Med-Surg Section 2 exam 302 psycology review

A nurse is caring for a client who has been treated with long term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia occurs, the nurse would most likely observe a. Abnormal movements and involuntary movements of the mouth, tongue and face b. Abnormal breathing through the nostrils c. Severe headache, flushing, tremor and ataxia d. Severe hypertension, migraine headache and "marbles in the mouth" syndrome

a. Abnormal movements and involuntary movements of the mouth, tongue and face

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety. This is accomplished best by a. Assigning a staff member to the client who will remain with the client at all times b. Admitting the client to a seclusion room where all potentially dangerous articles are removed c. Removing the client's clothing and placing the client in a hospital gown d. Requesting that a peer remain with the client at all times

a. Assigning a staff member to the client who will remain with the client at all times

A client who has just been sexually assaulted is very quiet and calm. The nurse identifies this behavior as indicative of which defense mechanism. a. Denial b. Rationalization c. Projection d. Intellectualization

a. Denial

The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to a. Examine and treat the wound sites b. Secure and record a detailed history c. Encourage and assist the client to ventilate feelings d. Administer an antianxiety agent

a. Examine and treat the wound sites

A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. What behaviors observed in the client would validate noncompliance with this medication. a. Frequent hand washing with hot soapy water b. Complaints of hunger c. A pulse rate below 60 beats per minute d. Complaints of insomnia

a. Frequent hand washing with hot soapy water

A patient taking divalproex (Depakote) is advised that blood samples will be taken periodically to monitor for a. Liver damage b. Kidney damage c. Dystonic reactions d. Extrapyramidal syndromes

a. Liver damage

Young people should be warned that inhalants can cause a. Progressive brain damage b. Schizophrenia c. Sexual dysfunction d. Aggressive behavior

a. Progressive brain damage

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. The best initial nursing action is to a. Quietly approach the client, escort her to her room, and assist her in getting dressed b. Approach the client in the hallway and insist that she go to her room c. Confront the client on the inappropriateness of her behaviors and offer her a time out d. Ask the other clients to ignore her behavior, eventually she will return to her room

a. Quietly approach the client, escort her to her room, and assist her in getting dressed

Mr White was arrested for public intoxication and was advised by his attorney to enroll in an alcohol treatment program. A nurse interviews him when he comes to a mental health center. He tells the nurse he really doesn't have a problem with alcohol, he just had a few too many while celebrating with a friend. This is an example of which defense mechanism. a. Rationalization b. Denial c. Projection d. Intellectualization

a. Rationalization

Buspirone HCL (Buspar) is prescribed for a client with an anxiety disorder. The nurse instructs the client regarding the medication and informs the client that which of the following are characteristics of this medication a. The medication can produce a sedating effect b. Tolerance can occur with the medication c. The medication is addicting d. Dizziness and nervousness may occur

a. The medication can produce a sedating effect dizziness and nervousness may occur

A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for treatment of a schizophrenic disorder. The nurse evaluates the laboratory studies that have been prescribed for the client. Which of the following laboratory studies will the nurse specifically review to monitor for an adverse reaction associated with the use of this medication a. WBC count b. Cholesterol level c. Platelet count d. Blood urea nitrogen

a. WBC count

Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. The nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which of the following data are most important for the nurse to obtain before administration of this medication a. When the last alcoholic drink was consumed b. A history of diabetes insipidus c. A history of hyperthyroidism d. When the last full meal was consumed

a. When the last alcoholic drink was consumed

A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When the psychiatric aide firmly states that this behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the aide. Based on the analysis of this situation, the nurses determines that the most appropriate action would be to a. With assistance, escort the manic client to his or her room and administer Haldol b. Tell the client that smoking privileges are revoked for 24 hours c. Orient the client to time, person and place d. Tell the client that the behavior is not appropriate

a. With assistance, escort the manic client to his or her room and administer Haldol

Which statement most accurately describes drug use among adolescents a. Only 1 in 10 adolescents has problems with substance abuse b. Adolescents tend to deny any possible negative outcomes of drug use c. Most adolescents seek treatment for substance abuse on their own d. Adolescents should be treated with adults who can model mature behavior

b. Adolescents tend to deny any possible negative outcomes of drug use

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation would indicate that the client is correctly following the medication plan a. Reports sleeping 12 hours per night and 3 to 4 hours during the day b. Arrives at the clinic neat and appropriate in appearance c. Reports not going to work for this past week d. Complains of not being able to "do anything" anymore

b. Arrives at the clinic neat and appropriate in appearance

Mr. Brooks was hospitalized after a major automobile accident in which another person died. Mr. Brooks reports having no sensation in his legs and is unable to move them. Diagnostic studies reveal no physical basis for his symptoms. The patient's syndromes are typical of a. Hypochondriasis b. Conversion disorder c. Postraumatic stress disorder d. Panic disorder

b. Conversion disorder

A 9 year old girl likes to wear her 14 year old sister's nail polish and tries to fix her hair like the older sister. This is an example of a. Regression b. Identification c. Introjection d. Projection

b. Identification

The key medication for patients with manic episodes is a. Xanax (alprazolam) b. Lithium c. Prozac(fluoxetine hydrochloride) d. Cogentin (benztropine mesylate)

b. Lithium

A client arrives at the health care clinic and tells the nurse that they have been doubling the daily dosage of bupropion (Welbutrin) to aid them in getting better faster. Which ongoing data collection is required based on this information a. Monitor for orthostatic hypotension b. Monitor for seizure activity c. Monitor for weight gain d. Monitor for insomnia

b. Monitor for seizure activity

People who are arrogant, need excessive admiration, and take advantage of others for their own gain may have which type of personality disorder a. Borderline b. Narcissistic c. Obsessive compulsive d. Histrionic

b. Narcissistic

When a patient who is taking disulfiram (Antabuse) consumes alcohol, expected outcomes include a. Hypertensive crisis b. Nausea and vomiting c. Cardiac depression d. Abdominal pain and diarrhea

b. Nausea and Vomiting

What are the nursing implications when a patient is taking phenelzine sulfate (Nardil)? a. Nardil is more effective if given with a tricyclic antidepressant b. Patients should be taught to avoid foods that contain tyramine c. Drugs that interact with Nardil can cause hypotensive crisis d. Because Nardil has few interactions, it is often used in combination with other drugs

b. Patients should be taught to avoid foods that contain tyramine

A nurse observes that a client is psychotic, pacing, agitated and presenting aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on those observations, the nurse's immediate priority of care is to a. Offer the client a less stimulated area to calm down and gain control b. Provide safety for the client and other clients on the unit c. Provide the clients on the unit with a sense of comfort and safety d. Assist the staff in caring for the client in a controlled environment

b. Provide safety for the client and other clients on the unit

A nurse has administered a dose of diazepam (Valium) to the client. The nurse would take which of the following most important actions before leaving the client's room a. Drawing the shades closed b. Putting up the side rails on the bed c. Giving the client a bedpan d. Turning the volume on the television set down

b. Putting up the side rails on the bed

The primary drug abused by older adults is/are a. Cocaine b. Sedatives/sleeping aids c. Amphetamines d. Alcohol

b. Sedatives/sleeping aids

A nurse is performing a follow up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to gather regarding the adverse effects related to the medication. a. Problems with excessive seating b. Gastrointestinal dysfunction c. Cardiovascular symptoms d. Problems with mouth dryness

b. gastrointestinal dysfunction

A client with depression who attempted suicide says to the nurse,"I should have died. I've always been a failure. Nothing ever goes right for me." The most therapeutic response by the nurse is a. "I don't see you as a failure." b. "Feeling like this is part of being ill." c. "You've been feeling like a failure for a while?" d. "You have everything to live for."

c. "You've been feeling like a failure for a while?" (Clarifying)

A physician orders Phenobarbital sodium (Lunimal Sodium) 200 mg divided by two doses a day. The medication bottle is labeled 15 mg per 5 ml. What will the nurse administer per dose. a. 25 ml b. 5 ml c. 33 ml d. 10 ml

c. 33ml 200mg x 5ml divided by 15 = 66 divided by two (for bid) = 33

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has a. Social phobia b. Claustrophobia c. Agoraphobia d. Hypochondriasis

c. Agoraphobia

A nurse is preparing a client for the termination phase of the nurse client relationship. Which of the following nursing tasks would the nurse most appropriately plan for this phase a. Identify expected outcomes b. Plan short term goals c. Assist in making appropriate referrals d. Assist in developing realistic solutions

c. Assist in making appropriate referrals

A client who is on lithium carbonate (Eskalith) will be discharged at the end of the week. In formulating a discharge teaching plan, the nurse will instruct the client that it is most important to a. Avoid soy sauce, wine and aged cheese b. Take medication only as prescribed because it can become addicting c. Check with the psychiatrist before using any OTC medications or prescription medications d. Have the lithium level checked every 2 weeks

c. Check with the psychiatrist before using any OTC medications or prescription medications

Possible side effects of electroconvulsive therapy are temporary memory loss and a. Orthostatic hypotension b. Tardive dyskinesia c. Confusion d. Parkinsonian syndrome

c. Confusion

A LPN enters a client's room, and the client is demanding release from the hospital. The LPN reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The LPN reports the findings to the RN and expects that the RN will take which of the following actions. a. Tell the client that discharge is not possible at this time b. Call the client's family c. Contact the physician d. Persuade the client to stay a few more days

c. Contact the physician

A client is admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit and run car accident, when a family of three were killed. The nurse suspects that the client may be experiencing a a. Psychosis b. Dissociative disorder c. Conversion disorder d. Repression

c. Conversion disorder

A client taking buspirone HCL (Buspar) for 1 month returns to the clinic for a follow up visit. Which of the following manifestations would indicate medication effectiveness a. No reports of alcohol withdrawal symptoms b. No paranoid thought processes c. Decreased anxiety d. No thought broadcasting or delusions

c. Decreased anxiety

A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out. There's nothing wrong with me. I don't belong here." The nurse identifies this behavior as a. Projection b. Regression c. Denial d. Rationalization

c. Denial

A nurse is assisting in planning care for a client being admitted to the nursing unit who attempted suicide. Which of the following priority nursing interventions will the nurse include in the plan of care a. Check the whereabouts of the client every 15 minutes b. Suicide precautions with 30 minute checks c. One to one suicide precautions d. Ask that the client report suicidal thoughts immediately

c. One to one suicide precautions

A woman comes into the emergency room in a severe state of anxiety after a car accident. The most important nursing intervention is to a. Put the client in a quiet room b. Teach the client deep breathing c. Remain with the client d. Encourage the client to talk about her feelings and concerns

c. Remain with the client

A nurse is caring for a male client diagnosed with catatonic stupor. The client is lying on the bed with the body pulled into a fetal position. The most appropriate nursing intervention is which of the following a. Leave the client alone and intermittently check on him b. Take the client into the dayroom with other clients so they can help watch him c. Sit beside the client in silence and verbalize occasional open ended questions d. Ask direct questions to encourage talking

c. Sit beside the client in silence and verbalize occasional open ended questions

A nurse collects data on a client with an admitting diagnosis of bipolar affective disorder-mania. The symptoms presentation that requires the nurse's immediate intervention is a. The client's outlandish behaviors and inappropriate dress b. The client's grandiose delusions of being a royal descendent of King Arthur c. The client's nonstop physical activity and poor nutritional intake d. The client's constant, incessant talking that includes sexual innuendoes and teasing the staff

c. The client's nonstop physical activity and poor nutritional intake

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern a. The presence of bruises on the client's body b. The client's report of not eating or sleeping c. The client's report of suicidal thoughts d. The significant other disapproving of the treatment

c. The client's report of suicidal thoughts

A patient is being treated for an overdose of opioids is given Narcan. Narcan is given to a. Stimulate the heart b. Raise the blood pressure c. Treat respiratory depression d. Sedate the patient and prevent seizures

c. Treat respiratory depression

A client states to the nurse, "I haven't slept at all the last couple of nights." The most therapeutic response by the nurse is a. "Go on...." b. "Sleeping?" c. "The last couple of nights?" d. "You're having difficulty sleeping?"

d. "You're having difficulty sleeping?" (Clarifying)

A client is attending a Gambler's Anonymous meeting for the first time. The model used by this group is the 12 step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12 step program is which of the following. a. Stating that the gambling will be stopped b. Discontinuing relationships with friends who are gamblers c. Substituting gambling for other activities d. Admitting to having a problem

d. Admitting to having a problem

An adult client is administered haloperidol (Haldol) intramuscularly twice a day. After 3 days of therapy, which of the following should be implemented first at the beginning of the nursing shift a. Check vital signs, compare the data with the client's record b. Assess the physical safety of other unit clients c. Monitor the client's nutritional intake d. Assess the client's orientation and delusional status

d. Assess the client's orientation and delusional status

A depressed client who is on tranylcypromine sulfate (Parnate) has been instructed on diet. The nurse feels confident that the client understands the client when given a choice of restaurant foods if the client selects a. Pepperoni/cheese pizza, salad and cola b. Roasted chicken, roasted potatoes and wine c. Pickled herring, French fries and milk d. Fried chicken, baked potato and cola

d. Fried chicken, baked potato and cola

A client receiving thioridazine (Mellaril) complains that they feel very "faint" when he or she tries to get out of bed in the morning. The nurse recognizes this complaint as a symptom of a. Psychosomatic symptoms b. Respiratory insufficiency c. Cardiac dysrhythmias d. Postural hypotension

d. Postural hypotension

A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention knowing that these problems are most likely due to a. In adequate dietary intake and dehydration b. Lack of exercise and poor diet c. Poor dietary choices d. Psychomotor retardation and side effects of medication

d. Psychomotor retardation and side effects of medication

A nurse employed in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was an informal voluntary admission. Based on this type of admission, the nurse would expect which of the following a. The client will be resistant to treatment measures b. The client's family will be very resistant to treatment measures c. The client will be angry and will refuse care d. The client will participate to the treatment plan

d. The client will participate to the treatment plan

A client taking lithium carbonate (Eskalith) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus and tremors. The lithium level is checked as a part of the routine follow up evaluation and the level is 3.0 mEg/L. the nurse knows this level is a. Normal b. Excessively below normal c. Slightly above normal d. Toxic

d. Toxic normal level is 0.5-1.5