BHN Exam 2

Which patient statement is an example of correct use of cognitive behavioral modifications used for a patient with an eating disorder? Select all that apply. "I don't need to be perfect." "When I feel anxious or nervous, I will journal my feelings instead of turning to food for comfort." "If I screw up and vomit even once, I'm going to give up." "People only like me when I am thin." "If I gain 1 pound per week, then I can exercise three times per week for 30 minutes each time."

"I don't need to be perfect." "When I feel anxious or nervous, I will journal my feelings instead of turning to food for comfort." "If I gain 1 pound per week, then I can exercise three times per week for 30 minutes each time."

A client is being discharged after 3 days of hospitalization for a suicide attempt that followed receiving notice that his wife wanted a divorce. Which of the following patient statements indicates to the nurse that the client is ready to discharge home? "I feel ready to go home now." "I have lots of people to help me and a support group for grieving and divorced people." "Things will be better very soon." "I have the name and phone number of a few divorce lawyers."

"I have lots of people to help me and a support group for grieving and divorced people."

When providing teaching for a patient with bulimia, what is the priority nursing statement? "You need to work on eating food from all of the food groups." "The amount that you eat needs to be balanced with the amount of energy you produce in order to not gain weight." "Do you eat because you're lonely?" "What do you think triggers you to binge eat?"

"What do you think triggers you to binge eat?"

An elderly man is brought to the emergency room after being found wandering around at night. The patient is disoriented and does not know where or who he is. After the patient's identity is confirmed, his wife is called into the hospital. the wife expresses concern over the patient's progressing dementia and states she is worried about caring for her husband. Which of the following responses is best? "Can your children take care of your husband?" "I can recommend a great nursing home." "The social worker can direct you to support groups" "What part of taking care of your husband is most concerning?"

"What part of taking care of your husband is most concerning?"

The nurse cares for a patient with Korsakoff's psychosis. The nurse should assess for which of the following? Memory loss Nystagmus Seizures Ataxia

Memory loss

A confused patient is being admitted to the hospital and the nurse is attempting to gather his health history. The patient denies the presence of any diseases, but he admits to discontinuing donepezil. The nurse understands that this medication is used to treat Alzheimer's disease Bipolar disorder Parkinson's disease Schizophrenia

Alzheimer's disease

The patient presents with the following signs and symptoms: Constipation, K+ 3.1, Ht: 65 inches, weight 110 pounds, weakness, amenorrhea, and feelings of always being cold. Which disorder is this patient likely to be diagnosed with? Bulimia Anorexia Failure to thrive Binge-eating disorder

Anorexia

The nurse is with a patient in the psychiatric unit watching for signs of alcohol withdrawal. Which of the following are early signs of withdrawal? Select all that apply. Anxiety Hypersomnia Hypotension Irritability Tachycardia Tremors

Anxiety Irritability Tachycardia Tremors

A patient's spouse died three months prior. The patient says, "I would like my friend Tom to have my art collection because I don't need to look at them anymore." Which of the following responses by the nurse would be appropriate? Select all that apply. Did Tom ask for the artwork? Are you planning to commit suicide? Does Tom know that you want to give him the artwork? Why do you want to give the artwork away?

Are you planning to commit suicide?

A client with anorexia nervosa is being seen in the outpatient eating disorders clinic. Two weeks ago, she had started refeeding. Her weight indicates that she has gained 9 pounds. What is the nurse's priority response? Praise the client for weight gain Suggest use of an exercise program Assess lung sounds and extremities Establish a higher target for weight gain for the next week

Assess lung sounds and extremities

A patient admitted to the psychiatric unit is prescribed aripiprazole. The nurse understands that this medication is a(n) Atypical antipsychotic Selective serotonin reuptake inhibitor Serotonin-Norepinephrine reuptake inhibitor Typical antipsychotic

Atypical antipsychotic

A schizophrenic patient has been admitted due to paranoia and disturbed thought processes. The nurse should instruct the staff to take what actions? Avoid laughing near the patient's room Encourage socialization and communication with the patient Have them begin patient education about how they can help Treat the patient normally

Avoid laughing near the patient's room

A patient with schizophrenia is unable to get out of bed and get dressed ujless the nurse prompts every step. This is an example of which behavior? Avolition Perseveration Tangentiality Word salad

Avolition "a lack of interest or engagement in goal-directed behavior, or apathy, feeling drained of energy and of interest in normal goals and unable to start or follow through on a course of action." Preservation: "Continual involuntary repetition of a mental act usually exhibited by speech or by some other form of overt behavior." Tangentiality "A speech disturbance characterized by digressing from one subject to another without ever reaching a conclusion." Word Salad "Confused or unintelligible mixture of seemingly random words and phrases."

A patient is admitted to the psychiatric unit after a failed suicide attempt. The nurse plans to write a suicide prevention contract. To promote compliance and build a trusting relationship with the patient, the contract should... Select all that apply. Be written by the patient Be written by the physician Be written by the social worker Be written jointly by the nurse and patient

Be written jointly by the nurse and patient

A patient receiving ziprasidone for schizophrenia has Parkinson-like symptoms. To decrease the Parkinson-like side effects, the nurse should advocate for which of the following medications? Benztropine Bethanechol Levodopa Ropinirole

Benztropine

The nurse is caring for a patient with Alzheimer's disease who is taking donepezil. The nurse should assess the patient for which of the following side effects associated with donepezil? Bradycardia Constipation Dry mouth Tachycardia

Bradycardia

A patient diagnosed with depression is interested in smoking cessation. The physician would most likely prescribe what antidepressant that also aids in smoking cessation? Bupropion Mirtazepine Nefazadone Trazadone

Bupropion

A nurse finds a patient slumped on the floor with a razor blade in hand and blood pouring from the wrist. What is most important for the nurse to do? Telephone the doctor to explain the situation. Call another nurse for help. Stay with the patient. Ask nurse assistant to hold his wrist while the nurse calls the doctor. Find out why the patient tried to commit suicide

Call another nurse for help. Stay with the patient.

The nurse care for a post-operative patient. The nurse notices admission notes where the patient states, "Most day I drink about one pint of vodka." The nurse understands that the most likely time for the patient to develop alcohol withdrawal is 6-12 hours after cessation of drinking 12-18 hours after cessation of drinking 24-48 hours after cessation of drinking 72 hours after cessation of drinking

24-48 hours after cessation of drinking

A patient on a medical-surgical floor is experiencing delirium tremens. Which of the following medications can the nurse expect to be ordered for the management of this acute episode? Chlordiazepoxide Flumazenil Naloxone Ziprasidone

Chlordiazepoxide

A patient is being seen in the clinic for a substance abuse follow-up. While evaluating the patient's progress, the nurse should recognize that which of the following is the best indicator of a lack of commitment? Appointment no-shows Continued drug use Crisis recurrence Rationalization

Continued drug use

Which of the following should be included in the discharge plan of a recovering cocaine addict? Select all that apply. Confront your friends from your former lifestyle Discuss exercise and nutrition Discuss relapse prevention Encourage chewing tobacco as an alternative to other drugs Encourage participation in a support group

Discuss exercise and nutrition Discuss relapse prevention Encourage participation in a support group

A patient has been prescribed phenelzine for the treatment of depression. The nurse should instruct the patient about which common side effects of monoamaine oxidase inhibitors (MAOIs)? Select all that apply. Arrhythmias Dizziness Excessive salivation and tears Incontinence Orthostatic hypotension

Dizziness Orthostatic hypotension

A patient is prescribed amitriptyline for the treatment of depression. The nurse educates the patient about what common side effects? Select all that apply. Diarrhea Dry mouth and eyes Excessive tears Hypertension Lethargy

Dry mouth and eyes Lethargy

Family members of a patient with bipolar disorder tell the nurse that they are concerned that the patient is becoming manic. The nurse knows that the manic phase is marked by Decreased self-esteem and increased physical restlessness Flight of ideas and inflated self-esteem Increased sleep Obsession with rules and maintaining order

Flight of ideas and inflated self-esteem

A patient is admitted to the hospital for overdose of lorazepam. The nurse should expect the physician to order the administration of: Methadone Flumazenil Naloxone Naltrexone

Flumazenil

When a patient is admitted to the psychiatric unit, he proclaims, "I am the Duke of York! How dare you touch me!" This is an example of Delusion of reference Delusional parasitosis Grandiose delusion Persecutory delusion

Grandiose delusion

The nurse is assessing a patient in the manic phase of bipolar disorder. While assessing the patient, the nurse can expect to observe Distractibility and dysthymia Dysphoria and racing thoughts Dysphoria and rapid cycling Grandiosity, pressured speech and racing thoughts

Grandiosity, pressured speech and racing thoughts

The nurse is caring for a 16-year-old girl recently hospitalized. She is slender but does not appear abnormal. Which of the following statements is the most concerning? I am 12% below my ideal body weight I check my weight 2 times per day I exercise 3.5 hours a day My best friend has been treated for anorexia

I exercise 3.5 hours a day

A patient is admitted to the psychiatric unit for suicidal ideation. The physician prescribes escitalopram and asks the nurse to review the side effects with the patient. The nurse should include which common side effect in the patient's education? Select all that apply. Confusion Constipation Insomnia Sexual dysfunction Weight loss Weight gain

Insomnia Sexual dysfunction Weight gain

The nurse is talking with a patient diagnosed with schizophrenia. Which of the following nursing approaches can help the schizophrenic patient improve self-concept? Select all that apply. Allow her to express her feelings in drawing Allow her to participate in competitive games Involve her in simple tasks that she can complete Redirecting to appropriate activities

Involve her in simple tasks that she can complete Redirecting to appropriate activities

A patient is admitted to the psychiatric unit for psychosis. When asked how she got to the hospital, the patient responds, "I took my car because people like brown hair, but then how did I get to Sesame Street? Angry birds!" This response is a(n) Distractible speech Grandiose delusion Loose association Somatic delusion

Loose association

A patient taking fluoxetine is admitted to the hospital due to serotonin syndrome. Which of the following are symptoms of serotonin syndrome? Select all that apply. Agitation Constipation Hypotension Myoclonic jerking Tachycardia

Agitation Myoclonic jerking Tachycardia

A patient states, "Nothing matters anymore." What is the nurse's priority response? "Are you having thoughts about suicide?" "I am not sure I understand what you are saying." "Try to stay hopeful. Things will work out." "What used to matter, before the depression?"

"Are you having thoughts about suicide?"

While receiving disulfiram (Antabuse) therapy, the client becomes nauseated and vomits severely. Which of the following questions should the nurse ask first? "Do you feel like you have the flu?" "How long have you been taking Antabuse?" "Have you ever felt like this before?" "How much alcohol did you drink today?"

"How much alcohol did you drink today?"

Which patient statement reflects correct understanding of the plan for inpatient management of the eating disorder? "If I gain 5 pounds this week, then I can go home." "If I gain 2 pounds this week, then I get to exercise as much as I want." "I filled out today's menu so that I can get a balanced diet: 1 orange for breakfast, 4 carrots for lunch, 3 crackers and peanut butter for supper." "You need to watch me while I eat and after I am done eating."

"You need to watch me while I eat and after I am done eating."

A patient is admitted to the hospital for an overdose of oxycodone. The nurse should expect the physician to order the administration of Flumazenil Methadone Naloxone Naltrexone

Naloxone

The nurse is assessing a 15-year-old girl who has been admitted for bulimia nervosa. Which clinical manifestation is the nurse most likely to find? Coarse hair growth Hypertension Metabolic acidosis Parotid gland tenderness

Parotid gland tenderness

A patient who is diagnosed with depression is taking a monoamine oxidase inhibitor (MAOI). What medication should be immediately available for administration when the nurse is assessing the patient for a hypertensive crisis? Atenolol Digoxin Furosemide Phentolamine

Phentolamine

A 45-year-old woman is referred to the clinic due to bizarre social interactions and inappropriate anger. When the patient called to schedule her appointment with the nurse, she sounded very energetic and jumped from topic to topic. Upon assessment, which of the follwing signs and symptoms suggest mania? Exaggerated self-esteem and increased sleep Interpersonal conflict and irritability in spring and summer Persistent sad or depressive mood, loss interest in things that were once pleasurable, and sleep disturbances Pressured speech, flight of ideas, and intense level of energy

Pressured speech, flight of ideas, and intense level of energy

A patient arrives intoxicated to an outpatient therapy appointment and tells the nurse, "It's not my fault. I am an alcoholic and cannot control my drinking." The nurse best identifies this as being the defense mechanism of: Conversion Compensation Projection Rationalization

Rationalization "The action of attempting to explain or justify behavior or an attitude with logical reasons, even if these are not appropriate."

A patient with bipolar disorder is in a manic state. The nurse should select which of the following foods for this patient's lunch? Eggs, bacon, and coffee Fruit salad and broth Sandwich, banana, and milk Spaghetti and milk

Sandwich, banana, and milk

A patient is prescribed imipramine for the treatment of depression. The nurse should educate the patient about which dangerous side effect? Congestive Heart Failure Guillian-Barre syndrome Hyperglycemia Seizures

Seizures

When assessing the patient with suspected bulimia, the nurse expects to find what? Select all that apply. Swelling in feet Amenorrhea Dental caries Callused fingers Normal body weight

Swelling in feet Dental caries Callused fingers Normal body weight

A client is admitted to the inpatient unit with the diagnosis of anorexia? What is a priority initial goal? The client will make a contract with the nurse that sets a target weight. The client will identify self-perceptions about body size as unrealistic. The client will establish adequate daily nutritional intake The client will verbalize three possible physiologic consequences to self starvation.

The client will establish adequate daily nutritional intake

A patient has been admitted to the unit due to an intentional overdose of narcotics. The patient is put on suicide precautions (1:1) and a nursing assistant is assigned to monitor him. Which of the following is correct? The nurse should verify this with the physician This is an appropriate delegation of a task This is illegal, an RN must provide 1:1 monitoring of a suicidal patient This is poor nursing practice since the nurse is responsible for patient care

This is an appropriate delegation of a task

Which of the following classes of drugs is the most fatal if a patient overdoses? Antihistamines Benzodiazepines Tricyclic antidepressants Typical antipsychotics

Tricyclic antidepressants

A client diagnosed with bulimia admits to vomiting every time she eats too much. The defense mechanism used by the client is Rationalization Conversion Undoing Projection

Undoing

Which variable(s) influence suicide? Select all that apply. Use of alcohol Being single or widowed Presence of a chronic physical illness Ability to openly communicate needs to others Presence of mental illness

Use of alcohol Being single or widowed Presence of a chronic physical illness Presence of mental illness

A client seeks crisis intervention. She tells the nurse, "I can't take it anymore! It has to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago, I found a lump in my breast. Yesterday, my son decided to drop out of college." The priority assessment for the nurse is How the client feels about the possibility of having a mastectomy. Whether the husband is still engaged in the affair. What strategies can be implemented to help the couple to better communicate. What the client has in mind when she says she cannot "take it anymore"

What the client has in mind when she says she cannot "take it anymore"