MH Final Study Guide
18) Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? a) "I am mixed up, but I know I need help." b) "I have no one to turn to for help or support." c) "It is worse when you are a person of color." d) "I tried to get attention before I cut myself last time."
ANS B
19) A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a) narcotic analgesic, such as hydromorphone. b) sedative, such as lorazepam or chlordiazepoxide. (Benzodiazepines) c) antipsychotic, such as olanzapine or thioridazine. d) monoamine oxidase inhibitor antidepressant, such as phenelzine.
ANS B
23) Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a) Assess for depression and anxiety. b) Observe for adverse effects of refeeding. c) Communicate empathy for the patient's feelings. d) Help the patient balance energy expenditures with caloric intake.
ANS B
10) A nurse instructs a patient taking a drug that inhibits 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.
ANS B
4) What is your priority intervention for a patient who has overdosed on amphetamines? a) Vitals- airway, breathing, circulation
ANS A
100) A nurse assesses a patient diagnosed with conversion (functional neurological) 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."
ANS A
13) 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 fluid. c) double the lithium dose if diarrhea or vomiting occurs. d) avoid eating aged cheese, processed meats, and red wine.
ANS A
16) A nurse assesses a patient diagnosed with conversion (functional neurological) 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."
ANS A
32) An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior? a) Family therapy b) Bibliotherapy c) Play therapy d) Art therapy
ANS A
34) An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with a) meals. b) an antacid. c) an antiemetic. d) a large glass of juice
ANS A
38) The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is a) within therapeutic limits. b) below therapeutic limits. c) above therapeutic limits. d) because of the time lapse since the last dose
ANS A
42) An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a) Drug actions and interactions b) Benzodiazepine withdrawal c) Hypotensive episodes d) Renal failure
ANS A
50) When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should 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
ANS A
60) A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make? a) Promote appropriate behavior during group therapy sessions. b) Encourage client input in the treatment plan. c) Communicate with the client using concrete language. d) Demonstrate assertive behavior.
ANS A
61) A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first? a) "What are the voices telling you?" b) "How often do you hear the voices?" c) "I know you hear the voices, but I do not." d) "The voices are part of your illness."
ANS A
7) A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? a) Denial b) Projection c) Introjection d) Rationalization
ANS A
73) A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? a) The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b) The adolescent identifies friends in the home community who are a positive influence. c) Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d) The adolescent experiences no anger and frustration for 1 week.
ANS A
76) An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior? a) Family therapy b) Bibliotherapy c) Play therapy d) Art therapy
ANS A
8) A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a) Remain safe in the environment. b) participate actively in self-care. c) communicate verbally. d) acknowledge reality.
ANS A
83) A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a) "Are you having thoughts of suicide?" b) "I am not sure I understand what you are trying to say." c) "Try to stay hopeful. Things have a way of working out." d) "Tell me more about what interested you before you became depressed."
ANS A
86) A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority? a) Determining if the client has psychotic thinking b) Asking the client to identify the cause of the crisis c) Identifying the client's coping skills d) Identifying the client's support systems
ANS A
87) A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing? a) Situational b) Maturational c) Adventitious d) Developmental
ANS A
89) While conducting the initial interview with a patient in crisis, the nurse should a) speak in short, concise sentences. b) convey a sense of urgency to the patient. c) be forthright about time limits of the interview. d) let the patient know the nurse controls the interview.
ANS A
9) After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a) Risk for injury related to physical abuse from partner b) Social isolation related to lack of a community support system c) Ineffective coping related to uneven distribution of power within a relationship d) Deficient knowledge related to resources for escape from an abusive relationship
ANS A
91) The principle most useful to a nurse planning crisis intervention for any patient is that the patient a) is experiencing a state of disequilibrium. b) is experiencing a type of mental illness. c) poses a threat of violence to others. d) has high potential for self-injury.
ANS A
95) A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a) History of family violence b) Loss of employment c) Abuse of alcohol d) Poverty
ANS A
96) An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult a) expresses frustration verbally instead of physically. b) explains the rationale for behaviors to the victim. c) identifies three personal strengths. d) agrees to seek counseling.
ANS A
1) A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a) Complete the physical assessment. b) Notify the health care provider to obtain a seclusion order. c) Document the incident objectively in the patient's medical record. d) Explain to the patient that seclusion will be discontinued when self-control is regained.
ANS B
27) A patient comes to the crisis clinic after an unexpected job termination. The patient paces, sobs, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse's best initial comment to this patient. a) "Everything is going to be all right. You are here at the clinic and the staff will keep you safe." b) "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c) "You need to try to stop crying and pacing so we can talk about your problems." d) "Let's set some guidelines and goals for your visit here."
ANS B
3) A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a) maintain a stern and authoritarian affect. b) provide care in a matter-of-fact manner. c) encourage the patient to express anger. d) be very rigid and challenging.
ANS B
31) A child known as the neighborhood bully says, "Nobody can tell me what to do." After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher's computer. These behaviors support a diagnosis of a) conduct disorder. b) oppositional defiant disorder. c) intermittent explosive disorder. d) attention deficit hyperactivity disorder.
ANS B
33) A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a) You will be able to stop the medication in about 1 month." b) "Taking the medication every day helps reduce the risk of a relapse." c) "Most patients take medication for approximately 6 months after discharge." d) "It's unusual that the health care provider hasn't already stopped your medication."
ANS B
36) A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect? a) Agranulocytosis b) Neuroleptic malignant syndrome c) Akathisia d) Tardive dyskinesia
ANS B
37) A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring? a) Tardive dyskinesia b) Neuroleptic malignant syndrome c) Acute dystonia d) Pseudoparkinsonism
ANS B
41) A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a) Benzodiazepine b) Mood stabilizing medication c) Monoamine oxidase inhibitor (MAOI) d) Cholinesterase inhibitor
ANS B
43) A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a) narcotic analgesic, such as hydromorphone. b) sedative, such as lorazepam or chlordiazepoxide. c) antipsychotic, such as olanzapine or thioridazine. d) monoamine oxidase inhibitor antidepressant, such as phenelzine.
ANS B
49) A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a) Constipation b) Gynecomastia c) Visual changes d) Photosensitivity
ANS B
5) A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a) Cardiovascular b) Respiratory c) Neurologic d) Hepatic
ANS B
53) What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a) Supporting behavioral change b) Maintaining consistent limits c) Monitoring suicide attempts d) Using aversive therapy
ANS B
57) The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? a) Conversion b) Projection c) Undoing d) Regression
ANS B
58) A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client? a) "We do this every day. Why are you so angry with me this morning?" b) "I don't like it when you address me with that tone of voice." c) "I know you can, but are you going to read it or not?" d) "Fine. Here is the schedule, and I will expect you to be on time to your therapies."
ANS B
63) A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should a) maintain a stern and authoritarian affect. b) provide care in a matter-of-fact manner. c) encourage the patient to express anger. d) be very rigid and challenging.
ANS B
64) A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as a) denial. b) splitting. c) defensive. d) reaction formation.
ANS B
65) A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take? a) Place the client in seclusion if visual hallucinations are present. b) Limit the number of questions asked during assessments c) Use frequent touch to provide client support. d) Directly tell the client that delusions are not real.
ANS B
67) A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make? a) "Why do feel that you need to leave?" b) "You feel that you don't belong here?" c) "We are here to help you and give you the care that you need right now." d) "Try to take some deep breaths and I'm sure you'll feel better."
ANS B
69) A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions? a) Persecution b) Control c) Erotomanic d) Somatic
ANS B
70) A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings is this client exhibiting? a) Flight of ideas b) Grandiosity c) Reality testing d) Derealization
ANS B
75) A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give? a) "Because you are a minor, I have to share any information that I feel is important with your parents." b) "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care." c) "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us." d) "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
ANS B
81) Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a) "Why do you want to kill yourself?" b) "Do you have access to medications?" c) "Have you been taking drugs and alcohol?" d) "Did something happen with your parents?"
ANS B
88) A patient comes to the crisis clinic after an unexpected job termination. The patient paces, sobs, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse's best initial comment to this patient. a) "Everything is going to be all right. You are here at the clinic and the staff will keep you safe." b) "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c) "You need to try to stop crying and pacing so we can talk about your problems." d) "Let's set some guidelines and goals for your visit here."
ANS B
92) A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support. a) "Has anything upsetting occurred in the past few days?" b) "Who can be helpful to you during this time?" c) "How does this problem affect your life?" d) "What led you to seek help at this time?"
ANS B
97) Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a) Voluntary control of symptoms b) Patient's style of presentation c) Results of diagnostic testing d) The role of secondary gains
ANS B
98) A patient with blindness related to conversion (functional neurological) disorder says, "All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don't find me as interesting." Which nursing diagnosis is most relevant? a) Social isolation b) Chronic low self-esteem c) Interrupted family processes d) Ineffective health maintenance
ANS B
11) A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: (It takes a few weeks to work.) a) discuss with the health care provider the need to increase the dose. b) reassure the patient that the medication will be effective soon. c) explain the time lag before antidepressants relieve symptoms. d) critically assess the patient for symptoms of improvement.
ANS C
12) A patient being treated for depression has taken sertraline daily for a year. The patient calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the patient to: a) Go to the nearest emergency department immediately." b) "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c) "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d) "Resume taking your antidepressants for 2 more weeks and then discontinue them again."
ANS C
14) Which scenario predicts the highest risk for directing violent behavior toward others? a) Major depressive disorder with delusions of worthlessness b) Obsessive-compulsive disorder; performs many rituals c) Paranoid delusions of being followed by alien monsters d) Completed alcohol withdrawal; beginning a rehabilitation program.
ANS C
20) Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a) Donepezil b) Rivastigmine c) Memantine d) Galantamine
ANS C
25) A patient's medical record documents sexual masochism. This patient derives sexual pleasure a) from inanimate objects. b) by inflicting pain on a partner. c) when sexually humiliated by a partner. d) from touching a nonconsenting person.
ANS C
26) An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? a) Offer the waiting spouse a cup of coffee. b) Explain that the patient's condition is not life threatening. c) Periodically provide an update and progress report on the patient. d) Suggest that the spouse return home until the patient's treatment is complete.
ANS C
28) Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a) clonazepam b) risperidone c) lamotrigine d) aripiprazole
ANS C
29) A nurse provides health education for an adult with sleep deprivation. It is most important for the nurse to encourage caution when the patient engages in a) using a vacuum cleaner. b) cooking a meal. c) driving a car d) bathing.
ANS C
30) An adolescent was recently diagnosed with ODD. The parents say to the nurse, "Isn't there some medication that will help with this problem?" Select the nurse's best response. a) "There are no medications to treat this problem. This diagnosis is behavioral in nature." b) "It's a common misconception that there is a medication available to treat every health problem." c) "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use." d) "There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you."
ANS C
35) Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a) clonazepam b) risperidone c) lamotrigine d) aripiprazole
ANS C
40) A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a) Neuroleptic malignant syndrome b) Hepatocellular effects c) Pseudoparkinsonism d) Akathisia
ANS C
46) A nurse is planning care for a client who has a prescription for alprazolam. For which of the following adverse effects should the nurse plan to monitor? a) Decreased urine output b) Manifestations of seizure activity c) Inability to recall events d) Increase in white blood cell count
ANS C
51) As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a) Reinforce this assertive action by the patient. Leave the medication on the table as requested. b) Respond to the patient, "I'm worried that you might not take it. I'll come back later." c) Say to the patient, "I must watch you take the medication. Please take it now." d) Ask the patient, "Why don't you want to take your medication now?"
ANS C
52) Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as a) seductive. b) detached. c) manipulative. d) guilt-producing.
ANS C
54) Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."
ANS C
59) A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take? a) Encourage the client to go back to bed. b) Give the client a PRN sleeping medication. c) Remain with the client. d) Explore alternatives to pacing the floor with the client
ANS C
62) A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? a) Recommend a game of table tennis with another client b) Suggest the client exercise on a stationary bike. c) Take the client outside for a walk d) Praise the client's efforts to engage in social interaction.
ANS C
68) A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first? a) Implement the client's behavioral modification plan. b) Document the size and location of the cuts. c) Inspect the cuts for debris. d) Administer a tetanus antitoxin.
ANS C
71) A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take? a) Turn on a dance video so the client can burn off excess energy. b) Offer the client a low-calorie snack in return for stopping the behavior. c) Take the client outside and sit with her in the garden area. d) Observe the client closely for the development of aggressive behavior.
ANS C
72) A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge? a) "Right now, I can't bathe or dress myself, but that's not important." b) "When I get home, I'm going to let the people who put me here know how I angry I am." c) "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts." d) "Taking care of myself is important, but it's okay if I want to take a break and not do anything."
ANS C
77) An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. a) Ignore the child's behavior. b) Send the child to time-out for 2 hours. c) Take the child to the gym and engage in an activity. d) Role-play a more appropriate behavior with the child.
ANS C
78) An adolescent was recently diagnosed with ODD. The parents say to the nurse, "Isn't there some medication that will help with this problem?" Select the nurse's best response. a) "There are no medications to treat this problem. This diagnosis is behavioral in nature." b) "It's a common misconception that there is a medication available to treat every health problem." c) "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use." d) "There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you."
ANS C
80) A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to a) current stress level. b) mood disturbance. c) suicide potential. d) level of anxiety.
ANS C
82) A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a) "I wish I were dead." b) "Life is not worth living." c) "I have a plan that will fix everything." d) "My family will be better off without me."
ANS C
84) A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? a) Provide professional counseling for staff members. b) Change policies for staff observation of clients who are suicidal. c) Identify cues in the client's behavior that might have warned them that he was contemplating suicide. d) Give the family an opportunity to talk about their feelings.
ANS C
15) An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient a) was threatening to others. b) was experiencing psychosis. c) presented an undeniable escape risk. d) presented a clear and present danger to others.
ANS D
17) Which individual in the emergency department should be considered at highest risk for completing suicide? a) An adolescent Asian American girl with superior athletic and academic skills who has asthma b) A 38-year-old single, African American female church member with fibrocystic breast disease c) A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d) A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate
ANS D
2) The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a) arrogant, grandiose, and a sense of self-importance. b) attention seeking, melodramatic, and flirtatious. c) impulsive, restless, socially aggressive behavior. d) socially anxious, rambling stories, peculiar ideas.
ANS D
21) A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have a) more dreams. b) excessive sleepiness. c) less slow-wave sleep. d) less REM sleep.
ANS D
22) A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a) Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b) Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c) Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d) Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
ANS D
24) Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a) Bromocriptine b) Methadone c) Disulfiram d) Naltrexone
ANS D
39) A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a) Phenytoin b) Clonidine c) Risperidone d) Carbamazepine
ANS D
44) A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have a) more dreams. b) excessive sleepiness. c) less slow-wave sleep. d) less REM sleep.
ANS D
45) A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam? a) The client states, "I see purple bugs crawling on the wall." b) The client tells the nurse that he is too tired to attend the group meeting c) The client tells the nurse he is a government agent. d) The client states, "My heart is pounding out of my chest."
ANS D
47) A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient a) monitors sodium intake and weight daily. b) wears support stockings and elevates the legs when sitting. c) can identify foods with high selenium content that should be avoided. d) confers with a pharmacist when selecting over-the-counter medications.
ANS D
48) A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a) Dry mouth b) Blurred vision c) Nasal congestion d) Urinary retention
ANS D
55) When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include a) preoccupation with minute details; perfectionist. b) charm, drama, seductiveness; seeking admiration. c) difficulty being alone; indecisive, submissiveness. d) grandiosity, self-importance, and a sense of entitlement.
ANS D
56) The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include a) arrogant, grandiose, and a sense of self-importance. b) attention seeking, melodramatic, and flirtatious. c) impulsive, restless, socially aggressive behavior. d) socially anxious, rambling stories, peculiar ideas.
ANS D
6) Which goal for treatment of alcoholism should the nurse address first? a) Learn about addiction and recovery. b) Develop alternate coping strategies. c) Develop a peer support system. d) Achieve physiological stability.
ANS D
66) A nurse in a mental health facility is preparing to interview a client who is has schizophrenia. Which of the following actions should the nurse take? a) Sit on the other side of a table from the client. b) Place the client in a chair higher than the nurse. c) Start the interview with a question the client can answer with a "yes" or "no." d) Sit beside the client rather than facing him.
ANS D
74) A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent's behavior? a) Attention deficit hyperactivity disorder (ADHD) b) Posttraumatic stress disorder (PTSD) c) Intermittent explosive disorder d) CD (conduct disorder)
ANS D
79) Four individuals have given information about their suicide plans. Which plan evidences the a) highest suicide risk?Turning on the oven and letting gas escape into the apartment during the night b) Cutting the wrists in the bathroom while the spouse reads in the next room c) Overdosing on aspirin with codeine while the spouse is out with friends d) Jumping from a railroad bridge located in a deserted area late at night
ANS D
85) A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a) "Let's make a list of all your problems and think of solutions for each one." b) "I'm happy you're taking control of your problems and trying to find solutions." c) "When you have bad feelings, try to focus on positive experiences from your life." d) "Let's consider which problems are very important and which are less important."
ANS D
90) An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? a) "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b) "What resources do you need to help you cope with this situation?" c) "Do you have enough support from your family and friends?" d) "Are you having thoughts of hurting yourself or others?"
ANS D
93) A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a) Risk for injury b) Ineffective coping c) Impaired social interaction d) Risk for other-directed violence
ANS D
94) A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is a) demonstrating withdrawal. b) working though angry feelings. c) attempting to use relaxation strategies. d) exhibiting clues to potential aggression.
ANS D
99) A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, "My chest is tight, and my heart misses beats. I'm often absent from work. I don't go out much because I need to rest." Which health problem is most likely? a) Dysthymic disorder b) Somatic symptom disorder c) Antisocial personality disorder d) Illness anxiety disorder (hypochondriasis)
ANS D
