329 Simulation Q's

When assessing Mr. Palo's risk for acute depression, the nurse is using the Geriatric Depression Scale: Short Form. What question(s) should the nurse be prepared to ask Mr. Palo? (Select all that apply.) A. "Do you often get bored?" B. "Are you basically satisfied with your life?" C. "When did you start feeling depressed?" D. "Do you have family that visits regularly?" E. "Do you feel pretty worthless the way you are now?"

A. "Do you often get bored?" B. "Are you basically satisfied with your life?" E. "Do you feel pretty worthless the way you are now?" This depression screening tool focuses on older patients' feelings and the possible presence of boredom, worthlessness, and satisfaction with their current life. The origin or specific circumstances associated with their feelings are not addressed by the screening's short form.

Which statement made by Mr. Palo would demonstrate that his religious belief system is influential in his decision not to consider suicide? A. "No! He gives it and only He can take it away." B. "No! Anna didn't kill herself when she was sick." C. "No! That would hurt my kids way too much." D. "No! I'd never do that; it just isn't right."

A. "No! He gives it and only He can take it away." Suicidal thoughts are common in people with mood disorders, especially depression. An individual's belief systems and values can influence his or her decision concerning the act of suicide. Mr. Palo's reference to his belief in the time of death being determined only by God supports the religious influence on his decision. The other statements express various ethical objections to suicide but do not indicate that they are based on his religious belief system.

Mr. Chen asks the nurse at discharge if his two children are at risk for developing major depression like their mother. Which is the best response by the nurse? A. "Possibly. Evidence shows a strong genetic link to depression, with children being at a higher risk if one parent is diagnosed." B. "No, major depression is more associated with socioeconomic factors than genetic factors." C. "Yes, the children are both highly likely to develop major depression." D. "Unfortunately, there is no research to show the genetic link."

A. "Possibly. Evidence shows a strong genetic link to depression, with children being at a higher risk if one parent is diagnosed." Research indicates that genetics is a strong risk factor for developing major depression. Children of parents who are diagnosed have a stronger likelihood of developing the disease during their lifetime. Genetics is a stronger risk factor for major depression than are socioeconomic factors. Although the children are at increased risk for developing major depression, they are not "highly likely" to develop it.

Which response by the nurse would best address Ms. Waterfall's doubts about the effectiveness of relaxation techniques to help manage her anxiety? A. "The exercises will help you regain your sense of calmness so you can better address your health concerns." B. "You have to get relaxed if you are ever going to make the right decisions about your health." C. "Deep breathing is a fundamental relaxation technique that is easy to learn and do effectively." D. "Anxiety is based on stress levels that are greater than we can cope with."

A. "The exercises will help you regain your sense of calmness so you can better address your health concerns." Stress can interfere with one's ability to think and make decisions effectively. Relaxation techniques can help manage the stress and bring about a sense of calmness that improves judgement and decision-making. The remaining options present true statements but none addresses the patient's question about the effectiveness of the techniques of relaxation as thoroughly as the correct answer.

Which serum level indicates that the patient is receiving an appropriate maintenance dose of lithium? A. 0.7 mEq/L B. 1.5 mEq/L C. 0.3 mEq/L D. 2 mEq/L

A. 0.7 mEq/L There is a narrow range of safety among maintenance levels (0.5 to 1 mEq/L), treatment levels (0.8 to 1.5 mEq/L), and toxic levels (1.5 mEq/L and above).

What is the primary risk factor for the development of cognitive disorders such as Alzheimer disease? A. Age B. Genetics C. Gender D. Ethnicity

A. Age Risk for Alzheimer disease increases with age. Although all the options are considered risk factors, the primary risk factor is advancing age (65 years of age and older).

Mr. Palo is demonstrating a rather pessimistic attitude when he and the nurse discuss ways to minimize his tendency to socially isolate. Which technique should the nurse implement to help him take a positive role in this discussion? A. Encouraging Mr. Palo to identify ways he could volunteer his time caring for animals B. Suggesting to Mr. Palo that a friend might be willing to go on a daily walk with him C. Asking Mr. Palo's children to include him in at least two family-oriented activities each week D. Providing Mr. Palo with three different but appropriate social activities he could participate in regularly

A. Encouraging Mr. Palo to identify ways he could volunteer his time caring for animals The nurse should use therapeutic techniques to encourage patients to generate their own solutions. Studies have shown that patients tend to act on plans or solutions they generate rather than those that others offer. Finding and acting on their own solutions gives patients a renewed sense of competence and self-worth. All the other options provide possible solutions for his issue with socialization.

Which nursing interventions implemented during Mr. Palo's assessment will assist him to communicate as effectively as his cognitive deterioration allows? (Select all that apply.) A. Arranging for frequent breaks in the assessment process B. Providing simple explanations about why questions are being asked C. Phrasing questions so as to require simple answers D. Allowing ample time for the patient to respond to questions E. Asking his daughter Maggie to be present during the assessment process

A. Arranging for frequent breaks in the assessment process B. Providing simple explanations about why questions are being asked C. Phrasing questions so as to require simple answers D. Allowing ample time for the patient to respond to questions The nurse provides simple explanations as often as patients need them, such as "I'm asking these questions so the staff can see how your health is." It helps to ask simple questions (those that require simple answers) rather than compound questions, and to allow patients ample time to answer. Patients may become confused or tire easily, so frequent breaks in the interview may be needed. Although it might become necessary to rely on family for answers to assessment questions, Mr. Palo appears capable of being the primary information provider. Relying on his daughter at this point would be nontherapeutic because it would minimize his role in the assessment process.

After Mrs. Chen has been discharged for 3 days, she tells her husband, "I do not know what is wrong with me. I keep thinking about overdosing and feel so helpless." What is the priority for Mr. Chen? A. Call 911 as instructed by the discharge nurse, because Mrs. Chen may be suicidal. B. Call the nurse on the floor to ask whether Mrs. Chen can attend a day program. C. Give Mrs. Chen the as-needed antianxiety medicine per the discharge paperwork. D. Give Mrs. Chen some warm tea and suggest she lie down.

A. Call 911 as instructed by the discharge nurse, because Mrs. Chen may be suicidal. At discharge, it is important for the family to be told the signs of suicidal thoughts and develop a safety plan. Because Mrs. Chen has had multiple suicidal attempts, her thoughts about overdosing and feeling hopeless are signs of relapse and possible suicidality. Therefore, Mr. Chen should call 911. The other responses are not appropriate.

Randy's wife, Joy, has taken over much of the decision-making for the family. She is working outside the home, making the household decisions, and helping Randy with his recovery. She is feeling frustrated and is beginning to have difficulties coping. The nurse identifies which as the priority care plan diagnosis for Joy? A. Caregiver role strain B. Ineffective impulse control C. Impaired social interaction D. Low self-esteem

A. Caregiver role strain Family members of loved ones with cognitive disorders can become overwhelmed by the ongoing demands of care. There is no evidence to support the other diagnoses listed in this case.

Which of the following are effective treatments for posttraumatic stress disorder (PTSD)? (Select all that apply.) A. Cognitive processing therapy B. Exposure therapy C. Cognitive behavioral therapy D. Angiotensin-converting enzyme (ACE) inhibitors E. Stimulants

A. Cognitive processing therapy B. Exposure therapy C. Cognitive behavioral therapy Cognitive behavioral therapy, exposure therapy, and cognitive processing therapy can all be used to treat PTSD. ACE inhibitors and stimulants are not used to treat this condition.

Which symptoms are consistent with a diagnosis of major depressive disorder? (Select all that apply.) A. Depressed mood B. Delusions C. Feelings of worthlessness D. Disruption in sleep E. Disruption in appetite

A. Depressed mood C. Feelings of worthlessness D. Disruption in sleep E. Disruption in appetite DSM-5 diagnostic criteria for major depressive disorder include disruption in sleep (such as insomnia or hypersomnia), decrease or increase in appetite, feelings of worthlessness, and depressed mood. Delusions (false beliefs) are associated with psychosis, not major depressive disorder.

When considering dementia, which mood-related characteristic is most likely observed in a patient in the early stages of this cognitive disorder? A. Depression B. Elation C. Irritability D. Anger

A. Depression Depression is a characteristic of dementia, especially in the early stages, whereas anger is demonstrated in later stages of cognitive impairment. Irritability is more likely noted in patients experiencing delirium. Elation is not a characteristic of a patient in the early stages of dementia.

The nurse knows that the patient who is being treated in the emergency room for traumatic injury should also be evaluated for which other comorbidities? (Select all that apply.) A. Depression B. Drug and alcohol use C. Bipolar disorder D. Posttraumatic stress disorder E. Suicidality

A. Depression B. Drug and alcohol use D. Posttraumatic stress disorder E. Suicidality Although patients treated for trauma events are often assessed for drug and alcohol use, they are less often screened for suicidality, depression, and PTSD, which are also important factors to assess. Bipolar disorder is not associated with traumatic injury.

Which signs and symptoms would indicate that Ms. Waterfall is experiencing a myocardial infarction (MI)? (Select all that apply.) A. Diaphoresis B. Vomiting C. Nausea D. Impaired concentration E. Substernal pain

A. Diaphoresis B. Vomiting C. Nausea E. Substernal pain Characteristic signs and symptoms of an MI include: persistent, crushing substernal pain that may radiate; nausea; vomiting; and diaphoresis. Impaired concentration is characteristic of an anxiety attack.

Which characteristics are associated with the manic phase of bipolar disorder? (Select all that apply.) A. Distractibility B. Flight of ideas C. High-risk behaviors D. Grandiosity E. Anti-social behaviors

A. Distractibility B. Flight of ideas C. High-risk behaviors D. Grandiosity The diagnosis of a manic episode or mania requires unusual and incessantly heightened, grandiose, or agitated mood, in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences. The behaviors associated with anti-social activity are not associated with mania.

When patients are admitted to a locked psychiatric unit, which action should be the nurse's priority intervention? A. Ensure that patients and their belongings have been searched. B. Educate the patient on the rules of the unit. C. Give the patients a tour so that they will be more comfortable. D. Complete the admission data tool.

A. Ensure that patients and their belongings have been searched. Safety of the milieu and the patients is the top priority. New patients must be checked for contraband to ensure the safety of both the new patient and the others on the unit. The other answers are of lower priority than the patient's safety.

Which assessment findings would indicate that Mr. Palo is experiencing both insufficient nutritional and fluid intake? (Select all that apply.) A. General weakness B. Altered mental status C. Bradycardia D. Poor skin turgor E. Weight loss

A. General weakness B. Altered mental status D. Poor skin turgor E. Weight loss Indications of poor nutritional and fluid intake would include all the options with the exception of bradycardia. Such deficiencies would result in tachycardia and hypotension.

What is the basic foundation for the nurse's response to the high degree of importance Ms. Waterfall places on her missing medicine bundle? A. Her feelings and beliefs should be accepted without judgement. B. Spiritual beliefs can influence one's health. C. She is entitled to her own unique spiritual beliefs. D. Her beliefs are very different from those of most Americans.

A. Her feelings and beliefs should be accepted without judgement Accept what the patient says without judgment. Never question or underestimate the validity of a threat. A crisis can result from a threat that is real or imagined. Always acknowledge the patient's feelings of pain and distress. Although the remaining options present true statements, none should be viewed as the basis for responding to Ms. Waterfall's cultural belief in the power of her medicine bundle. Remediation:

Which factors increase the index of risk for self-harm for a patient experiencing the manic phase of bipolar I disorder? (Select all that apply.) A. Increased energy B. Distorted thinking C. Lack of sleep D. Potential for delusional thinking E. Distractibility

A. Increased energy B. Distorted thinking D. Potential for delusional thinking A patient experiencing a manic episode is at high risk for suicide because of his or her increased energy, distorted thinking, and the potential for hallucinations and delusions. Distractibility and lack of sleep are risk factors for unintended injury.

When considering conditions that result in cognitive impairment, which characteristic is associated primarily with dementia, including Alzheimer disease? A. Initially presents with progressive memory impairment B. Onset of symptoms is acute C. Symptoms fluctuate throughout the day D. Level of consciousness can be altered dramatically

A. Initially presents with progressive memory impairment Dementia refers to a disease process marked by progressive cognitive impairment with no change in the level of consciousness. It involves multiple cognitive deficits—initially, memory impairment. Delirium is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Delirium usually develops over a short period (sometimes a matter of hours) and fluctuates, or changes, throughout the course of the day.

Which statement about light therapy is true? A. It can be effective for mild-to-moderate seasonal depressive episodes. B. Light therapy is not effective for any depressive diagnosis. C. It can be effective for severe major depression. D. It can be effective for major depression with manic episodes.

A. It can be effective for mild-to-moderate seasonal depressive episodes. Light therapy (phototherapy) is used for mild-to-moderate seasonal depressive episodes. Evidence correlates light to enhanced moods; oftentimes in patients with a diagnosed bipolar disorder, the light enhances manic symptoms.

Mrs. Chen begins to plan her aftercare to prevent another hospitalization. The case manager offers a partial hospitalization program after discharge. What is the priority rationale for this intervention to prevent relapse? A. It provides the patients with structure and additional teaching on coping strategies. B. It is not encouraged with patients with major depression. C. It is used if the patient is no longer able to stay in the hospital. D. It provides a therapeutic community where patients receive electroconvulsive therapy.

A. It provides the patients with structure and additional teaching on coping strategies. Partial hospitalization programs provide structure for patients, especially those with repeated admissions who may need additional support and assessment. The primary rationale for a patient entering a partial hospitalization program after discharge is not because the patient is unable to stay in the hospital any longer or to receive electroconvulsive therapy.

Which symptoms are consistent with a diagnosis of bipolar disorder? (Select all that apply.) A. Mania B. Delusion C. Anxiety D. Compulsiveness E. Depression

A. Mania E. Depression Bipolar disorder involves extreme mood swings from episodes of mania to episodes of depression. Although the individual may demonstrate other emotional characteristics, such as the ones suggested, they are not considered when diagnosing bipolar disorder. Remediation:

When Mr. Palo is unable to button his shirt appropriately after numerous attempts, the nurse matter-of-factly assumes the task for him. What is the primary rationale for the nurse's actions? A. Minimizes his frustration with his failure to complete the task B. Assures he is dressed appropriately C. Allows him to now engage in activities he is capable of completing D. Provides him with role modeling for the task

A. Minimizes his frustration with his failure to complete the task The nurse is correct in using a matter-of-fact approach when assuming tasks the patient can no longer perform. Preventing patients from working unsuccessfully at a task for an extended time helps in preserving their dignity and minimizing their frustration with their progressive memory loss. Although the nurse's action does help achieve the other options, none of them is the primary reason for the intervention.

Which interventions should the nurse implement initially to help establish a therapeutic rapport with Ms. Waterfall when she is demonstrating anxiety-related behaviors? (Select all that apply.) A. Present reflective responses to show interest. B. Elicit detailed information concerning the crisis. C. Clarify understanding of her concerns. D. Actively listen to her as she describes her concerns. E. Ask open-ended questions to confirm and clarify her statements.

A. Present reflective responses to show interest. C. Clarify understanding of her concerns. D. Actively listen to her as she describes her concerns. E. Ask open-ended questions to confirm and clarify her statements. To best develop a rapport with Ms. Waterfall in her emotional crisis, the nurse should initially engage in active listening, ask open-ended questions, reflect statements back to the patient to show that he or she is listening, and clarify and confirm understanding. This technique also helps validate the patient's experience. After reassuring Ms. Waterfall that she is safe, the nurse may then elicit information about the situation that caused the crisis.

Which of the following would most likely show that Randy's concussion symptoms are improving? A. Randy reports he is sleeping better. B. Randy reports increased muscle strength. C. Randy reports an increase in high-density lipoprotein levels. D. Randy reports improved appetite.

A. Randy reports he is sleeping better. Improvement in sleep patterns is considered an indication of improvement for acute concussion. Appetite, high-density lipoprotein levels, and muscle strength are not as directly affected by concussion as sleep quality is.

Which instruction should the nurse include in medication teaching to Mrs. Cole and her husband regarding lithium therapy? (Select all that apply.) A. Regular blood tests are vital to assure serum lithium levels remain below 1.5 mEq/L. B. If experiencing an abnormal heart beat, medication should be stopped immediately. C. Recognize that occasional light-headedness is an acceptable side effect. D. Fluid intake should be 2 ½ to 3 L daily. E. Thyroid function should be monitored every 6 to 12 months.

A. Regular blood tests are vital to assure serum lithium levels remain below 1.5 mEq/L. D. Fluid intake should be 2 ½ to 3 L daily. E. Thyroid function should be monitored every 6 to 12 months. Instructions concerning fluid intake and diagnostic monitoring are correct. Light-headedness and an abnormal heart beat require immediate medical attention, but lithium therapy should never be abruptly stopped.

During discharge teaching for a patient with major depression, which interventions should the nurse include? (Select all that apply.) A. Review the importance of therapy and attending follow up appointments. B. Encourage support groups for the patient as well as the family. C. Teach the patient and family to call for an appointment if the patient is feeling suicidal. D. Teach the patient and family to identify signs of early relapse. E. Explain that this will not happen again if the patient continues to take the medications.

A. Review the importance of therapy and attending follow up appointments. B. Encourage support groups for the patient as well as the family. D. Teach the patient and family to identify signs of early relapse. Patients and families should be able to identify triggers and signs of relapse to prevent another episode. Support groups for patients and families will allow each to verbalize feelings and also will provide a sense of universality. Continuing with therapy (as well as the follow-up appointments) will allow providers to monitor the patient, display accountability, and show the patient some coping skills. Relapses are common especially if there have been reoccurring suicide attempts, so the nurse should not give false hope to the patient and family by saying that it won't happen again. If suicidal, the patient and family should call 911, not call for an appointment.

Mrs. Chen is being discharged with orders for sertraline and venlafaxine. During discharge teaching, the nurse should make it a priority to ensure that the patient recognizes which symptoms that indicate a problem with the medication? A. Serotonin syndrome B. Hypertensive crisis C. ETOH withdrawal D. Serotonin withdrawal

A. Serotonin syndrome Serotonin syndrome should be considered when more than one selective serotonin reuptake inhibitor (SSRI)—or an SSRI and any other type of serotonin-increasing medication— are given together. Symptom onset is rapid and typically occurs a short time after elevated serotonin levels. Symptoms of serotonin syndrome include the following: confusion and agitation (not hypervigilance), muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, muscle paralysis, hyperthermia, tachycardia (not bradycardia), tachypnea, hypersalivation (not dry mouth), and diaphoresis. Eating foods containing tyramines while taking a monoamine oxidase inhibitor (MAOI) can lead to a hypertensive crisis. Serotonin withdrawal would occur if the patient were to stop taking an SSRI. Taking sertraline and venlafaxine together would not cause ethanol (ETOH) withdrawal.

Although Randy is being treated for a postconcussive injury from his car accident, he is also exhibiting some signs of posttraumatic stress disorder (PTSD). Which is a sign of both PTSD and postconcussive injury? A. Sleep disturbance B. Sensitivity to light C. Flashbacks D. Nausea

A. Sleep disturbance Problems with sleep are associated with both PTSD and concussion. Sensitivity to light and nausea are associated with concussion, whereas flashbacks are associated with PTSD.

What are the proper rationales for all healthcare professionals to ask patients about conditions that may be associated with military service? (Select all that apply.) A. The sooner a condition such as posttraumatic stress disorder (PTSD) is identified and treated, the better the prognosis. B. Most patients seeking healthcare have served in the military. C. Most veterans do not receive their care at Veterans Administration (VA) facilities. D. Some veterans avoid seeking care until secondary problems from a condition develop. E. Most veterans have mental illnesses associated with military service.

A. The sooner a condition such as posttraumatic stress disorder (PTSD) is identified and treated, the better the prognosis. C. Most veterans do not receive their care at Veterans Administration (VA) facilities. D. Some veterans avoid seeking care until secondary problems from a condition develop. The majority of veterans do not receive care at VA hospitals. Because PTSD causes people to avoid facing uncomfortable situations, veterans may not seek care until the illness causes some secondary problem such as fatigue, pain, or depression. Treatment of PTSD can lead to complete remission in 30% to 50% of cases, and improvement of symptoms can be expected in most patients who receive treatment, with an improved prognosis being associated with earlier treatment. It is untrue that most veterans have mental illnesses associated with military service or that most patients seeking healthcare have served in the military.

When providing care for Mrs. Chen, the nurse realizes that patients of Asian descent often do not verbalize depressive symptoms but rather report them as which of the following symptoms? (Select all that apply.) A. Tiredness B. Weakness C. Imbalance D. Headaches E. Overeating

A. Tiredness B. Weakness C. Imbalance D. Headaches People from different cultures express depressive symptoms in various manners. People from Asian cultures often do not report mood-related symptoms of depression but rather somatic symptoms, such as headache, weakness, tiredness, imbalance and other somatic complaints. Overeating is not a symptom of depression that people from Asian cultures would likely report.

Which biological assessment or assessments should be given initial priority for an older patient diagnosed with dementia who has begun to demonstrate signs of depression? (Select all that apply.) A. Weight change B. Sleep patterns C. Hydration D. Elimination patterns E. Appetite

A. Weight change C. Hydration E. Appetite Adequate nutrition and hydration are of primary importance to the patient in order to maintain optimal health. Poor appetite and weight loss are commonly observed in the depressed patient. Sleep and elimination are valid concerns but are secondary to the initial establishment of the patient's nutritional and fluid statuses.

Which characteristics are associated with anxiety? (Select all that apply.) A. feeling that is unavoidable in life B. A sensation of being afraid C. A reaction to internal or external stimuli D. A vague feeling of apprehension E. A response to a stimulus that is clearly identifiable

A. feeling that is unavoidable in life C. A reaction to internal or external stimuli D. A vague feeling of apprehension Anxiety is a vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person. Anxiety is unavoidable in life.

The patient is prescribed paroxetine 25 mg by mouth daily and asks, "Why is my mouth so dry? Water does not help." What is the nurse's best response? A. "The air in the hospital is very dry. Keep drinking lots of water." B. "A side effect of paroxetine is dry mouth and throat. Have you tried sugar-free candies?" C. "I am sorry you are having discomfort. That must be from your depression." D. "Have you had your throat examined for an infection?"

B. "A side effect of paroxetine is dry mouth and throat. Have you tried sugar-free candies?" Paroxetine is a selective serotonin reuptake inhibitor prescribed for major depression, and one of the side effects is dry mouth and throat, which are associated with its anticholinergic effects. Although patients often do not find relief with oral brushing or drinking water, sugar-free candies are helpful to keep the oral cavity moist. Dry mouth is not associated with infection or depression.

Mr. Chen asks for a rationale as to why his wife is depressed. Which statement from the nurse is the best rationale? A. "Depression is due to lack of motivation to perform better each day." B. "Depression is an illness that has many causes, including chemical imbalances in the brain." C. "Depression is very common in the Asian culture; many patients seek treatment." D. "Depression happens at midlife, but the exact cause is unknown."

B. "Depression is an illness that has many causes, including chemical imbalances in the brain." Depression is an illness and not a behavior characterized by lack of interest or motivation. Those, in fact, are symptoms. Asian cultures do not have a high documented incidence rate of depression due to patients seeking help for somatic complaints rather than emotional symptoms. Depression does not necessarily occur at midlife; it may occur at any age.

A patient reports that he fell and struck his head and has a sore, swollen area on the back of his head. Which assessment question is the most important for the nurse to ask? A. "On a scale of 1 to 10, what is your pain level?" B. "Did you lose consciousness or black out as a result of the fall?" C. "Did you have bleeding from the site of the injury?" D. "Do you need an ice pack for the swelling?"

B. "Did you lose consciousness or black out as a result of the fall?" Loss of consciousness is part of the Acute Concussion Evaluation. Although the other questions may be asked, they do not help assess for the presence of a concussion and thus are not priority questions.

Which statement made by Mr. Palo identifies an intervention that his family has implemented to help deal with his decline in executive functioning? A. "When Maggie goes to the gym, she drops me off to volunteer at the animal shelter." B. "I put all my bills in a special box, and Maggie pays them twice a month." C. "I really like it when my son visits and we have hamburgers for lunch." D. "One of my sons calls every morning to make sure that I'm up and have showered and dressed."

B. "I put all my bills in a special box, and Maggie pays them twice a month." Having difficulty paying one's bills on time and correctly would be an example of a disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior. The other options address Mr. Palo's poor nutrition, social isolation, and ineffective self-hygiene issues.

Mr. Chen asks the nurse whether light therapy would be helpful for his wife. What is the nurse's best response? A. "Why do you ask about light therapy? Do you not agree with the medications?" B. "Light therapy is known to be effective for patients with mild-to-moderate depression associated with seasonal onset." C. "There is no evidence to support the use of light therapy with patients diagnosed with depression." D. "Light therapy may make her symptoms worse."

B. "Light therapy is known to be effective for patients with mild-to-moderate depression associated with seasonal onset." Light therapy is a newer treatment of choice and has been found to be effective in patients with depressive symptoms, especially in the darker months.

When reviewing the discharge medications, Mr. Chen asks the nurse whether there are any specific instructions for administration of venlafaxine. What is the best response? A. "There are no special considerations with this medication." B. "Take the medicine with food to decrease gastrointestinal upset." C. "You may skip the dose if you do not feel it is needed." D. "Take venlafaxine at bedtime on an empty stomach."

B. "Take the medicine with food to decrease gastrointestinal upset." Venlafaxine is administered with food to decrease gastrointestinal upset.

Which of the following is an example of overgeneralization? A. "I should not have taken those pills." B. "The therapy will not work; it didn't last time." C. "Are my children going to be ok?" D. "I should tell my husband if I feel suicidal."

B. "The therapy will not work; it didn't last time." Overgeneralization is a cognitive distortion (thinking error) in which the patient assumes that because she had a negative experience with the first therapist, she will have negative experiences with all therapists. She is overgeneralizing (i.e., making a general statement about therapy based on too limited experience). The other responses express normal and accurate thoughts.

Mrs. Chen asks when she will be discharged home. What is the best response from the multidisciplinary team? A. "When the 12 days of your section 12 have expired." B. "You'll be discharged once you've met the goals we've developed with you." C. "Patients admitted with a suicide attempt are released after 10 days." D. "It's up to you. What do you think?"

B. "You'll be discharged once you've met the goals we've developed with you." The plan of care for a patient admitted on an inpatient psychiatric unit is developed using specific, individualized outcomes or goals. Although the outcomes are individualized, they are not based simply on the patient's desires or feelings. Discharge is not based on a standard number of days.

The nurse is providing medication education to Mrs. Cole and her husband regarding the appropriate administration and use of oral lorazepam. What information should be provided when her husband asks how long it will take for the medication to start to affect her symptoms? A. 90 minutes B. 1 hour C. 30 minutes D. 2 hours

B. 1 hour The onset of lorazepam is 1 hour, its peak is 2 hours, and its duration is 12 to 24 hours.

Which nursing interventions are appropriate for inclusion into the care plan of a patient demonstrating agitation resulting from a manic episode? (Select all that apply.) A. Manage initial signs of agitation with prescribed medication. B. Approach the patient in a nonjudgmental manner. C. Restrict the patient's sugar and carbohydrates intake. D. Provide the patient with a consistent routine. E. Maintain a calm, quiet environment for the patient.

B. Approach the patient in a nonjudgmental manner. D. Provide the patient with a consistent routine. E. Maintain a calm, quiet environment for the patient. Agitation refers to a state of hyperarousal, increased tension, and irritability that can arise gradually or suddenly and last for minutes or months. Appropriate interventions include providing an environment that is as free of external stimuli as possible, maintaining a predictable routine, and staff relationships that are nonjudgmental. The patient should be provided a well-balanced diet that meets his or her dietary and caloric needs. Agitation should be met initially with de-escalation techniques, with medications being used as a last resort.

A patient with multiple suicide attempts is at a higher risk of a repeat attempt. At discharge, the nurse should ask the family to carry out which priority intervention for a patient with a recent overdose? A. Designate who will be administering all medications to the patient. B. Discard previous medications. C. Provide a one-on-one sitter for the patient at home. D. Identify the medications that the patient may have left over.

B. Discard previous medications. Although it is important to ascertain the medication management plan at home as well as which medications the patient may have left, the priority is to discard all previous medications to lessen the chance of overdose.

A patient who has been diagnosed with posttraumatic stress disorder related to explosive incidents in the military says, "Sometimes when I hear a loud boom like the lid slamming down on a trash dumpster, I think I'm right back in the attack. My heart races, and I hit the ground. It is terrifying." Which term correctly identifies this patient's response? A. Persistent avoidance of stimuli B. Dissociative reaction C. Hypervigilance D. Sleep disturbance

B. Dissociative reaction Dissociative reaction, also known colloquially as a "flashback," occurs when a person feels as if he or she is back in the traumatic moment and re-experiences it. Hypervigilance is attention to surroundings with the expectation that something important or frightening is going to happen. In this situation, the patient did not avoid the stimulus but experienced it. The patient is not referring to a sleep disturbance.

Which intervention best demonstrates the nurse acting as an advocate for Ms. Waterfall as she experiences an emotional crisis regarding her impending surgery? A. Assuring the surgeon that Ms. Waterfall's family agrees with her decision to delay surgery B. Effectively communicating to Ms. Waterfall's surgeon her wish to delay surgery C. Being familiar with Ms. Waterfall's cultural beliefs in the importance of a medicine bundle D. Documenting the details of the conversation with Ms. Waterfall regarding her wish to delay surgery

B. Effectively communicating to Ms. Waterfall's surgeon her wish to delay surgery Patient advocacy takes on several roles, but effectively communicating Ms. Waterfall's wish to delay surgery is the best demonstration as it relates to her emotional crisis. Being familiar with her belief in the medicine bundle and its importance demonstrates culturally competent care. The mentally competent patient has a right to disagree with proposed medical care, regardless of the family's opinions. Documentation is a nursing responsibility associated with any nursing care provided

What are the classic behaviors associated with the manic phase of bipolar disorder? (Select all that apply.) A. Introvert tendencies B. Extreme distractibility C. Flight of Ideas D. Agitation E. Paranoid thinking

B. Extreme distractibility C. Flight of Ideas D. Agitation E. Paranoid thinking Mania is characterized by agitation, flight of ideas, paranoia, distractibility, and excessive social extroversion.

Which physiological response describes an individual preparing to defend himself or herself against a perceived stressor? A. Denial B. Fight-or-flight C. Panic D. Hypothalamus stimulation

B. Fight-or-flight Fight-or-flight is a physiological reaction that involves adaptation to meet the physical requirements of either defending against the threat or fleeing it. The hypothalamus initiates the responses needed to acknowledge the stressor. Denial is a defense mechanism that prevents the individual from taking any action related to the stressor. Panic is an emotional response that is so severe that the individual cannot respond to the stressor.

Which intervention is most likely to aid in the development of a positive and therapeutic relationship with the nurse? A. Patient participation in multiple groups B. Frequent and short conversations throughout the day C. Asking the patient to eat in the dining room D. Expecting the patient to sit and converse for at least 20 minutes

B. Frequent and short conversations throughout the day Short, frequent conversations are less threatening and frightening to patients. This will aid in developing the trust and rapport necessary for a therapeutic relationship. Patient actions such as eating in the dining room and participating in multiple groups are not as likely to help develop a therapeutic relationship with the nurse. Sitting and conversing for 20 minutes with the nurse might be intimidating to the patient.

Which factors should the nurse consider when determining what influenced the state of Ms. Waterfall's perceived crisis? (Select all that apply.) A. Her age and gender B. Her cultural belief in the power of a medicine bundle C. Circumstances surrounding her mother's death D. Physical distance from her family E. Her pre-existing cancer diagnosis

B. Her cultural belief in the power of a medicine bundle C. Circumstances surrounding her mother's death D. Physical distance from her family E. Her pre-existing cancer diagnosis A number of factors influence whether a situation will be perceived as a crisis, including pre-existing stress levels, cultural standards for coping with stressful life events, reactions of significant others, feelings about the event (e.g., guilt, blame, shame), whether the event was anticipated, and previous coping skills for dealing with a crisis. For Ms. Waterfall, the factors include her cultural beliefs concerning the missing medicine bundle and its effect on her mother's death, distance from her family and tribal healer, and certainly the stress of a cancer diagnosis. Her age and gender are not considered factors in crisis perception.

Randy indicates he prefers to sit where he can see the door to the room. The nurses identifies this to be a sign of which condition? A. Moderate anxiety B. Hypervigilance C. Cognitive distortion D. Dissociative reaction

B. Hypervigilance Hypervigilance is consistent with a diagnosis of PTSD and involves attention to surroundings with the expectation that something important or frightening is going to happen. Moderate anxiety is a feeling of dread or apprehension to such a degree that concentration is difficult. Dissociative reaction, also known colloquially as a "flashback," occurs when a person feels as if he or she is back in the traumatic moment and re-experiences it. Cognitive distortion occurs when a patient perceives reality inaccurately and thus adopts false beliefs.

To best encourage medication adherence to her newly prescribed lithium therapy, which instructions should the nurse provide Mrs. Cole and her family? (Select all that apply.) A. Cease drinking any beverage containing caffeine B. Initially expect a sensation of thirst C. Restrict salt intake to minimize polyuria D. Expect intermittent bouts of nausea for several days after lithium therapy begins E. Drink plenty of water when taking the medication to minimize gastrointestinal upset

B. Initially expect a sensation of thirst D. Expect intermittent bouts of nausea for several days after lithium therapy begins E. Drink plenty of water when taking the medication to minimize gastrointestinal upset Lithium can produce side effects that discourage adherence to the prescribed therapy. Educating the patient that some effects are temporary, or can be managed fairly easily, will help the patient stay on the medication. Nausea and thirst are often experienced initially but generally subside in a few days. Taking the medication with a sufficient amount of water tends to help manage gastrointestinal upset. Major changes in salt and caffeine intake should be avoided without first consulting the healthcare provider.

What are the positive functions associated with "normal anxiety"? (Select all that apply.) A. It is a learned response to stress. B. It triggers action to resolve an existing crisis. C. It serves to bring about a solution to a problem. D. It serves to motivate the individual to take action. E. It is usually easily managed.

B. It triggers action to resolve an existing crisis. C. It serves to bring about a solution to a problem. D. It serves to motivate the individual to take action. Anxiety is unavoidable in life, and normal anxiety can serve many positive functions, such as motivating the person to take action to solve a problem or to resolve a crisis. Anxiety is a naturally occurring response to stress that is generally involuntary. Managing anxiety, even normal anxiety, can be a challenge that requires learned techniques.

Which statement below is true only of the panic stage of anxiety? A. Restless pacing is common. B. Learning is impossible. C. Redirection is needed to maintain focus. D. Vital signs begin to increase.

B. Learning is impossible. In panic, the emotional-psychomotor realm predominates, with accompanying fight, flight, or freeze responses making problem-solving, planning, and learning impossible. A person with severe anxiety has trouble thinking and reasoning. Muscles tighten and vital signs increase. The person paces; is restless, irritable, and angry; or uses other similar emotional-psychomotor means to release tension. Moderate anxiety makes concentrating independently difficult, but the individual can be redirected to the topic.

Which interventions demonstrate advocacy for Ms. Waterfall's decision to delay surgery? (Select all that apply.) A. Suggest that her family be involved in her decision to delay surgery. B. Make all interventions focus on Ms. Waterfall. C. Defer the conversation regarding the surgery to her surgeon. D. Present the information to her in a clear, concise manner. E. Provide all appropriate information she requests.

B. Make all interventions focus on Ms. Waterfall. D. Present the information to her in a clear, concise manner. E. Provide all appropriate information she requests. To be an effective advocate, the nurse should make all interventions patient-focused. Although family wishes may be considered by the patient, it is her decision to make. All information she needs to make her decision should be presented in a clear, concise manner. The conversation should occur between the nurse and patient so that the nurse is in a position to be knowledgeable and confident of the patient's wishes and ability to make an informed decision.

The patient has overdosed on 50 tablets of nortriptyline. Which intervention is the priority action? A. Take vital signs B. Obtain an order for an electrocardiogram. C. Complete a mini mental exam. D. Complete the admission paperwork for transfer to an inpatient facility.

B. Obtain an order for an electrocardiogram. Tricyclic antidepressants, such as nortriptyline, can cause cardiac dysrhythmias and death in an overdose. Obtaining an electrocardiogram aids in the assessment of cardiac function. Although taking vital signs is important, assessment of cardiac rhythm with the possibility of cardiac arrest is the priority. The mini mental exam is for evaluating cognitive function in patients with dementia, and thus would not be appropriate to perform in this case. Transfer to an inpatient facility, if needed, would be a lower priority than conducting an electrocardiogram.

Which of the following should the nurse encourage Mr. and Mrs. Chen to do when she is discharged? A. Urge Mr. Chen to take on more household chores. B. Participate in individual or group therapy. C. Suggest a variety of jobs for Mrs. Chen outside the home. D. Encourage Mrs. Chen to rest as much as possible during the first weeks after discharge.

B. Participate in individual or group therapy For patients to decrease the likelihood of relapse, they are encouraged to problem solve and find their own solutions; participating in individual or group therapy can help accomplish this. This approach contributes to the patient's sense of self-worth. Encouraging Mr. Chen to do the chores would likely decrease Mrs. Chen's sense of self-worth. Allowing Mrs. Chen to choose a job outside the home herself would be more effective than suggesting a variety of jobs to her. Too much time spent alone and unproductive could trigger another depressive episode in Mrs. Chen

Randy has answered all four questions in the Primary Care Posttraumatic Stress Disorder (PTSD) Screen positively. The nurse knows that which conclusion is correct? A. Randy has PTSD and should be referred for further evaluation. B. Randy has been screened for PTSD, and the results indicate referral for further evaluation. C. Randy does not have PTSD and does not need further evaluation. D. Randy has been screened for PTSD, and the results do not indicate referral for further evaluation.

B. Randy has been screened for PTSD, and the results indicate referral for further evaluation. The Primary Care PTSD Screen is a screening test for symptoms of PTSD. Randy's positive responses indicate the need for further evaluation.

What is the priority safety-related outcome for a patient currently experiencing mania associated with bipolar disorder? A. Demonstrates compliance with the treatment program B. Remains free from injury or trauma C. Demonstrates the ability to follow safe health behaviors D. Demonstrates the ability to control impulsive behavior

B. Remains free from injury or trauma Because of the safety risks taken by patients in the manic phase, safety plays a primary role in care and is the priority nursing responsibility. Remaining free of injury or trauma is the associated outcome. The remaining options are outcomes that can be achieved once the patient's mania is being managed effectively.

What is the therapeutic value of a cholinesterase inhibitor for a patient diagnosed with Alzheimer disease? A. Significantly improves motor and language functioning B. Temporarily slows the progress of the dementia C. Permanently interrupts cognitive decline D. Extends life expectancy

B. Temporarily slows the progress of the dementia Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl, Razadyne, Nivalin) are cholinesterase inhibitors that have shown modest therapeutic effects and that temporarily slow the progress of dementia-related cognitive decline. They have no effect, however, on the overall course of the disease or on life expectancy.

Mr. Chen is anxious about his wife being home alone when he travels. He asks whether a visiting nurse would be helpful. Which of the following should the nurse mention regarding community-based supports? A. They can be intrusive and unwelcomed by many patients and make symptoms worse. B. They aid patients by providing structure and assessment. C. They will discourage patients from caring for themselves. D. They are only available when patients do not have a family.

B. They aid patients by providing structure and assessment. Community-based health care workers often notice subtle changes in a patient's condition or emotional state and are a valuable resource for any patient. They are not typically intrusive or unwelcomed and are available to anyone, not just those who do not have a family. In addition to providing care, they can also promote self-care in the patient.

Which intervention should be considered to help prevent Mrs. Cole from becoming more agitated? A. Take her out to the dayroom in a wheelchair. B. Turn off the television in her room. C. Medicate her with the prescribed as-needed lorazepam. D. Encourage her friends to visit often.

B. Turn off the television in her room. Provide a safe environment for the patient. Note that a patient in a manic phase requires a calm and highly structured environment to decrease stimuli that may agitate or excite her. Keeping the lights in her room dim and the television off are appropriate interventions. Spending time in the dayroom and interacting with friends will likely subject her to increased stimulation, which will adversely affect her manic behaviors. Medication with lorazepam is an option to help manage agitation that can arise if external stimulation isn't effectively managed.

Mr. Palo has been diagnosed with both mild dementia and depression. Which of his signs and symptoms are most likely associated with the dementia he is currently experiencing? (Select all that apply.) A. Hypertension B. Unkempt appearance C. Tearfulness D. Forgetfulness E. Easily frustrated

B. Unkempt appearance D. Forgetfulness E. Easily frustrated Dementia is commonly associated with poor hygiene and dressing habits, as well as a low frustration point and forgetfulness. All of these behaviors are generally related to the loss of ability to perform familiar tasks and the anxiety this creates. Depression is more likely responsible for his tearfulness. Hypertension is not generally associated with either of these disorders.

Mr. Chen is worried that his children will be depressed and he will not recognize the signs. What is the best response from the nurse? A. "Children with depression become more social and engaged in activities." B. "Often children do not show signs of depression until they are at least 16." C. "Children may become more irritable and display a school phobia." D. "Children will tell you when they feel sad."

C. "Children may become more irritable and display a school phobia." Children may not experience and express the classic symptoms of depression described in adults. They are more likely to display anxiety, fear of separation, somatic symptoms, and irritability. Children do not necessarily tell their parents when they are feeling sad. Children with depression can show signs at any age. Children are more likely to become less social and disengaged when depressed.

Considering bipolar I disorder, which statement made by a patient should be considered an indicator of high risk for self-harm? A. "I really don't want to hurt my family, but I can't seem to stop." B. "I haven't had a good night's sleep in weeks; that can't be healthy." C. "I hope my husband will remember how much I loved him after I'm gone." D. "I really enjoy all the freedom I have when I've got all this energy."

C. "I hope my husband will remember how much I loved him after I'm gone." Bipolar I disorder involves one or more manic or mixed episodes usually accompanied by major depressive episodes that pose a significant risk for suicidal ideations. Indicating a wish to be remembered as loving when "I'm gone" is the strongest suggestion of suicidal ideation. The remaining options relate to the patient's insight regarding the other classic behaviors associated with manic behaviors.

A care plan states that a patient should attend groups on the unit, but the patient states, "I do not want to go; just let me sleep." What is the best response by the nurse? A. "Oh, it will be fine. It is a glorious day." B. "You don't want to go?" C. "I know you feel like staying in bed, but it is time for group. I will walk with you." D. "Ok, I will check back with you after a few hours."

C. "I know you feel like staying in bed, but it is time for group. I will walk with you." Diminished interest in almost all activities and fatigue are symptoms of major depressive disorder. Patients who are depressed may not want to participate in therapeutic activities and may have a difficult time functioning if their day is unstructured. The nurse should not be overly cheerful but should try to engage them and not just leave them in bed. Reflecting patients' feelings and encouraging them to attend will increase their activity, which will also have a positive effect on their social skills and enhance sleep. The nurse should avoid asking "yes or no" questions.

Which statement made by a nurse best demonstrates an understanding of cultural competence relating to mental health issues? A. "Unfortunately, among some Native American tribes, mental illness is stigmatized." B. "I always conduct a thorough cultural assessment on all my clients." C. "It's easy to forget, but not all members of a cultural group always think alike." D. "Native Americans tend to rely on their shamans for both physical and emotional healing."

C. "It's easy to forget, but not all members of a cultural group always think alike." Knowledge of expected cultural patterns provides a starting point for the nurse to begin to relate to people with ethnic backgrounds different from his or her own. Being aware of the usual differences can help the nurse know what to ask or how to assess preferences and health practices. Nevertheless, variations among people from any culture are wide: Not everyone fits the general pattern. Although the remaining statements are true and reflect effective nursing practice, recognizing the uniqueness of each client best demonstrates understanding.

The patient asks what can be done to help prevent future concussions. Which statement is the nurse's best response? A. "Get 8 hours of sleep each night." B. "Most concussions get better on their own." C. "Wear a helmet during bike riding." D. "Avoid bright lights for 2 days."

C. "Wear a helmet during bike riding." Wearing a helmet is the only measure listed here that would help prevent future concussions. The other answers refer to measures to help a patient recover from a concussion. Other options might include the following: 1. Do not drive when you are taking drugs for pain or that cause you to be sleepy. 2. Do not drink alcohol and drive. 3. Do not drive when you are tired. 4. Always wear a seatbelt when you drive or ride in a car. 5. Wear proper protective equipment when you play sports. 6. Wear a helmet when riding a motorcycle, bicycle, skateboard, or roller skates or when skiing, snowboarding, or doing other similar activities. 7. Stay away from unsafe activities that may cause falls. 8. Wear hard hats and protective gear if you work in construction, work other dangerous jobs, work on ladders, or work in high places.

Which assessment question should the nurse ask Mrs. Cole to best help determine the cause of her manic behavior? A. "What were you doing when you fractured your ankle?" B. "What sort of stress have you been experiencing lately?" C. "When did you take your last dose of lithium?" D. "When were you diagnosed with bipolar disorder?"

C. "When did you take your last dose of lithium?" Treatment for bipolar disorder involves a lifetime regimen of medications: either an antimanic agent called lithium or anticonvulsant medications used as mood stabilizers to help control symptoms and prevention and/or minimize the severity and frequency of future episodes. Adherence to the prescribed medication therapy is critical to controlling the development of manic symptoms. Although the other options present appropriate assessment questions, none of them are as directly related to the development of manic behavior as medication compliance.

Mrs. Chen has been admitted after her third suicide attempt. What is the nurse's priority assessment for Mrs. Chen? A. Assess Mrs. Chen for appropriate coping skills. B. Assess Mrs. Chen for vitamin D deficiency. C. Assess Mrs. Chen for suicidality. D. Assess Mrs. Chen for support systems.

C. Assess Mrs. Chen for suicidality. The risk of successful suicide increases in lethality each time there is another attempt. Mrs. Chen has now had three attempts. Although the other answers represent important assessments, none is as important as assessing for suicidality.

Mrs. Chen has been taking sertraline and venlafaxine for several days. This morning she is smiling and engaging in conversation. During the conversation she tells the nurse, "I am feeling relieved." What is the nurse's priority assessment? A. Ensure the patient continues to attend groups. B. Assess the patient's vital signs. C. Assess the patient for suicidality and place her on closer observation. D. Monitor the patient's intake and output.

C. Assess the patient for suicidality and place her on closer observation. A client's mood often improves in response to antidepressant medication. When patients are suddenly feeling better, they may have the energy to carry out a plan to kill themselves. Closer observation is necessary to ensure safety. The patient's safety is more important than any other aspect being assessed.

Which behavior suggests that Mrs. Cole would benefit from a prescribed as-needed dose of lorazepam? A. Expressing auditory hallucinations B. Reporting pain at her surgical site C. Becoming noticeably agitated D. Pacing for extended periods of time

C. Becoming noticeably agitated Agitation often accompanies mania. Lorazepam may be prescribed as needed to help manage agitation. Hallucinations would be addressed by the use of an antipsychotic medication, whereas the manic pacing would require regularly prescribed lithium. Pain would not be improved by a dose of lorazepam.

The patient has been prescribed sertraline and venlafaxine. The nurse recognizes that these medications given together can cause which condition? A. Bradycardia B. Dry mouth C. Confusion D. Hypervigilance

C. Confusion Serotonin syndrome should be considered when more than one SSRI (or an SSRI and any other type of serotonin-increasing medication) are given together. Symptom onset is rapid and typically occurs a short time after elevated serotonin levels. Symptoms of serotonin syndrome include the following: confusion and agitation (not hypervigilance), muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, muscle paralysis, hyperthermia, tachycardia (not bradycardia), tachypnea, hypersalivation (not dry mouth), and diaphoresis.

Considering Mr. Palo's history and assessment findings, which factor is most likely the primary contributor to his recent weight loss? A. Living alone B. Alzheimer disease diagnosis C. Depression D. Prescribed galantamine therapy

C. Depression A commonly observed physical response to depression is poor appetite and the resulting weight loss. Although nausea and vomiting are possible side effects of galantamine, there are no assessment data to suggest the patient is experiencing either. Both living alone and dementia (including Alzheimer disease), especially in its later stages, can affect the patient's interest in preparing and eating food, but neither has the high degree of influence presented by depression.

Which of the following best defines "normal anxiety"? A. Apprehension that is ongoing and not associated with any specific stimulus B. Fright that is associated with a physical danger C. Dread that is appropriate to the situation in intensity and duration D. Terror triggered by the threat of known danger

C. Dread that is appropriate to the situation in intensity and duration Anxiety—a vague feeling of dread or apprehension—is considered normal when it is appropriate to the situation and dissipates when the situation has been resolved. Ongoing apprehension not associated with a specific stimulus is characteristic of an anxiety disorder, not of normal anxiety. Terror or fright in response to a known or physical danger is characteristic of fear, not anxiety.

Mr. Chen asks the provider about additional treatments to consider if his wife relapses. The provider tells Mr. Chen that electroconvulsive therapy (ECT) may be an option if the new medication does not help Mrs. Chen manage her depression. Which of the following is part of teaching for a patient considering ECT? A. ECT does not affect short-term memory the afternoon after ECT. B. ECT is no longer being used as a treatment for major depression. C. ECT is a treatment that requires conscious sedation. D. ECT is only performed if the patient is not suicidal.

C. ECT is a treatment that requires conscious sedation. ECT requires the patient to be NPO due to risk of aspiration with sedation. The patient is given sedation in a controlled environment.

In a patient with recurrent depression and multiple suicide attempts, which of the following is most likely to help preclude another depressive episode? A. Maintaining a healthy lifestyle B. Lithium carbonate C. Early recognition of symptoms D. Light therapy

C. Early recognition of symptoms Although maintaining a healthy lifestyle (and, for certain individuals, light therapy) can be helpful in treating depression, the most crucial aspect to prevent a future relapse is the early recognition of symptoms. Lithium carbonate is used to treat the manic phases of bipolar disorder, not depression. A healthy lifestyle consisting of healthy eating and exercise will aid in mental health clarity and will also increase self-esteem and self-worth.

When administering the Mini-Cog, the nurse asks Randy to draw a clock, place a time on the clock, and remember three words. What does the patient drawing a clock allow the nurse to assess about himself? A. Fine motor skills B. Short-term memory C. Executive/cognitive function D. Long-term memory

C. Executive/cognitive function When patients draw a clock, their executive/cognitive function can be assessed. This assessment does not provide any information regarding their short- or long-term memory or fine motor skills.

Which of Ms. Waterfall's behaviors or characteristics does the Hamilton Rating Scale for Anxiety consider? (Select all that apply.) A. Her deep spirituality B. Her current cancer diagnosis C. Her statement, "I can't breathe" D. That she is pacing about the room E. Her statement, "I feel like I'm going to die"

C. Her statement, "I can't breathe" D. That she is pacing about the room E. Her statement, "I feel like I'm going to die" The Hamilton Rating Scale for Anxiety considers respiratory symptoms, fears, and restless behaviors. Although factors associated with her spirituality and cancer diagnosis may contribute to her anxiety at present, they are not considered by the assessment tool.

Which symptom of mania places a patient with bipolar disorder at greatest risk for injury? A. Agitation B. Hyperactivity C. Impulsivity D. Insomnia

C. Impulsivity Patients in the manic phase demonstrate poor judgment and impulsivity, making them vulnerable for a variety of risk-taking activities. Although the other characteristics may contribute to the risk for injury, poor judgment and impulsivity are the primary risk factors.

What is the fundamental characteristic of anhedonia? A. Self-directed anger B. Slow body movements C. Lack of pleasure and enjoyment D. Extended verbal response time

C. Lack of pleasure and enjoyment Patients experiencing depression may describe themselves as hopeless, helpless, down, or anxious and often experience anhedonia, defined as the loss of any sense of pleasure from activities they formerly enjoyed. Although the other options identify possible characteristics of depression, none is associated with anhedonia.

Mrs. Chen articulates that she has learned new coping strategies while at the hospital. The nurse recognizes that Mrs. Chen's statement indicates which outcome? A. Mrs. Chen is still intelligent. B. Mrs. Chen has gained social skills. C. Mrs. Chen realizes that coping strategies can prevent a relapse. D. Mrs. Chen is safe for discharge and will not relapse.

C. Mrs. Chen realizes that coping strategies can prevent a relapse. Coping strategies are taught and developed at the outset of acute hospitalization and are a means to prevent relapse in the event that stress overwhelms a patient. Mrs. Chen's learning of new coping strategies indicates that she understands their value in helping to prevent a relapse. Just because Mrs. Chen has gained new coping skills does not necessarily indicate that she has gained new social skills, is still intelligent, or is safe for discharge.

The patient is being admitted to an inpatient psychiatric unit after an overdose in a suicide attempt. The patient is now medically stable. Which intervention should the registered nurse recognize as the priority action? A. Take the patient's vital signs and ensure he or she eats a meal. B. Complete the full admission history. C. Place the patient on safety precautions. D. Record the patient's current medications.

C. Place the patient on safety precautions. Maintaining the patient's safety is a priority, especially after an intentional overdose. Safety precautions are initiated to ensure the patient does not harm himself or herself. The other interventions should be performed after safety precautions are implemented.

The term lability is used to define what type of mood-associated behavior? A. A sense of guilt demonstrated by depression B. Demonstrations of low self-esteem C. Rapid shifts between emotional extremes D. Behaviors that result from one's current mood

C. Rapid shifts between emotional extremes Mood lability is associated with alternating periods of mania and depression (e.g., loud laughter and episodes of tears). None of the other options accurately describe the characteristics of mood lability.

The nurse should warn Mrs. Cole and her husband that lorazepam therapy should not be stopped abruptly because doing so will likely result in which consequence? A. A manic episode B. A depressive episode C. Triggering of withdrawal symptoms D. A decrease in the effects of lithium

C. Triggering of withdrawal symptoms Lorazepam is a benzodiazepine that can cause addiction when used long-term or when abused. Don't stop taking lorazepam abruptly after long-term use because withdrawal symptoms may occur. None of the remaining options are accurate statements about the effect of a sudden cessation in lorazepam therapy.

Mr. Palo states, "I'm old; when you get old, you naturally get depressed thinking of all the people you've lost and the things that have changed." To best address his safety, which initial response should the nurse make? A. "Losing loved ones is sad. Tell me about the people in your life that you've lost." B. "Depression is difficult to deal with. Let's discuss the medications that are available to help." C. "What sort of changes have you experienced? Which ones are you most sad about?" D. "Depression isn't a normal part of getting older. Are you thinking about ending your life?"

D. "Depression isn't a normal part of getting older. Are you thinking about ending your life?" Depression is not an expected, normal part of aging. To diagnose and treat the estimated 14% of older adults with depression, a standard, routine screening for depression should be part of a regular visit to the primary provider. Too often, both provider and older adult patient may view changes in mood as part of physical illness, or "just to be expected." Any patient suspected of being depressed should be assessed immediately for suicidal ideations. The other options encourage the patient to discuss his feelings and to explore possible treatment modalities.

Mrs. Chen states "None of the medications have made me feel better at all, and I've been on them for several months. Is there another treatment that may be helpful?" What is the best response from the nurse? A. "Why not try another medication to augment what you are currently taking?" B. "You should give it more time; your body will get used to the medication." C. "These medications do not work unless there is a sleeping medication used, too." D. "Have you discussed electroconvulsive therapy with your provider?"

D. "Have you discussed electroconvulsive therapy with your provider?" Some people do not respond to antidepressant medication. Electroconvulsive therapy is used for refractory depression, in which numerous medication trials have not been effective. Although medications can sometimes require 4 to 6 weeks to take effect, additional medications typically will not be effective unless another symptom is being treated. The medications do not require being combined with a sleeping medication to work.

A patient has been complaining of nightmares after having a car accident more than 4 weeks ago and tells the nurse, "I think I have PTSD." Which is the best response by the nurse? A. "Acute stress disorder is probably the cause of your nightmares." B. "PTSD is diagnosed when you have nightmares within a week of the accident." C. "You would only have PTSD if you were actually injured in the accident." D. "I will make you an appointment to talk with the provider for further evaluation."

D. "I will make you an appointment to talk with the provider for further evaluation." Nightmares that persist longer than a month after a traumatic event are consistent with a diagnosis of posttraumatic stress disorder (PTSD). Patients should be evaluated by a qualified provider rather than self-diagnosing. The other answers are not part of the criteria for PTSD.

Mr. Chen asks whether his wife will be able to resume her daily activities at home, such as laundry and cooking. What is the nurse's best answer? A. "A housekeeper would be a good idea." B. "Why would you ask that? Can't you take time off to be with your wife?" C. "No, she will need to rest for a few weeks." D. "Many people with recurrent depression have difficulty with responsibilities."

D. "Many people with recurrent depression have difficulty with responsibilities." Recurrent depression interferes with daily coping and ability to carry out roles and responsibilities. Patients and caregivers find this frustrating, and the inability to resume activities at the previous rate can lead to further depression.

The patient says, "I am having trouble remembering things since I had the head injury, and that is really frustrating." Which response by the nurse demonstrates the technique of restatement? A. "Your memory problems will go away soon." B. "That must be really worrisome." C. "Tell me more about your memory problems." D. "The memory problems are frustrating you."

D. "The memory problems are frustrating you." In restatement, the nurse repeats back to the patient what he or she has said in an effort to confirm understanding. Inviting the patient to tell more about his or her memory problems, although appropriate, is not restatement. Telling the patient, "That must be really worrisome" demonstrates empathy and active listening but not restatement. Telling the patient that his or her memory problem will go away soon is inappropriate, as it may provide the patient with false hope.

Randy reports that he has been referred to a mindfulness/meditation group by his nurse practitioner. The nurse knows that this referral is meant to address which symptom? A. Headache B. Sensitivity to light C. Difficulty remembering D. Anxiety

D. Anxiety Mindfulness has been found to be useful in the treatment for stress reduction. It would not be useful in treating other symptoms of traumatic brain injury, such as sensitivity to light, difficulty remembering, or headache.

What is the highest priority when educating the patient who is taking monoamine oxidase inhibitors? A. The purpose of frequent blood level draws B. The need for fluid and sodium replacement C. Careful recognition of signs and symptoms of toxicity D. Avoidance of foods containing tyramine

D. Avoidance of foods containing tyramine Tyramine is an amino acid naturally found in small amounts in protein-containing foods such as strong or aged cheeses; cured, smoked, or processed meats; pickled or fermented foods; soybeans and soy products; and dried or overripe fruits. Monoamine oxidase inhibitors block the breakdown of tyramine and may can cause a hypertensive crisis, which can be life threatening. Therefore, patients should be taught to avoid consuming foods that contain tyramine. The other answers are of lower priority because they are less likely to be life-threatening

The provider suggests changing Mrs. Chen's medication to phenelzine. Mrs. Chen says to the nurse, "The provider says I will need to watch my diet if I take a new medication; I am not sure I want to do this. Which foods would I have to avoid?" Which foods should the nurse mention? A. Black beans, garlic, pears B. Pork, shellfish, egg yolks C. Milk, kale, tomatoes D. Blue cheese, beer, pepperoni

D. Blue cheese, beer, pepperoni Patients who are prescribed monoamine oxidase inhibitors are urged to stay away from foods containing tyramine, which can cause a hypertensive crisis. Tyramine is an amino acid naturally found in small amounts in protein-containing foods such as strong or aged cheeses; cured, smoked, or processed meats; pickled or fermented foods; soybeans and soy products; and dried or overripe fruits. Monoamine oxidase inhibitors block the breakdown of tyramine and may cause a hypertensive crisis, which can be life threatening. The other answers are of lower priority because they are less likely to be life-threatening. The other foods listed do not contain tyramine.

What is a characteristic of moderate anxiety? A. Reasoning is disrupted B. Pupils enlarge to let in more light C. Adrenaline surge greatly increases vital signs D. Concentrating independently is difficult

D. Concentrating independently is difficult In moderate anxiety, the person has difficulty concentrating independently but can be redirected to the topic. Disrupted reasoning, adrenaline surge that greatly increases vital signs, and enlarged pupils are all associated with severe, not moderate, anxiety.

Which individual characteristic has the greatest influence on one's personal health beliefs and practices? A. Gender B. Education C. Age D. Culture

D. Culture Culture has the most influence on a person's health beliefs and practices. It has been shown to influence one's concept of disease and illness. Although the other options may exert some influence, none is as influential as the individual's culture.

Which nursing intervention would be most effective for assessing Ms. Waterfall's anxiety level? A. Discussing the importance of stress reduction B. Identifying which family members she needs to contact C. Reassuring her that her medicine bundle will be brought to the hospital D. Encouraging her to express her feelings and concerns

D. Encouraging her to express her feelings and concerns Encouraging the patient to express her feelings and concerns freely is the initial focus of the nurse-patient conversation. This helps identify both the root of the anxiety and which measures are required to help de-escalate her anxiety. She needs to first identify her feelings before it can be determined whether family or medicine bundle interventions are appropriate. Stress reduction techniques are effective only when the patient's feelings have been expressed.

What is the priority nursing intervention before Mrs. Chen leaves to go home? A. Ensuring that her insurance information is up to date B. Ensuring she has eaten a meal in case her family is not home C. Ensuring she has a ride, because she cannot drive while on medication D. Ensuring she is safe by asking if she feels suicidal

D. Ensuring she is safe by asking if she feels suicidal Safety is the first priority even at discharge. A patient with recurrent suicide attempts is at a higher risk for a repeat attempt. The patient can drive while on sertraline and venlafaxine. Ensuring that she has eaten a meal and that her insurance information is up to date is not as important as ensuring her safety.

Which scale is used to screen for the presence of depressive symptoms? A. Y-BOCS B. CIWA C. CAGE D. HAM-D

D. HAM-D The Hamilton Rating Scale for Depression (HAM-D) is a screening tool used to assess for the presence of depressive symptoms and the need for further assessment. The CAGE tool is used to screen for substance abuse. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is used to assess for obsessive compulsive disorder. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is used to assess for and manage alcohol withdrawal.

Which anxiety-related assessment tool is administered by a healthcare professional? A. Fear Questionnaire B. Beck Anxiety Inventory C. Anxiety Sensitivity Index D. Hamilton Rating Scale for Anxiety

D. Hamilton Rating Scale for Anxiety The Hamilton Rating Scale for Anxiety is the only clinician-rated tool for assessing symptoms of anxiety. All other options are self- or patient-rated.

An older adult has been diagnosed with Alzheimer disease and is currently demonstrating behaviors associated with the mild stage of the disorder. When considering social interaction, the nurse should expect which classic patient response? A. Refuses to leave the home B. Remembers the names of only close family members C. Seeks the companionship of friends D. Has begun to avoid social situations

D. Has begun to avoid social situations Dementia such as Alzheimer disease is described in stages. Forgetfulness is the hallmark of beginning, mild dementia. As the disorder progresses the person has difficulty finding words, frequently loses objects, and begins to experience anxiety about these losses. These deficiencies make social interaction less enjoyable and the individual may begin to attempt to avoid such situations. Seeking the opportunity to socialize with friends is not associated with behaviors regularly observed with dementia. Forgetting the names of friends and family as well as dramatic social isolation is observed in later stages of the disorder.

Randy Adams has been in a car accident, which resulted in a concussion. He has a history of prior concussive exposure from his time in the military. The nurse knows that multiple head injuries could result in which condition? A. Obsessive compulsive disorder B. Schizophrenia C. Narcolepsy D. Long-term dementia

D. Long-term dementia Studies show that repeated head injuries predispose a patient to long-term dementia. They would not predispose a patient to obsessive compulsive disorder, narcolepsy, or schizophrenia.

Which as-needed medication should the nurse administer to a patient demonstrating agitation related to mania? A. Risperidone B. Lithium C. Vancomycin D. Lorazepam

D. Lorazepam Lorazepam is a benzodiazepine prescribed for agitation. Lithium is a mood stabilizer, risperidone is an antipsychotic, and vancomycin is an antibiotic.

An older adult diagnosed with dementia has presented with behaviors that suggest a disturbance in executive functioning. Which assessment finding supports this finding? A. Speaks in only short phrases of no more than three or four words B. Refers to a favorite cup as "that blue thing" C. Has fallen three times in the last month D. Needs to be reminded to use toothpaste when brushing teeth

D. Needs to be reminded to use toothpaste when brushing teeth A disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior, would include the need to be reminded to use toothpaste when brushing one's teeth. Having fallen three times in the last month is likely a result of apraxia, or impaired ability to execute motor activities despite intact motor functioning. Referring to a cup as "that blue thing" is an example of agnosia, which is failure to recognize or identify objects despite intact sensory function. Speaking in only short phrases of no more than three or four words is an example of aphasia, or alterations in language ability.

A patient with posttraumatic stress disorder (PTSD) reports that his wife has left him and that he has been fired from his job because of angry outbursts. Which statement is true regarding patients experiencing PTSD? A. They refuse to apologize. B. They don't want any responsibilities. C. They prefer not to work. D. They have difficulties with relationships.

D. They have difficulties with relationships. Many people with PTSD have difficulty with trust and control, which makes it difficult to have intimate relationships and also to take direction from work supervisors. It is untrue that people with PTSD prefer not to work, do not want any responsibilities, or refuse to apologize.

Randy reports that he is taking different doses of his new medication, topiramate, over the next 2 weeks. Which is the correct rationale for Randy's dosing regimen? A. Topiramate is taken on an as-needed basis. B. Topiramate doses vary daily. C. Topiramate is alternated with another medication for the first 2 weeks. D. Topiramate is titrated by increasing the dose gradually until the recommended dose is reached.

D. Topiramate is titrated by increasing the dose gradually until the recommended dose is reached. Topiramate is titrated by increasing the dose gradually until the recommended dose is reached. Topiramate is not taken on an as-needed basis, is not alternated with another medication for the first 2 weeks, and is not prescribed in doses that vary daily. Remediation: