Chapter 21

Question 1

1. A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge?
   a.
   The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences.
   b.
   The adolescent identifies friends in the home community who are a positive influence.
   c.
   Temporary placement is arranged with a foster family until the parents complete a parenting skills class.
   d.
   The adolescent experiences no anger and frustration for 1 week.

Answer 1

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

Question 2

2.	A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, “We can’t manage our teenager.” The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent’s behavior?
a.
Attention deficit hyperactivity disorder (ADHD)
b.
Posttraumatic stress disorder (PTSD)
c.
Intermittent explosive disorder
d.
CD

Answer 2

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

Question 3

3.	A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic?
a.
Planned ignoring
b.
Establish firm limits
c.
Neutrally permit refusals
d.
Coaxing to gain compliance

Answer 3

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

Question 4

4.	An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which type of therapy might promote the greatest change in the adolescent’s behavior?
a.
Family therapy
b.
Bibliotherapy
c.
Play therapy
d.
Art therapy

Answer 4

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

Question 5

5. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which nursing diagnosis is most applicable?
   a.
   Disturbed personal identity related to acting out as evidenced by prostitution
   b.
   Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents
   c.
   Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out
   d.
   Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another

Answer 5

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

Question 6

6.	A 12-year-old has engaged in bullying for several years. The parents say, “We can’t believe anything our child says.” Recently this child shot a dog with a pellet gun and set fire to a neighbor’s trash bin. The child’s behaviors support the diagnosis of
a.
ADHD.
b.
intermittent explosive disorder.
c.
oppositional defiant disorder (ODD).
d.
CD.

Answer 6

ANS: D
The behaviors mentioned are most consistent with criteria for CD, including aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. The behaviors are not consistent with attention deficit or oppositional defiant disorder (ODD).

Question 7

7. An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation.
   a.
   Ignore the child’s behavior.
   b.
   Send the child to time-out for 2 hours.
   c.
   Take the child to the gym and engage in an activity.
   d.
   Role-play a more appropriate behavior with the child.

Answer 7

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

Question 8

8. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a heavy pool ball at another adolescent, which comment by the nurse would set appropriate limits?
   a.
   “Attention everyone: we are all going to the craft room.”
   b.
   “You will be taken to seclusion if you throw that ball.”
   c.
   “Do not throw the ball. Put it back on the pool table.”
   d.
   “Please do not lose control of your emotions.”

Answer 8

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

Question 9

9.	The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child’s plan of care will be provided by an advanced practice nurse rather than a staff nurse?
a.
Leading an activity group
b.
Providing positive feedback
c.
Formulating nursing diagnoses
d.
Dialectical behavioral therapy (DBT)

Answer 9

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

Question 10

10. Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, “I’d rather stay in my room and listen to music. It’s easier than thinking about what is happening in my family.” Which nursing diagnosis is most applicable?
    a.
    Chronic low self-esteem related to role within the family
    b.
    Decisional conflict related to compliance with school requirements
    c.
    Defensive coping related to adjustment to changes in family relationships
    d.
    Disturbed personal identity related to self-perceptions of changing family dynamics

Answer 10

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

Question 11

11.	A child known as the neighborhood bully says, “Nobody can tell me what to do.” After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher’s computer. These behaviors support a diagnosis of
a.
CD.
b.
ODD.
c.
intermittent explosive disorder.
d.
ADHD.

Answer 11

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

Question 12

12. An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurse’s initial action to defuse the situation?
    a.
    Say to the child, “Tell me how you’re feeling right now.”
    b.
    Take the child swimming at the facility’s pool.
    c.
    Establish a behavioral contract with the child.
    d.
    Administer an anxiolytic medication.

Answer 12

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

Question 13

13.	Parents of an adolescent diagnosed with a CD say, “We don’t know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?” Which therapy is likely to be helpful for these parents?
a.
Parent–child interaction therapy (PCIT)
b.
Behavior modification therapy
c.
Multi-systemic therapy (MST)
d.
Pharmacotherapy

Answer 13

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

Question 14

14.	An adolescent diagnosed with an impulse control disorder says, “I want to die. I spend my time getting even with people who hurt me.” When asked about a suicide plan, the adolescent replies, “I’ll jump from a bridge near my home. My father threw kittens off that bridge and they died.” Rate the suicide risk.
a.
Absent
b.
Low
c.
Moderate
d.
High

Answer 14

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

Question 15

15.	An adolescent diagnosed with CD has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication?
a.
Second-generation antipsychotic
b.
Antianxiety medication
c.
Calcium channel blocker
d.
β-blocker

Answer 15

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

Question 16

16. An adolescent was recently diagnosed with ODD. The parents say to the nurse, “Isn’t there some medication that will help with this problem?” Select the nurse’s best response.
    a.
    “There are no medications to treat this problem. This diagnosis is behavioral in nature.”
    b.
    “It’s a common misconception that there is a medication available to treat every health problem.”
    c.
    “Medication is usually not prescribed for this problem. Let’s discuss some behavioral strategies you can use.”
    d.
    “There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you.”

Answer 16

ANS: C
The parents are seeking a quick solution. Medications are generally not indicated for ODD. Comorbid conditions that increase defiant symptoms, such as ADHD, should be managed with medication, but no comorbid problem is identified in the question. The nurse should give information on helpful strategies to manage the adolescent’s behavior.

Question 17

17. An adolescent diagnosed with a CD stole and wrecked a neighbor’s motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent’s reaction?
    a.
    Serotonin dysregulation and increased testosterone activity impair one’s capacity for remorse.
    b.
    Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules.
    c.
    Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy.
    d.
    Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.

Answer 17

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

Question 18

18. Which assessment findings support a diagnosis of ODD?
    a.
    Negative, hostile, and spiteful toward parents. Blames others for misbehavior.
    b.
    Exhibits involuntary facial twitching and blinking; makes barking sounds.
    c.
    Violates others’ rights; cruelty toward people or animals; steals; truancy.
    d.
    Displays poor academic performance and reports frequent nightmares.

Answer 18

ANS: A
ODD is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. The distracters identify findings associated with CD, anxiety disorder, and Tourette’s syndrome.

Question 19

1.	A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient’s history support the suspected diagnosis? (Select all that apply.)
a.
Family history of mental illness
b.
Allergies to multiple antibiotics
c.
Long history of severe facial acne
d.
Father with history of alcohol abuse
e.
History of an abusive relationship with one parent

Answer 19

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

Question 20

2. What are the primary distinguishing factors between the behavior of persons diagnosed with ODD and those with CD? The person diagnosed with (Select all that apply)
   a.
   ODD relives traumatic events by acting them out.
   b.
   ODD tests limits and disobeys authority figures.
   c.
   ODD has difficulty separating from loved ones.
   d.
   CD uses stereotypical or repetitive language.
   e.
   CD often violates the rights of others.

Answer 20

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

Question 21

3. A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because (Select all that apply)
   a.
   it is a vital component of implementing a behavior modification program.
   b.
   a therapeutic alliance is the first step in a nurse’s therapeutic use of self.
   c.
   the adolescent has demonstrated resistance to other authority figures.
   d.
   acceptance and trust convey feelings of security for the adolescent.
   e.
   adolescents usually relate better to authority figures than peers.

Answer 21

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