Mental Health Midterm
A nurse is assessing a client who is currently taking perphenazine (Trilafon), for extrapyramidal symptoms (EPS). Which of the following is not an extrapyramidal symptom? a. Continual pacing b. Urinary Retention c. Drooling d. Involuntary arm movements
b. Urinary retention Rationale: Urinary retention is an anticholinergic effect, not EPS.
A nurse is discussing routine follow-up needs for a client who was started on clozapine (Cloazaril) while hospitalized. The nurse should inform the client of the need for routine monitoring of which of the following? a.WBCs, ANC and platelet counts b. BUN and creatinine c. Serum sodium and potassium d. ALT and AST
A. .WBCs, ANC and platelet counts Rationale: Clozapine (Clozaril) carries a black box warning and has a restricted distribution due to severe neutropenia risk that can lead to serious infection and death. Patient's need to adhere to frequent blood monitoring of Absolute Neurtraphil Count ((ANC) to insure safety prior to filling prescriptions for clozapine.
A client says she is experiencing increased stress because her significant other is "pressuring me and my children to go live with him. I love him, but I'm not ready to do that." She also states that her significant other "keeps nagging at my oldest son, which makes me mad, since he's my son, not his." Which of the following should the nurse recommend to promote a change in the client's situation? a. Use assertiveness techniques b. Rely on the support of a close friend c. Learn to practice mindfulness d. Exercise regularly
A. Use assertiveness techniques Rationale: Assertive communication allows the client to assert her feelings and then make a change in the situation.
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following does not belong in the plan of care? A. "I am a superhero and am immortal." B. "I am no one and everyone is me" C. "I know that you are stealing my thoughts." D. "I feel monsters pinching me all over"
B. "I am no one and everyone is me" Rationale: The comment indicates the client is experiencing a loss of identity and depersonalization.
A nurse is discussing normal uncomplicated grief with a client who recently lost a child. Which of the following statements made by the client requires additional intervention? a. "I may withdraw from others." b. "I may experience feelings of resentment" c. "It is possible to experience suicidal thoughts" d. It is possible to experience changes in sleep."
C. "It is possible to experience suicidal thoughts" Rationale: Suicidal ideations are associated with dysfunctional grieving. Therefore, this response requires additional intervention.
A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following is an expected finding? A. Diminished reflexes B. Recurring Nightmares C. Exaggerated displays of Emotions D. Obsessive need to talk about the traumatic event
C. Recurring Nightmares Rationale: These are associated with traumatic events are an expected finding of PTSD.
A nurse is assessing a client 4 hours after receiving an initial dose of flouxetine (Prozac). Which of the following findings should the nurse report to the provider as an indication of serotonin syndrome? a. Muscular Flaccidity b. Hypotension c. Constipation d. Hyperthermia
D. Hyperthermia Rationale: A fever is an indication of serotonin syndrome, along with agitation, diaphoresis, muscle twitching, and hallucinations
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following does not belong in the plan of care? A.Use a firm approach with communication B. Offer concise explanations C. Address the client's complaints D. Provide flexible client behavior expectations E. Establish consistent limits
D. Provide flexible client behavior expectations Rationale: The nurse should establish consistent client behavior expectations to decrease the risk of client manipulation.
Which of the following statements is true? a. People with mental health problems are violent and unpredictable b. Healthy people are not affected by traumatic events c. Mental disorders are signs of weakness or personality flaws d. Suicide is the tenth leading cause of death in the US.
D. Suicide is the tenth leading cause of death in the United States. Rationale: According to the Center for Disease Control (CDC), suicide is the 10th leading cause of death. However, it is the 2nd leading cause of death in age groups between 10 and 34 years of age. Fourth leading cause of death in ages 35 to 54 (2014).
A nurse is interviewing a 25-year old client who has a new diagnosis of Persistent Depressive Disorder (dysthymia). Which of the following findings should the nurse expect? A. There is an inflated sense of self-esteem B. The presence of manifestations for a least two years. C. There are wide fluctuations in mood D. The report of a minimum of five clinical findings of depression.
D. The report of a minimum of five clinical findings of depression. Rationale: The essential feature of dysthymia is depressed mood that occurs for most of the day, for more days than not, for at least 2 years (at least 1 year for children and adolescents)
A nurse is completing an admission assessment for a client who has schizophrenia and documenting positive symptoms. Which of the following findings should the nurse document as a negative symptom? A. Auditory hallucinations B. Use of clang associations C. Constantly waving arms D. Delusions of persecution E. Flat affect
E. Flat affect Rationale: Flat affect is an example of negative symptoms
A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse should: a Firmly and neutrally assist the patient with showering. b. Avoid forcing the issue c. Calmly tell the patient, "You must bathe daily" d. Bring up the issue at the community meeting
a. Firmly and neutrally assist the patient with showering. Rationale: When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem Calmly telling the patient to bather daily and bringing up the issue at a community meeting are punitive.
A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following is not associated with delirium? a. History of gradual memory loss b. Hallucinations c. Restlessness d. Family report of personality changes e. Altered level of consciousness
a. History of gradual memory loss. Rationale: The client who has delirium may experience memory loss with sudden rather than gradual onset.
Psychotherapy involves all below except: a. Appropriate Medications b. Positive expectancy c. Therapeutic relationship d. Neural plasticity
a. appropriate medications Rationale: Medication is not used in psychotherapy.
A nurse observes a client wringing her hands and looking frightened. The client reports to the nurse that she "feels out of control." Which approach by the nurse is most appropriate to maintain a safe environment? a. Move the client to a quiet area and talk about her feelings. b. Administer the prescribed PRN antianxiety medication immediately. c. Observe the client in an ongoing manner but do not intervene d. Isolate the client in a "time-out" room
Move the client to a quiet area and talk about her feelings. Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet location decreases environmental stimulus. Talking provides the nurse an opportunity to assess the cause of the client's feelings and to identify appropriate interventions. Isolation is appropriate if a client is a danger to self or others. Medication is used only when other noninvasive approaches have been unsuccessful.
In performing a lethality assessment with a suicidal client, the nurse most appropriately asks the client: a. "Do you have any thoughts of killing yourself?" b. "Do you wish your life was over?" c. "Do you have a death wish?" d. "Do you ever think about ending it all?"
a. "Do you have any thoughts of killing yourself?" Rationale: A lethality assessment requires direct communication between the client and the nurse concerning the client's intent. It is important to provide a question that is directly related to lethality. Euphemisms should be avoided.
A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get the bugs off me." What is the nurse's best response? a. "I don't see any bugs, but I know you are frightened so I will stay with you." b. "There are no bugs on your legs. Your imagination is playing tricks on you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "Don't worry, I will have someone stay here and brush off the bugs for you."
a. "I don't see any bugs, but I know you are frightened so I will stay with you." Rationale: When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering to help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.
A nurse is caring for a client who is on lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements by the nurse is appropriate? a. "Regular aspirin would be a better choice than ibuprofen" b. "That is a good choice. Ibuprofen does not interact with lithium." c. "Lithium decreases the effectiveness of ibuprofen" d. "The ibuprofen will make your lithium level fall too low"
a. "Regular aspirin would be a better choice than ibuprofen" Rationale: Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk for lithium toxicity.
A client with a history of depression will be participating in cognitive therapy for health maintenance. The client says to the nurse, "How does this treatment work?" The nurse makes which statement to the client? a. "This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties." b. "This type of treatment helps you examine how your past life has contribute to your problems." c. "This type of treatment will help you relax and develop new coping skills." d. "This type of treatment help you confront your fears by gradually exposing you to them."
a. "This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties." Rationale: Cognitive therapy is frequently used with clients who have depression. this type of therapy is based on exploring the client's subjective experience. It includes examining the client's thoughts and feelings about situations as well as how these thoughts and feelings contribute to and perpetuate the client's difficulties and mood. The other options are not characteristics of cognitive therapy.
What is the mnemonic to remember for the Mental Health Action Plan? a. ALGEE (Assess, Listen, Give Reassurance, Encourage treatment, Encourage self-help and supportive strategies) b. ASEPTIC (appearance and behavior, Speech, Emotion-mood and affect, Perception, Thought-content and process, Insight and judgement, Cognition) c. ADPIE (Assessing, Diagnosing, Planning, Implementing, Evaluation) d. ACT (Act, Care, Treat)
a. ALGEE (Assess, Listen, Give Reassurance, Encourage treatment, Encourage self-help and supportive strategies) Rationale: This is the mental health action plan.
Which nursing diagnosis is written correctly? a. Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20 lbs. weight loss. b. Risk for social isolation related to low self-esteem evidenced by staying in room during the day. c. Conduct disorder related to childhood sexual abuse evidenced by hostile and aggressive behaviors. d. Low self-esteem related to major depressive disorder evidenced by childhood abuse.
a. Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20 lbs. weight loss. Rationale: Imbalanced nutrition: less than body requirements related to suspiciousness evidenced by 20 lbs. weight loss is a correctly written nursing diagnosis. Evidence of a nutritional problem is documented and the cause of the problem, suspiciousness, is identified. "Imbalanced nutrition: less than body requirements" is an approved NANDA diagnostic stem.
A nurse in a psychiatric unit is caring for a patient who is being admitted involuntarily after attacking a neighbor. The nurse should know that a patient can be kept in the hospital against her will (involuntarily) if the patient a. Is a danger to herself or others b. Is unwilling to accept that treatment is needed. c. Does not have anyone that she could stay with. d. Is financial incapable of paying for prescribed medications.
a. Is a danger to herself or others. Rationale: Clients who have mental health problems can be admitted from care voluntarily or involuntarily. The criteria for involuntary admission includes a statement of the opinion that the patient has a mental disorder that will likely result in serious bodily harm to the person, or another person, unless the patient remains in a psychiatric facility. The other three options are not significant grounds for supporting involuntary status.
A client says, "I plan to commit suicide." Which of the following should be the nurse's priority assessment? a. Lethality of method and availability of means b. Quality of client's social support c. Client's insight into the reasons for the decision d. Client's educational and economic background
a. Lethality of method and availability of means Rationale: The greatest risk to the client is self-harm as a result of carrying out a suicide plan. Therefore, the priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.
Sixteen years ago a toddler died in a tragic accident. Once a year, the parents place flowers at the accident site. How would the nurse characterize the parents' behavior? a. Mourning b. Bereavement c. Complicated grief d. Disenfranchised grief
a. Mourning Rationale: Mourning refers to all of the ways in which a person outwardly expresses grief and the efforts taken to manage grief. It does not have a designated time frame and may continue for many years. A once-a-year ritual is an adaptive coping technique to recognized the parents' loss.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient has difficulty swallowing and is drooling. By 4:00 PM, the 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. The patient is diaphoretic. Select the nurse's best analysis and action. a. Neuroleptic malignant syndrome. Immediately notify the health care provider. b. Agranulocystosis. Institute reverse isolation. c. Cholestatic jaundice. Begin a high-protein, high-cholesterol diet. d. Tardive dyskinesia. Withhold the next dose of medication.
a. Neuroleptic malignant syndrome. Immediately notify the health care provider. Rationale: Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in this scenario are not consistent with the medical problems listed in the incorrect options.
This nursing diagnosis applies to a patient with 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. drink six servings of a high-calorie, high-protein drink each day b. Consistently sit with others for a least 30 minutes at mealtime within 1 week c. Consistently wear appropriate attire for age and sex within one week while in the psychiatric unit d. Ask staff for assistance with feeding within 4 days.
a. drink six servings of a high-calorie, high-protein drink each day. Rationale: High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity Sitting with others or asking for assistance does not mean the patient will eat or drink. the other indicator is unrelated to the nursing diagnosis.
A client is complaining of difficulty concentrating, having outbursts of anger, and feeling "keyed up" all the time. The nurse obtaining the client's history discovers that the symptoms started about 6 months ago. The client reveals that a best friend was killed in a drive-by shooting while they were sitting on the porch talking. The nurse suspects that the client is experiencing: a. Post-traumatic stress disorder (PTSD) b. b. Intermittent explosive disorder (IED) c. Panic disorder d. Acute stress disorder (ASD)
a. Post-traumatic stress disorder (PTSD) Rationale: Post-traumatic stress disorder (PTSD) is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, or outbursts of anger. Acute stress disorder (ASD) shares many of the same characteristics as PTSD, including emotional numbness, restlessness, anxiety, uncharacteristic irritability, problems focusing or concentrating, flashbacks, and sleep disturbance. There are two important distinctions between ASD and PTSD. One is that ASD is considered a more immediate, short-term response to trauma that lasts between two days and four weeks. The second being that ASD is more associated with dissociative symptoms. Panic disorder is characterized by as specific fear of a object or situation. Intermittent explosive disorder (IED) is characterized by an explosive outburst of anger to the point of rage along with impulsive aggression. These aggressive acts are frequently reported accompanied by a sensation of relief and in some cases pleasure, but often followed by later remorse.
A 22-year old college student presented to the ER with hypertension (BP= 200/110), tachycardia, cramping, hyperreflexia, and myoclonus. He was taking phenelzine (Nardil) and had been out to a restaurant with friends. What is the most likely food/drink that could have interacted with the medication? a. Red wine b. Eggs c. Cucumbers d. Grapefruit juice
a. Red wine Rationale: Monoamine inhibitors (MAOIs) inhibit the enzyme (MAO) that breaks down monoamine neurotransmitters (i.e., dopamine, norepinephrine, serotonin) once they have been pumped back into the presynaptic cell. While taking MAOIs, certain foods and alcohol that are high in the amino acid tyramine (aged, pickled, processed) can cause a severe hypertensive crisis and should be avoided. Alcohol (specifically beer and red wine) should be avoided or should be limited to only 4 ounces per day.
The client admitted to the mental health unit with major depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today, the client appears in the dayroom dressed and well-groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior? a. Speak to the client personally about the nurse's observations, and ask if the client is thinking about suicide. b. Continue to monitor the client's behavior from a distance. c. Notify the staff of these observations at the team meeting, which will begin in 3 hours. d. Document that the client is adapting to the unit and is feeling safe.
a. Speak to the client personally about the nurse's observations, and ask if the client is thinking about suicide. Rationale: A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other options are not the most appropriate initially.
A patient has taken trifluoperazine (Stelazine) 30mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders also move slowly in a snakelike motion. Which problem would the nurse suspect? a. Tardive dyskinesia b. Agranulocytosis c. Anticholinergic effects d. Tourette syndrome
a. Tardive dyskinesia Rationale: Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are observed. These symptoms are frequently not reversible, even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette syndrome is a condition in which tic are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.
A patient with major depression was hospitalized for 8 days. Treatment included six electro-convulsive 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 rational for this counseling. a. Temporary memory impairments and confusion are associated with electro-convulsive therapy. b. The patient needs time to reorient him- or herself to the pressured work schedule c. Antidepressant medications alter catecholamine levels, which impair decision making abilities d. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet.
a. Temporary memory impairments and confusion are associated with electro-convulsive therapy. Rationale: Recent memory impairment or confusion or both are often present during and for a short time after electro-convulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient him- or herself to a pressured work schedule is less relevant than the correct rationale.
A patient is started on a regimen of lamotrigine (Lamictal) 50 mg daily for bipolar depression. The client shows the nurse a red and purple rash on his arm that is blistering and peeling. What is the most likely explanation? a. The rash is a rare adverse effect which causes a toxic epidermal necrolysis b. The medication increases the patient's sensitivity to sunlight resulting in a sunburn from not using protection. c. The rash is a common side effect which resolves after the medication reaches therapeutic range. d. The patient is experiencing a benign rash to the medication which can be treated with diphenhydramine (Benadryl).
a. The rash is a rare adverse effect which causes a toxic epidermal necrolysis. Rationale: Stevens-Johnson syndrome is a serious rash requiring hospitalization and discontinuation of treatment. The incidence of this rash is approximately 0.08% in patients being prescribed Lamictal for mental health issues (higher for those being prescribed it for seizure disorders). The rash develops during in the first few months of the medication being titrated especially if the medication is increased too quickly. The potential to develop Steven-Johnson syndrome increase when Lamictal is used as adjunct therapy with Valproic Acid (Depakote).
A client tells the nurse, "I am a spy for the FBI. I am an eye, an eye in the sky." The nurse recognizes that this is an example of: a. Echolalia b. Clang associations c. Loosened associations d. Word Salad
b Clang associations Rationale: Repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language patten seen in schizophrenia. Clang associations often take the form of rhyming. Loosened associations occur when the individual speaks with frequent changes of subject, and the content is only obliquely related. Echolalia is the involuntary parrot-like repetition of words spoken by others. Word salad is the use of words with no apparent meaning attached to them or to their relationship to one another.
A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which of the following statements, if made by the student, indicates an understanding of the focus of this form of therapy? a. "A behavioral approach to changing behavior is the focus of milieu therapy." b. "A living, learning, or working environment is the focus of milieu therapy." c. "Milieu therapy provides a behavior modification approach type of therapy." d. "Milieu therapy provides a cognitive approach to changing behavior."
b. "A living, learning, or working environment is the focus of milieu therapy." Rationale: Milieu therapy, or "therapeutic community," has as its focus a living, learning, or working environment. Such therapy may be based on any number of therapeutic modalities, from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu therapy may include behavioral approaches, its primary focus is described in the correct option.
The nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization. When the nurse enters the client's room, the client asks the nurse, "Could you ask the physician to let me have a pass for the weekend?" The nursing response that assists the client in achieving these goals is: a. "You can't have a pass for the weekend. You are not ready, and I'm sure that your doctor will say no." b. "When the physician arrives on the unit, I will let him or her know that you have a question." c. "When your doctor comes in, I will ask for a pass for the weekend." d. "I will call the doctor and find out if you can have a pass so that you can make your arrangements."
b. "When the physician arrives on the unit, I will let him or her know that you have a question." Rationale: The nurse should become aware of the client's strengths and encourage the client to work at the optimal level of functioning. In "When the physician arrives on the unit, I will let him or her know that you have a question." the nurse is helping the client develop resources. The nurse does not act for clients unless absolutely necessary and then only as a step toward helping clients act on their own. Consistently encouraging clients to use their own resources helps minimize clients' feelings of helplessness and dependency and also validates their potential for change.
A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's best response? a. "If you feel this way, you should talk to a member of your clergy." b. "You sound upset about this." c. "Why do you think that?" d. "You believe God is punishing you for your sins?"
b. "You sound upset about this." Rationale: The nurse reflects on the patient's comment, a therapeutic technique to encourage sharing for perceptions and feelings. The incorrect responses reflect probing, closed-ended comments, and giving advice, all of which are non-therapeutic.
What is the peak onset of schizophrenia in males? a. 26-45 years b. 17-25 years c. 24-31 years d. 22-27 years
b. 17-25 years Rationale: The peak onset of schizophrenia in males is between the ages of 17 - 25 years. Peak onset in females is later, 24 to 35 years.
A nurse assess a confused older adult. The nurse experiences sadness and reflects, "the patient is like one of my grandparents...so helpless." What feelings does the nurse describe? a. Catastrophic reaction b. Countertransference c. Defense coping reactions d. Transference
b. Countertransference Rationale: Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view about the world.
A nurse wants to find a description of diagnostic criteria for a person with schizophrenia. Which resource should the nurse consult? a. Wikipedia b. DMS V c. North American Nursing Diagnosis Association (NANDA) International d. Journal of the American Psychiatric Association
b. DSM V Rationale: The DSM V identifies diagnostic criteria for psychiatric diagnoses. the other sources have useful information but are not the best resources for finding a description of the diagnostic criteria for a psychiatric disorder.
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions is appropriate to include in the plan of care? a. Establishing boundaries b. Discussing ways to use new behaviors c. Developing goals d. Practicing new problem-solving skills
b. Discussing ways to use new behaviors. Rationale: Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase.
A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." the nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? a. Offering general leads b. Restating c. Focusing d. Summarizing
b. Restating Rationale: Restating allows the nurse to repeat the main idea expressed.
A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Risk for suicide c. Social isolation d. Compromised family coping
b. Risk for suicide Rationale: This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.
Health maintenance and promotion efforts for patients with severe and persistent mental illness should include education about the importance of regular: a. Monitoring of self-care abilities b. Screening for cancer, HTN and diabetes c. Home safety inspections d. Determination of adequacy of a patient's support system
b. Screening for cancer, HTN and diabetes Rationale: Individuals with severe mental illness have an increased prevalence of medical disorders. Patients should be taught the importance of regular visits to a primary care physician for screening for these illnesses. Home safety inspections are more often suggested for patient s with physical impairments. Caregivers and family members usually evaluate self-care abilities, rather than the patient. Assessment of a patient's support is not usually considered part of health promotion and maintenance.
A nurse assesses a client at a community mental health facility using the SAD PERSONS tool. The nurse knows that this tool provides which of the following data related to the client? a. Problem-solving ability b. Suicide potential c. Stress inventory d. Current anxiety level
b. Suicide potential Rationale: SAD PERSONS is a tool that provides data related to a client's suicide potential.
The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will: a. describe feelings associated with loss and stress. b. identify healthy coping behaviors in response to stressful events. c. allow others to assume responsibility for major areas of own life. d. meet own needs without considering the rights of others.
b. identify healthy coping behaviors in response to stressful events. Rationale: The patient's ability to identify healthy coping behaviors indicates adaptive, healthy behavior and demonstrates an increased ability to recover from severe stress. Describing feelings associated with loss and stress does not move the patient towards adaptation. The remaining options are maladaptive behaviors.
A nurse is caring for a client with delirium who states, "Look at the spiders on the wall." The nurse makes which response to the client? a. "I can see the spiders on the wall, but they are not going to hurt you." b. "Would you like me to kill the spiders for you?" c. "I know you are frightened, but I do not see spiders on the wall." d. "You're having a hallucination; there are no spiders in this room at all."
c. "I know you are frightened, but I do not see spiders on the wall." Rationale: When hallucinations are present, the nurse should reinforce reality with the client. In option 3, the nurse addresses the client's feelings and reinforces reality. Option 1 and 2 do not reinforce reality. Option 4 reinforces reality but does not address the client's feelings.
A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my family and friends." b. "Sometimes I think I hear bombs exploding, but its just the noice of traffic in my hometown." c. "I saw my best friend get killed by a roadside bomb. It should have been me instead." d. "I sometimes have trouble sleeping and waking up with night tremors."
c. "I saw my best friend get killed by a roadside bomb. It should have been me instead." Rationale: he correct response indicates the soldier is thinking of death and feeling survivor's guilt. These emotions may accompany suicidal ideations, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. Several options are indicative of flashbacks, which is common with PTSD. the other option is a normal emotional response associated with returning home.
Which remark by a patient indicates passage from the orientation phase to the working phase of a nursing-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about my problems." c. "I want to find a way to deal with my anger without becoming violent." d. "I don't know how talking about things twice a week can help."
c. "I want to find a way to deal with my anger without becoming violent." Rationale: Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before raport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during orientation phase.
A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client's daughter is hypervigilant and anxious. The daughter says to the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which of the following responses by the nurse would be therapeutic? a. "Your mother has decided to have this treatment. You should support her." b. "Maybe you'll feel better if you see the ECT room and speak to the staff." c. "It sounds as though you are very concerned about the procedure. Let's discuss the procedure." d. "I think you need to speak directly to the psychiatrist."
c. "It sounds as though you are very concerned about the procedure. Let's discuss the procedure." Rationale: The most effective responses to a client or family member who is visibly anxious and upset are those that use therapeutic communication techniques. Therapeutic communication includes active collaboration that facilitates problem solving, change, learning, and growth. The correct option addresses the daughter's concerns while upholding the dignity of the client. When these concerns are verbalized, the nurse can then give information that may help allay fears. "I think you need to speak directly to the psychiatrist." "Maybe you'll feel better if you see the ECT room and speak to the staff." and "Your mother has decided to have this treatment. You should support her." are nontherapeutic responses.
A patient who is on haloperidol (Haldol) at bedtime also receives benztropine (Cogentin) at the same time.The nurse instructs the patient that the benztropine is given to: a. Enhance the effects of haloperidol b. Enhance the anticholinergic effects of the medications. c. Combat extrapyramidal side effects (EPS) d. Enhance sleep
c. Combat extrapyramidal side effects (EPS) Rationale: Haloperidol is a neuroleptic medication that may cause the patient to experience EPS. Antiparkinsonian medications such as benztropine may be administered concurrently to decrease the symptoms of EPS.Options 2, 3, and 4 are incorrect.
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client? a. Use a low-pitched voice and speak slowly b. Reassure the client that everything will be okay c. Demonstrate a calm manner while using simple and clear language. d. Ignore the client's anxiety so that she will not be embarrassed.
c. Demonstrate a calm manner while using simple and clear language. Rationale: Give information simply and calmly will help the client grasp essential facts.
A nurse is making a home visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following is an appropriate suggestion to decrease the client's risk for injury? a. Mark cleaning supplies with colored tape b. Place rugs over electrical cords c. Install childproof locks d. Place medication bottles within client reach.
c. Install childproof locks Rationale: Install childproof door locks is correct. Door locks that are difficult to open are appropriate to reduce the risk of the client wandering outside without supervision.
A patient 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 Rationale: Pseudoparkinsomism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malgnant sydrome is characterized by autonomic instability. Akathisia produces motor restlessness.
The family of a patient with undifferentiated schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. Family b. Transactional c. Psychoeducational d. Pscyhoanalytic
c. Psychoeducational Rationale: A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation.
The ability to become intentional—which could be defined as the opposite of post-traumatic reactivity—is predicated upon what important skill? a. Self-actualization b. Positive expectancy c. Relaxation/ Self-regulation d. Reframing
c. Relaxation/ Self-regulation Rationale: The model of self-regulation focuses on conscious personal management that involves the process of guiding one's own physiological and psychological mechanisms to reach goals. Learning to switch off the Sympathetic Nervous System and activate the Para-Sympathetic Nervous System.
A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for lorazepam (Ativan) for generalized anxiety disorder. Which of the following is appropriate for the nurse to include in teaching? a. Combining alcohol with lorazepam will produce a paradoxical response b. Lorazepam has a lower risk for dependency than other anti-anxiety medications c. Report confusion as a potential indication of toxicity d. 3 to 6 weeks of treatment is required to achieve therapeutic benefit
c. Report confusion as a potential indication of toxicity Rationale: Confusion is a potential indication of lorazepam toxicity that the client should report to the provider.
A depressed client is receiving imipramine (Tofranil) 300mg daily. The side effect of the drug for which the nurse should seek medical attention for the client is a. Dry mouth b. Nasal congestion c. Urinary retention d. Blurred vision
c. Urinary retention Rationale: All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Bethanechol may be given to promote urination, or urinary catheterization my be necessary. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.
A female client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner? a. Offering opinions about the need to eat b. Verbalizing reasons that the client may not choose to eat c. Using open-ended questions and silence d. Focusing on self-disclosure of own food preferences
c. Using open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems in a descriptive manner. Options 2 and 3 are not helpful to the client because they do not encourage the client to express feelings. Options 4 is not a client-centered intervention.
Which description best applies to a hallucination? A patient: a. tries to hit the nurse when vital signs are taken. b. looks at shadows on a wall and says, "I see scary faces." c. states, "I feel bugs crawling on my legs and biting me." d. becomes anxious when the nurse leaves his or her bedside
c. states, "I feel bugs crawling on my legs and biting me." Rationale: A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feelings bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.
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 a need for further teaching? a. "The client is at greatest risk for suicide during the first weeks of an MDD episode. b. "The goal of treatment during the maintenance phase is prevention of future episodes of MDD." c."Medication and psychotherapy are used to prevent a relapse of MDD." d. "Care during the continuation phase focuses on treating continued manifestations of MDD."
d. "Care during the continuation phase focuses on treating continued manifestations of MDD." Rationale: The focus of the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD.
A nurse is providing teaching to a client who has a new prescription for phenelzine (Nardil). Which of the following client statements indicates understanding of the teaching? a. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash" b. "This medication will help me loss the weight that I have gained over the past year." c. "I'll talk the medication at night due to it's sedative qualities" d. "I cannot eat my favorite pizza with pepperoni while taking this medication."
d. "I cannot eat my favorite pizza with pepperoni while taking this medication." Rationale: Consuming tyramine rich foods, such as Pepperoni, along with phenelzine increases the risk of a hypertensive crisis.
An older woman is brought to the emergency room. On physical assessment, the nurse notes old and new ecchymotic areas on both arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence, that her daughter frequently hits her if she gets in the way. Which of the following is the appropriate nursing response? a. "Are you sure you're just not fall frequently and not remembering?" b. "Let's talk about ways that will prevent your daughter from hitting you." c. "I promise I will not tell anyone, but let's see what we can do about this if it happens again." d. "I have a legal obligation to report this type of abuse."
d. "I have a legal obligation to report this type of abuse." Rationale: Confidential issues are not to be discussed with non-medical personnel or the person's family or friends without the person's permission. Clients should be aware that information is kept confidential, unless it places the nurse under a legal obligation. The nurse must report situations related to child or elderly abuse, gunshot wounds, threats to murder specific individuals and certain infectious diseases.
Cognitive therapy was provided for a patient who frequently said, "I'm stupid." Which statement by the patient indicates the therapy was effective? a. "Things always go wrong for me." b. "I always fail when I try new things." c. "I'm disappointed in my lack of ability." d. "Sometimes I do stupid things."
d. "Sometimes I do stupid things." Rationale: "I'm stupid" is an irrational thought. A more rational thought is, "Sometimes I do stupid things." The latter thinking promotes emotional self-control. The incorrect options reflect irrational thinking."
A nurse plans to assess a client for the vegetative signs of depression. The nurse assesses for these signs by determining the client's: a. Level of suicidal ideation b. Level of self-esteem c. Ability to think, concentrate, and make decisions. b. Appetite, weight, sleep pattern and psychomotor activity
d. Appetite, weight, sleep pattern, and psychomotor activity Rationale: the vegetative signs of depression are changes in physiological functioning during depression. These include appetite, weight, sleep patterns, and psychomotor activity. Options 1, 3 and 4 represent psychological assessment categories.
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. Interrupted family processes. b. Social isolation c. Ineffective health maintenance. d. Chronic low self-esteem
d. Chronic low self-esteem Rationale: The patient mentions that the symptoms make people more interested, which indicates that the patient believes he or she is uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of Chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in this scenario.
A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following is the priority nursing action? a. Prepare the client for gastric lavage b. Administer flumazenil (Romazicon) c. Infuse IV fluids d. Identify the client's level of orientation
d. Identify the client's level of orientation Rationale: When taking the nursing process approach to client care the initial step is assessment therefore identifying the client's level of orientation is the priority action.
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications? a. Chlorpromazine (Thorazine) b. Haloperidol (Haldol) c. Thiothixene (Navane) d. Olanzapine (Zyprexa)
d. Olanzapine (Zyprexa) Rationale: Atypical antipsychotics, such as olazapine, are effective in treating negative symptoms of schizophrenia, such as lack of grooming and flat affect.
A medication teaching plan for the patient receiving lithium should include: a. Dietary teaching to restrict daily sodium intake. b. Discontinuing the drug if weight gain and fine hand tremors are noticed. c. The importance of blood draw to monitor serum potassium level. d. Periodic monitoring of renal and thyroid function.
d. Periodic monitoring of renal and thyroid function. Rationale: Lithium is primarily excreted by the kidney as are other salts. With long term lithium use it can interfere with kidney functioning, and although rare it can lead to kidney failure. Lithium is also known to interfere thyroid hormone production and can cause permanent reductions in thyroid hormones.
What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Continue the assessment b. Document the observations and speculations in the medical record c. Discuss the findings with the child's teacher, principal and school psychologist d. Report the suspected abuse or neglect according to state regulations
d. Report the suspected abuse or neglect according to state regulations Rationale: Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that the abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.
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 staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Disturbed energy field. b. Disturbed thought processes. c. Self-care deficit. d. Risk for injury.
d. Risk for injury. Rationale: A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.
A nurse's sibling happily says, "I want to introduce you to my fiance. We're getting married in six months." The nurse has encountered the fiance in a clinical setting and is aware of the fiance's diagnosis of bipolar disorder. What is the nurse's best response? a. Ask the fiance, "Have you told my sibling about your mental illness?" b. Encourage the sibling to postpone the wedding for at least a year c. In private, tell the sibling about the fiance's diagnosis d. Say to the sibling and fiance, "I hope you will be very happy together"
d. Say to the sibling and fiance, "I hope you will be very happy together" Rationale: Despite personal misgivings, the nurse must maintain the fiance's confidentiality.
When a patient with paranoid 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. Mild fever, sore throat, and skin rash b. Sweating, nausea, and diarrhea c. Headache, watery eyes, and runny nose d. Sedation and muscle stiffness
d. Sedation and muscle stiffness Rationale: Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.
A client tells a student nurse, "don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? a. Keep the client's communication confidential, but watch the client and his roommate closely b. Report the incident, but do not inform the client of the intention to do so c. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife d. Tell the client that this must be reported to the health care staff because it concerns the health and safety of the client and others.
d. Tell the client that this must be reported to the health care staff because it concerns the health and safety of the client and others. Rationale: This is a serious safety issue that must be reported to the staff. Using the principle of veracity, the student tells this client truthfully what must be done regarding the issue.
An older adult patient takes digoxin and hydochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. Alzheimer's disease b. dementia c. amnestic syndrome d. delirium
d. delirium Rationale: Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.
The following patients are seen in the emergency department. Which of the following patients meets the severity of illness and intensity of care required for the admitting officer to recommend admission to the psychiatric unit? The patient who: a. experiencing anxiety and a sad mood after a separation from a spouse of 10 years. b. experiencing dry mouth and tremor related to side effects of haloperidol (Haldol) c. who self inflicted a superficial cut on the forearm after a family argument. d. who is a single parent and hears voices saying, "Smother your infant."
d. who is a single parent and hears voices saying, "Smother your infant." Rationale: Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.
