4203 xam 2 all review/eaq questions

In clients with a cognitive impairment disorder. the phenomenon of increased confusion in the early evening hours is called: A. Aphasia B. Agnosia. C. Sundowning. D. Confabulation.

Correct Answer: C. Sundowning. Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The term "sundowning" refers to a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression, or ignoring directions. Sundowning can also lead to pacing or wandering. Sundowning isn't a disease, but a group of symptoms that occur at a specific time of the day that may affect people with dementia, such as Alzheimer's disease. The exact cause of this behavior is unknown.

Which response by the nurse is most appropriate when a patient who has expressed suicidal ideation begins to cry and states, "I lost my job. I don't know how I am going to pay my bills. What if I lose my house?"? "I'm here and I will stay with you." "Do you have family or friends you can stay with?" "Sometimes I worry about my bills too. It is normal." "How devastating. Does that make you think about suicide again?"

"How devastating. Does that make you think about suicide again?" Rationale Answering with "how devastating" allows for reflection that communicates empathy and allows the nurse to discern the patient's probable feelings. Asking a direct question of the patient's thoughts on suicide allows for a suicide risk assessment. Staying with the patient may be therapeutic but would not address the patient's underlying feelings. Asking the patient if he or she has family or friends to stay with or sympathizing with the patient about the worry of paying bills may be perceived as ignoring the patient's current feelings.

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? "I am fat and ugly." "What I think about myself is my business." "I am grossly underweight, but that's what I want." "I am a few pounds overweight, but I can live with it."

"I am fat and ugly." Rationale: A. Patients diagnosed with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually disclose perceptions about self to others. The patient with anorexia will persist in trying to lose more weight.

Which patient statement does the nurse know exemplifies suicidal ideation? "My neighbor killed himself." "I overdosed on medicine, but it wasn't enough to kill me." "I plan to kill myself by slitting my wrists." "I have a terminal illness and have found a doctor who will help me end my life peacefully."

"I plan to kill myself by slitting my wrists." Rationale Suicidal ideation refers to the process of thinking about killing oneself, exemplified in the statement about planning to kill oneself by slitting the wrists. Suicide is the act of intentionally ending one's own life, exemplified by the statement that a neighbor has killed himself. Suicide attempt includes all willful, self-inflicted, life-threatening attempts that have not led to death, exemplified by overdosing but unsuccessfully committing suicide. Physician-assisted suicide is when a health care provider aids in assisting a terminally ill patient to self-administer a lethal dose of medication, exemplified by the statement from a patient who has a terminal illness.

Which response from the nurse would be appropriate when a confused and disoriented patient is admitted to the hospital and the adult child states, "I'll take my parent's glasses and hearing aid home so they don't get lost"? "That will be fine. I'll have you sign our hospital release form." "Because we do not have a copy of durable power of attorney, we cannot release them to you." "Don't worry. You can leave them at the bedside. We are insured for losses of this sort." "I would like to have your parent wear them. It will help alleviate confusion and disorientation."

"I would like to have your parent wear them. It will help alleviate confusion and disorientation." Rationale Patients with cognitive disorders usually profit from being able to see and hear clearly. The nurse should explain that the use of glasses and hearing aids would reduce the patient's confusion and disorientation. The nurse would not ask for a signed release form, refer to power of attorney, or explain that the hospital is insured for the loss. p. 284

Which complaint would receive the nurse's priority attention when a patient who is diagnosed with bipolar disorder and taking lithium calls the nurse with multiple complaints? "I've had bad diarrhea for 3 days." "I notice my hand trembling occasionally." "In the past 6 months, I have gained 8 pounds." "I have been putting a little extra salt on my food."

"I've had bad diarrhea for 3 days." Rationale Diarrhea makes this patient vulnerable to dehydration, which can result an increased concentration of lithium in the blood. This increased drug concentration can lead to lithium toxicity, a dangerous condition for which the nurse should monitor the patient. Fine tremors and weight gain are expected side effects associated with lithium therapy. The nurse should be sensitive to these concerns, but they are not a priority. Salt is important for patients who take lithium, so it is acceptable that the patient is putting a little extra salt on meals.

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: "I really doubt that one person can be blamed for all the bad things that happen." "Let's look at one bad thing that happened to see if another explanation exists." "You are being exceptionally hard on yourself when you say those things." "How does your belief in fate relate to your cultural heritage?"

"Let's look at one bad thing that happened to see if another explanation exists." Rationale: B. By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses are judgmental, irrelevant to an overgeneralization, and cast doubt without requiring the patient to evaluate the statement.

A depressed, socially withdrawn patient states, "There is no sense in trying. I am never able to do anything right!" Which response by the nurse will be helpful with this cognitive distortion? "Let's look at what you just said, that you can 'never do anything right.'" "Tell me what things you think you are not able to do correctly." "Is this part of the reason you think no one likes you?" "That is the most unrealistic thing I have ever heard."

"Let's look at what you just said, that you can 'never do anything right.'" Rationale Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the patient's willingness to participate after suggesting that they look at what the patient just said. Asking the patient to tell the nurse what the patient cannot do correctly, asking the patient whether this is the reason others do not like them, and labeling the patient's statement as unrealistic are not helpful to the patient. pp. 201-202

Which statement by the nurse indicates a need for education when a patient reports fear that "people are trying to poison me "? "Have other members of your family ever experienced this kind of thing?" "Tell me more about how someone keeps trying to poison your food. "How has this affected your ability to keep a job or care for yourself?" "Let's discuss the stressors you have in your life right now."

"Tell me more about how someone keeps trying to poison your food. Rationale It is nontherapeutic to reinforce the delusion by encouraging the individual to focus on the details, as suggested by asking the patient how his or her food is being poisoned. The statements "Have other members of your family ever experienced this kind of thing?", "How has this affected your ability to keep a job or care for yourself?", and "Let's discuss the stressors you have in your life right now" do not reinforce the delusion. Rather, they help gain knowledge about the history of the disorder in the family, the extent of the dysfunction the fear is causing, and the triggers that may have resulted in this behavior.

Which priority question would the nurse ask when assessing a patient who is experiencing command auditory hallucinations? "What are the voices telling you to do?" "What makes the hallucinations better?" "How long have you had the hallucinations?" "Are you having any other types of hallucinations?"

"What are the voices telling you to do?" Rationale Command auditory hallucinations are voices telling a patient to do something. These voices are usually distressing to the point that the patient feels compelled to do whatever act the voices are telling him or her to do. The priority question is to ask what the voices are telling the patient to do as they can be instructing the patient to cause harm to himself or herself or to someone else. Asking the patient what helps decrease the hallucinations, how long he or she has been experiencing the hallucinations, and if he or she has had other types of hallucinations are all important assessment questions, but asking about the command would be the priority question to maintain patient safety. pp. 261-262

A nurse assessing a patient with suspected delirium will expect to find that the patient's symptoms developed: A. Over a period of hours to days B. Over a period of weeks to months C. With no relationship to another condition D. During middle age

*A. Over a period of hours to days

Of the following outcomes, which one is most appropriate for a patient with cognitive impairment related to delirium? The patient will: A. Participate fully in self-care from admission on. B. Have stable vital signs 6 hours after admission. C. Participate in simple activities that bring enjoyment. D. Return to the premorbid level of functioning.

. Return to the premorbid level of functioning.

Which serum concentration of lithium would indicate to the nurse that the patient with mania who has persistent gastrointestinal upset has advanced signs of lithium toxicity? 0.5 mEq/L 1.8 mEq/L 2.5 mEq/L 3.4 mEq/L

1.8 Rationale Serum levels of more than 1.8 mEq/L can cause advanced signs of toxicity such as gastrointestinal upset, mental confusion, lack of coordination, and sedation. A serum level of 0.5 mEq/L indicates the therapeutic level of lithium. Serum levels of 2.5 and 3.4 mEq/L indicates severe toxicity. The symptoms of severe toxicity include oliguria, convulsions, severe hypotension, and death.

hen you hear the 3-11 shift report, you learn that one of your patients was aggressive during a manic phase and restrained (wrists and ankles) in the seclusion room. Which nursing action is your top priority? A.Offer fluids, a snack, and toileting. B.Wake your patient, and assess vital signs. C.Check each extremity for circulation. D.Check the electronic medication administration record (e-MAR) for recently administered scheduled and as-needed medications. E.Assess mental status.

1.B. Wake your patient, and assess vital signs. 2.C. Check each extremity for circulation. 3.E. Assess mental status. 4.D. Check the electronic medication administration record (e-MAR) for recently administered scheduled and as-needed medications. 5.A. Offer fluids, a snack, and toileting.

A patient has committed suicide while under team care in your facility. A coworker says, "Why are we being called to a 'postmortem' meeting? We didn't do anything wrong." Which is your best explanation? There is almost always litigation after an inhouse suicide, and it only makes sense that someone must be held responsible. Staff are at high-risk for hurting themselves after a suicide. It's important that the entire team collaborate to make documentation say the right things. A postmortem assessment can help the team determine any changes that might be made in agency protocol to improve safety.

A postmortem assessment can help the team determine any changes that might be made in agency protocol to improve safety.

Which term would the nurse document when a patient diagnosed with Alzheimer's disease looks confused when the phone rings and cannot recall many common household objects by name? Apraxia Agnosia Aphasia Anhedonia

Agnosia Rationale Agnosia is loss of the ability to recognize familiar objects. Apraxia is the loss of purposeful movement. Aphasia is the loss of language ability. Anhedonia is the inability to feel pleasure. p. 290

Psychobiological agents showing promise for the treatment of cognitive impairment associated with AD include: A.Cholinesterase inhibitors B.Herbals, including ginkgo biloba C.SSRIs and trazodone D.Benzodiazepines and buspirone

A.Cholinesterase inhibitors

Nursing staff that care for patients who are cognitively impaired can develop burnout. Strategies to avoid the development of burnout include: A.Setting realistic patient goals B.Insulating self from emotional involvement with patients. C.Sedating patients to promote rest and minimize catastrophic episodes. D.Encouraging the family to permit the use of restraints to promote patient safety.

A.Setting realistic patient goals

A nurse managing the care of a patient diagnosed with an eating disorder has begun to experience frustration when the patient consistently pushes back against the planned interventions. Which action is indicated to help strengthen the nurse-patient relationship? Demonstrate a very matter-of-fact attitude when addressing issues related to interventions. Acknowledge to the patient that working toward these treatment goals must be frightening. Regularly share feelings with peers and ask for their suggestions on minimizing the frustration. Ask that a more experienced nurse be allowed to act as monitor in order to identify any existing countertransference.

Acknowledge to the patient that working toward these treatment goals must be frightening. Rationale In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism or assume a parental role in the relationship. Frequent acknowledgment of the situation for the patient and of the constant struggle that so characterizes the treatment will help during times of extreme resistance. Being supervised by a competent, supportive, more experienced clinician and sharing with peers help minimize feelings of frustration and can contribute to therapeutic growth in the nurse.

Which medical complication may present in a patient diagnosed with anorexia nervosa? Select all that apply. One, some, or all responses may be correct. Acrocyanosis Severe abdominal pain Decreased bone density Reduced chewing ability Elevated blood carotene

Acrocyanosis, Decreased bone density, Elevated blood Carotene Rationale Acrocyanosis, or blue coloration of extremities, can be seen in a patient diagnosed with anorexia nervosa resulting from the presence of cool extremities caused by starvation. Decreased bone density also occurs because of low calcium intake caused by malnourishment and starvation. Carotenemia, or elevated levels of blood carotene, is seen as the patient restricts the diet to prevent weight gain. Patients diagnosed with bulimia nervosa may have severe abdominal pain resulting from gastric dilation caused by binge eating. Patients diagnosed with bulimia nervosa have reduced chewing ability because of dental cavities, which are caused by induced vomiting. p. 187

Which phase of schizophrenia is most likely when someone presents to ER with no food intake and sitting in a dark room for 3 days? Predromal Acute Stabilization Maintenance

Acute

A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the nursing milieu provide? (Select all that apply) Flexible mealtimes Unscheduled weight checks Adherence to a selected menu Observation during and after meals Monitoring during bathroom trips Privileges correlated with emotional expression

Adherence to a selected menu Observation during and after meals Monitoring during bathroom trips Rationale: C, D, E. Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patient's eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

Which advice is appropriate to provide to the family of a patient diagnosed with depression who is prescribed a tricyclic antidepressant medication? Do not give full dose to the patient at bedtime. Double the dose if the patient forgets to take the bedtime dose. Advise the patient to be cautious while driving. Stop the medication if hypotension occurs.

Advise the patient to be cautious while driving. Rationale Tricyclic antidepressants (TCAs) cause side effects such as drowsiness or dizziness. The patient must be advised to be cautious while crossing the road, driving, or working with machines. The patient must take a full dose at bedtime so that the side effects are less during the day. If the patient forgets to take the dose, the next dose should be taken at the scheduled time. A double dose should be avoided. The medication should not be stopped if there is reduction in blood pressure because medication cessation can cause nausea, altered heartbeat, cold sweats, and nightmares. p. 219

The nurse would document which term when a patient diagnosed with Alzheimer's disease picks up his or her glasses from the bedside table but does not recognize what they are or their purpose? Apraxia Agnosia Aphasia Agraphia

Agnosia Rationale Agnosia is the loss of sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.

What is your best intervention when you assess that a patient is responding to an auditory hallucination? Ask the patient, "Can you tell me what you are hearing?" check Ask the patient, "Are you afraid of the voice you are hearing?" Tell the patient, "Try to ignore the voices you hear." Tell the patient, "The voices you hear are not real."

Answer A Explanation *A. Knowing what the patient is hearing is important. A command hallucination could result in injury to self or others. For example, the voice may be telling the patient to self-mutilate. B. Whether or not the patient is fearful is important to know, but not a priority. C. A patient has no control over hallucinations. D. It is appropriate to state, "I believe the voices you are hearing are real, but I do not hear them." This presents reality and does not take priority over knowing the content of the hallucination.

Mrs. Chauncey, 80 years of age, complains of stomach pain and is now mute and staring out of her window. She is refusing food. Which of the following interventions are appropriate? (Select all that apply.) A.Give her privacy, and close her door. B.Speak with her, although she may not answer. C.Continue to offer her food and fluids. D.Regularly assess vital signs and skin turgor

Answer BCD Rationales A.Isolating Mrs. Chauncey is inappropriate. You need to be aware that older adults may experience increased depression while hospitalized. Although frail, Mrs. Chauncey may have energy to harm herself, even superficially. B.Sitting with Mrs. Chauncey and speaking to her lets her know you are available. C.You are legally and ethically responsible to offer patients regular food and fluids whether they accept them or not. D.Vital signs are an important regular assessment, as well as skin turgor assessment. The older adult who is depressed is at risk for dehydration and possible hypotension.

Mrs. Chauncey, 80 years old, is taking a selective serotonin reuptake inhibitor (SSRI) and Tylenol PM daily plus other medications. She has multiple, vague somatic complaints. This morning she complains of a "stomach ache" and "gas." What is your best initial nursing response? A. Tell her to increase her water intake. B. Perform a digital rectal examination for impaction. C. Document the complaint of abdominal pain. D. Assess bowel sounds in all four quadrants.

Answer D Rationales A. An increase in water intake may be an excellent intervention for an older patient as long as no fluids are restricted and no swallowing problems are evident. B. A digital rectal examination without further assessment is inappropriate and can be traumatic for the patient. C. Documenting a patient's complaint is appropriate as long as the intervention and evaluation are also completed and documented. D.Assessing bowel sounds is the best initial response. Older adults are at risk for constipation, and some medications can cause constipation. Mrs. Chauncey is taking an SSRI and Tylenol PM, which contains diphenhydramine.

Mr. Quang is dancing under the overhead television of the crisis stabilization unit and taunting the other patients in the room. He shouts, "I own the TV networks, so they have to do what I say!" As Mr. Quang's nurse, what is your best initial intervention at this time? A.Leave him alone, and remove the other patients. B.Tell Mr. Quang that he has to obey the rules, or he will be restrained. C.Medicate Mr. Quang with an anxiolytic agent, and place him in seclusion. D.Calmly motion for Mr. Quang to come with you to the dining room for a snack.

Answer D Rationales A. Leaving the patient alone is not safe, and other patients need to know that their rights and well-being are also important. B. Threatening a patient with restraints is not appropriate. C. Although Mr. Quang may need both an as-needed medication and seclusion, these are not the best initial responses. *D. Distraction is the best initial intervention. Accompanying the patient to a place away from the other patients is appropriate.

Mrs. Chauncey receives a visit from her priest. He runs out of her room and then pulls the nurse assistant back into her room. Mrs. Chauncey is cutting her left wrist (superficially) with the 5 x 7 glass from a framed photo of a grandchild. She is taken to the emergency department, where her wrist is bandaged. Her daughter and son-in-law are notified. As her nurse, which of the following statements help clarify what has taken place? A."Don't worry, I think your mom is just confused." B."Your mom has been more withdrawn over the last few days." C. "I am very concerned that your mom is suicidal." D. "When your mom's priest arrived, he found her cutting her wrist with the glass from a framed photo."

Answer D A.This statement offers false reassurance. B.Although true, this statement does not give the family a clear picture of the events. C.You may suspect suicidal ideation, but until Mrs. Chauncey is further assessed, you should not state your suspicions. D. This statement is a clear representation of what has actually happened. Once the family members understand this, then dialog related to care options can begin.

Which information is accurate for patients diagnosed with bulimia nervosa? Select all that apply. One, some, or all responses may be correct. Are often at or slightly below their ideal body weight Have a history of impulsivity and instability Are at low risk for suicidal ideation May or may not exhibit purging behaviors Commonly require surgery for gastric rupture

Are often at or slightly below their ideal body weight Have a history of impulsivity and instability May or may not exhibit purging behaviors Rationale Patients with bulimia nervosa are often at or slightly below their ideal body weight, often have a history of impulsivity and instability, and may or may not exhibit purging behaviors. They are at high risk for suicidal ideation. Gastric rupture is rare.

Which nursing action is the priority when a patient diagnosed with schizophrenia says, "I hear the voices every day. They always say bad things about me "? Assessing for suicidal thinking and plans Reviewing medication regime and compliance Educating regarding symptoms associated with schizophrenia Suggesting distracters to use when auditory hallucinations occur

Assessing for suicidal thinking and plans Rationale Auditory hallucinations can be dangerous for patients, particularly if they develop into command hallucinations; therefore, the nurse should assess the patient for suicidal thinking and plans before anything else. The nurse should ultimately review the patient's medication regime and compliance, educate the patient about symptoms associated with schizophrenia, and suggest distractors for the patient to use when auditory hallucinations occur, but each of these actions should come after an initial assessment for suicidal thinking and plans

Which action would the nurse perform when a patient with schizophrenia reports persistent feelings of restlessness and says, "I feel like I need to move all the time "? Adding an activity group to the patient's plan of care Performing a full mental status evaluation of the patient Assessing the patient for other extrapyramidal symptoms Educating the patient about psychomotor agitation associated with schizophrenia

Assessing the patient for other extrapyramidal symptoms Rationale The nurse should assess the patient for other extrapyramidal symptoms. Restlessness (akathisia) is a common extrapyramidal symptom. Adding activity to the patient's plan of care could benefit the patient but will not address the potential extrapyramidal symptoms, so this action can come later. Performing a full mental status evaluation of the patient is not necessary because the patient has been diagnosed with schizophrenia and is already discussing specific issues that the nurse can directly evaluate. Educating the patient about psychomotor agitation is not relevant to the patient's feelings of restlessness because this is typically an issue for people experiencing catatonia

Nurse jones assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms is considered a positive symptom?

Auditory hallucinations and delusions

Which sign or symptom is commonly associated with a diagnosis of bulimia nervosa? Select all that apply. One, some, or all responses may be correct. Helplessness Binge eating Disturbed self-concept Impulsive stealing Weight associated with self-worth

Binge eating, disturbed self concept, Impulsive stealing Rationale Binge eating, a disturbed self-concept, and impulsive stealing are all commonly associated with bulimia nervosa. Controlling feelings of helplessness by restricting food intake and associating self-worth with weight are more commonly associated with anorexia nervosa. p. 186

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "Monitor for complications of refeeding." Which body system should a nurse closely monitor for dysfunction? Renal Endocrine Central nervous Cardiovascular

Cardiovascular Rationale: D. Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

Which kind of medication would the family of a patient with Alzheimer's disease need education about? Antihypertensives Benzodiazepines Immunosuppressants Cholinesterase inhibitors

Cholinesterase inhibitors Rationale Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Cholinesterase inhibitors prevent the action of the chemical that destroys acetylcholine, thus leaving more available acetylcholine. Antihypertensives, benzodiazepines, and immunosuppressants are not medications targeted for Alzheimer's disease. p. 296

Which information should be provided about a prescription for fluoxetine to a patient with late luteal phase dysphoric disorder? Stop the medication immediately if the side effects are severe. Consult the health care provider if there is loss of libido. Take acetaminophen if there is fever. It may cause dry mouth and blurred vision.

Consult HCP if loss of libido Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), which is a class of drug known for having low side effects. The patient should be advised to consult the primary health care provider about any side effects, such as loss of libido or sexual dysfunction. Stopping the drug abruptly may cause serotonin withdrawal, so the patient should be advised not to stop the drug without first consulting the health care provider. Acetaminophen or any other over-the-counter drugs should not be taken without consulting the primary health care provider because of possible drug interactions. SSRIs do not cause dry mouth or low vision as some older

Which symptom is the patient experiencing when observing the nurse speaking with family members and believes they are plotting against the patient? Projection Disorganized thinking Paranoia Delusional jealousy

Paranoia Rationale The patient is experiencing paranoia, an intense and strongly defended irrational suspicion. Projection is the most common defense mechanism used by people with paranoia. Disorganized thinking reflects the degree to which disorganized speech, disorganized behavior, or inappropriate affect is present. Delusional jealousy occurs with the false belief that one's mate is unfaithful.

82-year-old Mr. Robeson together with his daughter arrived at the medical-surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis? A. "Maybe it's just caused by aging. This usually happens by age 82." B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast." D. "Dad has always been so independent. He's lived alone for years since mom died."

Correct Answer: B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." Delirium is an acute process characterized by abrupt, spontaneous cognitive dysfunction. Delirium, also known as the acute confusional state, is a clinical syndrome that usually develops in the elderly. It is characterized by an alteration of consciousness and cognition with reduced ability to focus, sustain, or shift attention. It develops over a short period and fluctuates during the day.

Which ability should Nurse Rebecca expect from a client in the mild stage of dementia of the Alzheimer's type? A. Remembering the daily schedule B. Recalling past event C. Coping the anxiety D. Solving problems of daily living

Correct Answer: B. Recalling past events Recent memory loss is the characteristic sign of cognitive difficulty in early Alzheimer's disease. The ability to recall past events is usually retained until the later stages of this disorder. Symptoms of Alzheimer's disease depend on the stage of the disease. Alzheimer's disease is classified into preclinical or presymptomatic, mild, and dementia-stage depending on the degree of cognitive impairment. These stages are different from the DSM-5 classification of Alzheimer's disease. The initial and most common presenting symptom is episodic short-term memory loss with relative sparing of long-term memory and can be elicited in most patients even when not the presenting symptom.

8. Which goal is a priority for a client with a diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture? A. The client will complete activities of daily living. B. The client will maintain safety. C. The client will remain oriented. D. The client will understand communication.

Correct Answer: B. The client will maintain safety. Maintaining safety is the priority goal for an acutely confused client who recently had surgery. All measures to promote physiologic safety and psychosocial wellbeing would be implemented. Remove all potentially dangerous objects from the client's environment; in a disoriented, confused state, clients may use objects to harm self or others. Have sufficient staff available to execute a physical confrontation, if necessary; assistance may be required from others to provide for the physical safety of the client or primary nurse, or both.

Nurse Isabelle enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date. month. and year are; and where the client is. The nurse is attempting to assess: A. Confabulation. B. Delirium. C. Orientation. D. Perseveration.

Correct Answer: C. Orientation. The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person). The tools for reality orientation aim to reinforce the naming of objects and people as well as a timeline of events, past or present. Multiple studies have demonstrated that the use of reality orientation has improved cognitive functioning for people living with dementia when compared to control groups who did not receive it. As a rule, reality orientation must be mixed with compassion and used appropriately to benefit someone living with the confusion of dementia. Applying it without evaluating if it might cause emotional distress to the individual since there are some times when it would not be appropriate.

7. Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A. Tell the client firmly that it is time to get dressed. B. Obtain assistance to restrain the client for safety. C. Remain calm and talk quietly to the client. D. Call the doctor and request an order for sedation.

Correct Answer: C. Remain calm and talk quietly to the client. Maintaining a calm approach when intervening with an agitated client is extremely important. Use a rather low voice and speak slowly to patients to increase the possibility of understanding. Divert attention of the client when agitated or behaving dangerously like getting out of bed by climbing the fence bed to promote safety and prevent risk of injury.

Which of the following is not included in the care of plan of a client with a moderate cognitive impairment involving dementia of the Alzheimer's type? A. Daily structured schedule B. Positive reinforcement for performing activities of daily living C. Stimulating environment D. Use of validation techniques

Correct Answer: C. Stimulating environment. A stimulating environment is a source of confusion and anxiety for a client with a moderate level of impairment and, therefore, would not be included in the plan of care. Limit sensory stimuli and independent decision-making. This decreases frustration and distractions from the environment. Decreasing stress of making a choice helps to promote security. Instruct the family to utilize distraction techniques, such as soothing music, going for a walk, or looking at picture albums if the patient has delusions. Distraction may be effective to calm the patient if stressful situations occur.

Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: A. Denies confusion by being jovial. B. Pretends to be someone else. C. Rationalizes various behaviors. D. Fills in memory gaps with fantasy.

Correct Answer: D. Fills in memory gaps with fantasy. Confabulation is a communication device used by patients with dementia to compensate for memory gaps. Confabulation is a type of memory error in which gaps in a person's memory are unconsciously filled with fabricated, misinterpreted, or distorted information. When someone confabulates, they are confusing things they have imagined with real memories. A person who is confabulating is not lying. They are not making a conscious or intentional attempt to deceive. Rather, they are confident in the truth of their memories even when confronted with contradictory evidence.

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition? A. Memory loss occurring as part of the natural consequence of aging B. Difficulty coping with physical and psychological change C. Severe cognitive impairment that occurs rapidly D. Loss of cognitive abilities. impairing ability to perform activities of daily living

Correct Answer: D. Loss of cognitive abilities, impairing ability to perform activities of daily living. The impaired ability to perform self-care is an important measure of a client's dementia progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal activities of daily living, such as maintaining hygiene and grooming, toileting, making meals, and maintaining a household, are significant indications of dementia. Slowing of processes necessary for information retrieval is a normal consequence of aging. However, the global statement that memory loss occurs as part of natural aging is not true.

Which of the following will Nurse Dory use when communicating with a client who has cognitive impairment? A. Complete explanations with multiple details B. Pictures or gestures instead of words C. Stimulating words and phrases to capture the client's attention D. Short words and simple sentences

Correct Answer: D. Short words and simple sentences. Short words and simple sentences minimize client confusion and enhance communication. Assess the patient's ability to speak, language deficit, cognitive or sensory impairment, presence of aphasia, dysarthria, aphonia, dyslalia, or apraxia. Presence of psychosis, and/or other neurologic disorders affecting speech. This identifies problem areas and speech patterns to help establish a plan of care.

Which statement describes the likely cause of a postoperative older adult patient at a well-maintained health care facility being terrified and reporting seeing "giant spiders crawling over the bedclothes"? Giant spiders are actually present. Delirium is causing visual hallucinations. The patient is disoriented and wants to go home. The patient is misinterpreting the folds in the bedclothes.

Delirium is causing visual hallucinations Rationale Delirious hospitalized patients, especially older adults, very commonly have visual hallucinations. Such patients may experience false sensory stimuli and see something such as giant spiders crawling over the bedclothes. Insects are highly unlikely to be found in a well-maintained health care facility. Delirious patients can also become disoriented and want to "go home." They may have errors in perception of sensory stimuli and may mistake folds in the bedclothes for spiders. p. 282

Which clinical manifestation is identified as a symptom of anorexia nervosa? Select all that apply. One, some, or all responses may be correct. Emaciation Russell's sign Dehydration Yellow skin Hyperkalemia

Emaciation, yellow skin, dehydration Anorexia nervosa is an eating disorder in which the patient has intense fear of weight gain and refuses to maintain optimal weight. Because of malnourishment and starvation, the patient is emaciated and dehydrated. The skin is yellow as a result of elevated carotene levels in the blood. Patients with bulimia nervosa have Russell's sign, or calluses and scars on the hand caused by self-induced vomiting; this is not typically associated with anorexia nervosa. Hypokalemia, as opposed to hyperkalemia, is present in patients with anorexia nervosa because of dehydration.

Which nursing intervention would the nurse implement during a suicidal patient's crisis period? Arranging for the patient to stay with family or friends Establishing frequent rapport with the patient Activating links to community social support Identifying situations that trigger suicidal thoughts

Establishing frequent rapport with the patient Rationale Establishing frequent rapport with the patient is a nursing intervention appropriate during the patient's crisis period. Arranging for the patient to stay with family or friends and activating links to community social support are more appropriate immediately following the crisis period. Identifying situations that trigger suicidal thoughts can be done during follow-up.

Which behavior is characteristic of the manic phase of bipolar disorder? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected Excessive energy Fatigue and increased sleep Low self-esteem Pressured speech Purposeless movement Racing thoughts

Excessive energy, pressured speech, purposeless movement, and racing thoughts. Rationale Excessive energy, pressured speech, purposeless movement, and racing thoughts are typical of mania. Fatigue and increased sleep and low self-esteem are more characteristic of depression. pp. 228, 230

Peter is diagnosed as having disorganized schizophrenia. Which behaviors would the nurse most likely assess in the client?

Extreme social withdrawal, odd mannerisms and behaviors

Which subjective symptom would be expected to be noted during assessment of a patient diagnosed with anorexia nervosa? Lanugo Hypotension 25-pound weight loss Fear of gaining weight

Fear of gaining weight Rationale Fear of gaining weight is the only subjective datum listed, and it is universally true. Lanugo, hypotension, and a 25-pound weight loss are objective data.

Which entree can the patient prescribed a monoamine oxidase inhibitor (MAOI) safely eat? Avocado salad plate Fruit and cottage cheese plate Kielbasa and sauerkraut Liver and onion sandwich

Fruit and cottage cheese plate Rationale MAOIs inhibit the breakdown of tyramine, which can lead to high blood pressure, hypertensive crisis, and eventually a cerebrovascular accident. Fruit and cottage cheese do not contain tyramine. Avocados, fermented food such as sauerkraut, processed meat, and organ meat contain tyramine.

Which behavior by a patient with Alzheimer's disease (AD) would the nurse identify as a sign of agnosia? Babbles and speaks incoherently when asked any question Cannot recall what was served for breakfast an hour ago Has difficulty identifying familiar sounds like the ring of the phone Talks about his or her role in convincing the president to pass a particular law

Has difficulty identifying familiar sounds like the ring of the phone Rationale When the patient is unable to identify the ring of a phone, there is loss of sensory ability to recognize familiar sounds. The nurse recognizes this as a feature of auditory agnosia. If the patient babbles and speaks incoherently, there is loss of language ability. The nurse identifies this as a sign of aphasia. In AD, there is gradual deterioration of recent and remote memory. A patient who is unable to recall what was served for breakfast an hour ago is showing signs of impairment of recent memory. Patients with AD often confabulate in an unconscious attempt to maintain self esteem. An example of confabulation would be talking about how the president's decision was directly influenced by the patient. p. 290

Which Symptom experienced by a client diagnosed with schizophrenia would predict a less positive prognosis?

Hearing Hostile voices talking about violence

A patient reveals self-induced vomiting as often as a dozen times a day. Which assessment finding is expected? Tachycardia Hypokalemia Hypercalcemia Hypolipidemia

Hypokalemia Vomiting causes loss of potassium, leading to hypokalemia. Tachycardia, hypercalcemia, and hypolipidemia are not associated with vomiting.

Which term is used to describe when a 72-year-old patient hospitalized with pneumonia is experiencing delirium and points to the intravenous (IV) pole screaming, "Get him out of here! He's going to hurt me!"? Hallucination Delusion Illusion Confabulation

Illusion Rationale Illusions are errors in perception of sensory stimuli. The stimulus is a real object in the environment that is misinterpreted and often becomes the object of the projected fear. Hallucinations are false sensory stimuli. For example, individuals experiencing delirium may become terrified when they "see" giant spiders crawling over the bedclothes or "feel" bugs crawling on or under their bodies. A delusion is described as thinking or believing something that is not true and is seen more often in schizophrenia. For example, a patient may firmly believe that government agencies can read and are monitoring his or her thoughts or that neighbors can see him or her through walls. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem. p. 281

The nurse understands that second-generation antipsychotics (SGAs)/atypical agents may cause which side effect? HIV Obesity Depressive symptoms Tobacco use

Obesity Rationale Obesity is significantly higher in schizophrenia caused in large part by side effects from antipsychotic medications, particularly SGAs/atypical agents. HIV, depressive symptoms, and tobacco use do not occur as a result of SGAs/atypical agents.

A patient was admitted to an intensive care unit after reporting chest pain, an elevated heart rate, and a very high body temperature. The patient's family reported that the patient was taking antidepressants and started having chest pain after eating avocados and cheese. Which antidepressant medication was the patient likely taking that would have caused this interaction? Isocarboxazid Desipramine Trazodone Duloxetine

Isocarboxazid Rationale Some foods, such as cheese, are rich sources of tyramine, which increases the production of serotonin in the body. Patients who are taking isocarboxazid, which is a monoamine oxidase inhibitor (MAOI), should avoid eating foods rich in tyramine because this substance can interact with MAOI drugs and cause adverse effects, such as hypertensive crisis and pyrexia (high body temperature). These reactions are seen within a few hours after consuming the contraindicated foods. The symptoms of hypertensive crisis are chest pain and increased or reduced heart rate. Desipramine is a tricyclic antidepressant and does not cause hypertensive crisis. Trazodone is a serotonin antagonist and reuptake inhibitor (SSRI), and its side effects are sedation and nausea. Hypertensive crisis is not a side effect associated with SSRI. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI); its side effects are nausea, headache, and dry mouth.

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which condition should be documented? Amenorrhea Alopecia Lanugo Stupor

Lanugo Rationale: C. The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

Which situation identifies how assessment findings differ for a patient diagnosed with bulimia compared to a patient diagnosed with anorexia nervosa? Maintaining a normal weight Purging to keep weight down Holding a distorted body image Performing more rigorous exercising

Maintaining a normal weight Rationale Many patients diagnosed with bulimia are at or near normal weight, whereas those diagnosed with anorexia nervosa are underweight. Patients with either disorder may engage in purging, distorted body image, or excessive exercise. pp. 186, 192

A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective approach to communication. Make observations. Ask the patient direct questions. Phrase questions to require "yes" or "no" answers. Frequently reassure the patient to reduce guilt feelings.

Make observations. Rationale: A. Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness.

A patient is taking Nardil and needs to prevent hypertensive crisis. A nurse teaching a patient about a tyramine-restricted diet would approve which meal? Mashed potatoes, ground beef patty, corn, green beans, apple pie Avocado salad, ham, creamed potatoes, asparagus, chocolate cake Macaroni and cheese, hot dogs, banana bread, caffeinated coffee Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

Mashed potatoes, ground beef patty, corn, green beans, apple pie Rationale: A. The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

Statistically speaking, which two patients do you predict are at greatest risk for suicide? Ms. R, a 22-year-old grad student who is engaged Mr. M, a 34-year-old male with multiple sclerosis Mr. A, a 68-year-old Vietnam veteran with TBI Ms. G, a 25-year-old single Navajo mother who struggles with alcohol

Mr. A, a 68-year-old Vietnam veteran with TBI Ms. G, a 25-year-old single Navajo mother who struggles with alcohol explanation though every patient who presents with possible suicidal ideation should be assessed equally, there may be additional risks for (a) veterans, especially with TBI (special risks); (b) older men (4 times as likely); (c) young American Indian adults (2.5 times more likely than their peers); and (d) those with mood disorders, (50%) and those who abuse alcohol (25%).

Which analysis and action would the nurse take when, after 3 days of a new medication regimen of haloperidol, a patient is drooling, has stiff and extended extremities, has moist hot skin, and has difficulty responding verbally A seizure is occurring; place the patient in a lateral recumbent position and monitor. Serotonin syndrome has developed; place an intravenous line, and rapidly infuse D5 ½ NS. Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit. An acute dystonic reaction is occurring; promptly administer an intramuscular injection of diphenhydramine.

Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit. Rationale The patient's symptoms of severe muscle rigidity, dysphasia, and an elevated temperature indicate neuroleptic malignant syndrome, which can occur within the first week of antipsychotic drug therapy. The patient is not demonstrating the symptoms of a seizure. Serotonin syndrome is not likely to be caused by haloperidol, and the patient's symptoms do not suggest the syndrome is occurring. Because the patient is not experiencing acute spasms of the tongue, jaw, face, neck, or back, he or she is not demonstrating an acute dystonic reaction.

A patient presents in the emergency department with 96.0° F (35.5° C) 2 body temperature, body mass index (BMI) of 16 kg/m , and heart rate of 37 beats per minute. Which action would the nurse take first? Order a psychiatric assessment. Order parenteral nutrition. Prepare the patient for inpatient hospitalization. Educate the patient about the ill effects of low weight.

Prepare the patient for inpatient hospitalization. Rationale This patient's physiological assessment meets the physical criteria for hospital admission. The nurse should admit the patient before ordering psychiatric assessment, ordering parenteral nutrition, or educating the patient. pp. 187, 189

Which nursing concern is the priority for a 75-year-old hospitalized patient with sudden-onset confusion and disorientation who wanders and is agitated? Preventing injury Managing confusion Orienting the patient to reality Assisting with activities of daily living (ADLs)

Preventing injury Rationale Risk for injury is the nurse's priority; managing confusion, orienting the patient to reality, and assisting with ADLs are also important but are not the highest concern in this scenario.

While weighing patients on an eating disorders unit, a psychiatric technician states to the patient, "I wish I had an eating disorder; maybe I'd lose a little weight." A nurse overhears the comment. Which action is appropriate for the nurse to implement? Report the incident to the nursing supervisor. Ask the psychiatric technician, "What did you mean by that comment?" Privately discuss the importance of sensitivity with the psychiatric technician. Immediately interrupt the interaction between the patient and psychiatric technician.

Privately discuss the importance of sensitivity with the psychiatric technician. Rationale It may be difficult for those working with patients diagnosed with eating disorders to understand that the disorder is not a lifestyle choice in the patient's control. All who care for the patient should keep in mind the goals of motivating the patient to be healthier and gain weight. Comments like this one reinforce the patient's unhealthy behavior. Discussing the importance of sensitivity will help the technician avoid making such comments in the future. Reporting the observation is not necessary if the technician is receptive to the nurse's guidance. What the technician means is irrelevant and therefore asking the technician what they mean is unnecessary; what matters is that it is an inappropriate comment to make to the patient. Immediately interrupting the interaction is inappropriate because of the presence of the patient.

Which term does the nurse document when a patient experiences four or more mood episodes in a 12-month period? Dyssynchronous Incongruent Cyclothymic Rapid cycling

Rapid Cycling Rationale Rapid cycling implies four or more mood episodes in a 12-month period, as well as more severe symptomatology. Dyssynchronous is not a term used to describe mood episodes. Incongruent is a term used to describe reactions or behaviors that are not consistent with a person's current mood or circumstances. Cyclothymic disorder presents with hypomanic episodes alternating with persistent depressive episodes.

Which behavior of the nurse is most appropriate when caring for a patient experiencing acute mania? Judging the values of the patient as incorrect Giving long, detailed explanations to the patient Using a soft and gentle approach with the patient Redirecting the patient's energy into alternate channels

Redirecting the patient's energy into alternate channels The best way for the nurse to manage a patient experiencing acute mania is to firmly redirect the patient's energy into more constructive channels. This intervention helps the patient utilize the elevated energy levels associated with acute mania for useful activities. The nurse should avoid judging the patient's values because this could provoke the patient to argue and may exaggerate the mania. In acute mania, the patient has a short attention span; therefore, the nurse should give short and precise explanations. The nurse should use a firm and calm approach when interacting with a patient experiencing acute mania.

Which goal is appropriate for all patients diagnosed with an eating disorder? Select all that apply. One, some, or all responses may be correct. Restore nutritional state. Achieve a body mass index (BMI) of at least 17 kg/m .2 Establish a minimum daily caloric intake. Modify disordered eating behaviors. Help change distorted beliefs about body image. Engage the patient in long-term group therapy.

Restore nutritional state. Modify disordered eating behaviors. Help change distorted beliefs about body image. Rationale The three main goals for all eating disorders are to restore the patient's nutritional state, modify the patient's disordered eating behaviors, and help change distorted beliefs about body image. Achieving a specific BMI and daily caloric intake and engaging the patient in long-term group therapy may not be appropriate for every patient. p. 189

In caring for a patient with late AD, which nursing diagnosis demands the nurse's highest priority? A.Risk for injury B.Self-care deficit C.Chronic low self-esteem D.Impaired verbal communication

Risk For injury The patient is bed bound; therefore a risk for falls is not so great. A risk for decubiti exists, but this is addressed as a need related to self-care deficit.

A patient states, "No matter what I do, I feel like there's always a dark cloud following me." Which action is the priority? Assess current sleep and eating patterns. Explain to the patient, "Everyone feels down from time to time." Suggest alternative activities for times when the patient feels depressed. Say, "Tell me more about what you mean by 'a dark cloud.'"

Say, "Tell me more about what you mean by 'a dark cloud.'" Rationale Inviting the patient to elaborate on what he or she means by the "dark cloud" will help the nurse evaluate the patient's thought processes and feelings. This helps ensure that care remains patient centered. Assessing the patient's sleeping and eating patterns is appropriate during the course of treatment, but this can happen after the nurse gets more information about the patient's remark. Saying that everyone feels down is a platitude that minimizes the patient's feelings. Suggesting alternate activities also does not address what the patient has shared; the nurse should elicit more information before making recommendations.

A patient's employment is terminated and major depressive disorder develops shortly afterward. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies? Powerlessness Defensive coping Situational low self-esteem Disturbed personal identity

Situational low self-esteem Rationale: C. The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to justify the other diagnoses.

A patient who is more forgetful and has difficulty performing familiar tasks such as bathing and dressing is in which stage of Alzheimer's disease? Stage 1, mild Stage 2, moderate Stage 3, moderate-severe Stage 4, end

Stage 3, moderate-severe Moderate-severe Alzheimer's disease is marked by ambulatory dementia and requires a high level of supervision. Wandering and inability to meet self-care needs become problematic. Stage 1 is marked by short-term memory loss. Stage 2 is marked by increasing confusion. Stage 4 is marked by immobility and the inability to recognize family and self

Which phrase describes the likely cause of a patient with delirium striking out at a staff member? Physical illness State of fear Unmet physical need Need for social interaction

State of fear Rationale Patients with delirium often misinterpret reality, perceiving threat where none actually exists. Patients diagnosed with delirium who are fearful may strike out at others, seemingly without provocation. Physical illness, an unmet physical need, or a need for social interaction generally are not associated with such aggressive behavior.

A patient states, "I had my first depression after I got divorced about 10 years ago. I recognized what was happening to me because both of my parents suffer from depression." Which theory regarding the etiology of depression has the patient described? Cognitive theory Biochemical factors Learned helplessness Stress-diathesis model

Stress-diathesis model Rationale The stress-diathesis model of depression takes into account the interplay between genetic and biological predisposition toward depression and life events. The physiological vulnerabilities, such as genetic predispositions, biochemical makeup, and personality structure, are referred to as a diathesis. The stress part of this model refers to the life events that impact individual vulnerabilities. Cognitive theory recognizes the role of early life experiences in the development of depression. Biochemical factors include genetic and biological variables in the etiology of depression. Learned helplessness refers to a theory about depression replacing anxiety.

Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization? Urine output: 40 ml/hr Pulse rate: 58 beats/min Serum potassium: 3.4 mEq/L Systolic blood pressure: 62 mm Hg

Systolic blood pressure: 62 mm Hg Rationale: D.Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

Which side effect of antipsychotic medication therapy is generally not reversible? Anticholinergic effects Pseudoparkinsonism Dystonic reaction Tardive dyskinesia

Tardive dyskinesia Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. Anticholinergic effects, pseudoparkinsonism, and dystonic reaction are side effects that often appear early in therapy and can generally be minimized with appropriate treatment.

Based on knowledge of early- and late-onset schizophrenia, which statement is true regarding a male twin who was diagnosed at 23 years of age and the female twin who was diagnosed at 31 years of age? The male and female twins have the same expectation of a poor long-term prognosis. The female twin will experience more positive signs of schizophrenia. The male twin will be more likely to hold a job and live a productive life. The female twin has a better chance for positive outcomes because of later onset

The female twin has a better chance for positive outcomes because of later onset Rationale Female patients diagnosed with schizophrenia between 25 and 35 years of age have more favorable outcomes than their male counterparts who are diagnosed earlier in life. These two patients do not have the same expectation of a poor prognosis. There is no evidence suggesting that the female twin will have more positive signs of schizophrenia. It is actually less likely that the male twin will be able to live a productive life because his earlier onset has a poorer prognosis. pp. 250, 252

Which information will be provided to a patient when preparing the patient for electroconvulsive therapy (ECT)? Maintenance treatments are seldom required. The initial course of therapy requires 6 to 12 treatments. This form of therapy is particularly successful for positive symptoms of schizophrenia. The initial therapy involves an ECT treatment repeated once a week for a prescribed time period.

The initial course of therapy requires 6 to 12 treatments. Rationale A usual course of ECT is 6 to 12 treatments. Maintenance ECT usually involves weekly treatments for the first month after remission, with gradual tapering to monthly ECT treatments. ECT is not typically used in the treatment of schizophrenia. Treatments are typically given two to three times per week.

Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? Weight, muscle, and fat are congruent with height, frame, age, and sex. Calorie intake is within the required parameters of the treatment plan. Weight reaches the established normal range for the patient. The patient expresses satisfaction with body appearance.

The patient expresses satisfaction with body appearance. Rationale: D. Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

Which outcome is desired for a patient with mania during the acute phase? The patient is free of injury. The patient is highly distractible. The patient ignores food and fluid. The patient reports racing thoughts.

The patient is free of injury. Rationale Risk for injury is a nursing diagnosis of high priority for patients with mania because of their hyperactivity. Remaining free of injury is a highly desirable outcome. Distractibility, ignoring foods and fluids, and racing thoughts are symptoms of unmanaged mania rather than outcomes of successful treatment.

A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, "I took a few extra tablets earlier in the day and now I feel bad." Which aspects of the nursing assessment are most critical? Vital signs Urinary frequency Increased suicidal ideation Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness

Vital Signs, Presence of abdominal pain and diarrhea, Hyperactivity or feelings of restlessness Rationale: A, D, E. The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected.

A patient who was referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient's oral intake, the nurse should ask: "Do you often feel fat?" "Who plans the family meals?" "What do you eat in a typical day?" "What do you think about your present weight?"

What do you eat in a typical day? Rationale: C. Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

Which action would the nurse take upon learning that a patient with mania has a serum lithium level of 1.8 mEq/L? Advise the patient to limit fluids for 12 hours. Continue to administer medication as prescribed. Advise the patient to reduce salt intake for 24 hours. Withhold medication, and notify the health care provider

Withhold medication, and notify the health care provider. Rationale The patient's lithium level has exceeded therapeutic limits. Additional doses of the medication should be withheld, and the health care provider should be notified. Thirst is a sign of lithium toxicity, and fluids should not be withheld. Administering the medication as prescribed could be dangerous. Low sodium intake can lead to lithium retention, so it is important for the patient to take in adequate salt.

A patient states, "I once enjoyed going to parks and museums with my family but that is not fun anymore." Which term would be used to document this statement? Anergia Euthymia Anhedonia Self-deprecation

anhedonia Rationale Anhedonia means that there is no pleasure or joy in life. It is a common finding with depression. Anergia refers to a lack of energy or physical passivity. Euthymia refers to a mood state that is normal and moderate, with neither depression nor mania. Self deprecation refers to negative statements about self.

A nurse is caring of a patient with major depressive disorder. A priority nursing intervention for a patient diagnosed with this is: distracting the patient from self-absorption. carefully and inconspicuously observing the patient around the clock. allowing the patient to spend long periods alone in self-reflection. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.

carefully and inconspicuously observing the patient around the clock. Rationale: B. Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: monitors sodium intake and weight daily. wears support stockings and elevates the legs when sitting. consults the pharmacist when selecting over-the-counter medications. can identify foods with high selenium content, which should be avoided.

consults the pharmacist when selecting over-the-counter medications. Rationale: C. Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

a 24 year old client is experiencing an acute episode of schizophrenia. he has vivid hallucinations that are making him agitated. the nurses best response would be to

explore the content of hallucinations.

Which medication is considered the first-line drug used to treat mania? Lithium Carbamazepine Lamotrigine Clonazepam

lithium Rationale Lithium, a mood stabilizer, is the first-line drug used in treating bipolar disorder. Carbamazepine and lamotrigine are anticonvulsant drugs that may be prescribed if the patient does not respond to lithium. Clonazepam is useful in the treatment of acute mania in some patients with treatment-resistant mania, but it is not a first-line drug. p. 240

What is likely to occur when a patient taking lithium carbonate has low sodium levels? A.Lithium toxicity B.Low serum lithium levels C.Increase in mania D.Decrease in mania

lithium toxicity

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: maintaining patients' concentration and attention. shifting the patients' focus from food to psychotherapy. focusing on weight control mechanisms and food preparation. processing the heightened anxiety associated with eating.

processing the heightened anxiety associated with eating. Rationale: D. Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

Physical assessment of a patient diagnosed with bulimia nervosa often reveals: prominent parotid glands. peripheral edema. thin, brittle hair. amenorrhea.

prominent parotid glands. Rationale: A. Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to: avoid exposure to bright sunlight. report increased suicidal thoughts. restrict sodium intake to 1 g daily. maintain a tyramine-free diet.

report increased suicidal thoughts Rationale: B. Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. This baby is the root of my problems." The priority nursing diagnosis is: insomnia. ineffective coping. situational low self-esteem. risk for other-directed violence.

risk for other-directed violence. Rationale: D. When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.