Exam 2 - Psychiatric/Mental Health Nursing

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Which action by a nurse constitutes a breach of a patient's right to privacy? a. Documenting the patient's daily behavior during hospitalization b. Releasing information to the patient's employer without consent c. Discussing the patient's history with other staff during care planning d. Asking family to share information about a patient's pre-hospitalization behavior

A nurse is concerned that an agency's policies are inadequate. Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice? a. Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. Faced with substandard policies, a nurse has a responsibility to inform the supervisor and discontinue patient care immediately. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

A patient in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action. a. Anonymously report the abuse by phone to the local child protection agency. b. Reply, "I'm glad you feel comfortable talking to me about it." c. File a written report with the agency's ethics committee. d. Respect nurse-patient relationship confidentiality.

A person in the community asks, "Why aren't people with mental illness kept in state institutions anymore?" Select the nurse's best response. a. "Less restrictive settings are available now to care for individuals with mental illness." b. "There are fewer persons with mental illness, so less hospital beds are needed." c. "Most people with mental illness are still in psychiatric institutions." d. "Psychiatric institutions violated patients' rights."

A psychiatric nurse best applies the ethical principle of autonomy by: a. exploring alternative solutions with a patient, who then makes a choice. b. suggesting that two patients who were fighting be restricted to the unit. c. intervening when a self-mutilating patient attempts to harm self. d. staying with a patient demonstrating a high level of anxiety.

In order to release information to another health care facility or third party regarding a patient diagnosed with a mental illness, the nurse must obtain: a. a signed consent by the patient for release of information stating specific information to be released. b. a verbal consent for information release from the patient and the patient's guardian or next of kin. c. permission from members of the health care team who participate in treatment planning. d. approval from the attending psychiatrist to authorize the release of information.

Insurance will not pay for continued private hospitalization of a mentally ill patient. The family considers transferring the patient to a public hospital but expresses concern that the patient will not get any treatment if transferred. Select the nurse's most helpful reply. a. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse." c. "You have a justifiable concern because the right to treatment extends only to provision of food, shelter, and safety." d. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable."

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 Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

A patient diagnosed with major depression 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 Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. 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 dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.

Which documentation for a patient diagnosed with major depression 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 Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding.

An adult diagnosed with major depression 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 Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January b. April c. June d. September

A The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.

A psychiatric nurse best applies the ethical principle of autonomy by: a. exploring alternative solutions with a patient, who then makes a choice.

ANS: A Autonomy is the right to self-determination, that is, to make one's own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. The distracters demonstrate beneficence, fidelity, and justice.

In which situations would a nurse have the duty to intervene and report? Select all that apply. a. A peer has difficulty writing measurable outcomes. b. A health care provider gives a telephone order for medication. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member violates relationship boundaries with a patient. e. A patient refuses medication prescribed by a licensed health care provider.

C, D

Which information is most important to obtain during assessment of an older adult diagnosed with a mental disorder? a. Functional ability and emotional status

ANS: A Information related to functional ability and emotional status provides an overview of patient problems and abilities. It guides selection of interventions and services to meet identified needs. The distracters reflect information of relevance, but are not of highest priority.

A patient diagnosed with major depression 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 The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. See relationship to audience response question.

A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? 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 Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self. See relationship to audience response question.

A patient being treated with paroxetine (Paxil) 50 mg po daily for depression 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 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. The patient may have urinary retention, but frequency would not be expected.

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 486-487 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you became depressed."

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 | Page 488-490 (Nursing Care Plan 25-1) and (Table 25-3) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." The parents' reaction reflects: a. guilt. b. denial. c. shame. d. rescue feelings.

ANS: A The parents' statements indicate guilt. Guilt is evident from the parents' self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 493-494 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

The highest priority for assessment by nurses caring for older adults who self-administer medications is: a. use of multiple drugs with anticholinergic effects.

ANS: A Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The distracters may be relevant but are not the highest priority.

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 483-484 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patient's needs? a. Adult day care program

ANS: A A day care program provides recreation and social interaction as well as supervision in a safe environment. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A group home is inappropriate and would not meet the patient's needs.

A patient asks, "What advantage does a durable power of attorney for health care have over a living will?" The nurse should reply, "A durable power of attorney for health care: a. gives your agent authority to make decisions during any illness if you are incapacitated."

ANS: A A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individual's agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individual's behalf.

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

An elderly patient must be physically restrained. Who is responsible for the patient's safety? a. The nurse assigned to care for the patient

ANS: A Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c.amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem.

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively. a. "Would you say your mood is often sad?"

ANS: A Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

ANS: A Laws regarding child abuse reporting discovered by a professional during the suspected abuser's alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

ANS: A Nurses are professionally bound to uphold standards of practice regardless of lesser standards established by a health care agency or a state. Conversely, if the agency standards are higher than standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.

ANS: A Nurses have an obligation to protect patients' privacy and confidentiality. Clinical information should not be released without the patient's signed consent for the release.

A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

ANS: A The community is a less restrictive alternative than hospitals for treatment of persons with mental illness. The distracters are incorrect and part of the stigma of mental illness.

A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization? a. Remotivation

ANS: A Remotivation therapy helps to resocialize regressed and apathetic patients by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies related to the topic. Group leaders give members acceptance and appreciation. Group psychotherapy would not be effective for this patient. An activity group does not address the patient's problem.

A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient? a. Risk for suicide related to recent deaths of significant others

ANS: A The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient's social isolation is important, but the risk for suicide has higher priority.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

ANS: A The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection.

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964.

A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include? a. Pain assessment techniques for older adults

ANS: A The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.

2. Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arm's-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patient's eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 491-492 (Table 25-5) and (Box 25-4) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

Select all that apply. Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? a. "Lately I have had a lot of aches and pains and just haven't felt very well." b. "People are in and out of my room all day and all night taking my things." c. "Don't ask me to eat. I can't because my stomach is upset all the time."

ANS: A, B, C Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The distracters do not suggest symptoms of depression.

Select all that apply. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? a. Failure of the elderly to receive necessary medical information b. Development of public policy that discriminates against the elderly c. Staff shortages because caregivers prefer working with younger adults

ANS: A, B, C Because of society's negative stereotyping of the elderly as having little to offer, some staff persons avoid working with older patients. Staff shortages in long-term care are common. Elderly patients are often provided less information about their conditions and fewer treatment options than younger patients are because some health care staff members perceive them as less able to understand. This problem exists among both professional and ancillary personnel. Public policy discriminates against programs for the elderly. Anger exists because the elderly are perceived to consume a disproportionately large share of medical resources.

Select all that apply. Which assessment findings would the nurse expect in a patient experiencing delirium? a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

ANS: A, B, D Whites have suicide rates almost twice those of non-whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 481-485 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

Select all that apply. A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

Select the example of a tort. b. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed.

ANS: B A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus, false imprisonment is a possible charge. The other options do not exemplify torts.

3. A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

ANS: A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, "No one can understand," can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

Select all that apply. A nurse assessing an elderly patient for depression and suicide potential should include questions about mood as well as: a. anhedonia. c. sleep pattern changes. e. increased concerns with bodily functions.

ANS: A, C, E The correct responses relate to symptoms often noted in elderly patients with depression. Somatic symptoms are often present but missed by nurses as related to depression. Anorexia, rather than hyperphagia, occurs in major depression. Grandiosity is associated with bipolar disorder.

22. Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."

ANS: B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

23. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

ANS: B Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487-488 | Page 493-494 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

4. Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 484-485 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

1. An adult outpatient diagnosed with major depression 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 (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 492 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: B The nurse must assess the patient's access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patient's safety. The information in the other questions may be important to ask but are not the most critical. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 483 (Box 25-2) | Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

A student nurse visiting a senior center says, "It's depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion." The student is expressing: b. ageism.

ANS: B Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student.

A patient living in community housing for the elderly says, "I don't go to the senior citizens club. They play cards and talk about the past because that's all they can do." The nurse analyzes these remarks to represent: b. thinking associated with ageism.

ANS: B Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of ageism as younger individuals. The other options are not substantiated by the information given in the scenario.

A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who: b. began drinking alcohol daily after retirement and says, "A few drinks keep my mind off my arthritis."

ANS: B Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.

Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important? b. Determine whether the patient can hear as the nurse speaks.

ANS: B Before proceeding with any further assessment, the nurse should assess the patient's ability to hear questions. Impaired hearing could lead to inaccurate answers.

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. b. "I am obligated to share that information with the treatment team."

ANS: B Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should also know that the team has a duty to warn the father of the risk for harm.

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a.Distraction using sensory stimulation b.Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety.

An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful? b. Ask clear, simple questions using concrete language.

ANS: B Communication with individuals who have schizophrenia might be difficult because of the individual's various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed. The nurse needs more information than "yes" or "no" questions will provide.

During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

A nurse and social worker co-lead a reminiscence group for eight elite-old adults. Which activity is appropriate to include in the group? b. Singing a song from World War II

ANS: B Elite-old adults are persons 100+ years of age. They were young people during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

Which nursing intervention demonstrates false imprisonment? b. A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion."

ANS: B False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. If a patient is not competent (confused), then the nurse should act with beneficence. Patients admitted involuntarily should not be allowed to leave without permission of the treatment team.

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

ANS: B It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not a violation of confidentiality.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

A nurse plans a staff education program for employees of a senior living community. Which topic has priority? b. Depression and suicide

ANS: B Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence.

Which statement about aging provides the best rationale for focused assessment of elderly patients? b. Vision, hearing, touch, taste, and smell decline with age.

ANS: B Only the key is a true statement. It cues the nurse to assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

ANS: B Patients have a right to treatment in the least restrictive setting. Safety is important, but less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion violates the patient's autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment.

ANS: B Patients have the right to be treated with dignity and respect. The technician's comment disregards the seriousness of the patient's illness. The Code of Ethics for Nurses requires intervention. Patient emotional abuse has been demonstrated, not negligence. An interaction with the technician is not an aspect of social interaction. The technician did not disclose clinical information.

ANS: B Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. The nurse, as an advocate and educator, should seek more information about the patient's decision and not force the medication.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety.

Which action by a nurse constitutes a breach of a patient's right to privacy? b. Releasing information to the patient's employer without consent

ANS: B Release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices. See relationship to audience response question.

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 G sodium diet, Restraint as needed, Limit fluids to 1800 mL daily, Continue antihypertensive medication, Milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should: b. question the order for restraint.

ANS: B Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

ANS: B The nurse has an obligation to honor the right to self-determination. An advanced psychiatric directive supports that goal. Since the patient is currently psychotic, the terms of the directive now apply.

An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, "It's awful to be old. Every day is a struggle. No one cares about old people." Select the nurse's best response. b. "It sounds like you're having a difficult time. Tell me about it."

ANS: B The nurse uses empathetic understanding to permit the patient to express frustration and clarify her "struggle" for the nurse. The distracters block communication.

An aide in a psychiatric hospital says to the nurse, "We don't have time every day to help each patient complete a menu selection. Let's tell dietary to prepare popular choices and send them to our unit." Select the nurse's best response. b. "Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality."

ANS: B The nurse's response to the aide should recognize patients' rights to be treated with dignity and respect as well as promote autonomy. This response also shows respect for the aide and fulfills the nurse's obligation to provide supervision of unlicensed personnel. The incorrect responses have flawed rationale or do not respect patients as individuals.

A 79-year-old white male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as: b. evidence of risks for suicide.

ANS: B The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment. b. "What are your beliefs about a person's right to take his or her own life?"

ANS: B This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

Select all that apply. Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? b. Older adults are able to learn new tasks. c. Aging results in a decline in restorative sleep. d. Older adults are prone to become crime victims.

ANS: B, C, D Myths about aging are common and can negatively impact the quality of care older patients receive. Older individuals are more prone to become crime victims. A decline in restorative sleep occurs as one ages. Learning continues long into life. These factors affect care delivery.

Select all that apply. Which assessment findings would alert the nurse that an older patient may have an increased risk for development of geriatric alcohol abuse? b. Eighth grade education c. Death of spouse d. Retirement e. Loneliness

ANS: B, C, D, E The geriatric problem drinker begins drinking in later life, often in response to stressors such as retirement, loss of spouse, and loneliness. Once the demands of job, career, and care of a family and household are gone, the structure of daily life is disrupted. Mild cognitive impairment is not a predisposing factor in the development of geriatric problem drinking. Other risk factors include less than a high school education, smoking, low income, and male gender.

5. 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

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

20. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

ANS: C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 493-494 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the nurse on duty and says, "Please document administration of the medication for me. My password is alpha1." The nurse receiving the call should: a. fulfill the request promptly. b. document the caller's password. c. refer the matter to the charge nurse to resolve. d. report the request to the patient's health care provider.

6. 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.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 486-487 (Table 25-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks "I am not going to harm myself, I am going to kill myself" or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 491-492 (Table 26-5) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

ANS: C The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem solving. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 484 | Page 488-491 (Nursing Care Plan 25-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487-490 (Table 25-3) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

13. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide.

ANS: C This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 488-491 (Nursing Care Plan 25-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 485-486 | Page 490 (Table 25-3) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now." Select the nurse's best response. c. "I will get them for you, but let's talk about your decision to leave treatment."

ANS: C A voluntarily admitted patient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient's wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. Facilitating discharge without consent is not in the patient's best interests before exploring the reason for the request.

An advance directive gives legally binding direction for health care interventions when a patient: c. is unable to make decisions for self because of illness.

ANS: C Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson's disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life

When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value? c. Medications the patient has recently taken

ANS: C Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d.Inability to feed or bathe self

ANS: C Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.

After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the nurse on duty and says, "Please document administration of the medication for me. My password is alpha1." The nurse receiving the call should: c. refer the matter to the charge nurse to resolve.

ANS: C Fraudulent documentation may be grounds for discipline by the state board of nursing. Referring the matter to the charge nurse will allow observance of hospital policy while ensuring that documentation occurs. Notifying the health care provider would be unnecessary when the charge nurse can resolve the problem. Nurses should not provide passwords to others.

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual: c. who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless

ANS: C Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary hospitalization also protects other individuals in society. An overdose of acetaminophen indicates dangerousness to self. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

A new nurse asks, "My elderly patient has Lewy body disease. What should I do about assessing for pain?" Select the best response from the nurse manager. c. "There are special scales for assessing patients with dementia. Let's review how to use them."

ANS: C Lewy body disease is a form of dementia. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depression. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient. c. Partial hospitalization

ANS: C Partial hospitalization will provide services the patient needs as well as give supervision and meals to the patient while the daughter is at work. Home care would not provide socialization. The patient does not need the intensity of a skilled nursing facility. A halfway house provides 24-hour care and usually expects involvement in off-campus programs.

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group? c. Discussing national leadership during the Vietnam War

ANS: C Young-old adults are persons 65 to 75 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more than the usual geriatric dose. The nurse should: c. withhold the medication and confer with the health care provider.

ANS: C The dose of antidepressants for elderly patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse's duty is to practice according to professional standards as well as intervene and protect the patient.

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

Select all that apply. In which situations would a nurse have the duty to intervene and report? c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member violates relationship boundaries with a patient.

ANS: C, D Both keyed answers are events that jeopardize patient safety. The distracters describe situations that may be resolved with education or that are acceptable practices.

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

Select all that apply. Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

Select all that apply. Which actions violate the civil rights of a psychiatric patient? The nurse: c. opens and reads a letter a patient left at the nurse's station to be mailed. e. restrains a patient who uses profanity when speaking to the nurse.

ANS: C, E The patient has the right to send and receive mail without interference. Restraint is not indicated because a patient uses profanity; there are other less restrictive ways to deal with this behavior. The other options are examples of good nursing judgment and do not violate the patient's civil rights.

25. Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

ANS: D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 482-483 (Box 25-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 487 | Page 492 (Table 25-4) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."

ANS: D The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 484 | Page 488-489 (Nursing Care Plan 25-1) | Page 491-492 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. 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

ANS: D This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. 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

ANS: D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 487-488 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

A newly admitted acutely psychotic patient is a private patient of the medical director and a private-pay patient. To whom does the psychiatric nurse assigned to the patient owe the duty of care? d. Patient

ANS: D Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse: d. can be charged with battery.

ANS: D Battery is an intentional tort in which one individual violates the rights of another through touching without consent. Forcing a patient to take medication after the medication was refused constitutes battery. The charge of battery can be brought against the nurse. The medication may not necessarily harm the patient; harm is a component of malpractice.

A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation. d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430.

ANS: D Documentation must be specific and detail the key aspects of care. It should demonstrate implementation of the least restrictive alternative. Justification for why a patient was secluded should be recorded, along with interventions attempted in an effort to avoid seclusion. Documentation should include a description of behavior and verbalizations, interventions tried and their outcomes, and the name of the health care provider ordering the use of seclusion.

What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

ANS: D In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who: d. threatens to harm self and others.

ANS: D Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled "Ativan" and one labeled "lorazepam," both of which are to be taken BID. There are also bottles labeled "hydrochlorothiazide," "Inderal," and "rofecoxib," each to be taken once daily. Which conclusion is accurate? d. Lorazepam and Ativan are the same drug, so the dose is excessive.

ANS: D Lorazepam and Ativan are generic and trade names for the same drug, creating an accidental misuse situation. The patient needs medication education and help with proper, consistent labeling of bottles; there is no evidence that the patient cannot self-administer medication. The other distracters are not factual statements.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

Select the best comment for a nurse to begin an interview with an elderly patient. d. "Hello. My name is _______ and I am a nurse. How you would like to be addressed by staff?"

ANS: D The correct opening identifies the nurse's role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.

Which documentation of a patient's behavior best demonstrates a nurse's observations? d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."

ANS: D The documentation states specific observations of the patient's appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.

A family member of a patient with delusions of persecution asks the nurse, "Are there any circumstances under which the treatment team is justified in violating a patient's right to confidentiality?" The nurse should reply that confidentiality may be breached: d. if the patient threatens the life of another person.

ANS: D The duty to warn a person whose life has been threatened by a psychiatric patient overrides the patient's right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision." Which ethical principle most clearly applies to this situation? d. Justice

ANS: D The nurse is concerned about justice, that is, fair distribution of care, which includes treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, "I get lonely and drink a little to help me forget." Select the nurse's most therapeutic intervention. d. Arrange for the person to attend an Alcoholics Anonymous meeting for older adults.

ANS: D This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.

Which individual with mental illness may need emergency or involuntary admission? The individual who: d. throws a heavy plate at a waiter at the direction of command hallucinations.

ANS: D Throwing a heavy plate is likely to harm the waiter and is evidence of dangerousness to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness. See related audience response question.

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

The intervention that will be most effective in preventing a nurse from making decisions that will lead to legal difficulties is a. asking a peer to review nursing intervention related decisions. b. balancing the rights of the client and the rights of society. c. maintaining currency in state laws affecting nursing practice. d. seeking value clarification about fundamental ethical principles.

A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should: a. review the directive with the patient to ensure it is current. b. ensure that the directive is respected in treatment planning. c. consider the directive only if there is a cardiac or respiratory arrest. d. encourage the patient to revise the directive in light of the current health problem.

A nurse prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to an outpatient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best action. a. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary. b. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." c. Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects. d. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the answer with the correct rationale. The psychiatrist: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.

A patient experiencing psychosis asks a psychiatric technician, "What's the matter with me?" The technician replies, "Nothing is wrong with you. You just need to use some self-control." The nurse who overheard the exchange should take action based on: a. the technician's unauthorized disclosure of confidential clinical information. b. violation of the patient's right to be treated with dignity and respect. c. the nurse's obligation to report caregiver negligence. d. the patient's right to social interaction.

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You are right. Federal law requires me to keep clinical information private." b. "I am obligated to share that information with the treatment team." c. "Those kinds of thoughts will make your hospitalization longer." d. "You should share this thought with your psychiatrist."

An aide in a psychiatric hospital says to the nurse, "We don't have time every day to help each patient complete a menu selection. Let's tell dietary to prepare popular choices and send them to our unit." Select the nurse's best response. a. "Thanks for the suggestion, but that idea may not work because so many patients take MAOI (monoamine oxidase inhibitor) antidepressants." b. "Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality." c. "Thank you for the suggestion, but the patients' bill of rights requires us to allow patients to select their own diet." d. "Thank you. That is a very good idea. It will make meal preparation easier for the dietary department."

Select the example of a tort. a. The plan of care for a patient is not completed within 24 hours of the patient's admission. b. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. c. An advanced practice nurse recommends hospitalization for a patient who is dangerous to self and others. d. A patient's admission status changed from involuntary to voluntary after the patient's hallucinations subside.

Two hospitalized patients fight whenever they are together. During a team meeting, a nurse asserts that safety is of paramount importance, so treatment plans should call for both patients to be secluded to keep them from injuring each other. This assertion: a. reinforces the autonomy of the two patients. b. violates the civil rights of both patients. c. represents the intentional tort of battery. d. correctly places emphasis on safety.

Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

A patient diagnosed with depression 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 diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

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 Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy."

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a.distracting the patient from self-absorption. b.careful unobtrusive observation around the clock. c.allowing the patient to spend long periods alone in meditation. d.opportunities to assume a leadership role in the therapeutic milieu.

B Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.

A patient diagnosed with major depression 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 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 cast doubt but do not require the patient to evaluate the statement.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

B During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

B Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.

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 Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A patient diagnosed with major depression 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 Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (non-therapeutic techniques). Saying "You must be feeling better today" is an assumption, which is non-therapeutic.

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 The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. 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 Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.

Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual: a. who has a panic attack after her child gets lost in a shopping mall b. with visions of demons emerging from cemetery plots throughout the community c. who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless d. diagnosed with major depression who stops taking prescribed antidepressant medication

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now." Select the nurse's best response. a. "I will get the forms for you right now and bring them to your room." b. "Since you signed your consent for treatment, you may leave if you desire." c. "I will get them for you, but let's talk about your decision to leave treatment." d. "I cannot give you those forms without your health care provider's permission."

A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more than the usual geriatric dose. The nurse should: a. consult a reliable drug reference. b. teach the patient about possible side effects and adverse effects. c. withhold the medication and confer with the health care provider. d. encourage the patient to increase oral fluids to reduce drug concentration.

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a.psychoanalytic therapy. b.desensitization therapy. c.cognitive behavioral therapy. d.alternative and complementary therapies.

C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.

A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

A patient diagnosed with major depression began taking escitalopram (Lexapro) 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 Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.

A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

C Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

C 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 patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." 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 The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.

Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

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 lead to other diagnoses.

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse: a. has been negligent. b. committed malpractice. c. fulfilled the standard of care. d. can be charged with battery.

The admission note indicates a patient diagnosed with major depression 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 Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

Which actions violate the civil rights of a psychiatric patient? The nurse: (select all that apply) a. performs mouth checks after overhearing a patient say, "I've been spitting out my medication." b. begins suicide precautions before a patient is assessed by the health care provider. c. opens and reads a letter a patient left at the nurse's station to be mailed. d. places a patient's expensive watch in the hospital business office safe. e. restrains a patient who uses profanity when speaking to the nurse.

C, E

Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer; more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others. d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."

A family member of a patient with delusions of persecution asks the nurse, "Are there any circumstances under which the treatment team is justified in violating a patient's right to confidentiality?" The nurse should reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation. a. Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours. b. Seclusion ordered by physician at 1415 after command hallucinations told the patient to hit another patient. Careful monitoring of patient maintained during period of seclusion. c. Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst. d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430.

Which individual with mental illness may need emergency or involuntary admission? The individual who: a. resumes using heroin while still taking naltrexone (ReVia). b. reports hearing angels playing harps during thunderstorms. c. does not keep an outpatient appointment with the mental health nurse. d. throws a heavy plate at a waiter at the direction of command hallucinations.

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who: a. is noncompliant with the treatment regimen. b. fraudulently files for bankruptcy. c. sold and distributed illegal drugs. d. threatens to harm self and others.

A patient diagnosed with depression is receiving imipramine (Tofranil) 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

D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A patient diagnosed with major depression 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 Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

D Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.

A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. b. over-involvement. c. interest and pleasure. d.ineffectiveness and frustration.

D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient's resistance. Guilt and despair might be seen when the nurse experiences the patient's feelings because of empathy. Interest is possible, but not the most likely result.

A nurse provided medication education for a patient diagnosed with major depression 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 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 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 Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.

A disheveled patient with severe depression and psychomotor retardation 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. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

D When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

Exam 2 - Psychiatric/Mental Health Nursing

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