Exam 2 Mental Health
Parents of an adolescent diagnosed with a CD say, "We don't know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?" Which therapy is likely to be helpful for these parents? a. Parent-child interaction therapy (PCIT) b. Behavior modification therapy c. Multi-systemic therapy (MST) d. Pharmacotherapy
A
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family
A
Which assessment findings support a diagnosis of ODD? a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior. b. Exhibits involuntary facial twitching and blinking; makes barking sounds. c. Violates others' rights; cruelty toward people or animals; steals; truancy. d. Displays poor academic performance and reports frequent nightmares.
A
A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a. Constipation b. Gynecomastia c. Visual changes d. Photosensitivity
B
A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first? a. Verify the patient's learning style. b. Lower the patient's current anxiety. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.
B
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention
B
A patient diagnosed with major depressive disorder repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress
B
A patient tells a nurse, "My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she's had." This patient is demonstrating a. denial. b. projection. c. rationalization. d. compensation.
C
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. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.
A
A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b. The adolescent identifies friends in the home community who are a positive influence. c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d. The adolescent experiences no anger and frustration for 1 week.
A
A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia
A
A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"
A
A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurse's office, furnished with chairs, files, magazines, and bookcases
A
A patient is experiencing psychomotor agitation associated with major depressive disorder. Which observation would the nurse associate with this symptom? The patient a. paces aimlessly around the room. b. asks the nurse to repeat instructions. c. complains of prickly skin sensations. d. demonstrates slowed verbal responses.
A
A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation
A, B
A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.) a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.
A, B, C
A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.) a. Caution in use of machinery b. Foods allowed on a tyramine-free diet c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives e. Take the medication on an empty stomach
A, C, D
A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient's history support the suspected diagnosis? (Select all that apply.) a. Family history of mental illness b. Allergies to multiple antibiotics c. Long history of severe facial acne d. Father with history of alcohol abuse e. History of an abusive relationship with one parent
A, D, E
A patient being treated with paroxetine 50 mg po daily reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness
A, D, E
A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic? a. Planned ignoring b. Establish firm limits c. Neutrally permit refusals d. Coaxing to gain compliance
B
A child known as the neighborhood bully says, "Nobody can tell me what to do." After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher's computer. These behaviors support a diagnosis of a. CD. b. ODD. c. intermittent explosive disorder. d. ADHD.
B
A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."
B
A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.
B
A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
B
Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depressive disorder. Which comment by the patient indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."
B
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.
B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors
A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room
C
A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."
C
A nurse educates a patient about the antipsychotic medication regime. Afterward, which comment by the patient indicates the teaching was effective? a. "I will need higher and higher doses of my medication as time goes on." b. "I need to store my medication in a cool dark place, such as the refrigerator." c. "Taking this medication regularly will reduce the severity of my symptoms." d. "If I run out or stop taking my medication, I will experience withdrawal symptoms."
C
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.
C
A patient being treated for depression has taken sertraline daily for a year. The patient calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."
C
A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.
C
The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.) a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation
C, D, E
A 12-year-old has engaged in bullying for several years. The parents say, "We can't believe anything our child says." Recently this child shot a dog with a pellet gun and set fire to a neighbor's trash bin. The child's behaviors support the diagnosis of a. ADHD. b. intermittent explosive disorder. c. oppositional defiant disorder (ODD). d. CD.
D
A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent's behavior? a. Attention deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Intermittent explosive disorder d. Conduct disorder (CD)
D
A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"
D
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's most therapeutic response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."
D
Nyctophobia
fear of darkness
Mysophobia
fear of germs
Acrophobia
fear of heights
Agoraphobia
fear of open spaces
Xenophobia
fear of strangers
A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).
A
A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia
A
A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating a. reaction formation. b. repression. c. projection. d. denial.
A
An acutely violent patient diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the prn medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.
A
An adolescent diagnosed with CD has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication? a. Second-generation antipsychotic b. Antianxiety medication c. Calcium channel blocker d. b-blocker
A
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior? a. Family therapy b. Bibliotherapy c. Play therapy d. Art therapy
A
An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy
A
An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression
A
Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."
A
Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Suppression c. Intellectualization d. Reaction formation
A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others.
A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? (Select all that apply.) a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.
A, B, E
A nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.) a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia
A, C, D, F
The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.) a. Ineffective home maintenance b. Situational low self-esteem c. Chronic low self-esteem d. Disturbed body image e. Risk for injury
A, C, E
A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.) a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"
A, E
A patient diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."
B
A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"
B
A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3 c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.
B
A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects
B
A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine
B
A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone b. lorazepam c. amitriptyline d. desipramine
B
A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion
B
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
B
A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patient's symptoms rather than on the patient.
B
A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c. Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family.
B
A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of a. dysthymia. b. anhedonia. c. euphoria. d. anergia.
B
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurse's initial action to defuse the situation? a. Say to the child, "Tell me how you're feeling right now." b. Take the child swimming at the facility's pool. c. Establish a behavioral contract with the child. d. Administer an anxiolytic medication.
B
An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate
B
A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because (Select all that apply) a. it is a vital component of implementing a behavior modification program. b. a therapeutic alliance is the first step in a nurse's therapeutic use of self. c. the adolescent has demonstrated resistance to other authority figures. d. acceptance and trust convey feelings of security for the adolescent. e. adolescents usually relate better to authority figures than peers
B, D
Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient
D
Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.) a. "Are there certain social situations that cause you to feel especially uncomfortable?" b. "Are there others in your family who must do things in a certain way to feel comfortable?" c. "Have you been a victim of a crime or seen someone badly injured or killed?" d. "Is it difficult to keep certain thoughts out of your awareness?" e. "Do you do certain things over and over again?"
B, D, E
What are the primary distinguishing factors between the behavior of persons diagnosed with ODD and those with CD? The person diagnosed with (Select all that apply) a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from loved ones. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.
B, E
A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The patient is 5'6'' and currently weighs 204 lbs. The patient has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the patient's plan of care? a. Skin care techniques b. Scheduling a colonoscopy c. Weight management strategies d. Teaching to limit caffeine intake
C
A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which pt needs are of priority importance? A. Self-esteem B. Psychosocial C. Physiological D. Self-actualization
C
A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best action. a. Ask, "I'm not sure what you mean. Give me an example." b. Capture the patient in a basket-hold to increase feelings of control. c. Tell the patient, "Stop running and take a deep breath. I will help you." d. Assemble several staff members and say, "We will take you to seclusion to help you regain control."
C
An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. a. Ignore the child's behavior. b. Send the child to time-out for 2 hours. c. Take the child to the gym and engage in an activity. d. Role-play a more appropriate behavior with the child.
C
An adolescent acts out in disruptive ways. When this adolescent threatens to throw a heavy pool ball at another adolescent, which comment by the nurse would set appropriate limits? a. "Attention everyone: we are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Hey, do not throw that ball. Put it back on the pool table please." d. "Please do not lose control of your emotions."
C
An adolescent diagnosed with a CD stole and wrecked a neighbor's motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent's reaction? a. Serotonin dysregulation and increased testosterone activity impair one's capacity for remorse. b. Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules. c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. d. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.
C
An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Disturbed personal identity related to acting out as evidenced by prostitution b. Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents c. Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out d. Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another
C
When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.
C
Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations
C
A patient diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice b. Orange juice c. Hot tea d. Milk
D
A disheveled patient in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. The nurse will a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. make observations about the patient's poor personal hygiene. d. firmly and neutrally assist the patient with showering.
D
A healthcare provider considers which antipsychotic med to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? A. Clozapine B. Ziprasidone C. Olanzapine D. Aripiprazole
D
A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective? a. Suggest analogies that might apply to a common daily problem. b. Assign each participant a problem to solve independently and present to the group. c. Ask each patient to read aloud a short segment from a book about problem solving. d. Invite participants to come up with solution to getting incorrect change for a purchase.
D
A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.
D
A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."
D
A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.
D
A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.
D
A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of a. the need for psychoeducation. b. medication nonadherence. c. chronic deterioration. d. relapse.
D
A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia
D
A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness
D
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.
D
A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of a. repression. b. devaluation. c. identification. d. compensation.
D
A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Help the person use online video calls to provide interaction with others. b. Advise the person to accept the situation and use a companion. c. Ask the person to explain why the fear is so disabling. d. Teach the person to use positive self-talk techniques.
D
A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience as a.culturally influenced. b.displacement. c.trait anxiety. d.mild anxiety.
D
An adolescent diagnosed with an impulse control disorder says, "I want to die. I spend my time getting even with people who hurt me." When asked about a suicide plan, the adolescent replies, "I'll jump from a bridge near my home. My father threw kittens off that bridge and they died." Rate the suicide risk. a. Absent b. Low c. Moderate d. High
D
For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Prepare to implement physical controls. d. Provide calm, brief, directive communication.
D
Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night
D