Test Bank for Psychiatric-Mental Health Nursing: From Suffering to Hope, 2nd Edition

Psychiatric-Mental Health Nursing, 2e (Potter/Moller) Chapter 2 Biological Basis For Mental Illness 1) A patient is having trouble learning from the past, difficulty putting on clothes, and cannot recognize written words. In which lobe of the brain should the nurse suspect the patient is experiencing a dysfunction? 1. Frontal 2. Temporal 3. Parietal 4. Occipital Answer: 4 Explanation: 4. The occipital lobe is involved in visual perception and recognition, language, and memory formation. The temporal lobe is the emotional center and is involved with memory, cognition, and understanding the acoustic aspects of language. The parietal lobe facilitates complex motor and cognitive skills, such as mastery of visual and spatial balance, mathematical ability, and spelling. The frontal lobe has functional responsibilities for muscular movement and behavior responses. Page Ref: 33 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches| NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the neuroanatomical structures that affect neurobiological and mental health. MNL LO: 1. Examine the neuroanatomical structures that affect neurobiological and mental health. 1 Copyright © 2020 Pearson Education, Inc. 2) A nurse is caring for a patient who is experiencing visual hallucinations. Which lobe of the brain should the nurse recognize as the source of the patient’s manifestations? 1. Parietal 2. Occipital 3. Temporal 4. Right frontal Answer: 2 Explanation: 2. The occipital lobe is involved in interpretation of visual perception and recognition, language, and memory formation. The parietal lobe facilitates complex motor and cognitive skills, such as a mastery of visual and spatial balance, mathematical ability, and spelling. The temporal lobe is the emotional center and is involved with memory, cognition, and understanding the acoustic aspects of language. The right frontal lobe has functional responsibilities for muscular movement on the left side of the body. Page Ref: 33 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the neuroanatomical structures that affect neurobiological and mental health. MNL LO: 1. Examine the neuroanatomical structures that affect neurobiological and mental health. 2 Copyright © 2020 Pearson Education, Inc. 3) The nurse is caring for a patient diagnosed with posttraumatic stress disorder (PTSD). In this disorder, which element of the nervous system should the nurse identify as malfunctioning? 1. Central 2. Peripheral 3. Sympathetic 4. Parasympathetic Answer: 4 Explanation: 4. The parasympathetic nervous system is responsible for “resetting” the autonomic nervous system after activation and can often function on hyper-alert in individuals who have experienced trauma. The peripheral nervous system consists of the nerves and ganglia located outside the central nervous system. The central nervous system consists of the brain and the spinal cord. The sympathetic nervous system mobilizes body systems during activity (especially during stress). Page Ref: 30 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the neuroanatomical structures that affect neurobiological and mental health. MNL LO: 1. Examine the neuroanatomical structures that affect neurobiological and mental health. 3 Copyright © 2020 Pearson Education, Inc. 4) An adolescent recovering from a motor vehicle crash is angry and demonstrating poor impulse control. Which lobe of the brain should the nurse suspect may have been injured in the accident? 1. Temporal 2. Frontal 3. Occipital 4. Parietal Answer: 2 Explanation: 2. Problems in the temporal lobe can lead to visual or auditory hallucinations, aphasia, and amnesia. When normal frontal lobe functioning is altered, destabilization of emotions, a loss of impulse control, and personality changes occur. Problems associated with the occipital region include visual field deficits, blindness, and visual hallucinations. The inability to recognize objects by touch or recognize parts of one’s own body, as well as problems calculating, writing, and drawing are associated with problems in the parietal lobe. Page Ref: 32 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the neuroanatomical structures that affect neurobiological and mental health. MNL LO: 1. Examine the neuroanatomical structures that affect neurobiological and mental health. 4 Copyright © 2020 Pearson Education, Inc. 5) A patient is experiencing auditory hallucinations and paranoid delusions. Which neurotransmitter should the nurse suspect is implemented in these manifestations? 1. Serotonin 2. Dopamine 3. Acetylcholine 4. Norepinephrine Answer: 2 Explanation: 2. Dopamine disruptions are involved in psychosis, with manifestations such as auditory hallucinations and paranoid delusions. Serotonin and norepinephrine are associated with mood disorders. Acetylcholine plays a role in learning and memory and is associated with Alzheimer disease. Page Ref: 46 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Analyze the role of neurotransmitters in neurobiological and mental health. MNL LO: 2. Analyze the role of neurotransmitters in neurobiological and mental health. 5 Copyright © 2020 Pearson Education, Inc. 6) The nurse is preparing a teaching tool for new employees. Which information about the role of neurotransmitters in neurobiology should the nurse include in the tool? 1. There are two classes of neurotransmitters. 2. Each neurotransmitter functions in the same manner. 3. Neurotransmitters and receptors do not vary in their affinity for each other. 4. Neurotransmitters consistently act in either an excitatory or inhibitory manner. Answer: 4 Explanation: 4. Neurotransmitters consistently have either an excitatory or inhibitory effect on the postsynaptic neuron. Each neurotransmitter functions in a unique manner. There are six classifications of neurotransmitters. Neurotransmitters and receptors vary in their affinity for each other, depending on the neurotransmitter involved. Page Ref: 40 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care| NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching and Learning Learning Outcome: 2. Analyze the role of neurotransmitters in neurobiological and mental health. MNL LO: 2. Analyze the role of neurotransmitters in neurobiological and mental health. 6 Copyright © 2020 Pearson Education, Inc. 7) A patient reports taking a serotonin reuptake inhibitor. For which health problem should the nurse suspect this medication has been prescribed for the patient? 1. Depression 2. Bipolar disorder 3. Schizophrenia 4. Sexual dysfunction Answer: 1 Explanation: 1. Serotonin reuptake inhibitors have been prescribed to treat depression. This medication is given in conjunction with other medications to treat bipolar disorder. Antipsychotic medications are the standard treatment for schizophrenia. Sexual dysfunction may be a side effect of serotonin reuptake inhibitors, but it is not the reason they are prescribed. Page Ref: 56-57 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Analyze the role of neurotransmitters in neurobiological and mental health. MNL LO: 2. Analyze the role of neurotransmitters in neurobiological and mental health. 7 Copyright © 2020 Pearson Education, Inc. 8) The nurse is reviewing the stress response. Which neurotransmitter should the nurse identify as most involved in this response? 1. GABA 2. Serotonin 3. Dopamine 4. Norepinephrine Answer: 4 Explanation: 4. Norepinephrine is an exciting neurotransmitter involved in the fight or flight response. Gamma-aminobutyric acid (GABA) is an inhibitory neurotransmitter that is calming, quieting, and relaxing. Serotonin is a modulating neurotransmitter involved in impulse control, mood, and affect. Dopamine is a modulating neurotransmitter involved in reward-seeking behavior. Page Ref: 43 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan| NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Assessment Learning Outcome: 2. Analyze the role of neurotransmitters in neurobiological and mental health. MNL LO: 2. Analyze the role of neurotransmitters in neurobiological and mental health. 8 Copyright © 2020 Pearson Education, Inc. 9) A patient reports having a test to examine brain function. Which type of test should the nurse recognize the patient is describing? 1. Positron emission test (PET) 2. Computerized tomography (CT) 3. Magnetic resonance imaging (MRI) 4. Transcranial doppler (TCD) Answer: 1 Explanation: 1. A PET scan provides information about the metabolic functioning of the brain. CT, MRI, and TCD are imaging techniques to examine the structure, and not function, of the brain. Page Ref: 53-55 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches| NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate diagnostic techniques that elicit information about patient neurobiological status. MNL LO: 3. Utilize appropriate tools, techniques, and collaborative testing for assessment of patients with psychiatric-mental health disorders. 9 Copyright © 2020 Pearson Education, Inc. 10) A patient is being evaluated for a mental health disorder. Which sensory function should the nurse assess as part of the initial examination? (Select all that apply.) 1. Pain 2. Smell 3. Pressure 4. Temperature 5. Proprioception Answer: 1, 3, 4, 5 Explanation: 1. As part of every initial psychiatric assessment, all registered nurses are expected to be able to complete and document a thorough neurological exam. Assessing sensory perception as part of that exam involves evaluating pain. 2. Evaluating smell is not a part of the initial evaluation. 3. As part of every initial psychiatric assessment, all registered nurses are expected to be able to complete and document a thorough neurological exam. Assessing sensory perception as part of that exam involves evaluating pressure. 4. As part of every initial psychiatric assessment, all registered nurses are expected to be able to complete and document a thorough neurological exam. Assessing sensory perception as part of that exam involves evaluating temperature. 5. As part of every initial psychiatric assessment, all registered nurses are expected to be able to complete and document a thorough neurological exam. Assessing sensory perception as part of that exam involves evaluating proprioception. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate diagnostic techniques that elicit information about patient neurobiological status. MNL LO: 3. Utilize appropriate tools, techniques, and collaborative testing for assessment of patients with psychiatric-mental health disorders. 10 Copyright © 2020 Pearson Education, Inc. 11) The nurse is preparing to complete an initial psychiatric assessment. What should the nurse realize is the most important part of this process? 1. Providing the DSM-5 diagnosis 2. Gathering information from the family 3. Ruling out a medical causation of symptoms 4. Evaluating the need for psychotropic medication Answer: 3 Explanation: 3. The cardinal rule in psychiatric assessment is to rule out a medical causation of symptoms. Following a thorough assessment, the healthcare provider may make a DSM-5 diagnosis. If family is present, information gathering may be helpful, but it is not the most critical part of the initial assessment. Evaluating the need for psychotropic medication is not the first step in an initial assessment. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate diagnostic techniques that elicit information about patient neurobiological status. MNL LO: 3. Utilize appropriate tools, techniques, and collaborative testing for assessment of patients with psychiatric-mental health disorders. 11 Copyright © 2020 Pearson Education, Inc. 12) A patient with bipolar disorder is being treated with lithium. What laboratory test should be used to evaluate the effectiveness and toxicity of the patient’s lithium levels? 1. Complete blood count 2. Basic metabolic panel 3. Urinalysis 4. Serum blood level test Answer: 4 Explanation: 4. A serum blood level test will monitor therapeutic levels of medications, such as lithium, and test for drug toxicity. A complete blood count (CBC) may be used to monitor for infections, toxins, preexisting conditions, or responses to medications. A basic metabolic panel (BMP) helps identify preexisting conditions or monitor side effects to medication. Urinalysis can identify pregnancy, diabetes, proteins, or drug abuse. Page Ref: 52 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate diagnostic techniques that elicit information about patient neurobiological status. MNL LO: 3. Utilize appropriate tools, techniques, and collaborative testing for assessment of patients with psychiatric-mental health disorders. 12 Copyright © 2020 Pearson Education, Inc. 13) A patient with bipolar disorder asks what caused the illness. What should the nurse respond about the genetic transmission of the disorder? 1. Bipolar disorder is caused by environmental factors. 2. There is one single gene responsible for bipolar disorder. 3. There is no known cause for the development of bipolar disorder. 4. There appears to be a genetic link in the transmission of bipolar disease. Answer: 4 Explanation: 4. Genetic abnormalities have been found for bipolar disorder. The environment acts in concert with genotype for the expression of mental disorders. There is no single gene responsible for any mental disorder. The exact cause of bipolar disorder is not known, but there appear to be genetic factors. Page Ref: 56 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Contrast the pathophysiology of different psychiatric symptoms and disorders. MNL LO: 4. Recognize the pathophysiology of psychiatric symptoms and disorders, and the role of neurobiology in suffering and hope for patients. 13 Copyright © 2020 Pearson Education, Inc. 14) The nurse is reviewing the pathophysiology and etiology of major depressive disorder. Which should the nurse identify about neurological structure alterations and the development of major depressive disorder? (Select all that apply.) 1. An increase in the central nervous system (CNS) volume is associated with major depressive disorder. 2. Excessive levels of serotonin and norepinephrine have been associated with major depressive disorder. 3. Impairments to cerebral structural plasticity and neuronal cellular resilience have been noted with major depressive disorder. 4. An increase in the numbers and sizes of glia and neurons in some areas of the brain have been noted with major depressive disorder. 5. Dysfunction of cerebral blood flow and glucose metabolism in some areas of the brain has been noted with major depressive disorder. Answer: 3, 5 Explanation: 1. A decrease in CNS volume has been associated with a major depressive disorder. 2. Excessive levels of serotonin and norepinephrine have been associated with anxiety disorder, not major depressive disorder. 3. Neurological structure alterations associated with the development of major depressive disorder include impairments to cerebral structure plasticity. 4. A decrease in the numbers and sizes of glia and neurons has been associated with a major depressive disorder. 5. Neurological structure alterations associated with the development of major depressive disorder include dysfunctions of cerebral blood flow and glucose metabolism in the prefrontal cortical, striatal, and limbic systems. Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Contrast the pathophysiology of different psychiatric symptoms and disorders. MNL LO: 4. Recognize the pathophysiology of psychiatric symptoms and disorders, and the role of neurobiology in suffering and hope for patients. 14 Copyright © 2020 Pearson Education, Inc. 15) The nurse is asked to explain the pathophysiology and etiology of depression. Which response should the nurse make? 1. “Cerebral structure is responsible for depression.” 2. “We know that heredity is the single cause of depression.” 3. “Because all patients respond the same to serotonin reuptake inhibitors, we have a thorough understanding of the neurochemistry of depression.” 4. “There is no unified hypothesis regarding pathophysiology and etiology of depression, in part because patients demonstrate individualized responses to treatments.” Answer: 4 Explanation: 4. Patients demonstrate individualized responses to treatments and individual courses of depression. Not all patients respond to treatment with serotonin reuptake inhibitors. Other factors besides heredity, such as life stress, may contribute to depression. Although changes in the cerebral structure are associated with depression, many other factors are currently under study. Page Ref: 56 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Contrast the pathophysiology of different psychiatric symptoms and disorders. MNL LO: 4. Recognize the pathophysiology of psychiatric symptoms and disorders, and the role of neurobiology in suffering and hope for patients. 15 Copyright © 2020 Pearson Education, Inc. 16) A patient is homeless as a result of an addiction to alcohol. Which should the nurse consider about this patient’s health problem? 1. Addictive behavior involves the limbic system. 2. Addictive behavior indicates character flaws. 3. Addictive behavior has a variety of neurological patterns. 4. Addictive behavior is related to dysfunctional parent-child relationships. Answer: 1 Explanation: 1. Addictive behavior is involved with neurological systems, not character flaws. All addictive behaviors follow the same neurological pathways of engagement and reward. Dysfunctional parent-child relationships have not been determined as specifically related to addiction. The neocortex and the limbic system are the two cerebral structures that are involved in addictive behaviors. Page Ref: 60 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Contrast the pathophysiology of different psychiatric symptoms and disorders. MNL LO: 4. Recognize the pathophysiology of psychiatric symptoms and disorders, and the role of neurobiology in suffering and hope for patients. 16 Copyright © 2020 Pearson Education, Inc. 17) A patient reports a significant reduction in energy level. What neurotransmitter might the nurse suspect is involved in this change? 1. GABA 2. Dopamine 3. Serotonin 4. Norepinephrine Answer: 4 Explanation: 4. Norepinephrine is a major factor in energy. GABA is considered an inhibitory neurotransmitter. Dopamine is largely responsible for the brain’s experience of pain and pleasure. Serotonin is a major factor in mood. Page Ref: 62 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Examine the role of neurobiology in suffering and hope. MNL LO: 4. Recognize the pathophysiology of psychiatric symptoms and disorders, and the role of neurobiology in suffering and hope for patients. 17 Copyright © 2020 Pearson Education, Inc. 18) A patient with paraplegia reports some advantages of having the disorder. To which secondary gain might the patient be referring? (Select all that apply.) 1. Attention 2. Sympathy 3. Personal services 4. Disability benefits 5. Escape from some responsibilities Answer: 3, 4, 5 Explanation: 1. Attention is identified as a primary gain. 2. Sympathy is identified as a primary gain. 3. Secondary gains are indirect benefits that a person may get from a condition that involves pain and suffering. These indirect benefits include the provision of personal services. 4. Secondary gains are indirect benefits that a person may get from a condition that involves pain and suffering. These indirect benefits include disability benefits. 5. Secondary gains are indirect benefits that a person may get from a condition that involves pain and suffering. These indirect benefits include escape from some responsibilities. Page Ref: 62 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship Centered Care: Practice-Know-How: Promote and accept the patient’s emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Examine the role of neurobiology in suffering and hope. MNL LO: 4. Recognize the pathophysiology of psychiatric symptoms and disorders, and the role of neurobiology in suffering and hope for patients. 18 Copyright © 2020 Pearson Education, Inc. 19) The nurse is assessing a patient’s neurological functioning. Which assessment should be completed to determine the patient’s motor ability? (Select all that apply.) 1. Reflexes 2. Romberg test 3. Point location 4. Tandem walking 5. Finger to finger test Answer: 1, 2, 4, 5 Explanation: 1. Reflexes are a part of the assessment of motor functioning. 2. The Romberg test is used to assess cerebellar-motor functioning. 3. Point location is a test to assess sensory functioning. 4. Tandem walking is used to assess cerebellar-motor functioning. 5. The finger to finger test is used to assess motor functioning Page Ref: 49, 52 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Distinguish elements of the neurologic examination. MNL LO: 3. Utilize appropriate tools, techniques, and collaborative testing for assessment of patients with psychiatric-mental health disorders. 19 Copyright © 2020 Pearson Education, Inc. 20) The nurse is planning to assess a patient’s vision and eye movements. Which action should the nurse take during this assessment? (Select all that apply.) 1. Touch the cornea with a cotton wisp. 2. Ask the patient to raise the eyebrows. 3. Shine a light into each of the patient’s eyes. 4. Ask the patient to read from a card one eye at a time. 5. Have the patient move the eyes through six directions. Answer: 3, 4, 5 Explanation: 1. The corneal reflex tests the ophthalmic branch of cranial nerve V, the trigeminal nerve. 2. Raising the eyebrows tests a branch of cranial nerve VII, the facial nerve. 3. Shining a light into the eyes tests for pupil response when assessing cranial nerve III, the oculomotor nerve. 4. Having the patient read from a card one eye at a time assesses vision, which is controlled by cranial nerve II, the optic nerve. 5. Having the patient move the eyes through six directions assesses cranial nerve VI, the abducens nerve. Page Ref: 50 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Assessment Learning Outcome: 3. Distinguish elements of the neurologic examination. MNL LO: 3. Utilize appropriate tools, techniques, and collaborative testing for assessment of patients with psychiatric-mental health disorders. 20 Copyright © 2020 Pearson Education, Inc.