Vous êtes sur la page 1sur 36

Ch.

17

1. 1.ID: 45529981
Which problem is not considered a causative agent in delirium?
A. Elevated blood urea nitrogen levels

B. Infection

C. Anticholinergic drugs

D. Correct Antibiotic therapy

While delirium may be a result of an infection, antibiotic therapy is not know to cause cognitive
disorders.
Text pages: 371, 372
Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 45529988
The term "perceptual disturbance" refers to difficulty
A. Correct processing information about one's internal and external environment.

B. changing one's way of thinking to accommodate new information.

C. performing purposeful motor movements.

D. formulating words appropriately.

Perceptual distortion refers to impaired ability to process intellectual, sensory and emotional data in
a logical meaningful way.
Text page: 373
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45529999
Which event would a client with early (stage 1) Alzheimer's disease have greatest difficulty
remembering?
A. High school graduation

B. The birth of one's children

C. A story of a teenage escapade

D. Correct What was eaten for breakfast

Initially, recent memory is impaired while remote memory remains intact.


Text page: 382
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 45530306
A client has been diagnosed with delirium caused by a metabolic disorder. He begs the nurse to get
someone to take away the huge snake in the hallway before it comes into his room. The nurse looks
to where he is pointing and sees the hose of the vacuum cleaner being used by the housekeeping
staff to clean the hall. The nurse can assess this symptom as
A. a hallucination.

B. Correct an illusion.

C. hypervigilence.

D. agnosia.
Illusions are errors in the perception of a sensory stimulus.
Text page: 373
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45530317
A client with delirium strikes out at staff. The nurse can most correctly hypothesize that this behavior
is related to
A. anger.

B. Correct fear.

C. meanness.

D. lack of social concern.

Clients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious
clients who are fearful may strike out at others, seemingly without provocation.
Text page: 374
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45530324
Which cause of dementia has a clear genetic link?
A. Dementia from advanced alcoholism

B. Multiinfarct dementia

C. Creutzfeldt-Jacob disease

D. Correct Alzheimer's disease

Family members of people with Alzheimer's disease have a risk of acquiring the disease that is
higher than that of the general population.
Text page: 380
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 45530335
What is the usual course of Alzheimer's disease?
A. A single short episode followed by years of normal function

B. Reoccurring remissions and exacerbations

C. Correct Progressive deterioration

D. No usual course exists


The usual progression of Alzheimer's disease is steadily downward.
Text page: 380
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45530342
A client with Alzheimer's disease looks confused when the phone rings and seems not to recognize
what the stimulus is. He also cannot recall many common household objects by name, such as a
pencil or glass. The nurse can document this as
A. apraxia.

B. Correct agnosia.

C. aphasia.

D. anhedonia.

Agnosia is the loss of the ability to recognize familiar objects.


Text page: 381
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45530351
The family of a client with Alzheimer's disease mentions to the nurse that seeing his loss of function
when he was once such a competent individual has been very difficult. A nursing diagnosis that
might be considered for such a family would be
A. ineffective denial.

B. Correct anticipatory grieving.

C. disabled family coping.

D. ineffective family therapeutic regimen management.


Anticipatory grieving involves working through potential loss.
Text page: 385
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45530360


A nursing diagnosis appropriate for a client with Alzheimer's disease, regardless of the stage, would
be
A. Correct risk for injury.

B.

C.

D.
Memory loss, agnosia, poor judgment, and the other symptoms of Alzheimer's disease contribute to
placing the client at risk for injuries such as burns and falling down stairs.
Text page: 385
Awarded 1.0 points out of 1.0 possible points.

1. 1.ID: 45530388
The physician mentions to the nurse that a client who is about to be admitted has "sundowning." The
nurse can expect to assess nightly
A. Correct agitation.

B. lethargy.

C. depression.

D. mania.
Sundowning involves increased disorientation and agitation occurring at night.
Text page: 373
Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 45530399
The nurse caring for a client with Alzheimer's disease can anticipate that the family will need
information about therapy with
A. antihypertensives.

B. benzodiazepines.

C. immunosuppressants.

D. Correct acetylcholinesterase inhibitors.

Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level.


Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting,
thus leaving more available acetylcholine.
Text page: 394
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45530506
A client is brought to the hospital by her daughter, who visited this morning and found her mother to
be confused and disoriented. The client has difficulty answering the questions asked by the nurse.
The daughter reports that her mother had been oriented and able to carry on a logical conversation
the evening before. The nurse can suspect that the client is displaying symptoms associated with
A. Correct delirium.

B. dementia.

C. amnesic disorder.

D. selective inattention.
Delirium is characterized by a disturbance of consciousness, a change in cognition (such as
impaired attention span), and a fluctuating level of consciousness that develop over a short period of
time.
Text page: 373
Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 45530517
A client is brought to the hospital by her daughter, who visited this morning and found her mother to
be confused and disoriented. The daughter remembered to bring her mother's medication to the
hospital. They include digoxin, an antihypertensive, a tricyclic antidepressant, and an antiparkinson
drug (benztropine mesylate) that the client has been taking for only 5 days. For planning purposes,
the nurse should realize that the least likely action the physician will take is
A. ordering benzodiazepine administration.

B. withdrawing the antidepressant and antiparkinson drugs.

C. having blood drawn for a serum digoxin level.

D. Correct suggesting the social worker talk to the family about institutionalization.

It is quite possible that the client's problem is delirium, which is a reversible disorder.
Institutionalization should not be necessary.
Text page: 371
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45530522
A client is brought to the hospital by her daughter, who visited this morning and found her mother to
be confused and disoriented. When the client is admitted, the daughter states "I'll take her glasses
and hearing aid home so they don't get lost." The best reply for the nurse would be
A. "That will be fine. I'll have you sign our hospital release form."

B. "Because we do not have a copy of durable power of attorney we cannot release


them to you."
C. "Don't worry. You can leave them at her bedside. We are insured for losses of this
sort."

D. Correct "I would like to have your mother wear them. It will help her to be less
confused."
Clients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is
reduced through the use of glasses and hearing aids.
Text page: 374
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45530529
The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of
Alzheimer's disease. What finding would be out of character if the client truly has stage 1 Alzheimer's
disease?
A. Correct Willingness to respond directly to questions posed by nurse

B. Charming behavior designed to hide memory deficit

C. Confabulation to compensate for forgotten information

D. Avoidance of questions by subject changing

During stage 1 Alzheimer's disease the client is aware of memory impairment and may attempt to
disguise it or cover it by being evasive or using confabulation.
Text pages: 382, 383
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45530535
A client with Alzheimer's disease can no longer perform hygiene and grooming. She often objects to
being led to the shower and does not participate in washing herself. She puts her arms into the legs
of her slacks, and so forth. She tests doors and walks through any door that will open. Sometimes
she seems unable to find the bathroom and is incontinent. Communication with her is difficult
because of the loss of language skills. The nurse would assess the client as being in the stage of
Alzheimer's disease labeled
A. stage 1, mild.

B. stage 2, moderate.

C. Correct stage 3, moderate-severe.

D. stage 4, end.
Moderate-severe Alzheimer's disease requires a high level of supervision because of the severe
memory loss the client is experiencing. Wandering and inability to meet self-care needs become
problematic.
Text page: 383
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45530545
An initial intervention the nurse might suggest to the family members of a client with Alzheimer's
disease who has begun to be incontinent for urine is to:
A. Correct label the bathroom door with a picture.

B. provide toileting on an as-needed basis.

C. apply disposable diapers.

D. encourage hourly toileting.

Labeling doors and various items with pictures can be helpful for a client who has forgotten where
things are and what certain items are.
Text page: 388
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45530552
Dementia in an older adult is often a misdiagnosis for:
A. Correct depression

B. cerebral emboli

C. normal effects of aging

D. poor nutritional statis

Depression in an older adult is frequently confused with dementia.


Text page: 381
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45530561


The family members of a client with stage 1 Alzheimer's disease have jobs and cannot provide
adequate supervision for the client. A reasonable alternative for the nurse to explore with them
would be
A. Correct day care.

B. acute care hospitalization.

C. long-term institutionalization.

D. group home residency.

Day care is a good option for clients with early-stage Alzheimer's disease. It provides supervision, a
protected environment, and supportive interactions.
Text page: 391
Ch.19

1. 1.ID: 45479918
A nurse caring for a client who has been diagnosed with a personality disorder should expect that
the client will exhibit which of the following characteristics?
A. Frequent episodes of psychosis

B. Constant involvement with the needs of significant others

C. Correct Inflexible and maladaptive responses to stress

D. Abnormal ego functioning


Personality patterns persist unmodified over long periods of time. Characteristics of inflexible and
maladaptive response to stress is one of these characteristics for individuals with personality
disorder.
Text page: 434
Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 45479928
Which statement is descriptive of clients with personality disorders?
A. Correct They are resistant to behavioral change.

B. They have an ability to tolerate frustration and pain.

C. They usually seek help to change maladaptive behaviors.

D. They have little difficulty forming satisfying and intimate relationships.

Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it
very difficult, if not nearly impossible, to change. Change proceeds very slowly.
Text page: 434
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45479936
Research has indicated that antisocial personality may be characterized by:
A. social isolation.

B. Correct lack of remorse.

C. learning difficulties.

D. difficulty with reality testing.


The antisocial personality exhibits a lack of remorse when confronted with the results of their
thoughtless, irresponsible behavior towards others.
Text page: 438
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 45479945
The primary goal of milieu therapy for clients with personality disorders is
A. Correct manage the affect behavior has on the entire group.

B. one-on-one therapy.

C. to help the client remain uninvolved with other patients.

D. a laissez faire attitude.


The primary goal of milieu therapy is affect management in a group context.
Text page: 448
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45479955
Characteristic behaviors the nurse will assess in the narcissistic client are
A. dramatic expression of emotion, being easily led.

B. perfectionism and preoccupation with detail.

C. Correct grandiose, exploitive, and rage-filled behavior.

D. angry, highly suspicious, aloof, withdrawn behavior.

Narcissistic clients give the impression of being invulnerable and superior to others to protect their
fragile self-esteem.
Text page: 439
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45479963
Which client with a personality disorder is most likely to be admitted to a psychiatric unit?
A. Mr. A, with paranoid personality disorder who is suspicious of his neighbors

B. Mr. B, with narcissistic personality disorder who is highly self-important

C. Correct Ms. C, with borderline personality disorder who is impulsive

D. Mrs. D, with dependent personality disorder who clings to her husband


Clients with borderline disorder can decompensate into psychotic states under stress.
Hospitalization is needed at these times.
Text page: 437
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45479972
Characteristics the nurse will assess in the client with antisocial personality disorder are
A. Correct deceitfulness, impulsiveness, and lack of empathy.
B. perfectionism, preoccupation with detail, and verbosity.

C. avoidance of interpersonal contact and preoccupation with being criticized.

D. need for others to assume responsibility for decision-making and seeks nurture.

Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to
do whatever serves them best without consideration for the rights or feelings of others.
Text page: 437
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45479982
Playing one staff member against another is an example of
A. devaluation.

B. Correct splitting.

C. impulsiveness.

D. social ineptitude.
Splitting involves setting up individuals or groups to disagree. While the two parties are busy
disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can
enjoy the spectacle and do as he or she pleases.
Text page: 437
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45479989
Splitting is a process in which the client
A. unconsciously represses undesirable aspects of self.

B. places responsibility for his or her behavior outside the self.

C. Correct sees things as divided into "all good" or "all bad."

D. evidences lack of personal boundaries.

Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An
individual is not seen as a person with good and bad traits, but rather as all good or all bad.
Text page: 437
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45480205


A 16-year-old has stolen money from his invalid grandmother, uses drugs and alcohol, and
frequently beats up acquaintances who disagree with him. Arrested for an assault in which he beat a
classmate and caused brain damage, he stated in court "The guy deserved everything he got." The
behaviors described are most consistent with the clinical picture of
A. Correct antisocial personality disorder.

B. borderline personality disorder.

C. schizotypal personality disorder.

D. narcissistic personality disorder.


Clients with antisocial personality act out feelings without consideration for the rights of others. They
feel no remorse for their antisocial acts.
Text page: 437

1.
2. 1.ID: 45480231
Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of
ineffective coping?
A. Difficulty in relationships

B. High levels of anxiety

C. Manipulation

D. Correct Interdependence

The characteristics for the diagnosis of ineffective coping include crisis, high levels of anxiety, anger
and aggression; child, elder, or spouse abuse; and difficulty in relationships and manipulation.
Interdependence would not be considered a symptom for ineffective coping.
Text page: 447
Awarded 1.0 points out of 1.0 possible points.

3. 2.ID: 45480249
A nurse is assigned to work with a client with borderline personality disorder. The nurse will need to
consider strategies for dealing with the client's
A. Correct mood shifts, impulsivity, and splitting.

B. grief, anger, and social isolation.

C. altered sensory perceptions and suspicion.

D. perfectionism and preoccupation with detail.


Borderline personality disorder has the central characteristic of instability in affect, identity, and
relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned. But
they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger.
Their frequent use of the defense of splitting strains personal relationships and creates turmoil in
health care settings.
Text pages: 437, 438
Awarded 1.0 points out of 1.0 possible points.

4. 3.ID: 45480255
A client has been diagnosed with dependent personality disorder. Which behavior descriptions can
the nurse expect to assess?
A. Correct Anxious, fearful

B. Odd, eccentric

C. Dramatic, emotional, erratic

D. Disoriented, disorganized

Dependent personality disorder has a primary feature of extreme dependency in a close relationship,
with an urgent search to find a replacement when one relationship ends. These individuals have
difficulty making independent decisions and are constantly seeking reassurance. They have deeply
held convictions of personal incompetence, with the fear that they cannot survive on their own. They
frequently seek treatment for anxiety or mood disorders related to a loss.
Text pages: 440, 441
Awarded 1.0 points out of 1.0 possible points.

5. 4.ID: 45480261
A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing
intervention of highest priority will be to
A. set firm limits on behavior.

B. Correct respect need for social isolation.

C. encourage expression of feelings.

D. involve in milieu and group activities.

Schizoid personality disorder has the primary feature of emotional detachment. The person does not
seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not
do well with resocialization.
Text pages: 436 and 449
Awarded 1.0 points out of 1.0 possible points.

6. 5.ID: 45480268
A client with dependent personality disorder who had been living with her newly married son was
admitted a week ago for treatment of depression, which began after her son suggested that she
move out. Which remark by the client would the nurse evaluate as showing improvement in the
client's condition?
A. "My son's suggestion hurt me greatly."

B. "My son is less at fault than my daughter-in-law."


C. Correct "I'm going to need help to afford to rent an apartment."

D. "How will I ever live alone with no one to look after my affairs?"
Dependent personality disorder has a primary feature of extreme dependency in a close relationship,
with an urgent search to find a replacement when one relationship ends. Clients have a deeply held
conviction of personal incompetence, with the fear that they cannot survive on their won. Self
reflection on the possibility of moving into an apartment shows improvement.
Text pages: 440, 441
Awarded 1.0 points out of 1.0 possible points.

7. 6.ID: 45480276
A client with histrionic personality disorder winks at an attractive nurse and states, "You and I should
be able to turn those resident physicians into jelly if you'd wear your skirts about two inches shorter."
The nurse's reply should be based on the understanding that the client's use of seductive behavior is
A. Correct a response to stress.

B. based on a need to dominate.

C. seated in primitive rage.

D. callous disregard for others.

The histrionic person is impulsive and melodramatic and may act flirtatious or provocative to get the
spotlight in an attempt to reduce stress.
Text pages: 438, 439
Awarded 1.0 points out of 1.0 possible points.

8. 7.ID: 45480287
A client with obsessive-compulsive personality disorder takes the nurse aside and mentions "I've
observed you interacting with Mr. D. You are not approaching him properly. You should be more
forceful with him." The best response for the nurse would be
A. Correct "I will be continuing to follow the care plan for Mr. D."

B. "I see you are trying to control Mr. D's therapy as well as your own."

C. "Your eye for perfection extends even to my nursing interventions."

D. "Mr. D's care is really of no concern to you or to other clients."


Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on
orderliness and control. These individuals get so preoccupied with details and rules that they may
not be able to accomplish the tasks. Guard against engaging in power struggles with a client with
obsessive-compulsive disorder.
Text pages: 440, 441
Awarded 1.0 points out of 1.0 possible points.
9. 8.ID: 45480298
The priority nursing intervention for a client with borderline personality disorder is to
A. protect other clients from manipulation.

B. respect the client's need for social isolation.

C. Correct assess for suicidal and self-mutilating behaviors.

D. provide clear, consistent limits and boundaries.


One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess
for suicidal and self-mutilating behaviors, especially during times of stress.
Text page: 437
Awarded 1.0 points out of 1.0 possible points.

10. 9.ID: 45480507


A danger of working with a client who idealizes the nurse is
A. Correct becoming overinvolved and being protective and indulgent.

B. becoming indecisive about planned interventions.

C. developing a prejudicial, blaming orientation.

D. stringent enforcement of boundaries and limits.

Finding an approach for helping clients with personality disorders who have overwhelming needs
can be overwhelming for caregivers. For example, a borderline female client may briefly idealize her
male nurse on the inpatient unit, telling staff and clients alike that she is "the luckiest client because
she has the best nurse in the hospital." The rest of the team initially realizes that this behavior is an
exaggeration, and they have a neutral response. But after days of constant dramatic praise, some
members of the team may start to feel inadequate and jealous of the nurse. They begin to make
critical remarks about minor events to prove that the nurse is not perfect. Open communication in
staff meetings and ongoing clinical supervision are important aspects of self-care for the nurse
working with these clients to maintain objectivity.
Text pages: 445, 446
Awarded 1.0 points out of 1.0 possible points.

11. 10.ID: 45480517


Clients with personality disorders have various self-defeating behaviors and interpersonal problems
despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that
addresses this sort of interpersonal dysfunction is
A. spiritual distress.

B. defensive coping.

C. Correct impaired social interaction.


D. disturbed sensory perception.

For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of
impaired social interaction would be used.
Text page: 447

Ch.26

1. 1.ID: 45508986
Which statement reflects a fact about family violence?
A. Ninety-five percent of abuse victims are women.

B. The victim's behavior is often the cause of the violence.

C. Correct Violence occurs in families of all backgrounds.

D. Alcohol and stress are the major causes of abuse.


Option 3 is a true statement. The others are false.
Text pages: 585 and 589
Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 45508995
A time when the victim of abuse can expect the abuse to worsen is when
A. the perpetrator feels he is in complete control.

B. the perpetrator is feeling remorseful for being abusive.

C. Correct the victim moves toward independence from the abuser.

D. the victim submits to the domination of the perpetrator.


When the abuser thinks he is losing control over the victim, the violence escalates.
Text pages: 587, 588
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45509204
An elderly woman who has been abused by her caregiver daughter tells the nurse "You don't have
to worry about me. My daughter cried and apologized. She promised me she will never hit me
again." The nurse can assess that this is the stage in the cycle of violence known as
A. tension building.

B. acute battering.

C. Correct honeymoon.

D. escalation.
During the honeymoon stage the perpetrator apologizes, promises never to abuse again, and tries to
make up for the violence. This stage is usually brief.
Text page: 585
Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 45509214
A couple are at a clinic visit with their son, who has Tourette's syndrome. Which statement would be
assessed as a risk factor for family violence?
A. Correct "My husband lost his job and it seems all our savings are going to pay for our
son's expensive medication and all the other things he needs."
B. "Our son is really a good little boy but it isn't easy to discipline him at home and in
school."

C. "Your teaching helped us understand our son's disorder and not to be ashamed of his
inability to control the tics in public."

D. "We have become active in the support group but still find the suggestions difficult to
put into practice."
Job loss, financial problems, and a child who is "different" and has special needs should alert the
nurse to the risk for family violence since all these factors contribute to a crisis situation.
Text page: 589
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45509226
A 72-year-old client lives with her son and daughter-in-law. She gives them the money from her
monthly Social Security check to help with household expenses. When her daughter-in-law
mismanages the household finances, she demands that the client give her extra money from a small
savings account. The client writes the check because she fears that her family will make her live
elsewhere if she doesn't "help out." The nurse who hears this should assess it as
A. neglect.

B. physical violence.

C. psychological abuse.

D. Correct financial maltreatment.

Financial maltreatment occurs when the perpetrator takes financial advantage of the elderly person,
often through the use of subtle threats of what unpleasant or frightening outcome will occur if the
elder does not supply funds.
Text page: 592
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45509237
A wheelchair-bound client lives with his wife, who is the breadwinner and his caretaker. Recently his
wife brought him to the hospital for treatment of facial contusions, a broken nose, and severe
bruising of his arm and shoulder. The wife reports that he tipped over in his wheelchair. Her husband
nods assent. The nurse performing the assessment suspects that this explanation may not be
entirely truthful. The nurse should
A. confront the wife with the suspicion that her husband's injuries are the result of abuse.

B. Correct have the wife wait in the waiting room so her husband can be interviewed in
private.
C. report the husband's injuries to the police and ask for a confidential investigation.

D. document the suspicion and follow a policy of "wait and see" if he returns again.
Suspected victims of abuse should always be interviewed in private. If the perpetrator is in the room
the victim cannot speak freely.
Text page: 590
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45509246
When the nurse interviews an adult victim of abuse the best approach is to be
A. confrontational.

B. gentle and direct.

C. Correct direct and professional.

D. sympathetic and outraged.

Expressing strong emotion does not help the victim. A direct, honest, and professional manner of
asking questions produces the best results.
Text page: 590
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45509256
When treatment for injuries sustained during an incident of abuse is sought from the primary
physician, the client is receiving
A. primary prevention.

B. Correct secondary prevention.

C. tertiary prevention.

D. stop-gap therapy.
Secondary prevention is synonymous with treatment.
Text page: 602
Awarded 1.0 points out of 1.0 possible points.
9. 9.ID: 45509268
Which child can be assessed as being at lowest risk for abuse?
A. A, aged 3 months, who has colic and teenaged parents.

B. B, aged 4 years, who has cerebral palsy and retarded parents.

C. Correct C, aged 2 years, who has leukemia and two working parents.

D. D, aged 5 years, who has ADHD and a father who was abused as a child.
Although C has a serious physical disorder, she is at lower risk than A, whose inconsolable crying
can be frustrating; B, who will not be as independent as other children his age and who has parents
who may not understand his needs; or D, whose hyperactivity can be annoying, especially to a
parent who himself has been abused.
Text page: 589
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45509277


What distinction can be made between abuse and neglect?
A. Neglect occurs in the psychological domain; abuse occurs in the physical domain.

B. Neglect is always physical; abuse can be verbal, physical, sexual, or emotional.

C. Neglect is perpetrated against children; abuse victims can be children or adults.

D. Correct Neglect is a failure to provide; abuse is a failure of control of aggression.

Neglect is failure to provide necessary care, and abuse is physical maltreatment.


Text page: 585

1. 1.ID: 45509516
The risk of elder abuse in a home is indexed by looking at
A. Correct the vulnerability of the elder and the stress of the caregiver.

B. the amount of disruption the elder causes in the home.

C. how much actual physical assistance the elder needs on a daily basis.

D. the financial contribution of the elder and the caregiver's early life experience with
abuse.
Abuse occurs across all segments of society and is reinforced by the society and the culture. The
actual occurrence of violence requires (1) a perpetrator (2) someone who by age or situation is
vulnerable (i.e., children, women, men, the elderly, mentally ill persons, and physically challenged
persons), and (3) a crisis situation.
Text page: 589
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 45509526
An abuse victim tearfully tells the nurse in the emergency department, "Don't tell my husband that
you know he beats me. I have to go back there and if he thinks anyone knows, he will beat me
again." The nursing diagnosis that may be appropriate to consider on the basis of this information is
A. chronic pain.

B. Correct fear.

C. posttrauma syndrome.

D. risk for self-directed violence.


The client is expressing fear based on a known threat.
Text page: 596
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45509537
A desirable goal for the perpetrator of violence against a developmentally delayed child would be
that the client will
A. Understand the impact of violence on the child with 2 days.

B. Correct attend anger management training sessions within 2 weeks.

C. state that he or she is considering attending a group for child abusers by [date].

D. express anger and aggression toward significant other rather than the child by [date].

Perpetrators of violence need help learning how to manage anger. A structured group is an excellent
way to provide this teaching.
Text page: 597
Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 45509546
A nursing intervention directed at the psychological needs of an abused woman is to
A. encourage the client to immediately leave the abuser.

B. Correct affirm that the client did not deserve or cause the abuse.

C. provide a referral to social services for economic problems.

D. facilitate contact with law enforcement to take legal action.


Abused clients often believe that they are deserving of the abuse and, in some way, prompt the
abuser to attack. They need specific reassurance that they did not deserve to be abused and they
did not cause the attack.
Text pages: 598 and 600
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 45509556
Which factor is of least importance as a victim of spousal abuse constructs an escape plan?
A. Correct Has the perpetrator actually harmed her?

B. Where will the victim go?

C. How will the victim get there?

D. What does the victim need to take?


Any abused person has been threatened. This is a given and does not enter into the details of the
escape planning.
Text page: 598
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45509568
The nurse has referred a battered woman to the battered women's shelter and believes the woman
left the emergency department to go there. An hour later the woman's husband comes to the
emergency department and pleads with the nurse to tell him his wife's whereabouts. The nurse
should
A. Correct refuse to provide any information.

B. give him the telephone number, but not the address, of the shelter.

C. inform him that no information can be given for a minimum of 24 hours.

D. call law enforcement to arrest the husband for the assault and battery of his wife.

The nurse must respect the client's right to confidentiality. Whether the questioner asks pleadingly or
in a demanding way, the answer must be the same.
Text pages: 597, 598
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45509584
A person experiencing violence from a spouse may feel trapped in a detrimental relationship. Which
of the following would be the most likely symptom that the woman would report as an attempt to
escape the situation?
A. The client relates that she is taking alcohol as a way to escape.

B. The client states she has recently become more aggressive toward her husband so
that she will not be physically beaten by him.

C. Correct The client states that she has recently made a suicide attempt.

D. The client states she needs help because when she calls the police to arrest her
husband but they do nothing.
A person experiencing violence may feel so trapped in a detrimental relationship, yet so desperate to
get out, that suicide may seem the only answer. A suicide attempt may be the presenting symptom
in the emergency department. At least 10% of abused women attempt suicide. The other reports are
not realistic for a woman who is being abused.
Text pages: 588 and 594
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45509592
A client is an abused wife. The nurse believes the cycle of abuse is escalating and that the client
may be in severe physical danger. What is the priority nursing intervention?
A. Advise her to enter counseling at the mental health center

B. Correct Assist her to develop a plan to go to a shelter in case of a crisis

C. Suggest she leave the abuser and go to a trusted friend's home

D. Teach her to counter verbal abuse with assertive replies

Every victim of abuse should have an escape plan, but one is particularly important when the nurse
believes the client is in severe danger.
Text page: 598
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45509702
A 4-year-old child is seen in a well-child clinic. He tells the nurse "I'm a bad boy. I'm not worth a
second look." The nurse gently questions the boy and his mother and learns that the boy's father
constantly browbeats the child. He tells him he's worthless and puts down all his efforts. He also
shouts verbal threats whenever the boy misbehaves. This situation can be assessed as
A. neglect.

B. physical maltreatment.

C. Correct emotional violence.

D. harsh parenting.

Emotional violence occurs when the child's self-esteem is attacked. It is as devastating to the child
as physical abuse.
Text page: 592
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45509713


When a nurse has reason to suspect that a child is being abused, what action should he or she
take?
A. Call the local police to report it
B. Correct Follow agency policy for reporting

C. Confront the parent or parents

D. Interrogate the child to obtain proof

Nurses are mandated reporters of child abuse. They must follow the rules set forth by the state
regarding the steps to take to report child abuse.
Text page: 597

Ch.27

1.
2. 1.ID: 45507922
Rape is best described as
A. Correct an act of violence using sex as the weapon.

B. assault by a stranger on an unsuspecting victim.

C. sexual desire satisfied inappropriately.

D. an act prompted by early childhood neglect.


Rape is a violent crime. Sex is only the medium for perpetrating the crime.
Text page: 610
Awarded 1.0 points out of 1.0 possible points.

3. 2.ID: 45507931
Which statistic concerning rape is true?
A. Correct Most male rape victims do not report the crime.

B. Male rape is perpetrated by homosexual men.

C. The peak incidence of rape is ages 25 to 29 years.

D. Most rapes occur after abductions.

Option 1 is the only true statement.


Text page: 610
Awarded 1.0 points out of 1.0 possible points.

4. 3.ID: 45507942
To provide discharge treatment and support, the nurse should realize that the most common
sequelae of acquaintance rape is the development of
A. Correct symptoms of sexual distress.

B. anxiety and fear of men.

C. a paranoid psychosis.
D. an eating disorder.

Women who have been raped by acquaintances frequently develop symptoms that prevent them
from participating in normal sexual relations. Sexual distress is more common among women who
have been sexually assaulted by intimates; fear and anxiety are more common in those assaulted by
strangers. Depression occurs in both groups.
Text page: 611
Awarded 1.0 points out of 1.0 possible points.

5. 4.ID: 45507956
Care planning for the rape victim is facilitated if the nurse understands that the rape trauma
syndrome is actually a variant of
A. Correct posttraumatic stress disorder.

B. a maturational crisis.

C. a dissociative disorder.

D. generalized anxiety disorder.


Most of those who have been raped are eventually able to resume their previous lives after
supportive services and crisis counseling. However, many carry with them a constant emotional
trauma: flashbacks, nightmares, fear, phobias, and other symptoms associated with posttraumatic
stress disorder.
Text page: 612
Awarded 1.0 points out of 1.0 possible points.

6. 5.ID: 45507964
What reaction is most commonly displayed by rape victims in the immediate aftermath of the rape?
A. Correct Disorganization

B. Philosophical acceptance

C. Total withdrawal from reality

D. Display of seductive actions

The acute phase of the rape trauma syndrome occurs immediately after the assault and may last for
a few weeks. This stage is seen by emergency department personnel. Nurses are the ones most
involved in dealing with these initial reactions. During this phase a great deal of disorganization in
the person's lifestyle and somatic symptoms are common.
Text page: 612
Awarded 1.0 points out of 1.0 possible points.

7. 6.ID: 45507973
Which statement reflects a truth about rape?
A. Many women want to be raped.

B. Rapists are oversexed.

C. Correct Most rapes are planned.

D. Most women are raped by strangers.


Many myths about rape exist. Most rapes are not impulsive, spur-of-the-moment acts, but are
carefully planned and orchestrated.
Text page: 616
Awarded 1.0 points out of 1.0 possible points.

8. 7.ID: 45507981
Anticipatory teaching of a rape victim should include information that a common survivor problem
often developing during the long-term reorganization phase of rape trauma syndrome is
A. denial of the event.

B. headaches and fatigue.

C. shock and numbness.

D. Correct intrusive thoughts.

Just as in posttraumatic stress disorder, intrusive thoughts haunt the rape victim in the weeks and
months during which long-term reorganization is occurring. Knowing this is a common occurrence is
reassuring to the client, who often is frightened by the symptom.
Text page: 613
Awarded 1.0 points out of 1.0 possible points.

9. 8.ID: 45507993
A rape victim in the emergency department repeats "I don't know why he did it." Although the nurse
does not necessarily give the answer at this juncture, the nurse correctly identifies the motivation for
most perpetrators of rape as
A. anxiety relief.

B. overwhelming sexual desire.

C. Correct a desire to dominate and humiliate.

D. a wish to be apprehended and punished.


Power and domination as well as humiliation of the victim are the motivations for rape. In this
scenario the nurse understands that rape is not a sexual act. Rape is a violent expression of
aggression, anger, and the need for power.
Text page: 616
Awarded 1.0 points out of 1.0 possible points.
10. 9.ID: 45508204
The emergency department nurse planning care for a rape victim must realize that the emotional
reaction displayed by many rape victims during assessment and treatment while in the emergency
department is
A. Correct fear.

B. eagerness.

C. suspicion.

D. disinterest.
Rape is an act of violence, and sex is the weapon used by the perpetrator. Rape engulfs its victims
in fear and anxiety, resulting in withdrawal for some and causing severe panic reactions in others.
After being traumatized, the person raped often carries an additional burden of shame, guilt, fear,
anger, distrust, and embarrassment.
Text page: 614
Awarded 1.0 points out of 1.0 possible points.

11. 10.ID: 45508213


In the acute phase of the rape trauma syndrome, nursing interventions should focus on
A. teaching stress management techniques to the client.

B. helping the client's family clarify feelings.

C. Correct providing client support and safety.

D. ensuring case management.

Helping the client feel safe and giving emotional support are two important interventions to combat
the disorganization common during the acute phase of the rape trauma syndrome.
Text page: 612

1. 1.ID: 45507601
A client tells the college health nurse she was raped by her date several weeks ago. Which reason is
the client most likely to give for waiting to tell someone?
A. Feeling embarrassed about having a physical examination

B. Correct Feeling guilty for somehow having caused it

C. Fear that no one would believe her

D. Fear of contracting a sexually transmitted disease


Many rape victims feel that they are somehow at fault for the rape and harbor feelings of guilt. This
guilt stands in the way of reporting the rape to the authorities.
Text page: 618
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 45507609
K calls a rape crisis hotline and reports having been raped. The nurse advises K to go to the nearest
emergency department for treatment. K states "I'll think it over while I take a shower." The nurse
should
A. question her regarding the circumstances of the rape.

B. advise her not to take too long before seeking treatment.

C. Correct explain that showering or changing clothes will destroy evidence.

D. ask if she may call a police woman to accompany her to the hospital.
Showering, washing, and changing clothes will destroy evidence such as semen and hairs shed
from the perpetrator's body. Victims should be advised regarding what to do to preserve evidence.
Text pages: 613 and 617
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45507618
When the nurse finishes addressing a group of college women about rape, the following comments
are heard during the discussion period. Which comment calls for additional teaching by the nurse?
A. "It makes sense that rape is a crime of violence, not a crime of sex."

B. "Who would have guessed that most rape victims know the rapist?"

C. Correct "So if you dress conservatively, your risk of being raped is small."

D. "I always thought rapes happened at night but now I know that isn't true."

Rapes have little to do with whether the victim dresses seductively because rape is a crime of
violence rather than a crime of sex.
Text page: 616
Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 45507629
A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse
does not believe in abortion. The action the nurse should take is to
A. "forget" to mention this to the physician.

B. Correct report and document the request.

C. ask the supervising nurse to reassign the client.

D. ask the client to reevaluate her request after 24 hours.


The nurse's ethical beliefs should never interfere with client rights. The nurse should report and
document the client's request. If the drug is ordered, however, the nurse can request that another
nurse administer the drug.
Text page: 616
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45507639
A sexual assault victim tells the nurse "I should have tried to fight him off! But I was so terrified that I
could not move. My whole body felt as though it was made of lead. I should have tried harder." A
supportive response for the nurse to make would be
A. "Try not to think about it. Put it out of your mind."

B. "We each behave in characteristic ways in a crisis. That was your way."

C. "Do you think others will think badly of you for not trying to fight?"

D. Correct "The way you behaved was the right thing to do at the time."

The victim should always be told that staying alive was the priority, and that whatever she did to that
end was the right thing to do.
Text page: 618
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45507650
What verbal nursing intervention in the immediate post-rape period would be designed to lower client
anxiety and increase feelings of safety?
A. Correct "You are safe here. I will stay with you while you have your examination."

B. "I know you feel confused. We will make all the necessary decisions for you."

C. "Please tell me as much about the details of the rape as you can remember."

D. "When you leave you will be given follow-up appointments for pregnancy and sexually
transmitted disease screening."
The presence of the nurse is reassuring, especially when the client is experiencing disorganization
and the environment is confusing.
Text pages: 612 and 614
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45507660
Three weeks after a client was raped she tells the nurse "I am going crazy. I have nightmares and
wake up screaming. Then during the day all sorts of thoughts about the rape intrude into whatever I
am concentrating on. I can't get anything done at work." The nurse should reply
A. "Becoming mentally ill is a frightening thought for you?"

B. Correct "These are a normal response to stress and will decrease with time and
therapy."
C. "You are right to be concerned. I can give you a referral for treatment."
D. "Would it help if you took some time off from work and stayed home?"

These symptoms are part of the response to rape trauma and parallel symptoms experienced by
other victims of posttraumatic stress disorder.
Text pages: 612, 613
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45507669
Which statement would be an appropriate outcome for a rape client? The client will
A. Correct integrate the rape event and resume an optimal level of functioning.

B. identify and develop coping skills necessary to reduce level of anxiety.

C. blame the rapist rather than blame herself for the situation.

D. repress feelings of shame, embarrassment, and self-blame.


This is the ideal long-term result of treatment for rape trauma syndrome, that life will go on and the
client will return to the usual pre-trauma level of functioning.
Text page: 617
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45507680
A client who comes to the emergency department states she has just been raped. She displays a
blank face and a rather calm appearance. During the assessment interview, however, she seems
shocked about the event and confused regarding the details. The nurse can assess this behavior as
A. indicating the client may be lying about the rape.

B. an expressed style of impact reaction to the rape.

C. Correct a controlled style of impact reaction to the rape.

D. a somatic reaction to stress from the rape.

This reaction is consistent with the controlled style of response. Other styles are expressed, somatic,
and emotional.
Text page: 612
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45507690


The nurse working with a rape victim in the week after the event tells her about the possibility of
experiencing intrusive thoughts, increased motor activity, and fears and phobias in the next few
weeks. The reason for this intervention is
A. to help the client redevelop a sense of control over herself.

B. Correct that anticipatory guidance allows planning to decrease stress.


C. that talking about feelings reduces their intensity.

D. that self-destructive behaviors develop out of negative feelings.


Anticipatory guidance helps the client understand what to expect. When the expected occurs it is not
as great a shock. Knowing what to expect also allows the client to plan for ways to cope.
Text page: 613

Ch.35

1. 1.ID: 45511160
The family function that helps define roles of members within families and allows for differences
between members is
A. communication.

B. management.

C. Correct clarity.

D. socialization

Clear boundaries maintain a distinction between individuals in the family.


Text page: 750
Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 45511174
A family is highly verbal. They openly tell each other what they are thinking and feeling. They are
noted to ask directly for what they want and to tell each other what displeases them. A nurse
listening to their interchanges would assess them as using
A. generalizing communication.

B. double-bind communication.

C. disengaged communication.

D. Correct healthy communication.

Healthy communication is exemplified by being clear and direct in saying what you want and need.
Text page: 751
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45511183
At what point would the nurse expect a family to demonstrate the greatest dislocation in the family
life cycle?
A. When the couple is deciding whether to have children

B. When the first child enters school


C. Correct When a member is diagnosed with multiple sclerosis

D. When the couple renegotiates the marital system as a dyad


Family stress is often the greatest at times of serious illness, death, or divorce.
Text page: 753
Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 45511189
A family consists of a husband, a wife, their three children, and the wife's mother. This family form is
called a(n)
A. Correct extended family.

B. dyadic family.

C. blended family.

D. indwelling family.

An extended family (multigenerational) is a composite of three or more generations.


Text page: 758
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45511401
Which situation is the best example of a double bind?
A. Correct Mrs. O sighs sadly and tells her husband "You can go out with the boys
tonight if it's what you really want to do."
B. Mrs. W tells her son "Under no circumstances will I give you permission to stay out
after midnight."

C. Mrs. E states "I would prefer to have you call if you think you are going to be late for
dinner."

D. Mrs. K says "I was surprised and delighted when my entry was chosen for an award."
A double bind is created when the verbal and nonverbal messages are incongruent, leaving the
listener confused or trapped ("damned if he does and damned if he doesn't").
Text page: 755
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45511415
A highly useful tool to uncover multigenerational issues in a family is the
A. Correct genogram.

B. focused interview.

C. family function checklist.


D. family assessment device.

A genogram maps family structure and family information for at least three generations. It graphically
depicts relational patterns and multigenerational issues. Demographics, sociocultural context, and
critical events can be noted.
Text page: 758
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45511423
A function of the entry-level staff nurse in caring for families is to
A. Correct assess the amount of stress on the system.

B. conduct private family therapy sessions.

C. prescribe psychobiological intervention.

D. determine the new skills the family needs.


An important function of entry-level staff nurses is to assess cues from various family members that
indicate the degree and amount of stress the family system is experiencing and report these so
appropriate interventions may be made in a timely manner by a qualified counselor.
Text page: 762
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45511432
Which family situation should the nurse assess as warranting a referral for family therapy?
A. A couple are having their first child after many months of infertility treatment. They
say "It's certainly going to be a change for us."

B. A husband and wife with clear individual and generational boundaries are sending a
son off to college and planning the daughter's wedding. They say "Soon we will be back to
having an empty nest again."

C. Correct A couple are having difficulty dealing with the erratic behavior of their bipolar
son who lives with them and their teenage daughter. They say "We are at the end of our
rope."
D. A blended family with two of "his" and three of "hers" ranging in age from 5 to 15
years say "It's never quiet, but the disagreements eventually get worked out."
This family is the only family system clearly expressing an unmanageable degree of stress. The
other systems may be undergoing stress but have not expressed distress.
Text page: 761-762
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45511441
A girl is overheard saying to her brother "If you stick up for me with Mom and Dad when I ask to go
to the mall with the girls, I will forget I ever heard you planning to sneak out tomorrow night after they
are asleep." This can be assessed as a type of communication called
A. Correct manipulative.

B. scapegoating.

C. generalizing.

D. placating.
One example of manipulation occurs when a family member makes a request with strings attached
so the other person has difficulty refusing.
Text page: 752
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45511453


An important means of promoting good self-esteem in children within the family is
A. for the mother to assume the role of placator to avoid family confrontations.

B. to tightly define roles and establish individual responsibility for most functions.

C. to establish closed boundaries to provide structure.

D. Correct to communicate validation of individual worth.

Self-esteem is developed when the individual is made to feel good about himself and his role within
the family. Offer praise for doing well. Discipline without making the child feel bad about himself; help
him recognize the action was wrong, not that he is bad.
Text page: 752

1. 1.ID: 45510932
During a family therapy session Mrs. S says to her daughter "I would like to know why you took the
piece of pie that was left after dinner last night. You knew I wanted it." Later Mr. S told his daughter "I
know exactly why you did that." The nurse therapist should consider the possibility that the family
has
A. clear boundaries.

B. Correct diffuse boundaries.

C. disengaged boundaries.

D. no boundary problems.
A common phenomenon within families with diffuse boundaries is that individuals expect other
members of the family to know what they are thinking.
Text page: 750
Awarded 1.0 points out of 1.0 possible points.

2. 2.ID: 45510943
During a family therapy session Mrs. G states "My husband is always angry about something or
other. The children and I are always on edge trying to escape his disapproval. We can never relax."
The nurse can make the assessment that Mrs. G is using the dysfunctional communication
technique known as
A. placating.

B. distracting.

C. Correct generalizing.

D. manipulating.

Generalization involves making global statements using "always" and "never" when dealing with
problematic family issues. Generalization allows the speaker to avoid dealing with specific examples.
Text page: 752
Awarded 1.0 points out of 1.0 possible points.

3. 3.ID: 45510954
The T family consists of the husband and wife, four children in elementary school, Mrs. T's 21-year-
old sister and Mr. T's elderly aunt. Which members are considered the nuclear family?
A. Correct Mr. and Mrs. T and their four children

B. Mrs. T and her sister

C. Mr. T and his aunt

D. The four children and Mrs. T's sister

The term nuclear family refers to parents and the children under the parent's care.
Text page: 757
Awarded 1.0 points out of 1.0 possible points.

4. 4.ID: 45510963
Mrs. D and her husband have a number of conflicts brewing, including whether Mr. D should seek a
promotion that will cause him to travel away from home several days each month. Mrs. D seeks the
opinion of their 12-year-old, who sides with her mother saying Mr. D is needed at home. This is an
example of
A. Correct triangulation.

B. enmeshment.

C. a double bind.

D. diffuse boundaries.
Triangulation occurs when a two-person relationship is under stress and one person draws in a third
person to stabilize the system by forming a coalition.
Text page: 756
Awarded 1.0 points out of 1.0 possible points.

5. 5.ID: 45510973
W is the eldest son in a family in which the father was an alcoholic and the mother was an enabler.
W's grandfather, too, was an alcoholic who lived with a long-suffering wife. W drinks heavily and has
married a woman who never complains about his drinking. This scenario suggests a
A. double bind.

B. sociocultural issue.

C. Correct multigenerational issue.

D. stage in the family life cycle.

Multigenerational issues refer to patterns that are passed down through generations.
Text page: 758
Awarded 1.0 points out of 1.0 possible points.

6. 6.ID: 45510985
The nurse who assesses a family as having enmeshed boundaries might see the possible goal of
"Family members will
A. Correct define individual beliefs and needs."

B. form triangles to reduce anxiety."

C. develop greater comfort with enmeshment."

D. increase intrafamilial relational conflicts."

Enmeshment occurs as the result of the blending together of individuals so that distinct persons fail
to emerge. A strategy would be to promote individuation resulting in each person being able to
emerge as a distinct entity.
Text page: 750
Awarded 1.0 points out of 1.0 possible points.

7. 7.ID: 45510996
D is a 26-year-old client with schizophrenia. His family is having difficulty adjusting to his return to
the community after hospitalization. They are dismayed by his poor hygiene and avolition. A useful
strategy for the nurse to suggest would be
A. Correct family attendance at a psychoeducational group.

B. close supervision of D on a daily basis.

C. to learn to ignore all symptoms except delusions.


D. to take turns monitoring D to avoid burnout.

Psychoeducation can help the family learn to accept the illness of a family member, learn to deal
effectively with symptoms, and understand medications.
Text page: 763
Awarded 1.0 points out of 1.0 possible points.

8. 8.ID: 45511105
Which technique would be least helpful in putting family members at ease as family therapy begins?
A. Getting each member's view of the way the problem affects the family

B. Correct Focusing on the identified patient's views about the family problems

C. Providing clear, understandable information to the family members

D. Maintaining a neutral, nonjudgmental demeanor as members speak


The problems of the identified patient will not be the focus of the sessions. The presenting problem
will be viewed in terms of circular causality, and the family system's anxiety will be addressed.
Text page:
Awarded 1.0 points out of 1.0 possible points.

9. 9.ID: 45511115
When the family therapist asks "Which problem is of greatest concern to you?" The family's
youngest daughter says, "They [parents] care more about her [sister] because she's older and gets
straight As in school." The nursing diagnosis for which the nurse might wish to continue gathering
data to determine an etiology statement is
A. deficient knowledge.

B. parental role conflict.

C. defensive coping.

D. Correct relational problems.

This discourse concerns relational problems related to a mental disorder, a generic medical
condition, or a sibling relational problem. No data suggest the other diagnoses.
Text page: 761
Awarded 1.0 points out of 1.0 possible points.

10. 10.ID: 45511127


At the first family therapy session Mr. L tells the therapist "We wouldn't have to be here if our
younger son wasn't such a brat. He runs around in school and won't mind the teacher, and so here
we are to learn how to cope with a brat." Mrs. L agrees "He seems so different from our other son.
We never had difficulty with him misbehaving." The other sibling offers "He gets upset pretty easily."
The nurse should suspect that the younger son is
A. Correct being scapegoated.

B. resisting boundaries.

C. assuming the family management function.

D. experiencing multigenerational transition.


A scapegoat is the person others blame for the family's distress. Those blaming the scapegoat are
usually trying to keep the focus off their own painful issues and problems. The parents seem to be
scapegoating the younger son.
Text page: 755