NUR 356 Exam 3 Practice Questions
A COWS scale is used to assess and monitor symptoms of ____?
Opiate/opioid withdrawal
The client is experiencing an episode of acute anxiety. The nurse will expect to observe which common coping behaviors? A. Social withdrawal B. Attention seeking C. Increased ability to problem solve D. Hypersomnia
A. Social withdrawal Rationale: The client in acute anxiety is not able to sleep, problem solve, or desire attention. This client will begin to socially withdraw. This client will require an environment with minimal stimulation.
The charge nurse on an inpatient psychiatric floor is teaching a floor nurse about signs and symptoms of alcohol withdrawal. The charge nurse knows the floor nurse demonstrates understanding when the floor nurse lists which of the following signs and symptoms? (Select all that apply) A. Vomiting B. Tremors C. Bradycardia D. Hypotension E. Hallucinations
A. Vomiting B. Tremors E. Hallucinations Rationale: Patients will exhibit restlessness, nausea and vomiting, tremors, hallucinations, hypertension, and tachycardia.
A CIWA scale is used to assess and monitor symptoms of ____?
Alcohol withdrawal
The nurse working on an inpatient psychiatric unit is caring for a patient with schizophrenia and substance abuse disorder. The nurse administers the patient's medications as ordered. Which patient response will the nurse report immediately to the health care provider? A. Decreased appetite B. Angry outbursts C. Nausea and vomiting D. Temp of 102.1 °F
D. Temp of 102.1 °F Rationale: Able to identify the most critical change in patient condition. The other findings are expected, the fever will alert the nurse to a more severe complication related to antipsychotic use (neuroleptic malignant syndrome).
Wernicke's encephalopathy results from heavy chronic alcohol use and ____ deficiency
Thiamine or vitamin B1
A nurse is caring for a client prescribed haloperidol for his chronic paranoid schizophrenia. Which complications should the nurse monitor? A. Chewing motion with the mouth B. Pin point pupils C. Bradypnea D. Orthostatic hypotension
A. Chewing motion with the mouth Rationale: Haldol causes alterations in QT and can cause dysrhythmias, blood dyscrasia is a common side effect of antipsychotics as well as EPS. The chewing motion with the mouth is a hallmark sign of EPS and will require treatment. This client may not realize and it is the nurse's role to recognize this side effect.
The nurse would express concern to the prescriber if the client has which of the following symptoms? A. Command hallucinations B. Delusions of grandeur C. Tangential thinking D. Thought blocking
A. Command hallucinations Rationale: Command hallucinations are often dangerous. These should be addressed immediately with the provider. The other symptoms are anticipated findings in the client with schizophrenia and are not often dangerous. With a command hallucination the nurse should immediately address SI or HI.
Which statement indicates to the nurse that a client is experiencing a delusion? A. "The government is watching everything I do." B. "There is a snake on the back of the television." C. "Spiders are crawling on the walls." D. "I don't care to do counseling today."
A. "The government is watching everything I do." Rationale: This statement indicates the client is experiencing a delusion. Delusions are fixed, false beliefs that are irrational and that the individual maintains are true despite evidence to the contrary.
Case Study: Amanda has been admitted to the hospital after being seen in an acute care walk-in clinic with blood in her urine. The admitting physician has ordered several invasive procedures: catheterization, blood work, and cystoscopy, among others. The physician does not know that Amanda has been taking anticoagulants to produce blood in her urine. What data will the nurse elicit from Amanda that will confirm this diagnosis? A. A history of multiple hospitalizations B. A history with few details C. An extensive history with a single provider D. A lack of understanding of medical terminology
A. A history of multiple hospitalizations Rationale: The client will intentionally produce or feign physical or psychological symptoms. It is often difficult to diagnose and treat clients with factitious disorders. It is also costly when medically unnecessary diagnostic procedures are performed. These clients are intelligent with an understanding of medical terminology and medical procedures. They are vague and unable to give an adequate answer to when and how long the symptoms and they will seek medical attention for psychological need for attention.
The nurse is caring for a client with phase III of schizophrenia. The nurse anticipates the patient will be exhibiting which signs or symptom the disorder? A. Active positive symptoms B. Normal behavior patters C. Active negative symptoms D. Shy and withdrawn, no wish to attend groups
A. Active positive symptoms Rationale: Schizophrenia is a chronic illness. Phase III is characterized by acute episodes in which symptoms are more pronounced. In the active phase of the disorder, psychotic symptoms (positive symptoms) are typically prominent. Premorbid personality and behavioral indications may include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating antisocial behavior.
The client states, "I haven't left my house for six years." The nurse suspects that this client experiences which disorder? A. Agoraphobia B. Generalized Anxiety Disorder C. Social Anxiety Disorder D. Panic Disorder
A. Agoraphobia Rationale: This client is demonstrating a hallmark trait of those that are afraid of other environments (agoraphobia). This is an anxiety disorder and also fits in the classification of a phobia, however it is a very specific statement that applies to this one phobia.
A nurse is assessing a client who has hypochondriasis (illness anxiety disorder). Which of the following findings should the nurse expect? A. Constant worry about undiagnosed illness B. Obsession over physical appearance C. Sudden unexplained loss of function D. La belle indifference
A. Constant worry about undiagnosed illness Rationale: Clients who have illness anxiety disorder constantly worry about the presence of a serious illness even though medical tests do not support this concern. This client should not be experiencing a loss of function. This client will experience actual symptoms without the medical cause identified.
When an individual's stress response is sustained over a long period, the nurse anticipates which physiological effect? A. Decreased resistance to disease B. Increased libido C. Decreased blood pressure D. Increased feelings of well-being
A. Decreased resistance to disease Rationale: Prolonged exposure to stress leads to a decreased immune response and resistance to disease. During the stage of exhaustion, the body's compensatory mechanisms no longer function effectively and diseases of adaptation occur.
The nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should the nurse expect to assess? A. Disproportionate and persistent thoughts about the seriousness of one's symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms
A. Disproportionate and persistent thoughts about the seriousness of one's symptoms Rationale: The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues.
A client comes in with descriptions of stress and identifies a life changing event. They explain that ever since the event, they have had worsening moods, increased impatience, and claims they never feel at peace. The client's response can be identified as a form of? A. Maladaptation B. Mistrust C. Depression D. Coping mechanism
A. Maladaptation Rationale: Maladaptation This occurs when an individual's physical or behavioral response to any change in his or her internal or external environment results in disruption of individual integrity or in persistent disequilibrium.
The nurse is administering risperidone to a client diagnosed with schizophrenia. The nurse anticipates the medication to have a therapeutic effect on which symptoms? (Select all that apply) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations
A. Somatic delusions C. Gustatory hallucinations E. Clang associations Rationale: Atypical antipsychotics, such as risperidone, have been shown to be effective in the treatment and prevention of the positive symptoms of schizophrenia. Somatic delusions, gustatory hallucinations, and clang associations are some of the positive symptoms of schizophrenia.
The nurse assigns ineffective coping as a nursing diagnoses for a client diagnosed with substance abuse. Which intervention does the nurse use to assist the patient to gain adaptive responses to stress? A. Spend time with the client and establish a trusting relationship B. Assign a new nurse daily to enable learning new coping skills C. Be inconsistent with pointing out negative or manipulative behaviors D. Discourage verbalization of feelings
A. Spend time with the client and establish a trusting relationship Rationale: The client will be able to verbalize use of adaptive coping mechanisms, instead of substance abuse, in response to stress. Spend time with the client and establish a trusting relationship.
An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intent to leave the hospital. What information should the nurse recognize as having an impact on the treatment team's next action? A. State law determines the length of time a psychiatric facility can hold a client. B. Federal law determines if the client is competent enough to be discharged. C. The client's family will be involved to determine if discharge is possible. D. Hospital policies will determine treatment team actions.
A. State law determines the length of time a psychiatric facility can hold a client. Rationale: Most states commonly cite that, in an emergency, a client who is dangerous to self or others may be involuntarily hospitalized.
A nurse is conducting a mental status exam. The nurse will assess for which of the following? (Select all that apply) A. Thought content B. Grooming C. Blood pressure D. Behavior E. Eye contact
A. Thought content B. Grooming D. Behavior E. Eye contact Rationale: The nurse will assess thought content, processes, eye contact behavior, and maintenance of ADLs. The nurse will collect VS, but this is not a part of the MSE.
A client with suspected factitious disorder presents to the clinic with severe back pain rated 9/10. The nurse understands that: A. Treat the client's pain as real until determined otherwise B. Refuse to medicate because the client's condition is a ruse C. Send the client to another clinic D. Place the client on a psychiatric hold
A. Treat the client's pain as real until determined otherwise Rationale: In clients with suspected factitious disorder, the pain must be treated as real unless it is known to be false.
Which client statement alerts the nurse that the client may be maladaptively responding to stress? A. "I signed up for a yoga class this week." B. "I really enjoy journaling; it's my private time." C. "Avoiding contact with others helps me cope." D. "I made an appointment to meet with a therapist."
C. "Avoiding contact with others helps me cope." Rationale: Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems.
The AIMS or Abnormal Involuntary Movement Scale assesses side effects of which medications?
Antipsychotics Rationale: AIMS assesses for extrapyramidal side effects seen with antipsychotic use.
A client is receiving nursing education after a prescription for disulfiram is ordered. What will the nurse include in the education? A. This medication only interacts with orally ingested alcohols B. If you use alcohol based products this medication will make you ill C. The only side effect of this medication is drowsiness D. This medication will only need to be taken a few times
B. If you use alcohol based products this medication will make you ill Rationale: This medication will make the client ill with any alcohol exposure to the body orally or otherwise, this medication has many side effects, clients may need to take this medication for months or more.
The nurse is providing education to a client diagnosed with anxiety. Which statement by the client indicates that teaching has been effective? A. "Anxiety is part of who I am, I am powerless to change it." B. "Practicing yoga or meditation may help reduce my anxiety." C. "If I ignore the symptoms of anxiety, it will go away." D. "Medication is the only way to treat anxiety."
B. "Practicing yoga or meditation may help reduce my anxiety." Rationale: Practicing yoga or meditation may help reduce the symptoms of anxiety. It is not possible to just ignore and will not go away on its own. The client will need to learn how to cope with anxiety, the patient who feels powerless is provided with education to manage their disorder.
A nursing instructor is teaching about specific phobias. Which student statement indicates that learning has occurred? A. "These clients do not recognize that their fear is excessive, and they rarely seek treatment." B. "These clients have overwhelming symptoms of panic when exposed to the phobic stimulus." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."
B. "These clients have overwhelming symptoms of panic when exposed to the phobic stimulus." Rationale: Student learning has occurred when the student states that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response.
An alcoholic client has been diagnosed with thrombocytopenia. With this information, what blood work result is to be expected? A. A high platelet count B. A low platelet count C. A high white blood cell count D. A low white blood cell count
B. A low platelet count During thrombocytopenia, it is expected that a patient will have a low platelet count because alcohol impairs platelet production and survival.
When working with a client that is non-compliant in treatment, what is the nurse's first intervention? A. Respect the client's decision and preserve their autonomy B. Address the reasons for non-compliance C. Notify the provider and place client in seclusion D. Reinforce the treatment plan
B. Address the reasons for non-compliance Rationale: The nursing process is ADPIE and the assessment of the treatment plan allows for the client's plan to be tailored to their needs and objectives.
During a nurse-client interaction, an adolescent client with a major depressive disorder stated, "I was on the basketball team at school, but I don't have the energy to play so I quit." The client is describing: A. Aphasia B. Anergia C. Anhedonia D. Ataxia
B. Anergia Rationale: This client is voicing a lack of energy which can be a symptom of depression. Depression may cause changes in the client's behavior and a lack of enjoyment in activities that were once enjoyable.
A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the past 24 hours. Which client symptom should the nurse immediately report to the ED physician? A. Bruising B. Blood pressure of 180/100 mmHg C. Mood rating of 2/10 D. Dehydration
B. Blood pressure of 180/100 mmHg Rationale: High blood pressure should immediately be reported to the physician. High blood pressure and other complications associated with alcohol withdrawal may progress to delirium tremens and seizures within 48 to 72 hours following cessation of prolonged alcohol consumption.
A nurse is providing care for a 30-year-old client on a medical/surgical floor that has undergone 12 elective plastic surgeries. The nurse recognizes this client may be experiencing? A. Conversion disorder B. Body dysmorphic disorder C. Malingering D. Factitious disorder
B. Body dysmorphic disorder Rationale: People with body dysmorphic disorder are preoccupied by an imagined defect. A person with a conversion disorder will report impaired physical function related to the expression of a psychological conflict.
A male client with a recent diagnosis of depression is worried that medication will cause a lack of sexual interest. The nurse will anticipate the client being prescribed which psychotropic medication? A. Olanzapine B. Bupropion C. Phenelzine D. Sertaline
B. Bupropion Rationale: Bupropion is the only psychotropic medication that does not have some sexual side effect.
A nurse is working with a client that states being in public places causes them debilitating anxiety and even panic. Which therapies will the nurse provide education on? (Select all that apply) A. Electroconvulsive therapy (ECT) B. Flooding C. Systematic desensitization D. Cognitive behavioral therapy (CBT) E. Thought stopping
B. Flooding C. Systematic desensitization D. Cognitive behavioral therapy (CBT) E. Thought stopping Rationale: ECT is the only listed therapy that will not benefit the client with anxiety. ECT will treat depression and works well at addressing this diagnosis. All of the other therapies address the anxiety disorders and work to help the client with positive responses and coping behaviors.
A nurse working in an emergency department is caring for a patient who has alprazolam toxicity. Which of the following actions is the nurse's priority? A. Administer flumazenil B. Identify the patient's level of orientation C. Infuse IV fluids D. Prepare the Patient for gastric lavage
B. Identify the patient's level of orientation Rationale: When taking the nursing process approach to client care, the initial step is assessment. Identifying the client's level of orientation is the priority action.
The nurse is caring for a client who has been diagnosed with dissociative disorder. The nurse knows that an appropriate intervention to promote effective role performance is to: A. Encourage the client to have no contact with friends and family. B. Include family members in therapy. C. Help the client alienate family members who do not believe the client is sick. D. Ignore the client's other personalities.
B. Include family members in therapy. Rationale: It is important to work with the client's family in order to help everyone in the family unit to adjust to role performance alterations. Including family members in a therapeutic counseling relationship helps them learn new ways of dealing with the client. As stated earlier, considerable secondary gain is often associated with dissociative behavior: some clients may use the illness to escape responsibility and get special treatment. Families often need support in learning to avoid reinforcing dissociative behavior by acting as the source of secondary gain.
The nurse assesses a client who exhibits a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement indicates the nurse understands the characteristics of positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms. B. Paranoia, neologisms, and echolalia are positive symptoms. C. Paranoia, anergia, and echolalia are negative symptoms. D. Paranoia, flat affect, and anhedonia are negative symptoms.
B. Paranoia, neologisms, and echolalia are positive symptoms. Rationale: Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. Positive symptoms are present in a person with schizophrenia and would not be present in a person without the illness.
A 21-year-old client diagnosed with dissociative identity disorder, presents in the emergency department (ED) after attempting suicide. Which data obtained during the client's health history would support the current diagnosis? A. Recent drug abuse and living homelessness B. Sexual abuse by biological parent during childhood C. Unidentified continuous abdominal and neck pain D. Multiple somatic and psychological issues over the past 6 months
B. Sexual abuse by biological parent during childhood Rationale: Clients with DID have sustained horrific physical and psychological abuse over time. These events lead to the client experiencing multiple ego states that help the client survive the trauma.
The nurse is assessing the client diagnosed with bipolar disorder. What assessment finding would cause the nurse to question possible substance abuse? A. The client is well-groomed and appears over nourished B. The client is disheveled and appears malnourished C. The client voices concern with mood changes D. The client states their family does not understand them
B. The client is disheveled and appears malnourished Rationale: The client that is malnourished is not eating regularly or properly and this client is also not maintaining ADLs. Substance abuse is a common concurrent diagnosis of BPD and this client should be evaluated more closely.
A nurse is educating an adolescent and their parents about the new prescription for an SSRI. What will the nurse include in the teaching? A. Chocolate is contraindicated while on this medication B. While on this medication, you are at an increased risk of suicide C. This medication should always be taken in the evening D. If you become anxious while on this medication take an additional dose
B. While on this medication, you are at an increased risk of suicide This medication can increase the risk of suicide in teens and young adults and should be monitored closely for this risk. This medication has some risk of insomnia so it should be taken in the morning and caffeine should be avoided. If the client experiences anxiety they need to report the symptoms to their provider.
During an intake assessment, the nurse asks a client physiological and psychosocial questions. The client angrily responds, "I'm here for my heart problems, not for my head." Which is the nurse's best response? A. "We ask all clients these questions." B. "Why are you concerned about these questions?" C. "Psychological stress can affect medical conditions." D. "We can skip these questions if you prefer."
C. "Psychological stress can affect medical conditions." Rationale: The nurse should not skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment. The nurse should always attempt to educate the client on the negative effects of excessive stress on medical conditions.
A recovering alcoholic relapses and drinks a glass of wine. The client presents in the ED experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse recognizes that the client's symptoms indicate which of the following? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine
C. A reaction to disulfiram (Antabuse) The client has most likely ingested alcohol while taking disulfiram (Antabuse), a drug that is administered as a deterrent to drinking. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.
During a nurse-client interaction, an adolescent client with a major depressive disorder stated, "I was on the swim team at school, but I don't enjoy swimming anymore so I quit." The client is describing: A. Aphasia B. Anergia C. Anhedonia D. Ataxia
C. Anhedonia Rationale: Depression may cause changes in the client's behavior and a lack of enjoyment in activities that were once enjoyable. This client is experiencing a lack of joy with swimming that the client enjoyed prior to the major depression.
A client with a somatic symptom disorder presents to the community clinic describing abdominal pain, refuses to complete informational forms, and dismisses the nurse's assessment attempts while demanding to be seen immediately by a doctor. Which approach would be best for the nurse to use when assessing this client? A. Realize client judgment is intact. B. Have sympathy for the psychopathology of the disorder. C. Avoid personalizing the behavior of the client. D. Expect the client to respond appropriately to the nurse's need to complete the assessment.
C. Avoid personalizing the behavior of the client. Rationale: The best approach is to avoid personalizing the behavior by recognizing that somatization is part of the illness. The nurse should have empathy, not sympathy for the psychopathology of the disorder. Given the self-absorption common to this disorder, it may be unrealistic to expect the client to respond appropriately to the nurse's need to complete the assessment. With this disorder, client judgment is impaired.
Chuck came into his parents' home and witnessed his parents' murder scene. The police and forensics arrived at this site and cordoned off the crime scene. Chuck was taken home by friends where he later reported blindness. A full examination was conducted at the hospital, where no physical reason for the blindness was found. The unlicensed assistive personnel asked the RN, what is the diagnosis? A. Hypochondria B. Illness anxiety disorder C. Conversion disorder D. Body dysmorphic
C. Conversion disorder Rationale: This patient is presenting with conversion disorder, a medical condition that is psychologically driven that has no basis for the symptoms. The client will lose function in a body system. This happens when the client has experienced a traumatic event.
An inpatient client is newly diagnosed with anxiety disorder stemming from severe childhood sexual abuse. Which is the priority nursing intervention? A. Encourage exploration of sexual abuse. B. Encourage guided imagery. C. Establish trust and rapport. D. Administer anti-anxiety medications.
C. Establish trust and rapport. Rationale: Establishing trust and rapport when beginning to work with a client diagnosed with DID is the priority intervention, as trust is the basis of every therapeutic relationship. DID was formerly called multiple personality disorder; each personality views itself as a separate entity and must be treated as such to establish rapport.
A client diagnosed with Somatic Symptom Disorder is most likely to exhibit which personality disorder characteristics? A. Uses "splitting" and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, anxiety, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange
C. Expresses heightened emotionality, anxiety, and strong dependency needs Rationale: A client with somatic symptom disorder would most likely exhibit heightened emotions, and strong dependency. These clients will be overly dependent and the diagnosis will effect their occupational function.
The nurse is working with a client who is being admitted to the psychiatric-mental health unit. The client was missing for two weeks was unaware that any time had passed after being found wandering the streets nowhere near his house. Which of the following dissociative disorders has this client experienced? A. Amnesia B. Depersonalization disorder C. Fugue D. Dissociative identity disorder (DID)
C. Fugue Rationale: A person with dissociative fugue wanders, usually far from home and for days, perhaps even weeks or months at a time. During this period, clients completely forget their past life and associations; but unlike people with amnesia, they are unaware of having forgotten anything. When they return to their former consciousness, they do not remember the period of fugue.
A client taking phenelzine has a blood pressure of 210/119, a HR of 104 bpm, and diaphoresis. The nurse discovers the client has recently taken over the counter medication for allergies and a cold. The nurse recognizes this client is experiencing: A. Hypertension B. Neuroleptic malignant syndrome (NMS) C. Hypertensive crisis D. Serotonin syndrome
C. Hypertensive crisis Rationale: Hypertensive crisis brought on by over the counter cold medication. Clients on MAOI should be counseled not to take any OTC medications prior to consulting their physician.
An 18-year-old client who joined the military shortly after graduating from high school is admitted to the mental health unit for depression and suicidal ideation. He tells the nurse the military is not what he expected and he wants to go home. The nurse observes a variance in affect between his interaction with peers and staff. The nurse suspects: A.Conversion disorder B. Factitious disorder C. Malingering D. Conduct disorder
C. Malingering Rationale: Malingering describes a person deliberately faking symptoms; it is usually adopted to obtain a secondary gain. Factitious disorder describes a person assuming a sick role by intentionally producing or feigning illness. People with body dysmorphic disorder are preoccupied by an imagined defect. A person with a conversion disorder will report impaired physical function related to the expression of a psychological conflict.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following immediate interventions should the nurse identify as the priority? A. Helping the client identify positive personality traits B. Confronting the use of denial and other defense mechanisms C. Providing for adequate hydration, nutrition, and rest D. Educating the client about the consequences of alcohol misuse
C. Providing for adequate hydration, nutrition, and rest Rationale: The nurse should be able to recognize the immediate needs of those who have alcohol use disorder. Nutrition, hydration, and rest are the priority needs according to Maslow's Hierarchy of needs.
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg BID; benztropine (Cogentin), 1 mg PRN; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Visual hallucinations C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices
C. Restlessness and muscle rigidity Rationale: An anticholinergic medication such as benztropine (Cogentin) would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of haloperidol (Haldol). The symptoms of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol (Haldol).
Warren's college roommate actively resists going out with friends whenever they invite him. He says he can't stand to be around other people and confides to Warren, "They wouldn't like me anyway." Which disorder is Warren's roommate likely suffering from? A. Agoraphobia B. Mysophobia C. Social anxiety disorder (social phobia) D. Panic disorder
C. Social anxiety disorder (social phobia) Rationale: Social anxiety disorder is an excessive fear of social situations related to fear that one might do something embarrassing or be evaluated negatively by others.
A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep-breathing relaxation exercises. B. Place the client in a Trendelenburg position. C. Stay with the client and offer reassurance of safety. D. Administer the ordered prn buspirone (Buspar).
C. Stay with the client and offer reassurance of safety. Rationale: The client's immediate need is for the presence of and assurance of safety. Individuals experiencing a severe panic attack often fear that they are dying. The nurse should stay with the client and offer reassurance of safety and security.
In assessing a potential client with Schizophrenia, which phase is research currently focused on in order to identify at-risk individuals as early as possible? A. The prodromal phase B. The residual phase C. The premorbid phase D. The active psychotic phase
C. The premorbid phase Rationale: Current research is focused on the premorbid phase to identify potential biomarkers and at-risk individuals in an effort to prevent transition to illness or provide early intervention.
Case Study: Amanda has been admitted to the hospital after being seen in an acute care walk-in clinic with blood in her urine. The admitting physician has ordered several invasive procedures: catheterization, blood work, and cystoscopy, among others. The physician does not know that Amanda has been taking anticoagulants to produce blood in her urine.The nurse is interviewing Amanda on her history. Which statement is most appropriate? A. "It must be terrible feeling ill all the time." B. "Your history doesn't make sense with your symptoms." C. "How would you describe your coping skills?" D. "Are you able to tell me about the onset and duration of your symptoms?"
D. "Are you able to tell me about the onset and duration of your symptoms?" Rationale: The client will intentionally produce or feign physical or psychological symptoms. It is often difficult to diagnose and treat clients with factitious disorders. It is also costly when medically unnecessary diagnostic procedures are performed. These clients are intelligent with an understanding of medical terminology and medical procedures. They are vague and unable to give an adequate answer to when and how long the symptoms and they will seek medical attention for psychological need for attention
The nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurse's best reply? A. "Encourage him not to worry about the voices." B. "Tell him the voices aren't real." C. "Tell him to stop talking about the voices." D. "Ask him what the voices are saying to him."
D. "Ask him what the voices are saying to him." Rationale: Safety is always the nurse's priority. The parents should ask what the voices are saying to identify whether the child is hearing commands to harm self or others. The nurse should encourage the parents to acknowledge the voices are real to the child, but let the child know they do not share the perception. Use of the word "voices" helps avoid reinforcing the hallucination.
The nurse is caring for a patient diagnosed with conversion disorder. Which statement made by the nurse is most therapeutic for this patient? A. "I think you could get over this condition if you tried hard enough. A positive outlook can change everything." B. "I'm so sorry that your back hurts so much. Yes, I'm happy to get you a wheelchair so you don't have to walk to meals." C. "I think that your symptoms are just in your head. Therapy can help you get rid of them." D. "I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties."
D. "I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties." Rationale: This statement encourages the patient to verbalize fears and anxieties. Verbalizing these feelings will help the patient identify physical symptoms as a coping mechanism that is used in times of extreme stress. The nurse should encourage the patient to be as independent as possible and should only intervene when the patient requires assistance.
A client comes in with signs of alcoholism and substance abuse. As a nurse, you know that genetics accounts for __% of the client's vulnerability to alcoholism. A. 10-15 B. 80-90 C. 70-80 D. 40-60
D. 40-60 Rationale: Genetics account for 40-60% of a person's vulnerability to alcoholism. A study concludes this, and have found some specific genes with this exact correlation, along with the development of reward centers in the brain.
A 22-year-old client with body dysmorphic disorder (BDD) tells the nurse that she plans to have a surgical procedure that will affect her appearance. The nurse understands that this plan is an effort to: A. Suppress intrusive thoughts B. Deal with multiple physical complaints C. Treat associated depression D. Cure the imagined defect
D. Cure the imagined defect Rationale: The client has a perceived defect. They will seek to alter this defect through means such as plastics procedures.
How would the nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.
D. Depersonalization is commonly seen in panic disorder and absent in GAD. Rationale: Panic disorder is characterized by recurrent, unpredictable panic attacks. GAD is characterized by persistent, excessive anxiety. Chest pain is among the physical symptoms that may occur during a panic attack. Hyperventilation is among the physical symptoms that may occur during a panic attack. A client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.
A client diagnosed with obsessive-compulsive disorder spends 45 minutes washing their hands and completing ritualistic tasks. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors. Rationale: Discussing triggers will enable the client to address and deal with obsessions and compulsions. Distracting the client will increase the anxiety. The client should only be stopped from completing the behaviors by trained professionals therapeutically.
A client with bipolar disorder commands another client, "Change the television channel. Get me something to drink...," and so forth. The nurse wants to interrupt this behavior without entering into a power struggle. Select the nurse's best approach: A. Humor: "How much are you paying servants these days?" B. Bargaining: "If you stop ordering other patients around I will get you something to drink." C. Honest feedback: "Your behavior is annoying other patients." D. Distraction: "Let's go to the dining room for a snack."
D. Distraction: "Let's go to the dining room for a snack." Rationale: Distracting a patient in this situation is the most appropriate form of intervention to avoid conflict with the patient. Do not argue, bargain, or try to reason with the patient. Merely state the limits and expectations. Confront the patient as soon as possible when interactions with others are manipulative or exploitative. This client is not only trying to start a fight, but the underlying message is that they are hungry. This client has a very short attention span and distraction will work well.
Which statement should the nurse identify as correct regarding a client's right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any type of psychiatric treatment at any time. C. The only treatment a client can refuse is electroconvulsive therapy (ECT). D. Professionals can override treatment refusal through court approval if the client is actively suicidal or homicidal.
D. Professionals can override treatment refusal through court approval if the client is actively suicidal or homicidal. Rationale: A client has the right to refuse any treatments unless he or she is determined to have suicidal or homicidal intent, as there is a serious risk of harm to self or others in that case. Health-care professionals can override treatment refusal to keep the client and/or others safe from harm.
To intervene effectively with clients with somatic symptom disorders, it is essential that the nurse: A. Help the client express a decreased degree of comfort regarding physical symptoms B. Encourage the client's expression of feelings symbolically through physical symptoms C. Address client anxiety at a later time D. Recognize and understand the client's somatizations as demonstrating an inability to cope
D. Recognize and understand the client's somatizations as demonstrating an inability to cope Rationale: Recognize and understand the client's self-perception as an inability to cope and as part of the disorder. Do not encourage expression of feelings symbolically through physical symptoms. Client anxiety should be addressed at the present time, not at a later date. The client should express an increased degree of comfort regarding physical symptoms.
A nurse is collecting past history data on a patient with acute stress disorder (ASD). Which of the following behaviors would the nurse anticipate finding? A. The patient remembers many details about the event B. The patient expresses a sense of elation about what is happening C. The patient notices manifestations of the disorder 30 days since the event occurred D. The patient expresses a sense of unreality concerning the traumatic event
D. The patient expresses a sense of unreality concerning the traumatic event Rationale: The patient who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality.
