NUR 103- MENTAL HEALTH

The wife of an alcoholic tells the nurse, "My husband only drinks on the weekends to relax. He has a very stressful job." The nurse recognizes that the patient's wife is using which defense mechanism? a. Repression b. Denial c. Rationalization d. Identification

ANS: C Rationalization is a justification for an unreasonable act to make it appear reasonable. Rationalization is used by many families to allay their own anxiety about the substance abuse of a family member. Repression refers to unconsciously blocking an unwanted thought or memory from open expression. Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently

The patient with Alzheimer's disease (AD) has been on donepezil (Aricept) for several weeks. In which situation would the nurse suspect an overdose? a. The patient hungrily eats meals and often searches for snacks between meals. b. The nurse assesses a radial pulse rate of 92 beats/min. c. The patient's blood pressure is elevated after periods of exertion. d. The patient fails to grasp a glass tightly enough to prevent dropping it.

ANS: D Inability to grasp the glass indicates muscle weakness, a cardinal indicator of overdose of Aricept. Other overdose signs are hypotension, nausea and vomiting, and bradycardia. Appetite changes are not consistent with the use of this medication.

The nurse adds an intervention to the nursing care plan for a patient on neuroleptics. Which intervention is most appropriate? a. Increase fluid intake to compensate for the side effect of diarrhea. b. Encourage snacks to prevent weight loss. c. Monitor vital signs for hypertension. d. Assess urinary output for evidence of urinary retention.

ANS: D Neuroleptics cause urinary retention, weight gain, constipation, and hypotension. Diarrhea is not associated with the administration of neuroleptics. Weight gain, and not weight loss, is associated with this type of medication. Hypertension is not associated with this type of medication.

As a nurse, you wish to reinforce functional behavior in your schizophrenic patient. Which intervention will accomplish reinforcement? A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors. B. Educate the patient about the symptoms of schizophrenia. C. Facilitate learning about the importance of medication compliance using written materials for reinforcing medication use. D. Focus on the feelings of delusion to reinforce reality and decrease false beliefs by talking to the patient.

A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors.Reason: Reinforcement by praise increases functional behavior.

When receiving report, the nurse learns that a schizophrenic patient has been displaying waxy flexibility. Which behavior is consistent with this report? a. The patient sits and stares at the wall without speaking. b. The patient arranges himself in several seated postures on the couch. c. The patient marches stiffly up and down the center of the dayroom. d. The patient holds his arm over his head with his fist clenched for an hour.

ANS: D Waxy flexibility refers to maintaining a limb in one position for a long time. The catatonic patient will exhibit a stuporous demeanor. It is associated with rigidity and unusual posturing.

a nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indication of clients use of cocaine? a. hypertension b. drowsiness c. bradycardia d. constricted pupils

a cocaine is CNS stimulant. also causes mental altertness, tachycardia and dilated pupils

which anorexia nervosa symptom is physical in nature a. dry yellow skin b. perfectionism c. frequent weighing d. preoccupation with food

a dry , yellow skin is a physical symptom

A person in jail for public intoxication has been without alcohol for 12 hours. Which finding indicates that the patient may be withdrawing from alcohol? a. Irritability b. Nausea and vomiting c. Hallucinations d. Seizures

a marked irritability is the early sign (6 to 12 hours after last drink) of alcohol withdrawal

The nurse is caring for a patient who is undergoing detoxification from alcohol. Which supplement can the nurse expect to be included in the prescribed medications? a. Potassium chloride b. Thiamine c. Riboflavin d. Folic acid

ANS: B The treatment for the alcoholic undergoing detoxification includes the administration of large doses of thiamine (vitamin B1 ). Thiamine acts as a nerve insulator in the body and is absent in the diets of most chronic alcoholics.

After having refused lunch and dinner because her "regular" chair was occupied at breakfast, the resident in a long-term care facility asks for a snack. How should the nurse respond? a. "You are hungry now. Is there something else you could have done earlier besides refusing to eat?" b. "Here is your snack. Maybe you won't be so quick to refuse meals the next time you don't get your way." c. "Refusing meals is not the answer. You must eat." d. "Tell me why you left the dining room without eating."

ANS: A After acute anxiety passes, the nurse should focus on helping the resident recognize the behavior that was exhibited and how to deal more effectively with the anxiety. Scolding the patient, attempting to induce guilt, or causing the patient to dwell on the trigger do not redirect the patient to consider different behaviors.

The home health nurse assesses caregivers for a person with a cognitive deficit. Which finding(s) is/are characteristic of exhaustion? (Select all that apply.) a. Irritability with other family members and the patient b. Report of sleep disturbances c. Anger at patient and self d. Depression e. fatigue

A, B, C, D, E All options are characteristics of exhaustion in caregivers to the cognitively impaired.

a client diagnosed with borderline personality disorder requests valium. when the physician refuses, the cleint becomes angry and demands to see another physician. what defense mechanism is the client using? a. undoing b. splitting c. altruism d. reaction formation

b

How does the nurse describe a person who is bulimic? a. Severely underweight b. Alternates binge eating with purging c. Introverted perfectionist d. Has extremely close family relationships

b Bulimia is characterized by alternating binge eating and purge behavior.

a student nurse is communicating with a client who suffered concussion after a dui involving crack cocaine, which reccomendation should the instructor give the student related to obtaining most accurate assessment data? a. it is important to teach affects of cocaine on the body b. after gaining client permission, validate this information with family members c. accurately record the cleints statement related to quantity of cocaine use d. instruct the client regarding what will happen during detox process

b substance abusers tend to minimize or deny use

a client is diagnosed bulimia nervosa has responded well to citalopram (celexa). which is the possible cause for this response) a. there is an association between bulimia nervosa and dilated blood vessels and intactive alpha-adrenergic and serotoninergic receptors b. there is an association between bulimia and the neurotransmitter dopamine c. there is an association between bulimia nervosa and the neurotransmitters serotonin and norepinephrine d. there is association between bulimia and malfunction of the thalamus

c

An intoxicated patient is admitted to a treatment center for detoxification. The nurse understands that his withdrawal will be supported with which method? a. Psychotherapy support b. Large doses opioids to ensure sedation for 72 hours c. Symptomatic relief until the substance clears his symptoms d. Titrated amounts of alcohol until severe withdrawal resolves

c the alcoholic in withdrawal is supported with symptomatic relief for nausea and vomiting, cramps, and possible seizure

How long does it take the body to metabolize a single can of beer? a. 20 minutes b. 30 minutes c. 40 minutes d. 60 minutes

d

a male client diagnosed with a personality disorder boasts to the nurse that he has to fight off female attention and is the highest paid in his company. these statements are reflective of which personality disorder? a. ocd b. avoidant personality disorder c. schizotypal d. narcissistic

d

when assessing a client diagnosed with histrionic personality disorder, the nurse might identify which characteristic? a. odd beliefs and magical thinking b. grandiose sense of self importance c. preoccupation with orderliness and perfection d. attention seeking flamboyance

d

a nurse is collecting data from a client who is exeriecing alcohol withdrawal. which of the following manifestations should the nurse expect? a. increased yawning b. bradycardia c. hypersomnia d. diaphoresis

d The nurse should expect a client who is experiencing alcohol withdrawal to experience diaphoresis, or increased sweating.

The nurse uses the CAGE challenge to alcoholics who persist in denial. What does the "G" in the set of questions from CAGE represent? a. Get: "Do you feel like you must get alcohol?" b. Go: "Do you go out to drink?" c. Gone: "Is memory of drinking episodes gone?" d. Guilty: "Do you feel guilty about your drinking?"

d a commonly used screening tool for alcohol abuse is the CAGE assessment. Two or more "yes" answers have a 90% correlation with an alcohol abuse problem. The G stands as a reminder for the question, do you feeling guilty about your drinking

A patient is admitted after abusing an inhalant. Which safety precaution is most important for the nurse to take? a. Check the patient's temperature hourly. b. Place the patient on seizure precautions. c. Monitor carefully for changes in urine output. d. Ensure that respiratory support equipment is present at the bedside.

d medical treatment and intervention for both hallucinogens and inhalants include provision of safety for the individual who may be experiencing a bad trip. Emergency measures may be necessary to provide respiratory support for an individual who has an impaired gas exchange as a result of inhalants

What does the Mini-Mental Status Exam (MMSE) assess? (select all that apply) a. Orientation b. Judgment c. Memory d. Insight e. Ability to follow directions

ANS: A, C, E The Mini-Mental Status Exam (MMSE) is a popular shortened version of the mental status examination that was developed by Folstein and colleagues in 1975. It can be used for patients who have cognitive disorders or thought disorders to assess orientation, memory, and ability to follow commands. It consists of 11 easily scored items and should take about 5 to 10 minutes to administer. The MMSE does not measure insight or judgment.

A nurse is hired to work in a psychiatric facility on a unit specializing in obsessive compulsive disorders (OCD). Which diagnoses might the nurse expect to encounter? (Select all that apply.) a. Trichotillomania b. Hoarding disorder c. Excoriation disorder d. Body dysmorphic disorder e. Oppositional defiant disorder

ANS: A, B, C, D Oppositional defiant disorder is described as an ongoing pattern of anger-guided disobedience, a hostile or defiant response to authority and is not considered a form of OCD.

Which characteristic(s) is/are an example of a negative symptom of schizophrenia? (Select all that apply.) a. Avolition b. Hallucination c. Psychomotor retardation d. Delusions e. Anhedonia

ANS: A, C, E Negative symptoms are abilities or personal characteristics that are absent or lost to the patient.

Which characteristic(s) of personality disorders should the nurse consider? (Select all that apply.) a. Impaired cognition b. Maladaptive response to life's events c. Inability to maintain relationships d. Poor impulse control e. Inappropriate emotional responses

ANS: B, C, D, E There is no impaired cognition in the individual with a personality disorder.

Which strategy/strategies best benefit(s) a late-stage Alzheimer patient with global amnesia? (Select all that apply.) a. Reorientation sessions b. Music therapy c. Reminiscence therapy d. Pet therapy e. Looking at family scrapbooks

ANS: B, D Global amnesia wipes out all memory. Orientation and family pictures will not be helpful. Activities that stimulate the senses, such as music, stroking an animal, or aroma therapy, can be pleasing.

The nurse is caring for an undernourished alcoholic patient. The nurse is helping the patient to select items from the menu. What dietary goal should the nurse try to help the patient achieve? a. Construct a diet that consists of at least 30% protein. b. Limit all fat and cholesterol. c. Limit sodium intake to less than 1.5 grams. d. Construct a diet that consists of at least 50% carbohydrates.

ANS: D The diet for the malnourished alcoholic patient should be high in protein and consist of at least 50% carbohydrates. There are no specific limitations for fat, cholesterol, or sodium.

What effect does the nurse desire to achieve by using clear, direct communication with patients with borderline personality disorder? a. Avoid generating an intense reaction from the patient. b. Eliminate the possibility of manipulation. c. Decrease the probability of the patient reacting emotionally. d. Provide a role model for good communication.

D Clear communication can model a communication style that allows a person to verbalize feelings and make thoughts and expectations known.

A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive motor activity with repetitive sit-ups. What is this behavior called? A. Delusional. B. Hallucinogenic. C. Paranoid. D. Catatonic.

D. Catatonic.Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive motor activity

the nurse suspects a client is experiencing delirium. which specific assessment information would support this suspicion? a. a decreased level of consciousness with intermittent hypervigilence b. slow onset of confusion and agitation c. onset is insidius and relentless d. the symptoms last for one month or longer

a

Which findings indicate that the recovering alcoholic may be developing Wernicke encephalopathy? (Select all that apply.) a. Confusion b. Hallucinations c. Verbally aggressive behavior d. Ataxia e. Seizures

a d A serious effect of chronic alcohol abuse is damage to brain cells. A condition that is reversible with treatment is Wernicke encephalopathy. This condition precedes Korsakoff syndrome (substance-induced persisting dementia), which is irreversible. If the individual has a history of alcohol use and displays the symptoms of confusion, ataxia, and significant memory loss, Wernicke encephalopathy is suspected. Verbal aggression, hallucinations, and seizures are not characteristic of Wernicke encephalopathy.

a nurse is reinforcing teaching with the family of a client who has histrionic personality disorder. which of the following high-risk behaviors should the nurse instruct the family to observe for in the client? a. self mutilation through cutting b. seductive behavior c. repeated physical aggression d. reckless driving

b The nurse should instruct the client's family to observe for seductive behavior. These clients are extremely dependent and easily influenced by others, which, coupled with this behavior, places them at an increased risk of harm.

a client with a long history of alcoholism recently has been diagnosed with wernicke-korsakoff syndrome. which symptom should the nurse expect to assess? a. sudden onset of muscle pain with elevations of creatinene phosphokinase b. signs and symptoms of congestive heart failure c. loss of short term and long term memory and the use of confabulation d. inflammation of the stomach and gastresophageal

c loss of short and long term memory and the use of confabulation are symptoms of wernicke-korsakoff syndrome. the treatment of this is alcohol abstinence and thiamine replacement

The nurse is caring for a patient who was admitted with fractures sustained during an MVC (motor vehicle collision). The patient tearfully confesses that she relives the accident in her dreams and is afraid to sleep. The nurse recognizes that this scenario is consistent with which disorder? a. Post-traumatic stress disorder (PTSD) b. Phobic disorder c. obsessive-compulsive disorder (OCD) d. Panic level of anxiety disorder

A Individuals with PTSD have endured one or more extreme life-threatening events, and the remembrance of these events now produces feelings of intense horror, with recurrent symptoms of anxiety and nightmares or flashbacks.

The nurse is caring for an older adult patient with a history of anxiety. Which complaint could indicate that the patient may actually be experiencing emotional distress? a. Upset stomach b. Heightened tooth sensitivity c. Unpleasant taste in mouth d. Dizziness

A The older adult population often expresses somatic complaints rather than openly verbalizing emotional distress. You may observe the anxious older adult complaining of an upset stomach, inability to sleep, fatigue, or increased need to urinate.

The nurse is educating a patient who has just been prescribed diazepam (Valium). The nurse cautions the patient that diazepam (Valium) may cause which problem? a. Dependency b. Urinary retention c. Severe dehydration d. Hallucinations

A Valium can cause a physiologic and a psychological dependence. Valium should not cause urinary retention, severe dehydration, or hallucinations.

The nurse is assessing a 16-year-old female for characteristics of anorexia nervosa. Which assessment finding(s) would lead the nurse to suspect the possibility of this diagnosis? (Select all that apply.) a. Amenorrhea b. Severe weight loss c. Oily skin d. Hypertension e. Lanugo on back

A, B, E The primary symptom of anorexia nervosa is severe weight loss. Adolescents who wish to be fashion models or actresses or who participate in sports, dance, or gymnastics activities may be at risk for developing an eating disorder. On physical examination, some of the following conditions may be evident: dry skin, amenorrhea, lanugo hair over the back and extremities, cold intolerance, low blood pressure, abdominal pain, and constipation.

A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty. What is your best nursing response? A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves. B. Does anyone in your family have schizophrenia, as this disease is known to be genetic? C. You may feel bad now, but there are so many other bad things out there, such as cancer and paralysis. D. Let me share with you some websites to help you deal with your guilt.

A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves.Reason: Schizophrenia has a multifocal origin and its cause may include a genetic component. Support is needed for both patients and caregivers.

The home health nurse is counseling a family who will be caring for a relative with moderate-stage Alzheimer disease (AD). Which information is most important to include? a. Construct a consistent routine to provide structured environment. b. Try to make each day different to enhance attention span. c. Use multiple caregivers to decrease unhealthy attachment and prevent caregiver burnout. d. Place bright scatter rugs, flower arrangements, and wall decorations around the room to stimulate sensory perception.

ANS: A A consistent routine—eating, resting, medication, hygiene—are all beneficial to the demented patient. Different caregivers and distracting environmental objects increase confusion.

In which situation should the nurse document that the patient with AD exhibited agnosia? a. The patient attempts to comb her hair with a fork. b. The patient struggles to express herself verbally. c. The patient appears unable to understand written language. d. The patient cannot feed herself, despite having adequate motor function.

ANS: A Agnosia is the inability to recognize an object and use it as intended. Expressive aphasia is difficulty in expressing oneself. Alexia is the inability to recognize the written language. Apraxia is the inability to do an activity despite having the motor function to accomplish it.

The delusional patient has become agitated and angry. The patient reports that the cook put tacks in his cereal. He is pacing back and forth in the crowded dining room and cursing the cook. How should the nurse respond? a. Keep distance from the patient and ask, "Can we go to the dayroom and talk?" b. Touch the patient's arm and say, "Calm down. I'm sure we can straighten this out." c. Call experienced CNAs to restrain the patient. d. Stand calmly and say, "This behavior is unacceptable. Sit down and eat, Carl."

ANS: A Allowing the angry patient space is important. Encourage the patient to find a quieter place. Acknowledge the anger and demonstrate willingness to help. The agitated patient should not be touched without permission. Restraints are a last resort and will increase the patient's anger and feelings of persecution.

Which action best aids in successful rehabilitation from substance abuse? a. The patient and family members collaborate to develop treatment goals. b. The patient and family members accurately list signs of relapse. c. The patient and family members commit to discarding all drugs and paraphernalia. d. The patient and family members commit to a 12-step program.

ANS: A Collaboration is basic for success of rehabilitation. The patient and family must be part of the decision- making process for the formulation of treatment goals. While it is important to be aware of signs of relapse and essential to discard any paraphernalia and a 12-step program could be helpful, it is most important for the patient and family members to be active participants in the treatment plan.

The nurse is caring for a schizophrenic patient who has been prescribed large doses of thioridazine (Mellaril). Which manifestation may signal an overdose of the medication? a. The patient walks with a shuffling gait and drooling. b. The patient is lethargic and takes frequent naps. c. The patient exhibits disorganized thought processes. d. The patient exhibits extreme excitability with periods of mania.

ANS: A Extrapyramidal side effects of pseudo-parkinsonism with a shuffling gait, tremors, and excessive salivation are cardinal signs of overdose of neuroleptics.

A nurse is planning to speak with a parent support group about childhood autism. What will the nurse include? a. Significant signs of the disorder manifest by 1 year of age. b. The earliest signs of autism are impulsivity and overactivity. c. Autism is usually diagnosed when the child goes to elementary school. d. Medications can cure childhood autism.

ANS: A Failure to use eye contact and look at others, poor attention span, and poor orienting to one's name are significant signs of dysfunction by 1 year of age

The nurse is aware that interventions for the negative symptoms of schizophrenia are based on which factor? a. Establishment of trust b. Acceptance of medication protocols c. Support in interpersonal social activities d. Promotion of conversation with the patient

ANS: A General nursing interventions for the negative symptoms include establishing trust and teaching the patient and family how to manage the signs and symptoms. An attitude of acceptance is necessary to promote trust.

A parent asks the nurse to describe what is meant by a "learning disability." Which is the nurse's most helpful response? a. "A child may have difficulty with perception, language, comprehension, or memory." b. "It is characterized by inattention, impulsiveness, and hyperactivity." c. "The child's intellectual ability limits his learning." d. "The child has difficulty learning because of brain damage."

ANS: A Learning disability is an educational term. Children with learning disabilities may have average to above- average intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization.

Memory lapses seen in early stages of Alzheimer disease (AD) are related to the pathophysiology of which condition? a. Frontal lobe atrophy b. Overproduction of neurotransmitters c. Pituitary disorders d. Inadequate clearance of metabolic toxins

ANS: A Loss of neurons in the frontal and temporal lobes results in atrophy and the many signs of AD, memory deficits being one of the earliest.

Which classic behavior characterizes bulimia? a. Bingeing and purging b. Refusal to eat c. Excessive exercising d. Hiding food to make it appear it was eaten

ANS: A Patients with bulimia nervosa induce vomiting after consuming large quantities of food. This binge eating occurs in a frenzied state and usually in secrecy; afterward, the patient experiences feelings of shame and self-criticism. Laxatives may be taken to purge the system after the binge. Ninety percent of patients with bulimia are young women.

An exhausted daughter is the sole caregiver to a patient with moderate Alzheimer disease (AD). She asks the nurse what respite care entails. Which statement indicates that the caregiver understands the nurse's response? a. "My mom would stay in a long-term care facility for a short time while I rest." b. "Home health aides would come to our home and help me with housework." c. "A registered nurse would provide total care for my mom in 3 day intervals." d. "I would be connected with a special support group to share stresses and communicate with other caregivers."

ANS: A Respite care is placing the patient temporarily in a long-term care facility (usually for no longer than a month) to give the family respite from the responsibility of 24/7 care.

The nurse is caring for a patient with a recent diagnosis of schizophrenia. His wife asks how long it will be until her husband is cured. What response by the nurse is most appropriate? a. "Unfortunately, there is no cure, but the condition can be managed." b. "It will take approximately 1 to 2 months of medication therapy to alleviate your husband's symptoms." c. "We cannot consider your husband cured until he has been symptom free for at least 1 year." d. "There is no way to predict his outcome during his initial episode."

ANS: A Schizophrenia can be managed with therapy and medications. It cannot be permanently cured. Evidence suggests that early treatment for schizophrenia improves long-term prognosis. Patients who are treated for first episodes generally respond to the therapeutic effects and require lower doses of antipsychotic medications. After starting a medication, the patient should be monitored for 2 to 4 weeks for therapeutic response.

The nurse is caring for a patient with moderate Alzheimer disease (AD) in a long-term care facility who "sundowns." The nurse understands that which action would be most beneficial for this patient? a. Scheduling social interaction activities in the morning. b. Darkening the bedroom to encourage sleep. c. Administering sedatives to enhance sleep initiation. d. Scheduling an exercise program after supper.

ANS: A Sundowning occurs when a patient is completely oriented during the day but becomes disoriented and confused during the evening and night hours. Planning interactive activities when the resident is not confused is beneficial. Exercise programs at night would add to agitation and confusion. Sedatives also frequently cause confusion. Lights should be left on to assist with reorientation should the resident wake up at night.

The nurse is caring for a patient who has a heightened risk for seizures during his alcohol detoxification. Which medication may be included in the patient's care? a. Magnesium sulfate b. Chlordiazepoxide (Valium) c. Promethazine (Phenergan) d. Dicyclomine (Bentyl)

ANS: A The person undergoing alcohol withdrawal is at risk for the development of seizures. Magnesium sulfate may be prescribed to prevent their onset. Chlordiazepoxide may be administered to reduce anxiety. Promethazine (Phenergan) and dicyclomine (Bentyl) may be used to reduce symptoms such as nausea and vomiting.

The nurse is caring for a patient with moderate anxiety. Which activity should the nurse encourage to best manage the patient's anxiety? a. Taking a walk b. Learning a new game c. Watching an intense television show d. Reading a pamphlet about the negative effects of anxiety

ANS: A To best manage moderate level anxiety, the nurse should help provide outlets for tension. These activities include walking, crying, and working at simple, concrete tasks. Learning something new, watching an intense TV show, or reading information about the negative effects of anxiety are activities that may exacerbate anxiety rather than relieve it.

Postmortem brain examinations of Alzheimer disease (AD) patients reveal which type of finding(s)? (Select all that apply.) a. Tangled nerve cells b. Abnormal buildup of proteins c. Hemorrhagic areas d. Occluded cerebral vessels e. Reduced white matter

ANS: A, B Tangled nerve cells and abnormal buildup of protein in the brain have been found on postmortem brain examinations of people who have AD.

What actions does becoming substance free involve? (Select all that apply.) a. Committing to a lifestyle change. b. Developing new coping skills. c. Committing to honesty in communication. d. Gaining an awareness of possible periods of relapse. e. Completing a program in 12 months.

ANS: A, B, C, D The limitation of 12 months is not part of the commitment. Rehabilitation may take several years or a lifetime.

In what ways do support groups benefit substance abusers? (Select all that apply.) a. Support groups provide healthy relationships. b. Support groups offer opportunities to practice new coping skills. c. Support groups decrease stress and anxiety. d. Support groups improve social skills. e. Provide cathartic opportunities.

ANS: A, B, C, D, E All options are benefits of support groups.

Which criteria must be established to assign a diagnosis of dementia? (Select all that apply.) a. Evidence of cognitive deficits. b. Evidence of aphasia, apraxia, or agnosia. c. Impairment in social function. d. Impairments of occupational function. e. Neurologic signs and symptoms, such as ataxic gait.

ANS: A, B, C, D, E Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic in nature. It is classified according

Milieu therapy is a therapeutic application for people with personality disorders. What principle(s) underscore(s) the basis of this method? (Select all that apply.) a. Maintaining a structured environment b. Participating as a member of the structured environment c. Practicing appropriate social behavior d. Actively attempting to modify behavior e. Learning to modify feelings and emotional responses

ANS: A, B, C, D, E Milieu therapy provides all these options for treating people with personality disorders.

Which signs and symptoms are consistent with general anxiety disorder (GAD)? (Select all that apply.) a. Heart rate of over 100 beats/min b. Restlessness c. Urinary retention d. Fatigue e. Muscular tension

ANS: A, B, D, E A person who experiences persistent, unrealistic, or excessive worry about two or more life circumstances for 6 months or longer is exhibiting symptoms associated with GAD. GAD usually develops slowly and is chronic in nature. Dieresis rather than urinary retention is a commonly seen with GAD. All other options listed are characteristics of GAD.

Which psychotic feature(s) is/are characteristic of schizophrenia? (Select all that apply.) a. Hallucinations b. Sexual dysfunction c. Delusions d. Disorganized speech e. Disorganized behavior

ANS: A, C, D, E Sexual dysfunction is not a characteristic of schizophrenia.

The nurse explains that neuroleptic drugs such as chlorpromazine (Thorazine) are very effective in treating specific symptoms of schizophrenia. Which effect(s) should chlorpromazine have? (Select all that apply.) a. Eliminating hallucinations b. Stimulating effective interpersonal relationships c. Enabling organized thought d. Increasing activity level e. Eliminating delusional systems

ANS: A, C, E Hallucinations, disorganized thought, and delusional systems are the positive symptoms that respond to neuroleptics. Negative symptoms such as withdrawal and inactivity do not respond well to these drugs.

The nurse is caring for a patient with memory deficits. The patient asks the nurse about foods that may help improve memory. Which food(s) is/are linked to enhanced memory? (Select all that apply.) a. Salmon b. Red meat c. Pork loin d. Leafy green vegetables e. Fruit

ANS: A, D, E Studies show that fish and omega-3 polyunsaturated fats, fruits and vegetables, curcumin (curry spice), and the traditional Mediterranean diet may lower the risk for loss of cognitive function and/or Alzheimer disease (AD).

How should the nurse speak when communicating with a patient with moderate Alzheimer dementia? a. Slowly b. Clearly c. Loudly d. Softly

ANS: B Clarity is essential when communicating with a patient with Alzheimer dementia. Placing self directly in front of the patient and using pictures or symbols is helpful.

The nurse is assisting the patient with middle-stage Alzheimer's disease (AD) with dressing. Which action is most appropriate? a. Select clothes and dress the patient. b. Layout clothing and coach the patient to dress self. c. Ask the patient what he wants to wear. d. Open the closet and tell the patient to choose a shirt.

ANS: B Coaching the patient to dress himself helps preserve dignity and function. Selecting clothes and dressing the patient does not allow the patient to actively participate in any way. Asking the patient what he wants to wear and telling him to choose a shirt could increase confusion and indecision.

The pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate. What action by 9-year-old child leads the nurse to question possible dyslexia? a. Becomes hyperactive and ceases to read b. Reads the word dog as God c. Makes up a story rather than reading the text d. Stutters as he reads

ANS: B Dyslexics often transpose a word as they read; for example, the word is dog, but it appears to the dyslexic child as the word God.

Which action is most important for the nurse to take before providing care for substance abusers? a. Become familiar with self-help programs. b. Examine personal bias relative to substance abuse. c. Become knowledgeable about theories of addiction. d. Ensure consistency with each patient.

ANS: B Nurses must first determine their own biases and attitude toward substance abuse and substance abusers before they can relate effectively with the patient. Familiarization with resources and knowledge about theories of addiction are tools of lesser importance. Consistency with patients occurs while providing care to substance abusers.

A 14-year-old girl with obsessive-compulsive disorder (OCD) tells the nurse other adolescents tease her because she washes her hands many times during the school day. For what does this disorder put the adolescent at greater risk? a. Anorexia nervosa b. Depression c. ADHD d. A learning disability

ANS: B OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for adolescents with OCD.

The nurse is educating a patient with generalized anxiety disorder (GAD) who has a new prescription for buspirone (BuSpar). Which information is most important for the nurse to include in the teaching plan? a. Use this medication as needed to manage your anxiety. b. Taper this medication before discontinuing. c. Allow 3 weeks before expecting any relief of symptoms. d. This medication poses a great risk of tolerance and dependence.

ANS: B Patients should not stop taking BuSpar abruptly, but should taper this medication according to health care provider instructions. BuSpar is always given as a scheduled drug (never on an as-needed basis). The patient should allow 7 to 10 days for symptoms to subside. No evidence exists that BuSpar causes tolerance or physical dependence

After signing a contract that he will no longer smoke in his room, the patient violates the contract. The contract consequences include confiscation of smoking materials and mandatory supervision for future smoke breaks. How should the nurse appropriately address the patient's behavior? a. "Why are you smoking in your room when you know it is not allowed?" b. "The contract states that if you smoke in your room, you must give me your smoking materials. Let me have them, please." c. "Okay, Larry, give me your cigarettes and lighter now." d. "I am going to give you one more chance, Larry. Let's see if you can live up to the contract."

ANS: B Reminding the patient of contract violation and the penalty attached should be done before taking the cigarettes. This approach is fair and puts the blame for the consequence on the offender. Providing the patient with the opportunity to "explain" the actions does not conform to the agreed-on contract. Providing additional opportunities for compliance does not support the contract and may encourage manipulative behavior.

A student nurse questions the nurse about the frequency of administration of antipsychotics, such as risperidone (Risperdal). Which advantage is true of newer antipsychotics like risperidone (Risperdal)? a. Decreased photosensitivity b. Fewer serious side effects c. Less expensive d. Decreased incidence of headaches

ANS: B Risperidone (Risperdal) is a newer generation of "atypical" antipsychotic medications that is known for having fewer serious side effects, such as tardive dyskinesia, but they still have significant effects.

The nurse explains that depression is thought to be the result of a deficit of which neurotransmitter? a. Norepinephrine b. Serotonin c. Acetylcholine d. Dopamine

ANS: B Serotonin is a neurotransmitter of the central nervous system. It is important in sleep, pain perception, and emotional states. Lack of serotonin can lead to depression. Norepinephrine and acetylcholine are neurotransmitters of the autonomic nervous system. Norepinephrine plays an important role in the fight- or-flight reaction (constriction of the blood vessels, dilation of the pupils, increased heart rate, increased awareness, and vigilance). Acetylcholine causes decreased heart rate and force of contraction and plays a role in the sleep-wake cycle. Dopamine is located mostly in the brainstem. It is thought to play a role in controlling complex movements, motivation, and cognition.

The nurse explains that use of stimulants will decrease hyperactivity in the autistic child. What is a negative aspect of stimulants? a. Sedating the child b. Impairing cognition c. Causing hypotension d. Creating fluid retention

ANS: B Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the potential of self-injuring behavior.

The nurse is talking with a patient who voices concerns about the incidence of schizophrenia in her family. The patient states that she is worried the condition will be inherited by her teenage daughter. What response by the nurse is most appropriate? a. "Unfortunately, schizophrenia does run in families." b. "Although some familial factors exist, there is no exact known cause for schizophrenia." c. "Your daughter would show some evidence of the condition by this point in her life, so there is no real reason to worry." d. "As long as your home environment is warm and loving, she will be fine."

ANS: B The exact cause of schizophrenia is unknown; however, current research favors the theory that there is a neurologic basis with a genetic component. As with most chronic conditions, an unfavorable social environment contributes to a poor prognosis. Schizophrenia usually develops in late adolescence or the early twenties.

The nurse is changing the dressing on self-inflicted cigarette burns on a patient with borderline personality disorder. When providing the care, which action is most therapeutic? a. Change the dressings while being nurturing and caring to keep patient from feeling abandoned. b. Approach the dressing change with a matter-of-fact demeanor to decrease secondary gains of sympathy. c. Present a stern attitude to underscore the seriousness of the act. d. Interact in a professional and distant manner to diminish the opportunity for manipulation.

ANS: B The person with borderline personality disorder will seek additional secondary gains in terms of attention about the manipulative act of self-mutilation. Nurturing will reinforce the effectiveness of the mutilation to gain attention. Stern and distant demeanors may appear confrontational to the patient and reduce the therapeutic aspects of the intervention.

The paranoid schizophrenic patient states that his whole family has conspired to have him put in the hospital and that the medical staff are part of the conspiracy. Which is the nurse's most therapeutic response? a. "I promise that I want to help you." b. "You know your family is concerned about you." c. "I'm sorry you feel that way. I'll be around if you want to talk about your feelings." d. "The doctors are trying to help you feel better. They have your best interest in mind."

ANS: C Arguing with the paranoid patient, or defending self or others, reinforces the paranoia. Passively offering self to the patient to approach you rather than the other way around is helpful to the nurse-patient relationship.

The CNA approaches the older adult in the long-term care facility and says, "Oh, look! Your pretty dress is icky with food spots! Let's change your clothes, sweetie." The nurse identifies that the CNA is using which type of communication? a. Instruction for personal hygiene b. Encouragement for self-care c. Simplistic "elderspeak" d. Reorientation techniques

ANS: C Elderspeak is a way of communicating with older adults that is infantile, oversimplistic, oversolicitous, and demeaning. It serves no therapeutic purpose.

The nurse is aware the patient with borderline personality disorder did not have a family visit this week and adds an intervention to address the patient's probable perception of abandonment. Which intervention is most appropriate? a. Schedule the patient for pet therapy visit. b. Arrange for remote activity during next visiting time. c. Assess daily for evidence of self-mutilation. d. Assign a young CNA to his care.

ANS: C Patients with borderline personality disorder have a deep fear of abandonment and react with intense, emotionally charge acts, such as suicide attempts or self-mutilation.

A recently licensed nurse is orienting to the Alzheimer disease (AD) care unit. The nurse is caring for a patient who is transitioning from oral rivastigmine (Exelon) to the medication patch. Which action indicates an accurate understanding of the medication? a. The nurse instructs the patient to apply the patch 12 hours after the last oral medication dosage. b. The nurse instructs the patient to replace the patch every 36 hours. c. The nurse explains that the sites of application will need to be rotated. d. The nurse instructs the patient to avoid placing the patch on the trunk region of the body.

ANS: C Rivastigmine (Exelon) is used to manage AD by elevating acetylcholine. The medication is available orally and transdermally. The patch should be applied 24 hours after the last oral dosage is given. The sites for application of the drug patches should be rotated.

The nurse observes a withdrawn schizophrenic. The patient is sitting alone and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear. What should the nurse do first? a. Hug the patient's shoulders, refer to the patient by name, and ask if she's praying. b. Document the patient's nonresponsiveness and continued detached behavior. c. Sit down in the chair next to the patient, touch her arm, and speak softly. d. Touch the patient's shoulder and then join another group of patients.

ANS: C Sitting with the patient and touching her presents the reality of the nurse's presence. Continued attention will make the patient feel safe. Feelings of safety are needed in the beginning of the nurse-patient relationship. Hugging the patient may invade the patient's personal space. The nurse's assessment will be documented but it is most appropriate to attempt an interaction with the patient.

The nurse is aware that the older adult is at risk for drug-induced delirium. Which age- related change contributes to this risk? a. Slower bowel motility b. Reduced fluid intake c. Overall reduced metabolism d. Sedentary lifestyle

ANS: C Slower renal and liver clearance of drugs allows the drugs to accumulate in the system of the older adult.

During report, the nurse is told that a patient has Cluster B group type of personality disorder. Which type of behavior can the nurse anticipate? a. Paranoia b. Avoidance c. Antisocial behavior d. Obsessive-compulsive behavior

ANS: C The antisocial personality disorder is included in Cluster B: dramatic and erratic.

What is the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder (ADHD) for the school nurse to suggest? a. Seat the child in the back of the room to prevent distractions for other children. b. Pair the child with a student buddy to offer reminders to pay attention. c. Divide work assignments into shorter periods with breaks in between. d. Separate the child from others to increase his focus on schoolwork.

ANS: C The child with ADHD needs breaks between periods of work and study.

A resident in a long-term care facility has been in a manic stage for 2 days. He has not slept and cannot focus long enough to eat a meal. How should the nurse best enhance the resident's nutrition? a. Insist he sit down and eat at the table. b. Spoon-feed him at the table at regular mealtimes. c. Offer him small glasses of high-protein drinks every hour. d. Make up a game about who can finish a meal first.

ANS: C The patient displays an inability to concentrate and a decreased need for sleep or nutrients. Offering a small amount of high-energy foods and drinks every hour will support nutrition until the manic behavior is under control. Because of the manic patient's abbreviated focus, eating an entire meal may not be possible. The nurse should not force the patient to sit and eat, demean him by spoon-feeding, or challenge him to process a new activity.

The family of a patient being treated for a recent diagnosis of schizophrenia voices concerns to the nurse. They report the patient just told them that the pepper flakes on his potatoes were crawling bugs. What response by the nurse is most appropriate? a. "At this stage it is most important to humor him and agree that you see them as well." b. "To reduce his stress, just throw out the food." c. "It is important to tell him that you do not see the bugs." d. "The best thing to do in this case is to confront him and let him know that he is mistaken."

ANS: C The patient is experiencing an illusion. It is most important to offer support but to attempt to provide reality orientation. Confronting him may cause anger or increased anxiety and should be avoided.

The nurse is caring for a patient with Alzheimer disease (AD) who wakes up moaning and frightened in the middle of the night. She begs that her husband's coffin be removed from her room. How should the nurse respond? a. Turn light on and say, "There is no coffin here. This is the dresser." b. Leave the light off and shine a flashlight on the dresser and say, "See! No coffin!" c. Turn the light on, assist patient to the bathroom, and say, "This is your dresser." d. Leave the light off and say, "You are in your room."

ANS: C Turning the light on helps reorient the patient. Distraction of going to the bathroom and identifying the dresser assist with reorientation after a frightening illusion. The other options would lead to greater confusion.

Which percentage of the population that is 85 years of age and older has some stage of Alzheimer disease (AD)? a. 10% b. 20% c. 35% d. 50%

ANS: D AD is the most common degenerative disease of the brain. Approximately 5.3 million Americans have AD (Alzheimer Association, 2010), and there is no known cause or cure. AD typically affects people over 65 years of age, but can also strike younger people. The 85-year-old and over age group is currently the fastest-growing age group in the United States. It is estimated that 50% of this age group have AD.

The nurse notes that the newly admitted patient with Alzheimer disease (AD) has significant anomia. Which intervention is most appropriate for this problem? a. Frequently reorient the patient to his room location. b. Remind the patient about the names and uses for particular items. c. Assist the patient with all meals. d. Wait patiently for the patient to find the word he wants.

ANS: D Anomia is the inability to recall a word. Waiting for the patient to remember the word or be able to substitute another is more supportive than supplying the word for him.

What thought process underscores a patient's anorexia nervosa? a. A desire to be attractive by staying slender. b. A desire to be involved with food preparation of food, but not eating it. c. A desire to punish self by denial of adequate nutrition. d. A desire to gain a sense of control by limiting food intake.

ANS: D Anorexia nervosa is characterized by the patient's refusal to maintain minimal body weight or eat adequate quantities of food. There is a disturbance in the perception of body shape and size and an extreme fear of becoming fat. The patient strives for perfection and control by controlling caloric intake. The person with anorexia nervosa gains a sense of control by limiting food intake.

An 85-year-old man is admitted to the hospital with gastroenteritis and dehydration. He receives a dose of meclizine hydrochloride, an anticholinergic, for vomiting. He begins to hallucinate and talk to his wife, who has been dead for 10 years. Which explanation best describes this behavior? a. Dementia related to advanced age b. Delirium related to dehydration c. Dementia related to early Alzheimer's disease (AD) d. Delirium related to side effect of anticholinergic

ANS: D Anticholinergic drugs can cause sudden confusion in older adults. There is nothing in the history that suggests that the behavior would be related to AD or any other dementia as dementias progress slowly. Dehydration would increase the effect of the anticholinergic.

What is an appropriate nursing intervention for a hospitalized child who is autistic? a. Place the child in a location where she can watch all of the activity on the unit. b. Use the child's chronological age as a guide for communication. c. Keep the child's room free of toys or objects that she might want to take home with her. d. Organize care to provide as few disruptions to the routine as possible.

ANS: D During hospitalization, the nurse should provide a highly structured environment with few distractions for a child who is autistic.

The nurse has asked a catatonic patient, "Where is your hat?" Which response should cause the nurse to document episodes of echolalia? a. The patient excitedly says, "Hat, cat, rat, fat, scat, splat!" b. The patient tearfully says, "I had a hat when my mother drove her yellow car." c. The patient repeatedly says, "Your hat, your hat, your hat." d. The patient places his hands on his head and says, "Where is your hat?"

ANS: D Echolalia is the repetition of words spoken to the patient by another person.

The nurse is caring for a patient who was admitted for a lorazepam (Ativan) overdose. Which assessment finding indicates that the patient is experiencing withdrawal? a. Lethargy b. Urine output of 40 mL/hr c. Heart rate of 48 beats/min d. Blood pressure of 140/90

ANS: D Elevated blood pressure is consistent with withdrawal from a central nervous system (CNS) depressant like lorazepam (Ativan), a benzodiazepine. If an individual has been abusing drugs that depress the CNS and goes through withdrawal, other symptoms would include an elevation in pulse, nervousness, and heightened anxiety. The patient would likely be agitated rather than lethargic and tachycardic. Urine output of 40 mL/hr is a normal finding.

The nurse is caring for a patient who has dementia and has been getting up out of bed at night. What action by the nurse is most therapeutic? a. The nurse raises all of the side rails. b. The nurse reassigns the patient to a room closer to the nurse's station. c. The nurse obtains orders from the physician to apply restraints at night. d. The nurse places the mattress on the floor.

ANS: D The patient poses a significant risk for falls and needs provisions to increase safety. Placing the mattress on the floor decreases the risk of injury from falling from a larger height. Moving the patient closer to the nurse's station does not offer protection or ensure that the patient will be seen or heard. The use of side rails can be considered a restraint and it can present an additional safety hazard. Restraints are to be the last option when caring for patients.

The nurse differentiates vascular dementia from Alzheimer dementia. Which causative factor is responsible for vascular dementia? a. Cerebral atrophy b. Global reduction of cognition c. Hypertension d. Emboli in cerebral vessels

ANS: D Vascular dementia occurs from brain tissue becoming hypoxic and necrotic in local areas due to small emboli. The deficits may be intellectual or loss of sensory function.

A long-term care facility resident with generalized anxiety disorder (GAD) enters the dining room and discovers that a visitor is sitting in her regular seat. The resident becomes agitated and insists that she cannot eat unless she sits in her chair. Which response is most appropriate? a. Instruct the visitor to move. b. Reassure the resident that she can sit in her regular spot at supper. c. Remind the resident that she will be hungry if she does not eat. d. Insist that the resident eat.

B A calm approach and reassurance will help the anxious patient to mimic the nurse's behavior. Asking the visitor to move, telling the resident that she will go hungry, or insisting that the resident eat are not therapeutic and will not help in reducing the patient's anxiety.

Which statement causes the nurse to document a schizophrenic patient's delusion of persecution? a. "Did you know that I own this hospital and pay all these people to work for me?" b. "My doctor talked to all the other patients, but not to me. He doesn't want me to get well." c. "The president's speech tonight is going to give me a coded message." d. "I am going to wait in front of the hospital this morning for my limousine to pick me up and take me to my private jet."

B Delusions can be either grandiose or persecutory. An individual who believes he owns the hospital or is planning to be picked up by a limousine or has a private jet is having delusions of grandeur. Individuals with delusions of persecution believe that they are being persecuted by agencies, by other people, or by supernatural beings. The patient who believes the president's speech is coded is having an idea of reference.

The nurse is caring for a patient with acquired immune deficiency syndrome (AIDS) dementia complex (ADC). Which factor places this patient at particular risk for injury? a. Manic behavior b. Numbness and muscle weakness c. Suicidal ideation d. Difficulty concentrating

B Peripheral neuropathy results in numbness and muscle weakness that may contribute to falls and thermal skin injuries.

Your patient is preoccupied with perfection and control, has difficulty relaxing, exhibits rule-conscious behavior, and cannot discard anything. What type of personality disorder does this behavior reflect?A. Antisocial personality. B. Obsessive-compulsive personality. C. Manic behavior. D. Anxiety disorder.

B. Obsessive-compulsive personality.Reason: Obsessive-compulsive disorder is a personality disorder that includes perfection, control, procrastination, excessive devotion to work, difficulty relaxing, rule-conscious behavior, and inability to discard anything.

The nurse explains that anxiety disorders differ from normal anxiety. Which statement accurately describes anxiety disorders? a. Anxiety disorders develop into suicidal tendencies. b. Anxiety disorders are seldom controlled. c. Anxiety disorders interfere with effective functioning. d. Anxiety disorders make maintenance of relationships impossible.

C Anxiety disorders interrupt normal day-to-day functioning in the workplace and in family settings.

The manipulative patient approaches the nurse and says, "I know it's too early to give me my pain medication, but you are the only one who seems to care. Could you give me my pain medication now?" Which response is best? a. "The charge nurse is very stringent about scheduled medications. She would be very angry with me if I gave you the medication now." b. "I know how it is when you are in pain. I'll give you your medication early." c. "Your medication is due in 2 hours. I will be glad to give it to you on schedule." d. "It makes me feel good to know you are appreciative of our care. Here is your medication."

C Setting clear limits is important when managing manipulative patients. Once limits are set, it is important to maintain them. Blaming the charge nurse provides incentive for further manipulative behaviors. The nurse telling the patient that they know what it is like when they are in pain is not accurate or therapeutic. Providing the medication early likely does not follow the prescribed plan.

The nurse observes a coworker who is always behind because he checks and rechecks the accuracy of his medication dosages. Even after being reassured his dosages are correct, he checks them again. The nurse suspects her coworker suffers from which disorder? a. Perfectionism b. Phobic disorder c. Obsessive-compulsive disorder (OCD) d. General anxiety disorder

C When a person has an OCD, he experiences an obsession, recurrent, or intrusive thoughts that he cannot stop thinking about, and these thoughts create anxiety. A compulsive act is an act that the person feels compelled to perform. For example, a person may experience anxiety and so performs repetitive handwashing in an attempt to reduce that anxiety. Time spent in these thoughts and rituals can become overwhelming to the point of interfering with normal life.

The nurse is reviewing the medical history of a patient who is being evaluated for anorexia nervosa. Which characteristic(s) would be consistent with the condition? (Select all that apply.) a. Weight loss of 2 to 3 pounds in the past month b. Binge eating c. Frequent mood changes d. Absence of three consecutive menstrual periods e. Body weight less than 85% of what is expected for height and weight

C, D, E Anorexia nervosa is characterized by the patient's refusal to maintain minimal body weight or eat adequate quantities of food. There is a disturbance in the perception of body shape and size and an extreme fear of becoming fat. The patient strives for perfection and control by controlling caloric intake. Defining characteristics include frequent mood fluctuation, absence of three consecutive menstrual periods, and body weight less than 85% of what is expected for height and weight.

You drive up to the house of your patient, who is known to have schizophrenia with manic episodes. This is your fifth visit. On this occasion, the patient is sitting on his front porch in a rocking chair with a shotgun in his arms. What should your next intervention be? A. Beep your car horn to get your patient's attention. B. Yell your patient's name out your car window and wave at him to say hello. C. Keep driving in a path that is going away from the patient's house. D. Stop the car in the patient's driveway and call your boss on your cell phone.

C. Keep driving in a path that is going away from the patient's house.Reason: Safety includes not placing yourself in vulnerable situations.

What is the priority nursing intervention to help orient a patient who has Alzheimer's disease? A. Post a schedule in the dining room of daily activities. B. Use an overhead loudspeaker to announce upcoming events. C. Provide a daily routine and easy-to-read clocks. D. Have the patient live alone in a private room.

C. Provide a daily routine and easy-to-read clocks.Reason: Daily routines and large clocks help patients' functional status.

Which statement made by a parent of an adolescent with anorexia nervosa indicates an understanding of this condition? a. "There really isn't anything to worry about. Don't they say you can never be too thin?" b. "My daughter just doesn't have much of an appetite." c. "She is just trying to punish me for divorcing her father." d. "She seems to see herself as fat, even though her weight is below normal."

D Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes.

Donepezil (Aricept) has been prescribed for a patient with Alzheimer disease (AD). Which statement indicates that the patient and spouse understand teaching about the medication? a. "It is best to take the medication at bedtime." b. "The medication will interact with dark leafy greens." c. "Taking the medication with a citrus beverage should improve absorption." d. "The medication should be taken with meals."

D Donepezil (Aricept) is used in the management of AD. It has been shown to elevate acetylcholine levels in the brain and will slow the progression of the condition. The medication should be taken with meals to reduce gastrointestinal distress.

Your patient's auditory, visual, and tactile hallucinations are controlled with bimonthly injections of haloperidol (Haldol) that the community health nurse administers during home visits. You are the new nurse on this case; the previous nurse has retired. The previous nurse has stated in her care plan that the patient will let the nurse in the house only if the nurse carries a public health-issued blue bag and wears black pants. You are scheduled to visit this patient tomorrow. What should you do? A. Call the patient and tell her that you are a new nurse and will be wearing white pants. B. Show up as scheduled carrying only a stethoscope, vial, alcohol wipe, and medication syringe. C. Show up as scheduled with a police officer. D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants.

D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants.Reason: The patient needs her medication, and following the care plan is the optimal course of action.

After detoxification from substance abuse, the patient says, "I feel better than I have in years! All I needed was some rest. I am not an alcoholic." Which response is best for the nurse to make? a. "What were you doing that got you admitted to the detoxification center?" b. "Alcoholism has many definitions. What is yours?" c. "Admitting to alcoholism is hard." d. "Alcoholism has ruined your life. How can you say you are not an alcoholic?"

a Confronting denial and encouraging self-diagnosis is the point of the treatment phase after detoxification. Asking for the patient's definition of alcoholism allows for the patient to intellectualize the problem. Stating that alcoholism is "hard" is a sympathetic and unhelpful response. "Alcoholism has ruined your life" is accusatory and counterproductive.

a nurse is caring for a client who has bipolar disorder and is expierincing a manic episode. which of the following interventions should the nurse take first? a. remove harmful objects from clients room b. decrease clients environmental stimuli c. administer antipsychotic medication to the client d. provide physical activities for client

a The greatest risk to this client is self-injury or injury to others. Therefore, the first action the nurse should take is to remove harmful objects from the client's room to protect the client.

The nurse is concerned about a coworker who she suspects is abusing amphetamines. Which behavior best validates the nurse's concern? a. Frantic, excited speech b. Poor attention to detail c. Poor personal hygiene d. Insatiable hunger

a excited speech, euphoric behavior, increased alertness, and anorexia are indications of abuse of amphetamines

which behavior would the nurse expect to observe if a client is diagnosed with paranoid personality disorder? a. the client sits alone at lunch and states "everyone wants to hurt me" b. the client is irresponsible and exploits other peers in the milieu for cigarettes c. the client is shy and refuses to talk to other because of poor self esteem d. the client sits with peers and allows others to make decisions for the entire group

a paranoid- want to be isolated and assume everyone is out to get them

Approximately what percentage of the U.S. population is affected with schizophrenia? a. 1% b. 2% c. 3% d. 4%

a schizophrenia is most common thought disorder. It is estimated that 1.1 % of general population is affected

Which statement accurately explains the difference between an enabler and a co- dependent? a. A codependent covers up the substance abuser's behavior. b. A codependent rationalizes the substance abuser's behavior. c. An enabler uses the substance abuser's behavior to build up his or her own self- esteem. d. An enabler is also a substance abuser.

a the codependent fixes things by overcompensating to prevent the abuser from facing reality. enabling refers to helping a person so that the persons consequences from unhealthy behavior are less severe; thus enabling helps the unhealthy behavior to continue

a nurse is speaking with a client who is expressing an intense disapproval of the current social worker. when the social worker approaches the nurse and client a few months later, the client cheerfully states "now, here is my favorite social worker!". the nurse should identify which of the following defense mechanisms? a. reaction formation b. dissociation c. denial d. projection

a The nurse should identify that this client is using reaction formation. This is the defense mechanism in which the client is unable to process unacceptable feelings or behaviors and expresses the opposite to decrease anxiety.

Which actions describe diagnostic criteria for the diagnosis of substance abuse? (Select all that apply.) a. Failure to meet obligations b. Putting self and others in potential harm c. Experiencing conflict with law enforcement authorities d. Developing physical debilitation e. Denying existence of a problem

a b c physical debilitation and denial are not in the criteria established by the american psychiatric association for the diagnosis of substance abuse

which of the following medications can be used to treat clients with anxiety disorders? SATA a. clonidine (catapres b. fluvoxamine maleate (luvox) c. buspirone (buspar) d. alprazalam (xanax) e. haloperidol (haldol)

a b c d

The nurse states that the members of a mental health team for child guidance include which member(s)? (Select all that apply.) a. Psychiatrist b. Pediatrician c. Psychologist d. Dietitian e. Social worker

a b c e A, B, C, E The traditional members of the child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team.

The nurse cautions the recovering alcoholic who is on disulfiram (Antabuse) should avoid even small exposure to alcohol. Which signs and symptoms are characteristic of a reaction of disulfiram (Antabuse) with alcohol? (Select all that apply.) a. Chest pain b. Nausea and vomiting c. Hypertension d. Blurred vision e. Blinding headache

a b d The nurse cautions the recovering alcoholic who is on disulfiram (Antabuse) should avoid even small exposure to alcohol. Which signs and symptoms are characteristic of a reaction of disulfiram (Antabuse) with alcohol? (Select all that apply.) a. Chest pain b. Nausea and vomiting c. Hypertension d. Blurred vision e. Blinding headache

The nurse is planning the care of an adolescent with anorexia nervosa. What characteristic(s) cause this disorder? (Select all that apply.) a. Discomfort relative to emerging sexuality b. Fear of intimacy c. Pervasive high self-esteem d. Egocentricity e. Inability to meet developmental needs

a b d e All options except pervasive high self-esteem are considered to be a cause of anorexia nervosa. Pervasive low self-esteem also is considered a cause of anorexia nervosa.

Which criteria are part of alcohol dependency diagnosis guidelines? (Select all that apply.) a. Identifiable withdrawal signs and symptoms b. Decreasing tolerance c. Altered family relationships d. Blackouts or amnesia pertinent to drinking episodes e. Altered occupational productivity

a c d e identifiable withdrawal signs and symptoms, altered family relationships, blackouts or amnesia pertinent to drinking episodes and altered occupational productivity are all part of the diagnoistic guidelines for diagnosis of alcohol dependency

Patients who use inhalants and hallucinogens are likely to experience which negative effects? (Select all that apply.) a. Distortion of senses b. Intense pruritus c. Uncontrolled flashbacks d. Koilonychia e. Severely impaired judgment

a c e Hallucinogens cause distortion of the senses, an inability to separate fact from fantasy, impaired sense of time, and severely impaired judgment. Users never know whether they will have a good "trip" or a bad one. Uncontrolled flashbacks (feelings and sensations associated with use despite being drug-free) can occur. This group of drugs is very dangerous because use is known to cause panic, paranoia, and death from extremely impaired judgment. Inhalants and hallucinogens are not known to cause intense itching (pruritus) or spoon-shaped nails (koilonychia).

a nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chloropromazine. which of the following statements should the nruse include in the teaching? a. the voices you have been hearing should decrease b. you will likely have more energy while on this medication c. you should now be able to spend more time in the sun d. call your provider immediately if you develop a dry mouth

a. the nurse should instruct the client that hallucinations and agitated behavior, which are positive symptoms of schizophrenia, are targeted by conventional antipsychotic agents, such as chlorpromazine.

a client on an in patient psychiatric unit has been diagnosed with bulimia nervosa. the client states "im going to the bathroom and will be back in a few minutes" which nursing response is most appropriate a. thanks for checking in b. i will accompany you to the bathroom c. let me know when you get back to the dayroom d. ill stand outside your door to give you privacy

b

a suicidal client is diagnosed with borderline personality disorder. Which short term oucome is most beneficial for this client a. the client will be free from self injurious behavior b. the client will express feelings without inflicting self injury by discharge c. the client will socialize with peers in the milieu by day 3 d. the client will acknowldge his or her role in altered interpersonal relationships

b

in which situation would benzodiazepines be prescribed appropriately a. long term tx of post traumatic stress disorder, convulsive disorder and alcohol withdrawal b. short term tx of generalized axiety disorder, alcohol withdrawal and preoperative sedation c. short term tx of OCD, skeletal muscle spasms and hypertension d. long term treatment of panic disorder, alcohol dependence and bipolar affective disorder, manic episode

b

the nurse is planning a teaching session for a client who has recently been prescribed antabuse as deterrent therapy for alcoholism. What statement indicates that the client has accurate knowledge of this subject matter a. otc cough and cold medication should not affect me while taking antabuse b. ill have to stop using my alcohol based aftershave while i am taking antabuse c. antabuse should decrease my cravings for alcohol d. antabuse is used as a subsitute for alcohol to help mea void alcohol withdrawal symptoms

b

which nursing intervention would directly assist a hospitalized client diagnosed with bulimia nervosa in avoiding the urge to purge after discharge? a. locking the door to the clients bathroom b. holding a mandatory group after mealtime to assist in exploration of feelings c. discussing preplanned meals to decrease anxiety around eating d. educating the family to recognize purging side effects

b

a nurse in a providers office is collecting data from an older adult client who adult child reports that she seems confused and cant seem to remember much. which of the following finding should lead the nurse to suspect delirium? a. the clients confusion worsens during stress b. the clients level of consciousness changes during the interview c. the clients confusion improves in the evening d. the client becomes irritable during the interview

b Delirium can rapidly alter the client's level of consciousness, which can manifest as agitation or stupor. Therefore, the nurse should suspect that this client is experiencing delirium.

Shortly after receiving one dose of naloxone (Narcan) for an overdose of opiates, a patient experiences a change in level of consciousness and a decreased respiratory rate. What should the nurse do first? a. Inform the charge nurse. b. Repeat the Narcan. c. Notify the health care provider. d. Update family members.

b Narcan has a short half-life, and opiate action may resume and cause respiratory depression. Narcan may be repeated, or the nurse can request a continuous intravenous infusion of the drug.

a nurse is reinforcing discharge teaching w a client who has a new prrescription for alprazolam. which of the following instructions is the priority for the nurse to include? a. avoid drinking beverages that contain caffeine b. do not drive until your reaction to the medication is determined c. avoid taking naps in daytime d. take this medication with a light snack

b The greatest risk to this client is injury to himself. Therefore, the priority information the nurse should include is to inform the client not to drive or handle major mechanical equipment while taking alprazolam.

a nurse on an inpatient unit is assisting with a group therapy session. during the session a client begins to shout, using aggressive language. which of the following statements should the nurse make to the client a. "Why do you feel the need to speak this way to others in the group? "b. "When you raise your voice, it makes me feel uncomfortable and unsafe." c. "You are frightening others in the group when you show your anger." d. "Why are you attending group therapy but not respecting the feelings of others?"

b Using "I feel" messages models the sharing and owning of personal feelings and helps minimize defensive responses.

a client has been diagnosed with a cluster a personality disorder. Which client statement would reflect cluster a characteristics? a. im the best chef on the east coast b. my food has been poisoned c. i have to wash my hands ten times before eating d. i just cant eat when im alone

b cluster a include feelings of mistrust

The alcoholic patient says to the nurse, "I am not an alcoholic. I can quit any time I want to." The nurse recognizes that the patient is using which defense mechanism? a. Repression b. Denial c. Rationalization d. Intellectualization

b denial is ignoring reality in spite of hard evidence. denial is a mechanism frequently used by substance abusers. repression refers to unconsciously blocking an unwanted thought or memory from open expression. rationalization attempts to justify a behavior or action by making an excuse or an explanation. intellectualization is the excessive reasoning and logic to counter emotional distress

on discharge, a client diagnosed with dementia is prescribed donepezil hydrochloride (aricept) which would the nurse include in the teaching plan for the clients family? a. donepezil is a sedative/hypnotic used for short term tx of insomnia b. donepezil is an alzheimers treatment used for mild to moderate dementia c. donepezil is an antipsychotic used for clients diagnosed with dementia d. donepezil is an antianxiety agent used for clients diagnosed with dementia

b donezepil is used for mild to moderate dementia. a decrease in cholinergic function may be the cause of alzheimers disease, and donezepil is a cholinesterase inhibitor.

Why do many people who abuse Cannabis (marijuana) rationalize their use? a. Cannabis sedates them. b. Cannabis expands their senses. c. Cannabis heightens sexual pleasure. d. Cannabis may be obtained legally for therapeutic purposes.

b many young people offer the increased sensitivity to sound, colors, and other environmental elements as a rationale for using the nonaddicting drug

a client with a long hx of alcohol abuse is showing signs of cognitive deficits. what drug would the nurse recognize as appropriate in assisting with this clients recovery a. disulfiram ( antabuse) b. naltrexone (revia) c. lorazepam (ativan) d. haloperidol )haldol

b naltrexone is an opiate antagonist that can decrease some of the reinforcing effects of alcohol and decrease cravings

a client diagnosed with personality disorder insists that a grandma, through reincarnation, has come back to life as a kitten. the thought process described is reflective of which personality disorder? a. obsessive compulsive disorder b. schizotypal personality disorder c. borderline personality disorder d. schizoid personality disorder

b schizotypal are characterized by peculuarities of ideation, appearance and behavior, magical thinking and deficits in interpersonal relatedness, not severe enough to meet characteristics of schizophrenia

The nurse is aware that when Korsakoff syndrome is suspected from behavioral cues, the syndrome can be confirmed by which diagnostic test? a. Liver biopsy b. Brain scan c. Magnetic resonance imaging d. Spinal tap

b the individual with Korsakoff syndrome has grossly impaired memory and gait disturbance. confabulation ( making up stories) frequently is seen as an attempt to communicate. A brain scan will show brain atrophy, currently there is no treatment to reverse the condition

a nurse is collecting data from a client who has bipolar disorder and a history of mania. which of the following findings should the nurse identify as an indication that the client is relapsing a. weight gain b. pressured speech c. ritualism behavior d. anhedonia

b the nurse should identify that rapid or pressured speech, provocative behavior, and insomnia are indications of potential relapse in a client who has bipolar disorder and a history of mania.

A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. which of the following statements indicates an understanding of the instructions? a. for the first step of my therapy i will look at pictures of cars b. i will snap a rubber band on my wrist when i feel anxious about riding in a car c. my therapist will be with me while we ride in a car together d. i will ride in a car for several hours at a time

b thought stopping is used to interrupt a clients negative thought with a distraction

when confronted, a client diagnosed with narcissistic personality disorder states " contrary to what everyone believes, i do not think that the whole world owes me a living". the client is using what defense mechanism? a minimilization b. denial c. rationalization d. projection

b denial used to refuse reality of a situation

A child is diagnosed with attention deficit hyperactivity disorder (ADHD). Which characteristics would the nurse assess in this child? (Select all that apply.) a. Social anxiety b. Impulsivity c. Hyperactivity d. Distractability e. Inattention

b c d e

a nurse in a mental health facility is collecting data from a client who has schizophrenia. the nurse should identify which of the following findings is referred to as a negative symptom of schizophrenia? a. delusions b. echolalia c. apathy d. paranoia

c Negative symptoms of schizophrenia are deficits in the client's ability to experience emotions. Apathy is a negative symptom of schizophrenia that is manifested by a loss of interest in one's surroundings.

a nurse in a long- term care center is caring for an adult whose client has alzheimers disease and whose partner died several years ago. the client appears upset and asks the nurse when his partner will visit again. the nurse states "it seems like you are feeling lonely. lets take a walk outside and talk" which of the following communication strategies is the nurse using? a. reminscence therapy b. feedback c. validation therapy d. reflecting

c Reminiscence therapy encourages the client to reflect on and think about the past. This therapy most often takes place in a group setting where older adult clients share significant past events with their peers. Feedback gives information to clients about how others perceive them and helps them consider changing their behavior. The nurse is using validation therapy as a strategy to communicate with the client. This strategy validates the client's feelings and emotions, even when they don't coincide with reality. The nurse should also attempt to integrate redirection techniques without the client realizing he is being redirected. Reflecting refers questions and feelings back to clients so they realize that their point of view has value. This technique is used most often when clients ask the nurse for advice.

a nurse collecting data from client who has major depressive disorder. which of the following findings is the priority for the nurse to report to provider a. inability to make decision b. anhedonia c. feeling of hopelessness d. fatigue

c When using the urgent vs. nonurgent approach to client care, the nurse should identify that feelings of hopelessness indicate this client is at risk for suicide. Therefore, this is the priority finding for the nurse to report to the provider.

a diabetic client admitted to a medical floor for medication stabilization has a history of antisocial personality disorder. which documented behaviors would support this diagnosis? a. labile mood and affect and old scars noted on wrists bilaterally b. appears younger than stated age with flamboyant hair and makeup c. began cursing when confronted with drug seeking behaviors d. demands foods prepared by personal chef to be delivered

c antisocial personality disorder is characterized by a pattern of social irresponsible, exploitative, and guiltless behavior. these clients disregard the rights of others and frequently fail to conform to social norms with respect to lawful behaviors

on a 24 hour assessment, the nurse documents a client diagnosed with alzheimers disease presents with aphasia. which client behavior supports this finding? a. the client is sad and has no ability to expxerience pleasure b. the client is extremely emaciated and appears to be wasting away c. the client is having difficulty forming words d. the client is using perservation to maintain self esteem

c aphasia is the term used when an individual is having difficulty communicating through speech, writing, or signs

a client tells the nurse "when i was a waiter i use to spit in the dinners of annoying customers" this statement would be associated with which personality trait? a. paranoid personality trait b. schizoid personality trait c. passive aggressive trait d. antisocial trait

c clients exhbiting passive aggressibe trait are characterized by adequate performance in occupational and social functioning. the client in the question is demonstrating passive aggressive traits toward customers

a client who is delirious yells out to the nurse "you are an idiot get me your supervisor". which is the best nursing response? a. you need to calm down and listen to what i am saying b. youre very upset i will call my supervisor c. youre going through a difficult time i will stay with you d. why do you feel that calling my supervisor will solve anything?

c empathetically expressing understanding of the clients situation promotes the client. delirious or confused clients may be at high risk for injury and should be monitored closely

a client with a history of bulimia nervosa is seen in the emergency dept. the client is seeing things that others do not, is restless, and has dry membranes. which is most likely the cause of his symptoms? a. mood disorders, which often accompany the diagnosis of bulimia nervosa b. nutritional deficits, which are characteristic of bulimia nervosa c. vomiting which may lead to dehydration and electrolyte imbalance d. binging, which cause abdominal discomfort

c purging behaviors such as vomiting may lead to dehydration and electrolyte imbalance. hallucinations and restlessness can be signs of electrolyte imbalance

which structure in the brain contains the appetite regulation center? a thalamus b amygdala c hypothalamus d medulla

c the hypothalamus exerts control over the actions of the autonomic central nervous system and regulates appetite

a nurse at an outpatient mental health clinic is assisting with a group therapy session. one of the participants is having diffuculty staying seated and states loudly to the therapyist "i know more than you do about the people in this room"! the nurse should identify which of the following findings is the explanation for the clients behavior? a. somatization b. opiod intoxication c. hypomania d. marijuana intoxication

c The nurse should suspect hypomania as the likely cause of the client's current behavior and investigate these actions further after calmly escorting the client from the therapy session. Clients who have hypomania exhibit excessive energy and a decreased need for sleep. These clients are easily distracted in a group setting and have a pretentious, grandiose sense of self.

a nurse is caring for a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following client statements indicates the medication is effective? a. naltrexone calms my nerves b. i get flushed when i drink alcohol while taking naltrexone c. naltrexone decreases my fine hand tremors d. i drink less alcohol in a day while taking naltrexone

d Clients taking naltrexone have a decreased craving for alcohol and experience decreased pleasurable effects from alcohol consumption. Although the goal for most clients who have alcohol use disorder is to maintain abstinence, clients who ingest alcohol while taking this medication often drink less per day.

a nurse is collecting data from a client who is experiencing opiod withdrawal. which of the following manifestations should the nurse expect? a. hypotension b. bradycardia c. hypothermia d. pupilary dilation

d The nurse should expect a client who is experiencing opioid withdrawal to have dilated pupil, hypertension, bradycardia, hypothermia, and pupil dilation

a nurse is collecting data from a client who has paranoid personality disorder. which of the following manifestations should the nurse suspect a. preoccupied with details b. attention seeking behaviors c. exploitive of others d. projects blame onto others

d The nurse should expect clients who have paranoid personality disorder to project blame onto others rather than taking responsibility for their own actions.

a nurse on an inpatient unit is collecting data from a group of clients. which of the following findings should the nurse report to the provider? a. a client who has schizophrenia and is using neologisms b. client who has bipolar disorder and is experiencing flight of ideas c. a client who has depression and avoids eye contact d. a client who has borderline personality disorder and is pacing restlessly

d The nurse should identify that a client who has borderline personality disorder and is pacing restlessly is at increased risk for violence towards herself or others. This behavior should be reported to the provider.

The nurse explains that an alternative to disulfiram (Antabuse) is the drug naltrexone (ReVia). Which information should the nurse include in the teaching plan? a. Naltrexone (ReVia) causes severe headaches if alcohol is consumed while using the drug. b. Naltrexone (ReVia) can cause a dependence on the medication itself if taken improperly. c. Naltrexone (ReVia) releases endorphin-like enzymes that mimic intoxication. d. Naltrexone (ReVia) blocks craving and prevents relapse.

d naltrexone can be used to block craving for alcohol and prevent relapse in recovery phase

a nursing student is learning about narcissistic personality disorder. which student statement indicates that learning has occured? a. these clients have peculiarities of idealization b. these clients require constant approval affirmation c. these clients are impulsive and self- destructive d. these clients express a grandiose sense of self importance

d sense of self importance and preoccupations with fantasies of success, power, brilliance and beauty

The nurse encourages the recovering alcoholic to participate in group therapy. Which benefit is most important for the nurse to mention? a. Development of improved social skills b. Progression toward sobriety c. Provision of a sense of belonging d. Increasing self-discipline

d the learning of the skill of self- discipline is the long-lasting benefit from group therapy. the other options are also benefits, but the major one is self-discipline, a skill a drug abuser must acquire for successful rehabilitation

a nurse is collecting data from a newly admitted client who has anorexia nervosa. which of the following manifestations should the nurse expect a. tachycardia b. bmi of 22 c. hypertension d. peripheral edema

d Peripheral edema is an expected finding for a client who has anorexia nervosa due to hypoalbuminemia and weight loss.