I learn is considered confidential.

ANS: A

Adolescence is a time for exploration before adulthood. Without any other behavioral changes, the adolescent may just be interested in history, so it would be most therapeutic for the nurse to obtain further information from the parent before seeing the adolescent or recommending help.

DIF: Cognitive Level: Application REF: Text Pages: 693-694

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

7. A parent calls the school nurse to say, My teenager got a forearm tattoo without my permission and wont be returning to school. We will educate our child at home, away from all the evil influences at your institution. Which is the most appropriate initial action for a school nurse to take?

a.

Report the parents comments to the school guidance counselor.

b.

Invite the parent to meet with the nurse and guidance counselor.

c.

Educate the parent that to some people a tattoo is considered body art.

d.

Share with the parent that many students get tattoos as a sign of independence.

ANS: B

The parent is upset because she equates the tattoo with negative aspects of growth and may not know that a tattoo is often considered no worse than piercing ones ears to many individuals. Although the parent may elect to educate the child at home, such an approach may fail if it lacks the proper purpose for its implementation. Persuading the parent to come in and see the nurse and counselor will help her to problem solve more effectively and view the tattoo in a healthier perspective.

DIF: Cognitive Level: Analysis REF: Text Page: 695

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

8. When a teacher reports that an adolescent has begun failing in class and is isolated from friends during laboratory sessions, the nurse responds most therapeutically by stating:

a.

Lets discuss this. The symptoms of adolescent depression can look very different from those of adult depression.

b.

Have you set limits on the students behavior and called for an immediate family intervention?

c.

Ill call the students parents and see if I can get their permission to assess for possible depression.

d.

Have you noticed whether others have been bullying the student in your class?

ANS: A

The symptoms the teacher is observing may well be adolescent depression, but the nurse would be most therapeutic to offer perspective discussion regarding how adolescents generally display depression.

DIF: Cognitive Level: Application REF: Text Page: 698

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

9. Which statement would be the most therapeutic initially when interviewing an adolescent who attempted suicide in the school bathroom?

a.

Can you tell me what you were thinking that caused you to attempt suicide?

b.

It appears that you were really interested in letting your classmates know you were angry.

c.

If you are willing to discuss the reasons you wanted to die, Im certainly willing to listen to you.

d.

How do you feel I can help you, since most suicide attempts are really cries for help?

ANS: A

The most therapeutic communication is the one that facilitates discussion about feelings and thoughts as well as more adaptive problem solving and suggests that there are options other than suicide.

DIF: Cognitive Level: Application REF: Text Pages: 699-700

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

10. A teacher shows a nurse an adolescents textbook that has been defaced with sexually explicit drawings and asks, Do you think that this student is being molested at home? The nurse responds most therapeutically by:

a.

identifying for the teacher that this is fairly normal adolescent behavior but encouraging the teacher to continue to monitor the child.

b.

seeing the adolescent immediately to discuss the drawings and calling social services to report the situation.

c.

asking the teacher what the adolescent said about the drawings and then giving direct attention to the behavior and its implications.

d.

instructing the teacher to call the parents and have them come to the school immediately so the situation can be discussed with the principal.

ANS: C

The initial step is to determine what the adolescent says about the schoolbook defacement and then respond from there. The behavior may be a cry for help, but the teacher needs to view it correctly and not jump to premature conclusions.

DIF: Cognitive Level: Analysis REF: Text Page: 693

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

11. Which nursing intervention would be most effective when assisting an adolescent whose best friend recently committed suicide?

a.

Arrange for crisis intervention therapy for the adolescent lasting at least 1 year.

b.

Establish a trusting relationship while periodically assessing the adolescent for depression.

c.

Encourage the adolescent to meet weekly for lunch and discussion regarding the feelings of loss.

d.

Perform an ongoing mental status and lethality assessment every month for a period of no less than 6 months.

ANS: B

The adolescent has experienced a deep loss. The nurse is responsible for identifying adolescents who may be at risk for depression and other problems and then determining the need, if any, for monitoring and treatment.

DIF: Cognitive Level: Application REF: Text Pages: 699-700

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

12. An adolescent says, What am I supposed to do? My parents are so strict. They never let me do anything or go anywhere with my friends. Which nursing intervention would be most effective?

a.

To determine the extent of the countertransference, ask the adolescent, Why do you think a nurse could help?

b.

Maintain a balanced stance with the adolescent, but plan to teach the parents to gradually allow for independence.

c.

To establish trust, tell the adolescent that the nurse will strongly encourage the parents to allow more opportunities for independence.

d.

In order to encourage dialogue, ask the adolescent to provide specific examples and situations in which the parents acted strictly.

ANS: D

Adolescents can exaggerate situations and issues and often need time and perspective to view issues more objectively. By helping the adolescent view the issues more dispassionately, the nurse will assist him or her to problem solve more effectively and to begin to view issues from the parents perspective as well.

DIF: Cognitive Level: Application REF: Text Pages: 695-696

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

13. Since the divorce of parents 6 months ago, an adolescent has been absent from school nearly every Friday and gives vague complaints of various illnesses. Which nursing intervention would be most therapeutic in this situation?

a.

Ask the student to discuss what is happening on Fridays.

b.

Call the students parents to determine their view concerning the behavior.

c.

Request that the school counselor invite the students parents for a family meeting.

d.

Arrange for an examination including diagnostic testing to rule out any medical illnesses.

ANS: C

The most effective action by the nurse would be to arrange for a family meeting to determine what is happening to cause the student to feel sick on Fridays. Directly asking the student may be too threatening, because there seems to be an inability to articulate concerns, except somatically. The medical examination is premature and outside the nurses authority. A telephone call is a superficial intervention for serious adolescent maladaptive behavior.

DIF: Cognitive Level: Analysis REF: Text Pages: 706-707

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

14. Which response by an adolescent during the termination of outpatient substance abuse therapy indicates the need to reevaluate the treatment plan? The adolescent:

a.

says, Im ready to get started, but Im just a little worried.

b.

becomes tearful, and the voice quivers while saying, goodbye.

c.

says, I never thought Id be sorry to stop coming here!

d.

writes a note sharing fears of relapsing once independent.

ANS: D

Expressing doubts about readiness is also within the range of answers, but the therapist will want to work with the adolescent before termination to build support and feelings of confidence. The remaining options reflect responses within the normal range of emotional readiness to terminate.

DIF: Cognitive Level: Analysis REF: Text Page: 709

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

15. An adolescent currently being treated for aggressive behavior says, I need to tell you something very important, but first you have to promise not to tell anyone else. Which communication by the nurse would be most therapeutic?

a.

As you know nurses are obligated to document patient conversations, but I can be trusted not to tell anyone else but staff what you share with me.

b.

A nurse has a sacred responsibility to advocate for our patients, and I have taken an oath to maintain the confidentiality of all my patients.

c.

I am very discrete when it comes to issues my patients discuss with me when they consider the topics to be serious or important.

d.

I will always maintain your confidence except when I think that what you tell me might place you or others in danger.

ANS: D

The nurse has a duty to report any information that is provided that could present danger to the patients themselves or to others.

DIF: Cognitive Level: Application REF: Text Page: 710

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

16. An adolescent refuses to go to gym class after classmates jokingly called two freckles under his nipples extra breasts. Which intervention would be most therapeutic for this adolescent?

a.

Reassure him that they are freckles not extra breasts, and send the student back to the gym to play basketball.

b.

Acknowledge the students self-consciousness while reflecting the reality that the statement was made as an insensitive joke.

c.

Call the principal and explain the situation and the possibility that the school may be experiencing a bullying problem that focuses on anatomy jokes.

d.

Inform his parents of their childs concerns, and suggest they have a discussion about hurtful joking and age appropriate anatomy to deal with the issue.

ANS: B

It is important to acknowledge the patients concern while still focusing on reality. Inadequately addressing and minimizing the patients concerns and sending the child back to the gym set up a situation that may create a regressive struggle. Calling the principal is an overreaction at this point. Informing the parents and suggesting a follow-up discussion would be premature and could overwhelm an already traumatized and sensitive adolescent.

DIF: Cognitive Level: Analysis REF: Text Page: 695

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

17. A father drags his adolescent to the nurses office at school and says, I caught him trying to run away from school again. The nurse should initially:

a.

ask the child why he feels a need to keep running away.

b.

inform the parent that these actions could be considered physical abuse.

c.

refer both the adolescent and the parent to the local juvenile justice authorities.

d.

encourage the parent and child to talk with the nurse about the current problems.

ANS: D

Although running away may be a cry for help, an attempt to escape from an unbearable living situation, or both, it also can be a solution that would be chosen by an unmotivated youth who may have a conduct disorder. The most therapeutic intervention is one that initiates communication regarding the root of the childs behavior.

DIF: Cognitive Level: Application REF: Text Page: 698

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

18. A parent reports, My adolescent sometimes acts like an adult and at other times like a child. The nurse reassures the parent, explaining that this represents an expected attempt to cope with changes in which developmental area?

a.

Sexual behavior

b.

Peer pressure

c.

Social role

d.

Identity

ANS: D

In response to the changes of puberty that affect identity and the feelings that are associated with this, adolescents use defenses against these feelings that were helpful in childhood and also experiment with new, more adult-like attempts at mastery. Because of these attempts to cope, adolescents sometimes act like adults and at other times act like children.

DIF: Cognitive Level: Comprehension REF: Text Page: 695

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

19. An adult states, When I was young, I would never have even thought of being disrespectful or being disobedient to my parents. The nurse gains insight that supports the theory that this adult was probably raised in a home with which parenting style?

a.

Authoritarian

b.

Traditional

c.

Democratic

d.

Permissive

ANS: A

Authoritarian parents are oriented toward shaping, controlling, and restricting the adolescent to fixed standards. Obedience is seen as a virtue, and power and responsibility are not shared with the adolescent. Traditional parents value a sense of continuity and order. Democratic parents do not believe that their standards are always right. Permissive is not a parenting style identified in the textbook.

DIF: Cognitive Level: Comprehension REF: Text Page: 696

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

20. A nurse would be most concerned about the risk of suicide in which adolescent?

a.

A 13-year-old girl with poor school performance

b.

A 14-year-old male exhibiting hostile behavior

c.

A 17-year-old female with alcohol abuse issues

d.

An 18-year-old male with relationship problems

ANS: D

All the problems described are indicators of depression in adolescents. Although the incidence of depression is twice as great in girls as in boys, the male suicide rate for 15- to 19-year-olds is five times the female rate.

DIF: Cognitive Level: Application REF: Text Page: 698

TOP: Nursing Process: Diagnosis|Nursing Process: Analysis

MSC: NCLEX: Psychosocial Integrity

21. An adolescent self-mutilates by cutting. Which strategy would best support the child in eliminating these urges initially?

a.

Encourage the adolescent to identify and verbalize feelings rather than acting them out.

b.

Encourage the adolescent to select individuals to call when the urge to self-mutilate occurs.

c.

Teach the adolescent stress management techniques to reduce impulsivity, such as counting to 10.

d.

Teach the adolescent to use distraction techniques, such as snapping a rubber band, when destructive urges arise.

ANS: B

Actively engaging in the identification and verbalization of feelings that result in the urge to self-mutilate is the primary intervention directed toward elimination of the need. The remaining strategies listed are useful in reducing self-mutilation but require teaching and practice.

DIF: Cognitive Level: Analysis REF: Text Page: 701

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

22. An adolescent is just beginning individual therapy. The nurse suspects the adolescent is demonstrating resistance when stating:

a.

There isnt anything so wonderful about this kind of therapy.

b.

Im really busy and may miss some of our meetings because of things I have to do.

c.

I dont really need to be here. Its my parents who have the real problems, not me.

d.

It is so embarrassing to have to come here and talk with someone I hardly know about my problems.

ANS: C

Adolescents often test nurses early in the therapeutic relationship to see whether they are anxious, defensive adults or whether they will respond as authority figures. This type of behavior is called resistance. Interestingly, arguing is a way for adolescents to learn. Limit testing is a way for adolescents to see how firm and consistent nurses will be. Embarrassment about being in therapy is common in adolescents and can be discussed openly in a therapy session.

DIF: Cognitive Level: Analysis REF: Text Page: 710

TOP: Nursing Process: Diagnosis|Nursing Process: Analysis

MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. When asked to manage the care of an intoxicated adolescent who was found drinking alcohol in the school bathroom, the school nurse should: (Select all that apply.)

a.

arrange for the adolescent to sleep in a safe place.

b.

report the adolescents drinking to the local police.

c.

inform the parents that the child will be suspended.

d.

call the parents to notify them of the situation.

e.

notify the schools alcohol counselor.

ANS: A, D, E

The correct options safeguard the adolescent while he or she is inebriated and seek assistance that uses a family-centered approach to the adolescents problems. Notifying the police is premature since no actual crime was committed and the issue of suspension is not within the nurses scope.

DIF: Cognitive Level: Analysis REF: Text Pages: 704-705

TOP: Nursing Process: Implementation

MSC: NCLEX: Psychosocial Integrity|NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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