Mental Health Exam 1

A nurse in an acute metal health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step-by-step instructions during hygiene activities. D. Monitor the client for escalating behavior.

D. Monitor the client for escalating behavior.

A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide? A. Three to six weeks of treatment is required to achieve therapeutic benefit. B. Combining alcohol with diazepam will produce a paradoxical response. C. Diazepam has a lower risk for dependence than other anti-anxiety medications. D. Report confusion as a potential indication of toxicity.

D. Report confusion as a potential indication of toxicity.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change his behavior C. Distract the client with a TV show D. Stay with the client and remain quiet

D. Stay with the client and remain quiet

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect? A. The client remembers many details about the traumatic incident. B. The client expresses heightened elation about what is happening. C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred. D. The client expresses a sense of unreality about the traumatic incident.

D. The client expresses a sense of unreality about the traumatic incident.

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care? A. Teach the client to recognize how stress brings on a personality change in the client. B. Repeatedly present the client with information about past events. C. Make decisions for the client regarding routine daily activities. D. Work with client on grounding techniques.

D. Work with client on grounding techniques.

What can withdrawal from Xanax lead to?

Death

What does Benedryl prevent?

EPS- extrapyramidal side effects

clang association

"red in head going to bed" rhyming without reason

To be diagnosed with general anxiety disorder how long do symptoms have to last and what is the most common symptom?

-3 months -muscle tightness

What questions should you ask a client who has major depression?

-Are you planning on hurting yourself or others? -What is your plan?

What are some things that can trigger PTSD?

-TV -fireworks -startled awake

What two substances cause severe withdrawal?

-alcohol -Xanax

If a client is on tricyclic antidepressants what should they avoid?

-alcohol -driving

What medications are used for PTSD?

-antidepressants -fluoxetine

What is the number one medication given for anxiety?

-buspar -anticonvulsants

What are patients who have mania like?

-enjoy euphoric feeling -noncompliant with medications

How can you help a client who has OCD?

-find out what triggers their anxiety -actions to try and decrease anxiety

What is transference?

-ineffective communication -placing past feelings, conflicts, and attitudes into present relationships, situations, and circumstances

Why should you not stop medications abruptly?

-infection can come back stronger -therapeutic effect diminished

What to know about clozapine (clozaril)

-last resort drug -for severe schizophrenia -weekly labs for 1st 6 months: CBC, differential to check absolute neutrophil count, WBCs, BP, HR -more at risk for metabolic disorders ex. phenylketonuria, nonketotic hyperglycemia

What should be monitored and maintained when a client is taking lithium?

-maintain sodium and fluid intake -monitor for hand tremors=sign of toxicity

systemic desensitization

-masters relaxation technique -client exposed to increased levels of anxiety producing stimulus -use relaxation to overcome anxiety -toleration increases over time -good technique with phobias

What symptoms must a client have to be diagnosed with major depressive disorder?

-must occur almost everyday for two weeks -last most of the day -at least 5 specific clinical findings depressed mood difficulty sleeping or excessive sleeping indecisiveness decreased ability to concentrate suicidal ideation increase or decrease in motor activity inability to feel pressure increase or decrease in weight of more than 5% of total body weight over 1 month

Auditory hallucinations can be...

-nutritional -viral -genetic

What does the grounding technique do for people with anxiety?

-rechannels thoughts -touch the wall and ground -makes client feel safe

Should a nurse report sexual abuse?

-report if child -adult has choice to report or not

What are the clinical manifestations for generalized anxiety disorder (GAD)?

-restlessness -muscle tension -seeks reassurance -avoidance -procrastination

client care for acute mania

-safety -self harm -finger food (decreased appetite)

Under what type of mental health disorder do clients experience command hallucinations?

-schizophrenia -reduce stimuli

What is diazepam used for?

-seizures -relaxes muscles, muscle spasms -do not take with alcohol can cause CNS and respiratory depression

What types of questions should you ask a client who is at risk for suicide?

-strictly open-ended questions -don't ask why questions

How can bipolar disorder develop?

-substance induced -ADHD -grow up with bipolar -genetic

____ out of ____ clients have a mental health problem.

1 out of 5

How long does it take for antidepressants to be effective?

2-7 weeks

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Lets discuss the medications your provider is prescribing to decrease your anxiety."

A. "Tell me about how you are feeling right now."

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I will need to monitor the client for hyponatremia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common side effect of this medication."

A. "This medication increases the release of serotonin and norepinephrine."

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (Select all that apply.) A. "When did you start hearing the voices?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices telling you to hurt yourself." E. "Why are the voices talking to only you?"

A. "When did you start hearing the voices?" C. "It must be scary to hear voices." D. "Are the voices telling you to hurt yourself."

A nurse is working for an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all that apply.) A. Age B. Gender C. History of chronic asthma D. Smoking E. Being married

A. Age B. Gender C. History of chronic asthma D. Smoking

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Assessing the client's risk for self harm B. Instilling hope for positive outcomes C. Encouraging the client to participate in group therapy sessions D. Encouraging the client to participate in treatment decisions

A. Assessing the client's risk for self harm

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat effect

A. Auditory hallucination C. Use of clang associations D. Delusion of persecution

A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply.) A. Concurrent administration of buspirone B. Administration of a different SSRI C. Use of a mouth guard D. Changing to a different class of anti-anxiety medication E. Increasing the dose of paroxetine

A. Concurrent administration of buspirone C. Use of a mouth guard D. Changing to a different class of anti-anxiety medication

A nurse is working on an acute mental health unit is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.) A. Difficulty concentrating on tasks B. Obsessive need to talk about the event C. Negative self-image D. Recurring nightmares E. Diminished reflexes

A. Difficulty concentrating on tasks C. Negative self-image D. Recurring nightmares

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Need for reassurance

A. Excessive worry for 6 months D. Restlessness E. Need for reassurance

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? A. Placing the client on one-to-one observation. B. Assisting the client to perform ADLs. C. Encouraging the client to participate in counseling. D. Teaching the client about medication adverse effects.

A. Placing the client on one-to-one observation.

A nurse is teaching a client who has a new prescription for imapramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Void just before taking the medication. B. Increase the dietary intake of potassium. C. Wear sunglasses when outside. D. Change positions slowly when getting up. E. Chew sugarless gum.

A. Void just before taking the medication. C. Wear sunglasses when outside. E. Chew sugarless gum.

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A. "Why do you think you feel the need to give away money." B. "I am here to provide care and cannot except this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."

B. "I am here to provide care and cannot except this from you."

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and I am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

B. "I am no one, and everyone is me."

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash." B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

B. "I may feel drowsy for a few weeks after starting this medication."

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there too." D. Continue the interview without comment on the client's behavior.

B. Ask the client, "Are you seeing something on the ceiling?"

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestations of a depressive relapse.

B. Difficulty sleeping can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestations of a depressive relapse.

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply.) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation

B. Hallucinations D. Diaphoresis E. Agitation

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority? A. Administer flumazenil. B. Identify the client's level of orientation. C. Infuse IV fluids. D. Prepare the client for gastric lavage.

B. Identify the client's level of orientation.

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following actions should the nurse take first? A. Use therapeutic communication to discuss the hallucination with the client. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

B. Initiate one-to-one observation of the client.

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client complaints E. Use a firm approach with communication

B. Offer concise explanations C. Establish consistent limits E. Use a firm approach with communication

A nurse is caring for a client who is taking phenelzine. For which of the following adverse effects should the nurse monitor? (Select all that apply.) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Headache E. Bruxism

B. Orthostatic hypotension D. Headache

A nurse is usually involved in a serious prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply.) A. Avoid thinking about the actual incident when it is over B. Take breaks during the incident for food and water C. Debrief with others following the incident D. Hold emotions in check in days following E. Take advantage of offered counseling

B. Take breaks during the incident for food and water C. Debrief with others following the incident E. Take advantage of offered counseling

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during maintenance phase lasts for 6-12 weeks." C. "Client is at greatest risk for suicide during first weeks of MDD episode." D. "Medication and psychotherapy are more effective during acute phase of MDD."

C. "Client is at greatest risk for suicide during first weeks of MDD episode."

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disease. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disease." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disease."

C. "ECT is effective for clients who are experiencing severe mania."

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I will use light therapy 30 min/day to prevent further recurrences of PMDD." C. "I am aware that PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

C. "I am aware that PMDD causes me to have rapid mood swings."

A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet while taking this medication." C. "I will need to discontinue this medication slowly." D. "I will be at risk for weight loss with long-term use of this medication."

C. "I will need to discontinue this medication slowly."

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C. Attempt to reduce anxiety

A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthmic disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of a minimum of 5 clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self-esteem

C. Presence of manifestations for at least 2 years

A nurse is reviewing a medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression. B. The client currently smokes 1.5 packs of cigarettes per day. C. The client had a motor vehicle crash last year and sustained an injury. D. The client has BMI of 25 and has gained 10 lb over the last year.

C. The client had a motor vehicle crash last year and sustained an injury.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client explains that her body seems to be floating above the ground. B. The client has the idea that someone is trying to kill her and steal her money. C. The client states that the furniture in the room seems to be small and far away. D. The client cannot recall anything that happened in the past two weeks.

C. The client states that the furniture in the room seems to be small and far away.

True or false: More women have PTSD than men.

False More men have PTSD than women.

If a patient has OCD related to hand washing, what can the nurse do to help them?

Limit the amount of times they wash their hands, wean

What can sexual abuse cause?

PTSD

What is neuroleptic malignant syndrome?

a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction

Which statement is mostly likely to be made by a patient diagnosed with agoraphobia? a. "Being afraid to go out seems ridiculous, but I can't go out the door." b. "I'm sure I'll get over not wanting to leave home soon. It takes time." c. "When I have a good incentive to go out, I can do it." d. "My family says they like it now that I stay home."

a. "Being afraid to go out seems ridiculous, but I can't go out the door."

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. "Converses without interrupting; 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."

a. "Converses without interrupting; clothing matches; participates in activities."

Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states: a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

a. "I cannot recall why I'm living in this town."

Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving the car accident."

a. "I check where my car keys are eight times."

A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion."

A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

a. Acute dystonic reaction

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.

a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply. a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids. d. Restrain the patient in bed with padded limb restraints. e. Assist the patient to prepare an advance directive.

a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids.

A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines b. Allow the patient to telephone a local restaurant to deliver meals c. Offer to taste each portion on the tray for the patient d. Begin tube feedings or total parenteral nutrition

a. Allow the patient to have supervised access to food vending machines

Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Sublimation c. Suppression d. Passive aggression

a. Altruism

A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication? a. Beta-blockers b. Antipsychotic medications c. Tricyclic antidepressant agents d. Monoamine oxidase inhibitors

a. Beta-blockers

A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used? a. Bringing up an irrelevant topic b. Responding to physical needs c. Addressing false cognitions d. Focusing

a. Bringing up an irrelevant topic

A patient says, "I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study." Which term should the nurse use to document this complaint? a. Depersonalization b. Hypochondriasis c. Dissociation d. Malingering

a. Depersonalization

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. Select the best initial approach by the nurse. 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."

a. Distraction: "Let's go to the dining room for a snack."

A nurse assesses a patient suspected to have somatic system disorder. Which findings support the diagnosis? Select all that apply. a. Female b. Reports frequent syncope c. Complains of heavy menstrual bleeding d. First diagnosed with psoriasis at 12 years of age e. Reports of back pain, painful urination, frequent diarrhea, and hemorrhoids

a. Female b. Reports frequent syncope c. Complains of heavy menstrual bleeding e. Reports of back pain, painful urination, frequent diarrhea, and hemorrhoids

A student nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to 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. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia

A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurse's office, furnished with chairs, files, magazines, and bookcases

a. Interview room furnished with a desk and two chairs

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then 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. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

a. Labile and euphoric

A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective approach to communication. 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. Make observations.

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

a. Mashed potatoes, ground beef patty, corn, green beans, apple pie

The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply. a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress

a. Neurobiological d. Genetic

A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict the intake of processed foods.

a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment.

A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such 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

a. Powerlessness c. Chronic low self-esteem

A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply. a. Provide structure b. Limit credit card access c. Encourage group social interaction d. Limit work to half days e. Monitor the patient's sleep patterns

a. Provide structure b. Limit credit card access e. Monitor the patient's sleep patterns

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

a. Psychoeducational

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression

a. Rationalization

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. Risk for injury

A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processes

a. Risk for injury

A patient diagnosed with schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to assault me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

a. Risk for other-directed violence b. Disturbed thought processes

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

a. Sedation and muscle stiffness

Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder 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. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques

a. Social skills training

A patient diagnosed with somatic symptom disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

a. Spiritual distress e. Ineffective role performance

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

a. Supporting physiologic stability

A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.

a. Teach the person to use positive self-talk.

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. 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. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient himself or herself to a pressured work schedule.

a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.

A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.

a. Use a calm manner and low voice. b. Maintain simplicity in the environment. e. Explain and reinforce reality to avoid distortions.

A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder (GAD) who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allow only tyramine-free foods in diet. c. Restrict intake of caffeine. d. Avoid using alcohol and other sedatives. e. Take the medication on an empty stomach.

a. Use caution when operating machinery. c. Restrict intake of caffeine. d. Avoid using alcohol and other sedatives.

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

a. Use of a long-acting antipsychotic injections

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.

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

a. Vital signs d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. 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 should: a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. teach the patient how to use pursed-lip breathing.

a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks.

A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nursing intervention most suitable for assisting the student is to: a. explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. b. advise the student to discuss this experience with a health care provider. c. encourage the student to begin antioxidant vitamin supplements. d. listen without comment.

a. explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects.

The causes of somatic system disorders may be related to: a. faulty perceptions of body sensations. b. traumatic childhood events. c. culture-bound phenomena. d. mood instability.

a. faulty perceptions of body sensations.

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 fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salt and fluids in the diet.

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

a. meals.

A patient diagnosed with schizophrenia begins to talks about "cracklomers" in the local shopping mall. The term "cracklomers" should be documented as: a. neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

a. neologism.

A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.

a. provide for patient safety.

A person who is speaking about a contender for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial.

a. reaction formation.

A nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is: a. risk for self-harm b. cognitive functioning c. identification of drug abuse d. readiness to reestablish identity or memory

a. risk for self-harm

The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

a. several factors, including genetics, are implicated.

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate 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. consent to take 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. verbalize realistic positive characteristics about self by (date).

A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

a. within therapeutic limits

What type of disorder do children experience when they lose a parent?

adjustment disorder

What cannot be taken with Flagyl?

alcohol

Why are patients who take antidepressants at a higher risk for suicide?

antidepressants increase client's energy level

flight of ideas

associative looseness. The client might say sentence after sentence, but each sentence can relate to a different topic, and the listener is unable to follow the client's thoughts.

If someone is waxy (Catetonic, doesn't move or talk) what medication should you administer?

ativan

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

b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder."

A person diagnosed with schizophrenia has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me." Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help if you will let them." d. "Staff members are health care professionals who are qualified to help you."

b. "Feeling that people want to destroy you must be very frightening."

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient: a. "Restrict oral fluids for 24 hours and stay in bed." b. "Have someone bring you to the clinic immediately." c. "Drink a large glass of water with 1 teaspoon of salt added." d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."

b. "Have someone bring you to the clinic immediately."

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: 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 exceptionally hard on yourself when you say those things." d. "How does your belief in fate relate to your cultural heritage?"

b. "Let's look at one bad thing that happened to see if another explanation exists."

A patient says, "I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive restructuring? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking." b. "Let's see whether any other explanations for your vomiting are possible." c. "You seem so worried. Let's talk about how you're feeling." d. "We should talk about something else."

b. "Let's see whether any other explanations for your vomiting are possible."

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 most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider has not already stopped your medication."

b. "Taking the medication every day helps prevent relapses and recurrences."

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. "You look nice this morning." b. "You are wearing a new shirt." c. "I like the shirt you're wearing." d. "You must be feeling better today."

b. "You are wearing a new shirt."

During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should 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. Affect flat; mood depressed

A patient says to the nurse, "My life does not have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint? a. Vegetative symptom b. Anhedonia c. Euphoria d. Anergia

b. Anhedonia

A person comes to the clinic reporting, "I wear a scarf across my lower face when I go out but because of my ugly appearance." Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? a. Dissociative identity disorder b. Body dysmorphic disorder c. Pseudocyesis d. Malingering

b. Body dysmorphic disorder

A patient with blindness related to a functional neurological (conversion) disorder says, "All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital don't find me interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

b. Chronic low self-esteem

A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

b. Concerns stated aloud become less overwhelming and help problem solving to begin.

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

b. Darting eyes, tilted head, mumbling to self

A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner, using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.

b. Describe the procedure again in a calm manner, using simple language.

A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later, and then sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? a. Functional neurological (conversion) disorder b. Dissociative identity disorder c. Dissociative amnesia d. Body dysmorphic disorder

b. Dissociative identity disorder

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

b. Disturbed sleep pattern

A nurse prepares the plan of care for a patient having a 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

b. Disturbed thought processes c. Sleep deprivation

A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patient's symptoms rather than on the patient.

b. Encourage the patient to participate in social activities.

A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

b. Hold a staff meeting to discuss consistency and limit-setting approaches.

A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results are normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Illness anxiety disorder (hypochondriasis) c. Body dysmorphic disorder d. Dissociative amnesia with fugue

b. Illness anxiety disorder (hypochondriasis)

A patient experiencing acute mania 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 most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.

b. Invite the patient to sit with the nurse and look at new fashion magazines.

A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What are they going to do?" Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

b. Moderate

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. 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

b. Neutral walls with pale, simple accessories

A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security

b. Physiologic

A patient experiencing 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 physiologic functioning b. Provide a subdued environment c. Supervise personal hygiene d. Observe for mood changes

b. Provide a subdued environment

Which treatment modality should a nurse recommend to help a patient diagnosed with somatic symptom disorder cope more effectively? a. Flooding b. Relaxation c. Response prevention d. Systematic desensitization

b. Relaxation

A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? a. Anxiety b. Risk for suicide c. Disturbed body image d. Ineffective role performance

b. Risk for suicide

A patient diagnosed with major depressive disorder repeatedly tells staff members, "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. Risk for suicide

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

b. Set limits on the patient's behavior as necessary.

Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior

b. Social withdrawal and ineffective communication

patient has taken trifluoperazine (Stelazine) 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects

b. Tardive dyskinesia

A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taking your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking

b. The importance of correctly taking your medication e. Ways to quit smoking

A nurse observes a patient who is diagnosed with schizophrenia. The patient is standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

b. Waxy flexibility

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5?2'6?3? tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

b. Weight management strategies

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

b. an idea of reference.

A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably: a. readily seek psychiatric counseling. b. be resistant to accepting psychiatric help. c. attend psychotherapy sessions without encouragement. d. be eager to discover the true reasons for physical symptoms.

b. be resistant to accepting psychiatric help.

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

b. bring hyperactivity under rapid control.

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

b. carefully and inconspicuously observing the patient around the clock.

A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. assume roles and functions of the other family members. b. demonstrate a resumption of former roles and tasks. c. focus energy on problems occurring in the family. d. rely on family members to meet his or her personal needs.

b. demonstrate a resumption of former roles and tasks.

A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply should be based on the knowledge that buspirone: a. does not produce blood dyscrasias. b. does not cause dependence. c. can be administered as needed. d. is faster acting than diazepam.

b. does not cause dependence.

This nursing diagnosis applies to a patient experiencing 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 the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 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 mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day.

A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed himself or herself after explaining the arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed himself or herself unassisted. d. address the needs of other patients in the dining room, and then feed this patient.

b. expect the patient to feed himself or herself after explaining the arrangement of the food on the tray

A nurse instructs a patient taking a drug 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. hypertensive crisis.

A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as an as-needed (PRN) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)

b. lorazepam (Ativan)

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. chlorpromazine (Thorazine) d. diphenhydramine (Benadryl)

b. olanzapine (Zyprexa)

A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.

b. perform self-care activities with coaching by the end of day 3.

A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is: a. suppressing accurate feelings regarding the problem. b. relieving anxiety through the physical symptom. c. meeting needs through hospitalization. d. refusing to disclose genuine fears.

b. relieving anxiety through the physical symptom.

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

b. report increased suicidal thoughts.

grandeur

believes that she is powerful and important, like a god

A patient diagnosed with bipolar disorder is hyperactive and manic 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?"

c. "Do not hit anyone. If you are unable to control yourself, we will help you."

Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"

c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"

A patient's roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. Dissociative identity disorder (DID) is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply. a. "Are you sexually promiscuous?" b. "Do you think you need an antidepressant medication?" c. "Have you ever found yourself someplace and did not know how you got there?" d. "Are your memories of childhood clear and complete, or do you have blank spots?" e. "Have you ever found new things in your belongings that you can't remember buying?"

c. "Have you ever found yourself someplace and did not know how you got there?" d. "Are your memories of childhood clear and complete, or do you have blank spots?" e. "Have you ever found new things in your belongings that you can't remember buying?"

A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I will stay with you. Focus on what we are talking about, not the voices." d. "Forget the voices. Ask some other patients to sit and talk with you."

c. "I will stay with you. Focus on what we are talking about, not the voices."

A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."

c. "I'm not sure I understand. Give me an example."

A patient being treated for major depressive disorder 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 should advise the patient: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider." d. "Resume taking the antidepressant for 2 more weeks, and then discontinue it again."

c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider."

If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. "I don't know why it happens." b. "I have always had poor impulse control." c. "That person should not have provoked me." d. "Inside I am a coward who is afraid of being hurt."

c. "That person should not have provoked me."

A woman wears a size 7 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." The patient tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a. Dissociative amnesia with fugue b. Illness anxiety disorder c. Body dysmorphic disorder d. Dissociative identity disorder

c. Body dysmorphic disorder

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

c. Broiled chicken breast on a roll, an ear of corn, apple

A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to overdose me." How does this patient perceive the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarre

c. Dangerous

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea

A patient who fears serious heart disease was referred to the mental health center by a cardiologist after diagnostic evaluation showed no physical illness. The patient says, "My heart misses beats. I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Body dysmorphic disorder b. Antisocial personality disorder c. Illness anxiety disorder (hypochondriasis) d. Persistent depressive disorder (dysthymia)

c. Illness anxiety disorder (hypochondriasis)

The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to: a. Verify the patient's learning style. b. Create outcomes and a teaching plan. c. Lower the patient's current anxiety level. d. Assess how the patient uses defense mechanisms.

c. Lower the patient's current anxiety level.

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. 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 deficit and sad mood

c. Poor judgment and hyperactivity

A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation

c. Poor personal hygiene

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

c. Projection

For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.

c. Provide calm, brief, directive communication.

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

c. Pseudoparkinsonism

A person has minor physical injuries after an automobile accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

c. Severe

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

c. Situational low self-esteem

Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to: a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.

c. avoid alcoholic beverages.

Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. asks, "What's the matter with me?" b. stays in a room alone and paces rapidly. c. can concentrate on what the nurse is saying. d. states, "I don't want anything to eat. My stomach is upset."

c. can concentrate on what the nurse is saying.

A patient diagnosed with bipolar disorder has rapid 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. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

c. carbamazepine (Tegretol)

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.

c. clear the room of all other patients.

When counseling patients diagnosed with major depressive disorder, 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.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. 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. consults the pharmacist when selecting over-the-counter medications. d. can identify foods with high selenium content, which should be avoided.

c. consults the pharmacist when selecting over-the-counter medications.

A patient was started on escitalopram (Lexapro) 5 days ago and 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 change medications. 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 symptom relief.

c. explain the time lag before antidepressants relieve symptoms.

A patient has the nursing diagnosis Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. ensuring the health of household members b. attempting to avoid interactions with others c. having persistent thoughts about bacteria, germs, and dirt d. needing approval for cleanliness from friends and family

c. having persistent thoughts about bacteria, germs, and dirt

A patient tells a nurse, "My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can't find a single flaw." This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation.

c. idealization.

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

c. lamotrigine (Lamictal)

A patient diagnosed with somatic symptom disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. unsuccessful. b. minimally successful. c. partially successful. d. totally achieved.

c. partially successful.

A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

c. put a blanket around the patient, and walk with the patient to a quiet room.

A patient diagnosed with somatic symptom disorder says, "I have pain from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. mood. b. cognitive style. c. secondary gains. d. identity and memory.

c. secondary gains.

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

c. self-control of distorted thinking.

To assist a patient diagnosed with a somatic system disorder,a nursing intervention of high priority is to: a. imply that somatic symptoms are not real. b. help the patient suppress feelings of anger. c. shift the focus from somatic symptoms to feelings. d. investigate each physical symptom as soon as it is reported.

c. shift the focus from somatic symptoms to feelings.

A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. acrophobia. b. agoraphobia. c. social anxiety disorder (social phobia). d. Post-traumatic stress disorder (PTSD).

c. social anxiety disorder (social phobia).

thought stopping

client says "stop" when negative thoughts or compulsive behaviors arise -substitute a positive thought

Which assessment question would be most appropriate for the nurse to ask a patient who has possible generalized anxiety disorder (GAD)? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"

d. "Do you find it difficult to control your worrying?"

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."

d. "I am having difficulty understanding what you are saying."

A patient became severely depressed when the last of 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. "The staff here cares about you and wants to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say negative things about yourself." d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Do the messages from the voice frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"

d. "What is the voice telling you to do?"

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You are laughing. Tell me what's happening."

d. "You are laughing. Tell me what's happening."

Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

A patient diagnosed with schizophrenia says, "High heat. Last time here. Did you get a coat?" What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

d. Associative looseness

Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure

d. Congestive heart failure

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention? 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.

d. Consider the need to check the lithium level. The patient may not be swallowing medications.

A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial

d. Denial

What is the primary difference between somatic system disorders and dissociative disorders? a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic. b. Dissociative disorders are precipitated by psychological factors, whereas somatic system disorders are related to stress. c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound. d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychological stress through somatic symptoms.

d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychological stress through somatic symptoms.

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

d. Eyes pointed downward

Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d. Milk

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurse's best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, low fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

A patient diagnosed with schizophrenia says, "Everyone has skin lice that jump on you and contaminate your blood." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

d. Paranoia

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

d. Psychoeducation

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

d. Risk for other-directed violence

A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. 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. Urinary retention

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)

d. aripiprazole (Abilify)

A patient experiencing 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.

d. arrange for one-on-one supervision.

A patient experiencing severe anxiety suddenly begins running and shouting, "I'm going to explode!" The nurse should: a. say, "I'm not sure what you mean. Give me an example." b. chase after the patient, and give instructions to stop running. c. capture the patient in a basket-hold to increase feelings of control. d. assemble several staff members and state, "We will help you regain control."

d. assemble several staff members and state, "We will help you regain control."

Patients diagnosed with schizophrenia who are suspicious and withdrawn: a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

d. avoid relationships because they become anxious with emotional closeness.

Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder: Disturbed personal identity, related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

d. cognitive distortions associated with unresolved childhood abuse issues.

A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.

d. cognitive restructuring.

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. repression. b. devaluation. c. identification. d. compensation.

d. compensation.

For a patient diagnosed with dissociative amnesia, complete this outcome: "Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: a. functioning independently." b. verbalizing feelings of safety." c. regularly attending diversional activities." d. describing previously forgotten experiences."

d. describing previously forgotten experiences."

A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, "You must bathe daily." d. firmly and neutrally assist the patient with showering.

d. firmly and neutrally assist the patient with showering.

A nurse assessing a patient diagnosed with a somatic system disorder is most likely to note that the patient: a. readily sees a relationship between symptoms and interpersonal conflicts. b. rarely derives personal benefit from the symptoms. c. has little difficulty communicating emotional needs. d. has unmet needs related to comfort and activity.

d. has unmet needs related to comfort and activity.

A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." The nurse should help the patient by: a. encouraging meditation. b. administering an anxiolytic medication. c. helping the patient visualize a pleasant scene. d. helping the patient focus on the here and now.

d. helping the patient focus on the here and now.

A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.

d. ineffectiveness and frustration.

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

d. maintain a normal social interaction distance from the patient.

A patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, "You are mean and nasty. No one trusts you or wants to be around you." Select the most likely analysis. The patient: a. is trying to manipulate the nurse by using negative comments. b. is likely to experience disorganization and catatonia in the near future. c. is jealous of the nurse's position of power in the relationship. d. may be identifying another person's shortcomings in order to preserve his or her own self-esteem.

d. may be identifying another person's shortcomings in order to preserve his or her own self-esteem.

A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nurse can correctly assess the student's experience as: a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety.

d. mild anxiety.

A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates: a. acting out. b. projection. c. suppression. d. passive aggression.

d. passive aggression.

To plan effective care for patients diagnosed with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. are generally chronic in nature. b. have a physiological basis. c. can be voluntarily controlled. d. provide relief from health anxiety.

d. provide relief from health anxiety.

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse

d. relapse

What is early isolation a symptom for?

depression

What does DSM stand for?

diagnostic systemic manual -book of disorders and their manifestations, diagnostic criteria

Visual hallucinations are usually...

drug induced

How often should lithium levels be checked?

every 3 months

What is the reversal agent for benzodiazepines?

flumazenil

If a patient is taking MAOIs what should be avoided in their diet?

foods high in tyramine which include: -red wine -smoked meats -beer -soy products -strong or aged cheeses -pickled products -rasberries -avocados -sourdough bread

auditory hallucination

hearing voices or sounds

dissociative amnesia

inability to recall personal information regarding stressful events for a period of time

delusion

involves cognitive deficits, sleep-wake cycle -irreversible

Ideas of reference

misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about him

Can you have psychosis with depressive disorders?

no

visual hallucination

seeing persons or things

What is a major side effect of electroconvulsive therapy?

short-term memory loss

What is the side effect of Haloperidol?

shuffling gait

Why does tardive dyskinesia develop?

sometimes develops after long-term treatment with antipsychotics

What is major risk when giving children fluxetine (Prozac)?

suicide

What should you assess for if the patient is depressed?

suicide

When someone is giving away their belongings they are at risk for?

suicide

delirium

temporary mental state with sudden onset, usually reversible -S&S: confusion, inability to concentrate, disorientation, anxiety, and sometimes hallucinations -can be from alcohol or UTI

command hallucination

the voice instructs the client to perform an action, such as to hurt self or others

Why should a manic client have finger food?

they are not able to sit down and eat

What should be done to antipsychotics before they administered?

they should be titrated down

Why do depressed client have substance abuse issues?

they try to self medicate

world health organization disability assessment schedule (WHODAS)

this scale helps to determine the client's level of global functioning, scale is used to rate how serious a mental illness may be. It measures how much a person's symptoms affect his or her day-to-day life on a scale of 0 to 100.

abnormal involuntary movement scale (AIMS)

this tool is used to monitor involuntary movements and tardive dyskinesia in clients who take antipsychotic medication

True or false: Two people can experience the same trauma and only one of them will have PTSD.

true

word salad

words jumbled together with little meaning or significance to the listener, such as, "Hip hooray, the flip is cast and wide-sprinting in the forest."