PSYCH FINAL

A client diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Pseudoparkinsonism b. Akathisia c. Hepatocellular effects d. Neuroleptic malignant syndrome

a. Pseudoparkinsonism

The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

a. Practice and teamwork

The partner of a patient in hospice care angrily tells the nurse, "The care provided by the aide and other family members is inadequate, so I must do everything myself. Can't anyone do anything right?" How best should the palliative care nurse respond? a. Providing teaching about anticipatory grieving b. Assigning new personnel to the patient's care c. Arranging hospitalization for the patient d. Refer the partner for crisis counseling

a. Providing teaching about anticipatory grieving

A client with a diagnosis of bipolar disorder has had several hospitalizations to treat this mental illness and feels that the care he received was not consistent with his best interests. The client's experience is indicative of which of the following needs? a. Psychiatric advance directive (PAD) b. Informed consent c. Right to treatment d. Competency

a. Psychiatric advance directive (PAD)

The nurse and a client talk about the signs and symptoms of acute mania. The client states, "When I am feeling really good and don't need to sleep, I am manic, but the last thing I want is treatment." The nurse recognizes that this experience is indicative of the need for: a. Psychiatric advance directive (PAD). b. Competency. c. Informed consent. d. Right to treatment.

a. Psychiatric advance directive (PAD).

A staff nurse tells another nurse, "I evaluated a new patient using the modified SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."

b. "A score over 8 requires immediate hospitalization."

A client diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The client threatens to hit another client. Which comment by the nurse is appropriate? a. "You know we will not let you hit anyone. Why do you continue this behavior?" b. "Do not hit anyone. If you are unable to control yourself, we will help you." c. "Stop that! No one did anything to provoke an attack by you." d. "If you do that one more time, you will be secluded immediately."

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

How is severe and persistent mental best characterized? a. Mental illness with longer than 2 weeks' duration. b. Major ongoing mental illness marked by significant functional impairments. c. Mental illness accompanied by physical impairment and severe social problems. d. Major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

b. Major ongoing mental illness marked by significant functional impairments.

A depressed client asks why a physical exam is necessary before being admitted for outpatient treatment. The nurse explains to the client that a physical exam will: a. Ensure the client has not ingested any caustic. material or inhaled noxious vapors. b. Make sure the client gets all necessary treatment. c. Complete the admission process. d. Provide information about medications the client will need.

b. Make sure the client gets all necessary treatment.

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients. They make me so angry" Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. Expression of anger d. Preoccupation with the incident

c. Expression of anger

What are the causes of somatic system disorders generally related to? a. Culture-bound phenomena b. Traumatic childhood events c. Faulty perceptions of body sensations d. Mood instability

c. Faulty perceptions of body sensations

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

a. Altruism

The client says to the nurse, "It's my right to refuse medications." Which statement best reflects the nurse's ability to create a mutual understanding? a. "Can you tell me what concerns you have about medications?" b. "Refusing your medications is your right, but it won't get you out of here." c. "Can you tell me why you're so angry that you will refuse your medications?" d. "If you refuse your medications, you will just get sick again."

a. "Can you tell me what concerns you have about medications?"

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

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

The parents of identical twins ask a nurse for advice when one twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

a. "Genetics are associated with suicide risk. Monitoring and support are important."

A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them."

a. "I am feeling safe and comfortable here. Nobody bothers me."

Which of the following best describes the information the nurse will use to construct a nursing care plan? a. A psychiatric history and mental status examination b. An intake assessment and reason for admission c. A detailed psychiatric history d. A mental status examination

a. A psychiatric history and mental status examination

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child diagnosed with attention deficit disorder c. A single mother with an executive position, a gifted and talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent and an adolescent son who has just begun dating girls

a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

A patient whose blindness is related to a functional neurological (conversion) disorder appears to be unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? a. Anxiety is relieved through the physical symptom. b. Emotional needs are met through hospitalization. c. The patient refuses to disclose genuine fears. d. Suppressing accurate feelings regarding the problem.

a. Anxiety is relieved through the physical symptom.

A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Today the patient telephones to say, "I'm feeling empty and want to cut myself." The nurse should implement what intervention? a. Assist the patient to identify the trigger situation and choose a coping strategy. b. Send the patient to the crisis intervention unit for 8 to 12 hours. c. Advise the patient to take an antianxiety medication to decrease the anxiety level. d. Arrange for emergency inpatient hospitalization.

a. Assist the patient to identify the trigger situation and choose a coping strategy.

A family member reports that his mother has started hiding valuables around the house, then can't remember where she put them. He asks the nurse to explain what is happening. Which of the following assessment tools might the nurse utilize to screen the mother for signs of cognitive dysfunction? a. Benton Visual Retention Test b. Raven's Progressive Matrices Test c. Sentence Completion Test d. Thematic Apperception Test

a. Benton Visual Retention Test

A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." What emotional response does the parents' reaction reflect? a. Denial b. Anger c. Anxiety d. Projection

a. Denial

A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Disgust b. Concern c. Empathy d. Compassion

a. Disgust

A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. What action should the nurse take? a. Firmly and neutrally assisting the patient with showering. b. Avoid forcing the issue. c. Calmly telling the patient, "You must bathe daily." d. Bringing up the issue at the community meeting.

a. Firmly and neutrally assisting the patient with showering.

A nurse and social worker co-lead a reminiscence group for six "baby boomer" adults. Which activity is appropriate to include in the group? a. Post-World War II music b. Learning to send and receive email c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

a. Post-World War II music

The psychiatric examination includes a psychiatric history and a mental status assessment. When conducting the mental status assessment, the nurse:Select all that apply. a. Includes observations. b. Provides the client with a form to complete. c. Uses a group format. d. Limits the assessment to verbal responses. e. May or may not follow a strict sequence.

a. Includes observations. e. May or may not follow a strict sequence.

A client becomes upset when touched by a staff member who is attempting to assess the client's blood pressure. The nurse recognizes that there is a problem with: a. Informed consent. b. Duty to protect. c. Confidentiality. d. Staff control.

a. Informed consent.

A client with schizophrenia has decided to develop a psychiatric advance directive. What would be included in this document? a. List of persons who can make decisions on the client's behalf b. Conditions under which life support will be discontinued c. A legal representative for power of attorney d. Do not resuscitate (DNR) requests

a. List of persons who can make decisions on the client's behalf

An adult after an attempted suicide is hospitalized and takes an antidepressant medication for 5 days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

a. Supervise the patient 24 hours a day.

The nurse in the community mental health clinic assesses a client and determines the presence of an Axis II diagnosis. What conclusions can the nurse draw? a. The client has a personality disorder. b. The client will need a special diet. c. The client is in need of further evaluation. d. The client is a candidate for the least restrictive environment.

a. The client has a personality disorder.

Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. The patient expresses satisfaction with body appearance. b. Weight reaches the established normal range for the patient. c. Weight, muscle, and fat are congruent with height, frame, age, and sex. d. Calorie intake is within the required parameters of the treatment plan.

a. The patient expresses satisfaction with body appearance.

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome. a. The patient will verbalize realistic positive characteristics about self by (date). b. The patient will consent to take antidepressant medication regularly by (date). c. The patient will initiate social interaction with another person daily by (date). d. The patient will identify two personal behaviors that alienate others by (date).

a. The patient will verbalize realistic positive characteristics about self by (date).

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

a. Use accepting, nurturing, and empathetic communication techniques.

A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how soon death will occur or how sad I am." Which response by the nurse would be most therapeutic? a. "I'm glad you are protecting him at a time when he is so vulnerable." b. "He might be more comforted than disturbed by your tears." c. "It's important for you to know that time is running out." d. "You definitely need to be honest about your feelings."

b. "He might be more comforted than disturbed by your tears."

Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

b. "I have no one for help or support."

An adult patient assaulted another patient and was restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."

b. "My fingers are tingly."

Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision.

Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Ability to evoke interpersonal conflict c. Inability to develop trusting relationships d. Flexibility and adaptability to stress

b. Ability to evoke interpersonal conflict

A patient with burn injuries has demonstrates good coping skills for several weeks. Today, a new nurse is poorly organized and does not follow the patient's usual schedule. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?"

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

b. Acute phase

A 75-year-old patient comes to the clinic reporting frequent headaches. After an introduction at the beginning of the interview, what should the nurse address? a. Initiate a neurological assessment. b. Assess if the patient can hear the spoken word clearly. c. Suggest that the patient lie down in a darkened room to rest. d. Administer medication to relieve the patient's pain prior to the assessment.

b. Assess if the patient can hear the spoken word clearly.

What is a priority nursing intervention for a patient diagnosed with major depressive disorder? a. Offering opportunities for the patient to assume a leadership role in the therapeutic milieu b. Carefully and inconspicuously observing the patient around the clock c. Allowing the patient to spend long periods alone in self-reflection d. Distracting the patient from self-absorption

b. Carefully and inconspicuously observing the patient around the clock

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." How should the nurse respond to the request? a. Arrange for the patient to shower. b. Explain that washing would destroy evidence. c. Give the patient a basin of hot water and towels. d. Instruct the victim to wash above the waist only.

b. Explain that washing would destroy evidence.

When assessing a 2-year-old diagnosed with autism spectrum disorder, what should a nurse expects? a. Hyperactivity and attention deficits b. Failure to develop interpersonal social skills c. History of disobedience and destructive acts d. High levels of anxiety when separated from a parent

b. Failure to develop interpersonal social skills

A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Administer lorazepam every 4 hours to reduce the patient's anxiety.

b. Help the patient identify incidents that trigger impulsive acting out.

The nurse is talking with the family of a mentally ill client who lives with them. The client is being admitted to the inpatient psychiatric unit. What is the priority information to gather from the family? a. The number of medications prescribed for the client b. How the client's symptoms are expressed at home c. The type of soap the client prefers to used d. Whether the client had a flu shot recently

b. How the client's symptoms are expressed at home

A nurse counsels a patient diagnosed with serious and persistent mental illness. The patient lives at home with family. Which resource could the nurse suggest assisting the patient and family to cope with the stigma of mental illness as well as provide support and education? a. American Psychiatric Association (APA) b. National Alliance on Mental Illness (NAMI) c. Community Mental Health Centers (CMHCs) d. Programs of Assertive Community Treatment (PACT)

b. National Alliance on Mental Illness (NAMI)

A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. What is the justification for the use of seclusion? a. Patient demonstrates a thought disorder, rendering rational discussion ineffective. b. Patient's actions present a clear and present danger to others. c. Patient demonstrates an apparent and plausible escape risk. d. Patient's actions display features of psychotic thinking.

b. Patient's actions present a clear and present danger to others.

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.

b. Periodically provide an update and progress report on the patient.

Select the priority nursing diagnosis for a client with a Global Assessment of Functioning (GAF) score of 10. a. Knowledge Deficit b. Risk for Injury c. Risk for Impaired Social Interaction d. Risk for Communication Deficit

b. Risk for Injury

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to under involvement with the victim. d. Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment.

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. The patient needs time to reorient him or herself to a pressured work schedule. b. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. c. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. d. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet.

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

The nurse on the inpatient unit is reviewing the record of a client admitted the previous day, and notes the client has an Axis I diagnosis. What inferences can the nurse make about the client? a. The client is in need of immediate medical attention. b. The client has a clinical psychiatric disorder. c. The client has a chronic condition. d. The client lacks a support system.

b. The client has a clinical psychiatric disorder.

The nurse receives a laboratory report indicating a client's serum level is 1 mEq/L. The client's last dose of lithium was 8 hours ago. What does this result indicate? a. above therapeutic limits. b. within therapeutic limits. c. below therapeutic limits. d. invalid because of the time lapse since the last dose.

b. within therapeutic limits.

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "What I think about myself is my business." b. "I am grossly underweight, but that's what I want." c. "I am fat and ugly." d. "I am a few pounds overweight, but I can live with it."

c. "I am fat and ugly."

A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

c. "You believe this would not have happened if you had not been alone?"

A patient has been diagnosed with a somatic symptoms disorder after various testing has failed to confirm a physiological cause for the patient's reports of back pain. What intervention by the nurse demonstrates the appropriate response when the patient continues to monopolize the group discussion with about back pain? a. Offer to discuss additional pain medication with the patient's health care provider. b. In a matter-of-fact manner tell the patient that their pain is somatic in nature. c. Acknowledge the presence of pain but then redirect to another topic. d. Offer to discuss the back pain with the patient after the group session is over.

c. Acknowledge the presence of pain but then redirect to another topic.

A nurse observes an acutely psychotic client scratching at his arms with his fingernails until his arms bleed. When asked what is happening, the client states he is trying to let the evil spirits out of his body. He is easily redirected by the nurse, but resumes scratching when the nurse leaves his side. The nurse orders 1:1 supervision of the client to keep him from harming himself. Which principle of bioethics was applied in this situation? a. Fidelity b. Justice c. Beneficence d. Veracity

c. Beneficence

Which nursing diagnosis is likely to apply to the plan of care for a homeless individual diagnosed with severe and persistent mental illness? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

c. Chronic low self-esteem

A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for which disorder? a. Attention-deficit/hyperactivity disorder (ADHD) b. Childhood depression c. Conduct disorder (CD) d. Autism spectrum disorder (ASD)

c. Conduct disorder (CD)

When making a distinction as to whether a patient is experiencing confusion related to depression or dementia, what information would be most important for the nurse to consider? a. The patient with dementia is persistently angry and hostile. b. Early morning agitation and hyperactivity occur in dementia. c. Confusion seems to worsen at night when dementia is present. d. A patient who is depressed is preoccupied with somatic symptoms.

c. Confusion seems to worsen at night when dementia is present.

A nurse provided medication education for a patient who is prescribed phenelzine for depression. Which patient behavior indicates effective learning? a. Monitors sodium intake and weight daily. b. Wears support stockings and elevates the legs when sitting. c. Consults the pharmacist when selecting over-the-counter medications. d. Can identify foods with high selenium content, which should be avoided.

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

A client makes the following statement during a mental status assessment: "I can't use the phones; the CIA has bugged all the wires." Which of the following categories will the nurse use to document the client's response? a. Emotional state b. Orientation c. Content of thought d. General behavior

c. Content of thought

A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. What is an appropriate outcome for this patient? a. Focuses energy on problems occurring in the family. b. Assumes roles and functions of the other family members. c. Demonstrate a resumption of former roles and tasks. d. Relies on family members to meet personal needs.

c. Demonstrate a resumption of former roles and tasks.

A nurse and social worker co-lead a reminiscence group for eight adults aged 65 to 70. Which activity is most appropriate to include in the group? a. Singing a song from World War II b. Learning how to join an online social network c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

c. Discussing national leadership during the Vietnam War

A nurse cared for a terminally ill patient for over a month and always looked forward to spending time with the patient. When the patient died, the nurse experienced sadness and felt mildly depressed. Eventually, the nurse explains these feelings to a mentor. What should be the mentor's focus should counseling the nurse? a. Implementing stress-reduction strategies b. Seeking therapy for dysfunctional grief c. Discussing the experience of disenfranchised grief d. Considering taking a leave of absence to pursue healing

c. Discussing the experience of disenfranchised grief

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: imbalanced nutrition: less than body requirements. Within 1 week, the expectation is that the patient will demonstrate what? a. Limit exercise to less than 2 hours daily. b. Select clothing that fits properly. c. Gain 1/2 to 3/4 pound. d. Weigh self accurately using balanced scales.

c. Gain 1/2 to 3/4 pound.

Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? a. Plays with one toy for 90 minutes. b. Repeats words spoken by a parent. c. Holds the parent's hand while walking. d. Spins around and claps hands while walking.

c. Holds the parent's hand while walking.

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patient's current serum potassium is 2.7 mg/dL. Which nursing diagnosis is most applicable? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia d. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia

c. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia

Instructions concerning what stress management technique should be included in the care plan of a patient diagnosed with a somatic symptom disorder? a. Mindful awareness b. Positive self-talk c. Meditation d. Take a time out

c. Meditation

A nurse will prepare teaching materials regarding which medication for the parents of a child diagnosed with enuresis? a. Haloperidol b. Desmopressin c. Methylphenidate d. Carbamazepine

c. Methylphenidate

Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium b. Trazodone c. Olanzapine d. Valproic acid

c. Olanzapine

A 15-year-old girl is brought by her mother to see a psychiatric nurse practitioner. The client's mother demands that her daughter be admitted for treatment of "behavioral problems." Her mother states that the daughter stays out until 4 a.m. and is hanging out with "bad" kids. The nurse will recommend which of the following? a. Involuntary admission for the daughter b. Therapy for the mother c. Outpatient therapy for the mother and daughter d. Therapy for the daughter

c. Outpatient therapy for the mother and daughter

Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by a military attack team d. Completion of alcohol withdrawal and beginning a rehabilitation program

c. Paranoid delusions of being followed by a military attack team

A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with everyone." The patient verbally abuses nurses for providing poor care. What is the most likely explanation for this behavior? a. Poor child-rearing that did not teach respect for others. b. Automatic thinking, leading to cognitive distortion. c. Personality style that externalizes problems. d. Delusions that others wish to deliver harm.

c. Personality style that externalizes problems.

A psychiatric-mental health nurse is attending a seminar. The speaker discusses how certain psychiatric diagnoses are associated with stereotypes. Which of the following actions ensures that the client's social identity is not discredited? a. Refer to a client as a schizophrenic. b. Refer to a client as delusional and psychotic. c. Refer to a client as X who has a diagnosis of schizophrenia. d. Refer to a client as a paranoid.

c. Refer to a client as X who has a diagnosis of schizophrenia.

What is the priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder? a. Prevent the patient from violating the nurse's rights. b. Engage the patient in many community activities. c. Respect the patient's need for periods of social isolation. d. Teach the patient how to match clothing

c. Respect the patient's need for periods of social isolation.

Before working with patients regarding sexual concerns, what is a prerequisite for providing nonjudgmental care? a. Sympathy b. Assertiveness training c. Sexual self-awareness d. Effective communication

c. Sexual self-awareness

The nurse conducts ongoing evaluation of the crisis situation to ensure the client's right to the least restrictive intervention. This means the assessment factor receiving the highest priority is: a. The client's mental status. b. The client-staff ratio. c. The client's condition in comparison to the adequacy of the environment designed to prevent injury. d. The comfort level of the environment.

c. The client's condition in comparison to the adequacy of the environment designed to prevent injury.

The student nurse is learning how to reduce the stigma associated with mental illness. Which of the following statements by the student nurse reflects that learning has taken place? a. "They've added another paranoid to the unit." b. "We're admitting another crazy client." c. "We're admitting another schizophrenic who hears God talking." d. "A 19-year-old who reports hearing voices is being admitted with a diagnosis of psychosis not otherwise specified."

d. "A 19-year-old who reports hearing voices is being admitted with a diagnosis of psychosis not otherwise specified."

The student nurse is learning how to reduce the stigma associated with mental illness. Which of the following statements by the student nurse reflects that learning has taken place? a. "We're admitting another schizophrenic who hears God talking." b. "We're admitting another crazy client." c. "They've added another paranoid to the unit." d. "A 19-year-old who reports hearing voices is being admitted with a diagnosis of psychosis not otherwise specified."

d. "A 19-year-old who reports hearing voices is being admitted with a diagnosis of psychosis not otherwise specified."

The nurse finds the client crying in the room. The client states, "I'm so sad and lonely. I'm sitting here crying like a baby." Which of the following responses best reflects the nurse's sensitivity toward the client? a. "It's a gray, rainy day. A lot of clients are feeling sad." b. "Don't worry about crying. I think you are a fine person." c. "Why don't you come to the dayroom to be with others?" d. "Are you feeling embarrassed because you are crying?"

d. "Are you feeling embarrassed because you are crying?"

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

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

The nurse is working with a client who has just stated that she beats her toddler with a wooden paddle. The nurse determines that the client's verbal admission warrants: a. A report to the chief of staff. b. A report to the physician. c. A report to the nursing supervisor. d. A report to appropriate government authorities.

d. A report to appropriate government authorities.

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "It is difficult for others to care about you when you repeatedly say negative things about yourself." b. "The staff here cares about you and wants to try to help you get better." c. "Things will look brighter soon. Everyone feels down once in a while." d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

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

A patient being treated for major depressive disorder has taken 300 mg amitriptyline daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." How should the nurse advise the patient? a. "Resume taking the antidepressant for 2 more weeks, and then discontinue it again." b. "Go to the nearest emergency department immediately." c. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." d. "Take one dose of the antidepressant, and then come to the clinic to see the health care provider."

d. "Take one dose of the antidepressant, and then come to the clinic to see the health care provider."

A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health professional."

d. "Talk with your health care provider about a referral to a mental health professional."

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

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

An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty at my job." Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder (GAD) c. Borderline personality disorder d. Adult attention-deficit/hyperactivity disorder (ADHD)

d. Adult attention-deficit/hyperactivity disorder (ADHD)

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

d. Anhedonia

The school nurse, who must be familiar with mental health issues, will find child clinical disorders classified under: a. Axis VII. b. Axis X. c. Axis II. d. Axis I.

d. Axis I.

A female client disclosed to the nurse that she is in an abusive situation. This information will be used to contribute to: a. Axis III. b. Axis I. c. Nothing, since this is confidential information and should not be shared. d. Axis IV.

d. Axis IV.

Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquire knowledge of the patient's sexual roles and preferences. b. Develop an understanding of human sexual responses. c. Assess the patient's sexual functioning. d. Clarify the nurse's own personal values.

d. Clarify the nurse's own personal values.

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of which defense mechanism? a. Devaluation b. Repression c. Identification d. Compensation

d. Compensation

A nurse assesses a 3-year-old diagnosed with autism spectrum disorder. Which finding is most associated with the child's disorder? a. Has occasional toileting accidents. b. Is unable to read children's books. c. Cries when separated from a parent. d. Continuously rocks in place for 30 minutes.

d. Continuously rocks in place for 30 minutes.

A recently widowed patient tells the health care provider, "I have so much epigastric discomfort. I wonder if I have an ulcer." Diagnostic tests are negative. What does the symptom likely demonstrate? a. Early reorganization behavior b. Disorganization and depression c. Preoccupation with the deceased d. Normal phenomenon of mourning

d. Normal phenomenon of mourning

A nurse prepares a plan of care for a patient diagnosed with adult attention-deficit/hyperactivity disorder (ADHD). Which intervention should be included? a. Remind the patient of priorities and deadlines. b. Teach work-related skills such as basic computer literacy. c. Establish penalties for failing to organize and prioritize tasks. d. Give encouragement and strategies for managing and organizing.

d. Give encouragement and strategies for managing and organizing.

A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

d. High level

A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence

d. Risk for other-directed violence

A patient newly diagnosed with pancreatic cancer says, "My father also died of pancreatic cancer. I took care of him during his illness. I can't go through that." Select the highest priority nursing diagnosis. A. anticipatory grieving b. Ineffective coping c. Ineffective denial d. Risk for suicide

d. Risk for suicide

The nurse conducts ongoing evaluation of the crisis situation to ensure the client's right to the least restrictive intervention. This means the assessment factor receiving the highest priority is: a. The comfort level of the environment. b. The client-staff ratio. c. The client's mental status. d. The client's condition in comparison to the adequacy of the environment designed to prevent injury.

d. The client's condition in comparison to the adequacy of the environment designed to prevent injury.

The psychiatric home health nurse is evaluating whether a client's level of functioning has improved since starting the prescribed psychotropic medication. What evidence does the nurse look for? a. There is no change in the GAF score. b. The client no longer qualifies for a GAF score. c. There is a significant decrease (by 10 or more points) in the client's GAF score. d. There is an increase in the client's GAF score.

d. There is an increase in the client's GAF score.

A child drowned while swimming in a local lake 4 years ago. Which behavior indicates that the parents are effectively coping with their loss? a. Prohibits their other children from going swimming. b. Sets a place for the deceased child at the family dinner table. c. Keeps their child's room exactly as the child left it 4 years ago. d. Throw flowers on the lake at each anniversary date of the accident.

d. Throw flowers on the lake at each anniversary date of the accident.

The manager of a health club put a hidden camera in the women's locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism

d. Voyeurism

Treatment interventions may include: a. education. b. nutritional modifications. c. medications. d. all of the above.

d. all of the above.

A client diagnosed with bipolar disorder who takes lithium carbonate 300 mg three times daily reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with what? a. an antacid. b. an antiemetic. c. a large glass of juice. d. food.

d. food.

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to achieve what? a. integration of self-concept. b. inpatient treatment for the child. c. language and communication skills d. loneliness and increase self-esteem.

d. loneliness and increase self-esteem.

The psychiatric-mental health nurse is working with the new graduate nurse who is orienting to the psychiatric unit. Which comment by the new graduate indicates further clarification of the generalist-nursing role is needed? a. "I am a little nervous about conducting psychotherapy with clients." b. "I will spend time each day evaluating the effectiveness of the therapeutic milieu." c. "I would feel better if you would look at my documentation that addresses progress toward treatment goals." d. "I am doing some reading on how to incorporate complementary interventions into treatment plans."

a. "I am a little nervous about conducting psychotherapy with clients."

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

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

A nurse has completed orientation to a locked psychiatric unit. Which statement best demonstrates that the nurse is prepared to fulfill the professional role? a. "I will ask for support from colleagues when I need it." b. "I know there is a fine line between the clients and the staff." c. "I can maintain proper distance by engaging in therapeutic interventions." d. "I took a course in self-defense so I can take care of myself."

a. "I will ask for support from colleagues when I need it."

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

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

A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates catatonia. Which client needs are of priority importance? a. Physiological b. Psychosocial c. Self-actualization d. Self-esteem

a. Physiological

The nurse is sharing client assessment data with the multidisciplinary health care team. Which comment by the nurse is irrelevant and indicates a misunderstanding of the concept of a mental disorder? a. "The client has some very inappropriate religious ideas and spiritual beliefs." b. "The client denies thoughts of harming self or others." c. "The client reports significant emotional distress about the current situation." d. "The client reports a loss of interest in usual pleasurable activities and commitments."

a. "The client has some very inappropriate religious ideas and spiritual beliefs."

The client has frequently presented to the clinic with multiple physical complaints. The multiple physical complaints would warrant the nurse to screen the client for: a. A mental disorder. b. A chronic illness. c. Hospitalization. d. Deviant behavior.

a. A mental disorder.

Upon arrival on the psychiatric unit this morning, which activity should be the nurse's focus? The nurse should do which of the following? a. Assess each client for whom the nurse will be providing care. b. Identify community resources for clients to be discharged this morning. c. Schedule the individual therapy sessions for all clients. d. Review psychological testing results for all clients.

a. Assess each client for whom the nurse will be providing care.

The nurse is teaching the client regarding the concept of mental disorders. In instructing the client, what areas should be covered in the explanation of what impacts the determination of a mental disorder?Select all that apply. a. Biochemistry b. Mother-child interactions c. Brain structure d. Social conditions e. Culture

a. Biochemistry c. Brain structure d. Social conditions e. Culture

The psychiatric-mental health nurse is asked to develop an intervention for the nursing unit based on Watson's theory of caring. Given this assignment, which intervention is most appropriate for the nurse to implement? a. Clarification of values and cultural beliefs that might pose barriers to caring for clients b. One-to-one debriefing sessions each week with individual unit nurses and the unit manager c. Identification of additional coping skills for new nurses on the unit d. Discussion of the impact of recent changes in hospital policy on the nursing staff

a. Clarification of values and cultural beliefs that might pose barriers to caring for clients

Due to a staff member's absence, the nurse is reviewing staff assignments for the day. Which task can the nurse delegate to the psychosocial rehabilitation worker? a. Conflict resolution teaching to a small group of clients b. Comparison of physician's orders with the medication records c. Assessment of a long-term client d. Routine medication administration to a stable client

a. Conflict resolution teaching to a small group of clients

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for clients? a. Prescribe psychotropic medication. b. Individualize nursing care plans. c. Establish therapeutic relationships. d. Perform mental health assessment interviews.

a. Prescribe psychotropic medication.

The nurse is told that the client most likely has the diagnosis of obsessive-compulsive disorder. The nurse is not sure of the assessment data and behaviors that accompany this disorder. Which action would be most appropriate for the nurse to take? a. Consult the Diagnostic and Statistical Manual of Mental Disorders for diagnostic criteria. b. Research obsessive-compulsive disorder in the medical dictionary. c. Ask the primary health provider to identify needed subjective and objective assessment data. d. Document all subjective and objective data provided by the client.

a. Consult the Diagnostic and Statistical Manual of Mental Disorders for diagnostic criteria.

The mental health team nurse is having some role issues regarding how best to facilitate client progress toward therapeutic goals. What is the priority action by the nurse in order to aid the team as they assist the client? a. Determine personal values, biases, and goals. b. Recognize that conflict is natural and expected. c. Acknowledge the diversity of the mental health team. d. Attend all mental health team meetings.

a. Determine personal values, biases, and goals.

Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others' conversations. How should the nurse document these behaviors? a. Impulsivity b. Anxiety c. Disobedience d. Hyperactivity

a. Impulsivity

A client comes to the nurse's station yelling, "I have to call the FBI. The bombs are set to destroy Washington, D.C. at 1:00 p.m. Please help me. It will be your fault if I don't call." Which intervention best demonstrates the nurse's sensitivity? a. Listen carefully for the underlying emotion expressed by the client's request. b. Switch the topic of conversation to defuse the client's underlying agitation. c. Assist the client to become aware that this is a delusional belief. d. Share your concerns that the client's request is unreasonable.

a. Listen carefully for the underlying emotion expressed by the client's request.

The psychiatric-mental health nurse is planning a personal program of continuing education to better meet the challenges of the future in psychiatric nursing practice. What areas should be included in the nurse's plan for continuing education? Select all that apply. a. Psychobiology b. Psychiatric nursing care in nontraditional settings c. Psychopharmacology d. Genetic research e. Physical health of psychiatric clients

a. Psychobiology b. Psychiatric nursing care in nontraditional settings c. Psychopharmacology d. Genetic research e. Physical health of psychiatric clients

The nurse is reflecting on psychiatric nursing care in the 19th century. Which nursing diagnosis is most consistent with the focus of psychiatric nursing care during the 19th century? a. Self-care deficit b. Anxiety c. Ineffective individual coping d. Altered thought processes

a. Self-care deficit

When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Take the aggressive child to another room. b. Direct the aggressive child to stop immediately. c. Instruct the parents to take the aggressive child home. d. Call for emergency assistance from other staff.

a. Take the aggressive child to another room.

The client on the psychiatric unit is asking questions about prevention of sexually transmitted diseases. Given the Psychiatric-Mental Health Nursing Standards of Practice, which action would be most appropriate for the nurse to take at this time? a. Teach safer sexual practices. b. Consult with the mental health care team. c. Notify the attending psychiatrist. d. Investigate the questions in individual psychotherapy.

a. Teach safer sexual practices.

A client diagnosed with schizophrenia has been stable for a year; however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of what? a. relapse. b. the need for psychoeducation. c. chronic deterioration. d. medication nonadherence.

a. relapse.

Ritalin (methylphenidate) mechanism of action blocks removal of DA, NE, and lesser (5HT) from synapse and is ordered for a. Alchoholism b. ADHD c. Bipolar disorder d. Depression

b. ADHD

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? a. interrupts or intrudes on others. b. cries when separated from a parent. c. has occasional toileting accidents. d. continuously rocks in place for 30 minutes.

d. continuously rocks in place for 30 minutes.

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Your observation indicates the medication is effective." b. "Tics often change frequency or severity. That doesn't mean they aren't real." c. "Perhaps your child was misdiagnosed." d. "This finding is unexpected. How have you been administering your child's medication?"

b. "Tics often change frequency or severity. That doesn't mean they aren't real."

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

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

A nurse is taking a class on providing culturally competent care for clients with severe mental illnesses. Which response best reflects the nurse's self-awareness of the sociocultural factors influencing his or her beliefs? a. "My father was a psychiatrist, so I am very knowledgeable about how to work with mental illnesses." b. "When I was growing up, my parents believed that mental illnesses were the work of evil spirits." c. "All that I need to understand about the culture of mental illness is available on the Internet." d. "I have been through therapy, so I know what to expect from clients with mental illnesses."

b. "When I was growing up, my parents believed that mental illnesses were the work of evil spirits."

The nurse plans to implement health promotion activities at the local senior citizen center. To meet the goal of promoting knowledge related to maximizing mental health and functional ability, the nurse's teaching is guided by World Health Organization research and should include discussion of which priority area specific to the leading causes of mental disability? a. Dementia b. Alcohol c. Social isolation d. OTC meds

b. Alcohol

The psychiatric-mental health nurse reflecting on professional role activities is referred to the standards of professional performance by a colleague. To which organization should the nurse look for guidance? a. American Nurses Credentialing Center b. American Nurses Association c. North American Nursing Diagnosis Association d. National League for Nursing

b. American Nurses Association

A health care provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also overweight and hypertensive. Which drug should the nurse advocate? a. Ziprasidone b. Aripiprazole c. Clozapine d. Olanzapine

b. Aripiprazole

The nurse is researching statistics of the five psychiatric disorders that comprise the top 10 causes of disability worldwide. Given this information, the nurse chooses which of the following as a priority screening for clients? a. Schizophrenia b. Depression c. Bipolar disorder d. Alcohol abuse

b. Depression

During the evaluation of the effectiveness of the nurse's discharge teaching, which client report would indicate to the nurse that the client understands the leading cause of disability and decrement in health? The client reports a need to incorporate strategies to prevent: a. Obesity. b. Depression. c. Cancer. d. Anxiety.

b. Depression.

The psychiatric mental health nursing student is preparing to attend a meeting of the psychiatric mental health care team to discuss possible updates to clients' diagnoses. In preparing for this meeting, the nursing student should consult which of the following references? a. Standards of Psychiatric Nursing Practice b. Diagnostic and Statistical Manual of Mental Disorders c. Dictionary of common mental disorders d. Psychiatric nursing care plan manual

b. Diagnostic and Statistical Manual of Mental Disorders

A nurse is teaching a group of students about the stigma that is often associated with mental illness. The nurse tells the group that stigma associated with mental illness is about which of the following? a. Respect b. Disrespect c. Appreciation d. Intelligence

b. Disrespect

A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a. Photosensitivity b. Gynecomastia c. Constipation d. Visual changes

b. Gynecomastia

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this client's plan of care? a. Pressured speech and grandiosity b. Hyperactivity; not eating and sleeping c. Poor concentration and decision making d. Insulting, aggressive behavior

b. Hyperactivity; not eating and sleeping

The nurse is caring for a client who was recently admitted to the unit. During the nursing assessment of the client, the nurse finds the client's beliefs and actions related to many health practices to stray from the norm. Which action would be most appropriate for the nurse to take at this time? a. Communicate the findings to the health care team. b. Inquire as to the culture with which the client identifies. c. Repeat the assessment later in the day. d. Write a nursing diagnosis to address the "bizarre" beliefs and actions.

b. Inquire as to the culture with which the client identifies.

The psychiatric nurse is reflecting on the treatment and care of the mentally ill throughout history. Which of the following philosophical beliefs most guided treatment of the mentally ill during 17th century Europe? a. The body's humors were responsible; blood, bile, and phlegm must be balanced. b. Madness was best overcome by discipline and brutality. c. The mentally ill were possessed by evil spirits that inflicted emotional suffering. d. The mentally ill were divinely inspired and should be treated with care and benevolence.

b. Madness was best overcome by discipline and brutality.

The nurse reflecting on the nursing role within the mental health team, understands that the main purpose of delivering care using a multidisciplinary team is to do which of the following? a. Maximize the efficiency of the health care team with each team member learning from the others. b. Make the best use of the different abilities of mental health team members in order to facilitate client progress. c. Increase the opportunity for interpersonal interaction among the client, family, and team members. d. Facilitate the case management process by delivering care using a multidisciplinary health care team.

b. Make the best use of the different abilities of mental health team members in order to facilitate client progress.

Observation of the behavior of the mental health team seems to indicate that one team member is primarily interested in client progress as a measure of their knowledge and expertise. Given the nurse's knowledge of game theories, this team member might be functioning as which of the following? a. Leader b. Maximizer c. Rivalist d. Enabler

b. Maximizer

The nurse is assessing a client in the home. Given the nurse's knowledge of the top 10 causes of disability worldwide, choose the priority area for data collection. a. Social interactions and history of abuse b. Mood and patterns of alcohol usage c. Irrational fears and quality of communication d. Memory and childhood history

b. Mood and patterns of alcohol usage

On which dimension would the nurse most likely focus data collection if the nurse was assessing the client from primarily a 19th century perspective? a. Emotional b. Physical c. Spiritual d. Social

b. Physical

A client diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Impaired social interaction b. Risk for injury c. Ineffective therapeutic regimen management d. Ineffective coping

b. Risk for injury

The psychiatric nurse is asked to explain the primary focus in the assessment and treatment of mental illnesses during the mid-20th century. Given this request, the nurse would emphasize beliefs and actions related to which of the following? a. Decay of intellect or of the nervous system b. Social dimension and drug treatment c. Faulty life habits and interactions d. Classification of symptoms

b. Social dimension and drug treatment

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Insight-oriented group therapy b. Social skills group c. Reality therapy d. Simple restitution

b. Social skills group

The nurse receives the shift report on a newly admitted client with a history of drug abuse and prostitution. Prior to hospitalization, the client's parental rights were terminated. Which of the following actions best demonstrates the nurse's ability to enhance self-knowledge? a. The nurse will review the current literature pertaining to drug addiction. b. The nurse will examine his or her own feelings with regard to this client. c. The nurse will ignore the challenge to his or her self-view. d. The nurse will ask for guidance from the charge nurse.

b. The nurse will examine his or her own feelings with regard to this client.

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for which disorder? a. communication disorder. b. attention deficit hyperactivity disorder (ADHD). c. intellectual development disorder. d. stereotypic movement disorder.

b. attention deficit hyperactivity disorder (ADHD).

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

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

The nurse is working with a client who becomes upset and tells the nurse, "I've decided to give up on finishing my bachelor's degree." Which response best reflects the nurse's belief that the client is able to find the solution to this concern? a. "It is probably too much for you to handle right now." b. "You don't need to make a decision about this right now." c. "It sounds like you feel it is too much for you to finish now." d. "If you put your mind to it, you could finish the program."

c. "It sounds like you feel it is too much for you to finish now."

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

c. Risk for injury

The nurse is teaching a group of students the various historical explanations of mental illness. Which statement by the students indicates understanding of the nurse's teaching regarding the era of magico-religious explanations? a. "Mental illnesses were caused by imbalances in body humors: blood, bile, and phlegm." b. "Mental illnesses were influenced by the moon; hence, the term lunacy." c. "Mental and physical illness were the result of superhuman forces that inflicted suffering." d. "The insane were believed to be divinely inspired and care was generally benevolent and kindly."

c. "Mental and physical illness were the result of superhuman forces that inflicted suffering."

A nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective? a. "If I run out or stop taking my medication, I will experience withdrawal symptoms." b. "I will need higher and higher doses of my medication as time goes on." c. "Taking this medication regularly will reduce the severity of my symptoms." d. "I need to store my medication in a cool dark place, such as the refrigerator."

c. "Taking this medication regularly will reduce the severity of my symptoms."

The correct response of the nurse who is asked if Florence Nightingale had any impact on the role of the nurse in psychiatric-mental health nursing should be which of the following? a. "No, Nightingale emphasized the physical environment for healing." b. "No, Nightingale focused her ideas on nursing education rather than direct client care." c. "Yes, Nightingale was among the first to note that the influence of nurses has psychological components." d. "Yes, Nightingale developed the idea of the therapeutic relationship."

c. "Yes, Nightingale was among the first to note that the influence of nurses has psychological components."

Which child demonstrates behaviors indicative of a neurodevelopmental disorder? a. A 9-month-old who does not eat vegetables and likes to be rocked b. A 3-month-old who cries after feeding until burped and sucks a thumb c. A 3-year-old who is mute, passive toward adults, and twirls while walking d. A 4-year-old who stuttered for 3 weeks after the birth of a sibling

c. A 3-year-old who is mute, passive toward adults, and twirls while walking

A nurse educator is teaching a group of students the definition of a mentally healthy individual. The nurse educator knows that an individual is considered mentally healthy when which of the following concepts give evidence to psychological, emotional, and social health? a. Age b. Gender c. Behavior d. Interpersonal relationships e. Intrapersonal relationships

c. Behavior

The home health nurse is caring for a number of clients with chronic illnesses. Given World Health Organization (WHO) research, the nurse realizes that the client with which of the following is at greatest risk for mental disability? a. Panic disorder b. Psychotic disorders c. Bipolar disorder d. Anxiety disorders

c. Bipolar disorder

The nurse educator is teaching a group of students about stigma. The educator states that stigma can affect the judgment of which of the following people about the person who is labeled as mentally ill? a. Family b. God or other higher powers c. Co-workers d. Friends e. Health care providers

c. Co-workers

A client diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The client twirls and shadow boxes. The client says gaily, "Do you like my scarves? Here they are my gift to you." How should the nurse document the client's mood? a. Suspicious b. Irritable c. Euphoric d. Confident

c. Euphoric

A client demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Explain to the client that the behavior is unacceptable. b. Conduct a meeting with all staff and clients to discuss the behavior. c. Hold a staff meeting to discuss consistency and limit-setting approaches. d. Confer with the health care provider to consider use of seclusion for this client.

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

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Anxiety related to nightmares and repetitive activities b. Chronic low self-esteem related to excessive negative feedback c. Impaired social interaction related to difficulty maintaining relationships d. Deficient fluid volume related to abnormal eating habits

c. Impaired social interaction related to difficulty maintaining relationships

The nursing assistant verbalizes to the psychiatric nurse that normal people don't have mental disorders. Which approach by the nurse would be best? a. Refer the nursing assistant back to the psychiatric orientation materials. b. Ignore the comment; the nurse has no responsibility in this situation. c. Instruct the nursing assistant that anyone can have a mental health problem. d. Alert the nursing manager of the nursing assistant's remark.

c. Instruct the nursing assistant that anyone can have a mental health problem.

The psychiatric nurse states that today's nursing practice is based on contemporary theories concerning the etiology of mental disorder. Given this theoretical basis, the nurse would most likely give priority to which of the following assessments? Select all that apply. a. Family communication patterns b. Early childhood interactions c. PET and CT scans of the brain d. Psychotropic medications e. Family history of mental disorder

c. PET and CT scans of the brain d. Psychotropic medications

The nursing student is asked which historical event was most significant in the development of psychiatric nursing as a specialty and psychotherapeutic roles for nurses. Which response by the nursing student indicates understanding of important events related to development of the psychiatric nursing role? a. Passage of the Community Mental Health Centers Act b. Publication of Commonsense Psychiatry c. Passage of the National Mental Health Act d. Release of the report Nursing for the Future

c. Passage of the National Mental Health Act

During an admission assessment on an adult unit, the nurse is thinking that the client's beliefs and actions regarding commonly accepted health practices are "bizarre." To help establish the presence of a mental disorder, the nurse should first collect information about the client's: Select all that apply. a. Age. b. Family history. c. Psychiatric history. d. Culture. e. Occupational history.

c. Psychiatric history. d. Culture. e. Occupational history.

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

c. Sedation and muscle stiffness

What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for attention deficit hyperactivity disorder (ADHD)? a. Neuroleptic malignant syndrome b. Dystonia, akinesia, and extrapyramidal symptoms c. Sleep disturbances and weight loss d. Bradycardia and hypotensive episodes

c. Sleep disturbances and weight loss

Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority? a. Chronic low self-esteem b. Decisional conflict c. Social isolation d. Disturbed personal identity

c. Social isolation

During the shift report, a nurse describes a client as "crazy." Which approach by the nurse would be best? a. Role model using the term "nervous breakdown." b. Ask the staff what terminology they wish to use. c. Suggest that staff use the term "mentally ill." d. Say nothing.

c. Suggest that staff use the term "mentally ill."

A client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the client grimaces and constantly smacks both lips. The client's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Tourette's syndrome b. Anticholinergic effects c. Tardive dyskinesia d. Agranulocytosis

c. Tardive dyskinesia

The nurse is writing a care plan for a client with schizophrenia. Which of the following interventions demonstrates that the nurse is working from the Medical model? a. The nurse will ask the client to identify responsible ways to manage delusional material. b. The client will learn techniques that will interrupt hallucinations. c. The client will learn about the therapeutic effects of medications. d. The nurse will teach the client appropriate social behaviors in group and one-on-one interactions.

c. The client will learn about the therapeutic effects of medications.

A newly hospitalized client experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Neologism b. Echolalia c. Word salad d. Anhedonia

c. Word salad

A child diagnosed with attention deficit hyperactivity disorder (ADHD) had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? a. shows increased responsiveness to authority figures. b. has an improved ability to identify anxiety and use self-control strategies c. engages in cooperative play with other children. d. has increased expressiveness in communication with others.

c. engages in cooperative play with other children.

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child demonstrating what? a. intellectualization to deal with problems. b. a passive temperament. c. resiliency. d. at risk for post-traumatic stress disorder (PTSD).

c. resiliency.

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

d. Denial

The nurse is teaching staff at a community mental health clinic about what constitutes a mental disorder. Which comment by staff indicates to the nurse the need for further teaching? a. "Experiencing pain and suffering may imply a mental disorder." b. "Being unable to function in everyday life is consistent with a mental disorder." c. "Experiencing distressful symptoms may imply a mental disorder." d. "Grieving after a loss may signal a mental disorder."

d. "Grieving after a loss may signal a mental disorder."

The nursing assistant asks the psychiatric nurse the location of the first asylum for the mentally ill. Which response by the nurse is most appropriate? a. "This is not part of your role on this unit." b. "The first asylum for the mentally ill was St. Mary of Bethlehem (Bedlam)." c. "Why do you want to know this?" d. "The first asylum for the mentally ill was in Morocco."

d. "The first asylum for the mentally ill was in Morocco."

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

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

The nurse is planning care for the client who presents with frequent reports of multiple physical complaints. Given knowledge of the leading causes of mental disability, the nurse should plan to include further data collection in which of the following priority areas? a. History of family violence b. Clarity of thought processes c. Relationships with others d. Alcohol usage

d. Alcohol usage

A child diagnosed with attention deficit hyperactivity disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? a. Tricyclic antidepressants b. Anxiolytics c. Antipsychotics d. CNS stimulants

d. CNS stimulants

A client's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating? a. Detachment and overconfidence b. Euphoric mood, hyperactivity, distractibility c. Foot tapping and repeatedly writing the same phrase d. Darting eyes, tilted head, mumbling to self

d. Darting eyes, tilted head, mumbling to self

A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts. The nurse should monitor for which desired behavior? a. Tolerates social interactions for short periods without disruption or frustration b. Abilities to identify anxiety and implement self-control strategies c. Increased expressiveness in communication with others d. Improved abilities to participate in cooperative play with other children

d. Improved abilities to participate in cooperative play with other children

The nurse is asked to provide traits of a mentally healthy individual at a hospital in-service. The nurse knows that mentally healthy individuals are: a. Middle-aged and physically ill. b. Physically healthy and dependent. c. Dependent and needy. d. Independent and autonomous.

d. Independent and autonomous.

The unit manager is consistently advocating for self-awareness among the psychiatric-mental health nursing staff in order to promote quality care. From which theoretical base is the unit manager operating? a. Martha Rogers's principles of homeodynamics b. Dorothea Orem's theory of self-care c. Sister Callista Roy's adaptation theory d. Jean Watson's theory of human caring

d. Jean Watson's theory of human caring

A nurse wants to teach alternative coping strategies to a client experiencing severe anxiety. Which action should the nurse perform first? a. Assess how the client uses defense mechanisms. b. Verify the client's learning style. c. Create outcomes and a teaching plan. d. Lower the client's current anxiety.

d. Lower the client's current anxiety.

A client insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Idea of reference c. Thought insertion d. Magical thinking

d. Magical thinking

The nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Psychomotor agitation b. Auditory hallucinations c. Delusions of grandeur d. Poor personal hygiene

d. Poor personal hygiene

The nurse assesses that the mental health client has problems choosing productive, safe leisure activities. Which member of the mental health team should the nurse consult with? a. Occupational therapist b. Attending psychiatrist c. Clinical psychologist d. Recreational therapist

d. Recreational therapist

A newly admitted client diagnosed with major depressive disorder has gained 20 pounds over a few months and has suicidal ideations. The client has taken antidepressant medication for 1 week without remission of symptoms. What is the priority nursing diagnosis? a. Chronic low self-esteem b. Hopelessness c. Imbalanced nutrition: more than body requirements d. Risk for suicide

d. Risk for suicide

Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? a. The child's best friend was absent from the child's birthday party. b. The child moved to three new homes over a 2-year period. c. The child was not promoted to the next grade one year. d. The child has been raised by a parent with recurring major depressive disorder.

d. The child has been raised by a parent with recurring major depressive disorder.

The new nurse is working with a preceptor on a medical-surgical unit. The nurse has just assessed a client and states to the preceptor, "This client has many odd notions regarding several common health practices. He seems like a deviant to me." In planning a response, the preceptor is guided by: a. A definition of deviance that covers all clinical situations. b. The need for further assessment to determine the duration of the beliefs and actions. c. The knowledge that beliefs and behaviors are only deviant if the client thinks there is a problem. d. The knowledge that beliefs and behaviors are judged by cultural and social considerations.

d. The knowledge that beliefs and behaviors are judged by cultural and social considerations.

A client demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? a. To minimize the side effects of lithium. b. To enhance the antimanic actions of lithium. c. To be used for long-term control of hyperactivity. d. To bring hyperactivity under rapid control.

d. To bring hyperactivity under rapid control.

A client fearfully runs from chair to chair crying, "They're coming! They're coming!" The client does not follow the staff's directions or respond to verbal interventions. What is the initial nursing intervention of highest priority? a. respecting the client's personal space. b. offering an outlet for the client's energy. c. encouraging clarification of feelings. d. providing for the client's safety.

d. providing for the client's safety.

While the exact cause of bipolar disorder has not been determined; however, what is consistent for most clients? a. inadequate norepinephrine reuptake disturbs circadian rhythms. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. several factors, including genetics, are implicated

d. several factors, including genetics, are implicated