Psychiatric and Mental Health Nursing

Bipolar disorder

-A disorder in which one's mood varies from manic to depressive episodes. -If the depressive episodes and manic episodes are very mild, the condition is labeled cyclothymia.

Personality disorders

-A disruption within personality traits that leads to functional impairment and behavioral instability. -Several types which are organized by 3 clusters: A, B, and C -The patient's symptoms are used to diagnose the type of cluster for the particular personality disorder.

Depression

-A group of clinical disorders characterized primarily by an abnormally low mood that can develop at any age from childhood to adulthood. -Mood is a pervasive feeling that is experienced subjectively and influences thoughts, behaviors, physical sensations, and perceptions. -A depressed mood is different from a brief passing sadness or grief after a loss. -A decrease in the necessary levels of serotonin in the CNS combined with environmental stressors is believed to be the cause.

Generalized Anxiety Disorder (GAD)

-A group of disorders characterized as long-term state of worry. -The symptoms decrease one's participation in activities of daily life because of the constant state of worry. -Can vary from mild to a feeling of panic, with intensifying symptoms at each stage. -Obsessive compulsive disorder adds repetitive thoughts (preoccupied with germs or locking doors) and actions (repeatedly washing hands, rechecking doors multiple times) to the anxiety and is a long-term disorder.

Schizophrenia

-A series of thought disorders characterized by perceptual distortions or a break from reality. -1% of the population has the genetic predisposition (dopamine abnormality) for schizophrenia, and when an individual with this predisposition is exposed to significant life stressors, symptoms often develop. -Because of the perceptual distortions associated with this disorder, patients often have difficulty functioning and meeting basic needs and they demonstrate erratic or agitated behavior. -These symptoms also result in social skills deficits and often depression and anxiety.

Signs and symptoms of delirium

-Acute change in cognition lasting only a short time -Confusion -Decreased level of attention -Agitation -Fatigue -Visual hallucinations

Nursing care for patients on SSRIs or SNRIs

-Advise the patient to take medication as ordered. -It takes 2-4 weeks before changes in vegetative signs and improved mood are noticed. -Therapy must be used to facilitate recovery as well as prevent future episodes. -Many patients feel hopeless and stop the medications when they don't experience improvement in a few days. -It is important to point out improvements to patients and families as they occur. -Assess for side effects and, if severe, contact the physician. -Tell the patient to take medication with food to decrease GI upset. -There are many medication contraindications so caution while taking SSRIs is best. -Advise patients to take SSRIs at night in case dizziness occurs. -Assess BP and watch for a decrease in BP when changing positions. -Liver and renal function tests are monitored while on long-term therapy. -Depressed patients are still at risk for suicide, so continue to monitor while on treatment.

Nursing care for patients on MAOIs

-Advise the patient to take these medications as directed. -Obtain a medication history because of the many contraindications, and monitor signs of hypertensive crisis. -Monitor BP. -Teach the patient to avoid foods with tyramine, such as bananas, cheese, wine, yogurt, figs, raisins, coffee, and certain meats. -Patients should use caution when changing position because of the risk of decrease in BP.

Types of Antianxiety medications

-Alprazolam (Xanax) -Lorazepam (Ativan) -Diazepam (Valium) -Clonazepam (Klonopin) -Chlordiazepoxide (Librium) -Midazolam (Versed) -Oxazepam (Serax) -Buspirone (BuSpar)

Types of tricyclic antidepressants

-Amitriptyline (Elavil) -Trazodone (Desyrel) -Butriptyline (Evadyne) -Clomipramine (Anafranil) -Doxepin (Adapin or Sinequan) -Imipramine (Tofranil) -Imipraminoxide (Imiprex) -Maprotilene (Ludiomil) -Trimipramine (Surmontil) -Desipramine (Norpramin) -Nortriptyline (Aventyl) -Protriptyline (Vivactil)

Drug therapy for depression

-Antidepressants (SSRIs are used first) -Antianxiety meds -Sleep meds -If the patient is not responding well, an antipsychotic may be added to the antidepressant.

Drug therapy for schizophrenia

-Antipsychotics -Antiepileptics -Antianxiety medications -Antidepressants

Cluster C Clinical Signs

-Anxious -Withdrawn -Ritualistic -Impulsive -Irritable -Tends to lack social skills

Diagnostics for generalized anxiety disorder

-Based on clinical symptoms and DSM categories. -GAD is diagnosed if the patient's symptoms persist for more than 6 months

Diagnostics for bipolar disorder

-Based on symptoms of mania and depressive episodes. -Various depression scales may be used to help make a diagnosis.

Complications of delirium

-Because of the rapid change in cognition, the patient may experience suicidal thoughts. -Maintain safety and implement suicide precautions.

Drug therapy for generalized anxiety disorder

-Benzodiazepines -SSRIs

Pharmacokinetics of Antianxiety medications

-Benzodiazepines are taken orally. -They should be administered with food to decrease GI upset.

Diagnostics for dementia/Alzheimer's disease

-CBC -Urine test -Drug screen -CT scan -Electrocardiogram -Lumbar puncture to examine the spinal fluid

Side effects of antipsychotics

-Can cause extrapyramidal symptoms, which can present as pseudoparkinsonism, akinesia (stiffness), akathisia, dystonia, and tardive dyskinesia. -Parkinsonism presents as tremors, a shuffling gait, drooling, and rigidity. -Akathisia occurs days after taking the medication and presents as restlessness or not being able to sit still. -Dystonia is spastic, uncontrollable muscular movements. -Tardive dyskinesia develops after long-term use and involves bizarre dystonic and choreic movements of the mouth, lips, limbs, and entire body. This is irreversible and caused by excessive stimulation of dopamine. -Neuroleptic malignant syndrome is a fatal complication that can occur with antipsychotics and should be treated immediately. Symptoms are severe fever, tachycardia, sweating, BP changes, dyspnea, seizures, extrapyramidal symptoms, and change in mental status. Treatment needs to occur immediately, a physician needs to be called, the vital signs and I/O are monitored, the medication is stopped, the mental status is assessed, and the ordered medications are administered.

Diagnostics for depression

-Clinical exam using the DSM. -Many self-reports and structured interviews available to assist with diagnosis

Signs and symptoms of dementia/Alzheimer's disease

-Confusion -Disorientation -Poor judgment -Inability to make decisions -Personality changes -Sleep disturbances -Poor nutrition -Aphasia -Incontinence -Inability to perform activities of daily life

Complications of schizophrenia

-Decreased quality of life -Suicidal thoughts -Danger to self and others

Cluster A Clinical Signs

-Delusions -Withdrawal -Hallucinations -Magical thinking -Flat affect -Disorganized speech -Suspicious, combative, and paranoid ideation/behavior

Side effects of Antianxiety medications

-Dizziness -Sedation -HA -GI upset -Agranulocytosis -Change in mental status -Difficulty sleeping

Complications of bipolar disorder

-Erratic behavior can be harmful to the patient or others. -The patient may experience suicidal thoughts.

Complications of personality disorders

-Erratic behavior can lead to harm to self or others -Low functioning

Side effects of MAOIs

-GI upset -Anticholinergic symptoms -Orthostatic hypotension -Dizziness -Difficulty sleeping -Weight gain -Restlessness -Hypertensive crisis occurs when MAOIs are taken with other medications such as amphetamines, nasal decongestants, opioids, or tyramine. Symptoms of a hypertensive crisis: -Increased BP -Fever -N/V -Increased HR -HA -Chest pain -Neck stiffness -Dilated pupils -Sweating -A hypertensive crisis is treated with phentolamine (Regitine), which is given intravenously.

Pharmacokinetics of MAOIs

-Given orally with food to decrease GI upset. -Emsam is given transdermally.

Mood stabilizers

-Given to control manic and depressive episodes in patients with bipolar disorder. -Often given in conjunction with antidepressants. -Lithium is the most common medication prescribed for bipolar disorder.

Signs and symptoms of schizophrenia

-Hallucinations -Delusions -Flat affect -Algolia (diminished thoughts) -Lack of motivation -Impaired judgment -Inability to make decisions -Social withdrawal -Erratic behavior -Paranoia -Poor hygiene -Loss of appetite -Poor sleeping habits -Difficulty with speech -Suicidal thoughts

Nursing care for patients with generalized anxiety disorder

-If the patient is experiencing an anxiety episode, stay with them and use breathing techniques to help them stay calm. -Decrease stimuli. -Administer meds as ordered. -Refer the patient for cognitive therapy if needed.

Dementia/Alzheimer's disease

-Impaired cognition that progresses over time. -Can be caused by an organic brain disease, age, genetics, depression, and head trauma. -Alzheimer's disease is a type of dementia caused by cell damage and is irreversible.

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

-Inhibit reuptake of serotonin at the synapse, resulting in increased levels of serotonin, therefore causing an antidepressant reaction. -Given to patients with depression or anxiety -SNRIs also prevent reuptake of serotonin as well as norepinephrine and are usually ordered if the SSRI is not effective.

Nursing care for patients on tricyclic antidepressants

-Instruct the patient to take medication as directed. -Assess for side effects and treat individually if needed. -Advise patients to take TCAs at night to avoid dizziness and sedation. -Renal and liver function tests are needed with long-term usage. -Assess for suicidal tendencies; changes in behavior can increase these thoughts. -Patients who discontinue taking TCAs are gradually tapered off to avoid discontinuation syndrome, which resembles flu-like symptoms.

Nursing care for patients on cognitive enhancers

-Instruct the patient to take the medication as directed. -Educate the patient's family about how to administer the medication if the patient is not mentally capable. -Teach the patient and family the side effects of the medications and remind them that they should be taken with food to avoid GI upset. -Renal and liver function tests are assessed periodically throughout therapy. -Patients with asthma should use caution when taking these medications because of the potentially serious complication of bronchoconstriction. -Advise that these meds only slow the progress of the illness; they do not reverse symptoms. -Refer family for supportive therapy. -The patient should keep physically, socially, and mentally active to maximize functioning. -Maintain a safe environment.

Nursing care for patients on mood stabilizers

-Instruct the patient to take the medication as directed. -Teach the patient to avoid diuretics, caffeine, alcohol, OTC medications, and MAOIs while taking lithium. -If the patient is not monitored closely, lithium toxicity can occur; these symptoms need to be reported immediately. -The therapeutic serum level of lithium is 0.8-1.4 mEq/L; this should be monitored throughout drug therapy. -Monitor fluid intake while taking this medication. -Monitor renal, liver, and cardiac function periodically. -Mood stabilizers should not be stopped abruptly but should be gradually decreased. -Patients should be monitored for suicidal thoughts or activities throughout the course of therapy.

Types of mood stabilizers

-Lithium -Valproic acid (Depakote) -Lamotrigine (Lamictal) -Quetiapine (Seroquel) -Risperidone (Risperdal) -Gabapentin (Neurontin) -Aripiprazole (Abilify) -Carbamazepine (Tegretol) -Olanzapine (Zyprexa)

Side effects of mood stabilizers

-Lithium Ca cause toxic symptoms if not taken as directed. -Signs of lithium toxicity: -GI upset -Polyuria -Polydipsia -Sedation -Hand tremors -Confusion -Rigid muscle movements -Blurred vision -Ringing in the ears -Fatigue -Weakness

Nursing care for patients with delirium

-Maintain safety and take precautions because of the rapid changes in cognition. -Perform a series of diagnostics to find an underlying cause. -Treat the underlying cause rapidly and extensively. -Obtain a health history from a family member, if available. -Provide support to both the patient and family.

Drug therapy for dementia/Alzheimer's disease

-Medications that help slow the progression of dementia and Alzheimer's disease include donepezil (Aricept), tacrine (Cognex), and rivastigmine (Exelon) -Treatment for depression includes SSRIs, commonly fluoxetine (Prozac) and paroxetine (Paxil)

Diagnostics for delirium

-Mental status exam -Electrocardiogram (EKG) -Electroencephalogram -CBC -Arterial blood gases -Urine culture -Drug screen -MRI -CT scan

Nursing care for patients with bipolar disorder

-Monitor the patient frequently and closely because of rapid changes in mood. -Keep the patient and others away from harmful objects or situations. -Administer meds as prescribed, assessing for side effects. -Encourage patient to maintain a regular diet, with periods of rest. -During periods of erratic behavior, stay with the patient and decrease stimuli. -Assistance may be needed if the patient's behavior becomes combative or violent.

Drug therapy for bipolar disorder

-Mood stabilizers (lithium, SSRIs, benzodiazepines) -Antidepressants should always be ordered with a mood stabilizer to avoid activation of mania. -Poor compliance is often an issue.

Side effects of cognitive enhancers

-N/V -Diarrhea -Dizziness -Weight loss -Loss of appetite -Constipation -HA

Pharmacokinetics of antipsychotics

-Orally prescribed per physician dosage -Have the patient take medication with food to decrease GI upset -Long-acting injections are available for several antipsychotics and are useful for patients who do not take medications as ordered. -Some are also available in short-acting injection form and used to decrease agitation if oral meds are not effective.

Complications of generalized anxiety disorder

-Panic disorder -Suicidal thoughts -Depression

Contraindications to SSRIs and SNRIs

-Patients taking MAOIs and antipsychotics should use caution when taking SSRIs. -SNRIs may raise BP as well as cause urinary retention.

Contraindications to tricyclic antidepressants

-Patients taking MAOIs or other antipsychotics should use caution when taking TCAs. -TCAs can alter the effects of antihypertensive, antihistamine, and other over-the-counter medications.

Types of MAOIs

-Phenelzine (Nardil) -Tranylcypromine (Parnate) -Moclobemide (Manerix) -Isocarboxazid (Marplan) -Selegiline (Emsam)

Nursing care for patients with personality disorders

-Provide a safe environment for the patient, with frequent monitoring to prevent self-destructive actions. -Help patients recognize erratic behavior and coach them through these behaviors. -Encourage patients to attend group therapy sessions or to keep a journal to write down their feelings, -Maintain trust and avoid behaviors that may make the patient hostile. -Cognitive behavior therapy, in conjunction with medication, is also used to treat personality disorders. -Administer meds as prescribed and assess for side effects.

Nursing care for patients with depression

-Provide safety. -Develop a crisis plan if the patient's suicidal thoughts increase. -Encourage involvement in therapy as well as adherence to medications. -Cognitive behavior therapy to reduce depressive thoughts has been successful in decreasing recurrences of depression by providing a problem-solving approach and support therapy. -Exercise and well-balanced meals are also important in preventing recurrences. -Use of a full-spectrum light box is effective for seasonal affective disorder. -Psychoeducation for the patient's family is important. -Encourage involvement in self-help groups.

Drug therapy for personality disorders

-SSRIs -Monoamine oxidase inhibitors (MAOIs) -Antipsychotics

Nursing care for patients with schizophrenia

-Safety is first and most important. -Avoid large groups and overstimulation. -Avoid encouraging delusional ideas and try to bring the patient back to a state of reality. -If the patient is experiencing suicidal thoughts, precautions and frequent monitoring are needed. -ECT can also be used to treat symptoms, especially if the patient is catatonic. -Administer meds as ordered while assessing for side effects. -Because of long-term treatment, side effects are common. -Poor compliance is also a problem. -Social rehabilitation is important when the disorder is chronic. -Cognitive behavior therapy is used to cope with the symptoms as well as supportive therapy for patients and families.

Cluster B Clinical Signs

-Self-centered attitude -Inappropriate attire -Dramatic change in behavior -Anxiety -Depression -Withdrawal -Easily distracted -Manipulative

Delirium

-Sudden change in cognition that occurs throughout the day for short periods. -Before treatment occurs, a cause must be identified. -The causes are usually medication reactions, substance abuse, and/or lack of sleep.

Complications of depression

-Suicide -Increased physical problems, especially in older adults -Slower healing from surgery

Types of cognitive enhancers

-Tacrine (Cognex) -Donepezil (Aricept) -Rivastigmine (Exelon) -Memantine (Namenda) -Galantamine (Razadyne)

Nursing care for patients on Antianxiety medications

-Teach patients the importance of taking the correct dosage. -Overdosing is common and can cause serious complications; teaching the proper usage of benzodiazepines can prevent these occurrences. -Patients can also experience withdrawal symptoms if the medications are discontinued abruptly, so they should gradually decrease the dosage per physician order. -Advise patients to take the medications at night because of the side effects of sedation and to avoid alcohol. -Continue to monitor patients and side effects throughout treatment.

Nursing care for patients on antipsychotics

-Teach the patient the correct dosage and possible side effects. -Advise them to monitor for any complications or severe side effects and to report them immediately. -Monitor vitals and I/O. -Advise patient to avoid alcohol or CNS depressants while on these medications. -Patients should wear protective clothing when outdoors to avoid excessive sun exposure. -Antipsychotics should not be discontinued abruptly but should be gradually decreased.

Antipsychotics

-Treat symptoms of patients with schizophrenia -Used to decrease hallucinations, delusions, and erratic or violent behaviors

Nursing care for patients with dementia/Alzheimer's disease

-Treating the underlying cause can slow the patient's progression during the early stages. -Assist with activities of daily living and help teach strategies to assist memory. -Encourage continued activity: physical, social, and mental. -Provide support to family and patient. -Refer to a support group.

Signs and symptoms of generalized anxiety disorder

-Trembling -Increased heart rate -Cold hands/feet -Sweating -Palpitations -Dizziness -Sense of impending doom -Irritability -Fatigue -Frequent urination -Impaired concentration -SOB -Chest pain -Vision changes -Decreased attention span -Muscle tension -GI upset

Monoamine Oxidase Inhibitors (MAOIs)

-Used if other antidepressants are ineffective. -MAOIs inhibit monoamine oxidase, which results in increased serotonin and norepinephrine, decreasing symptoms of depression.

Antianxiety medications

-Used to decrease symptoms of anxiety -Benzodiazepines are able to decrease anxiety through CNS depression.

Which statement made by a patient with post-traumatic stress disorder (PTSD) would indicate improvement to the nurse? 1. "I exercise when those fears surface." 2. "I take Valium to help me relax." 3. "I usually meet my friends for a beer when I feel upset." 4. "I try to forget by blocking those thoughts from my mind."

1. "I exercise when those fears surface." Rationale: One of the goals of therapy for a patient with post-traumatic stress disorder would be to use alternative ways, such as exercise, to cope with stress when the fears surface. Exercise is an effective coping mechanism. Taking an anxiolytic (2) would mask the fears temporarily, as would alcohol (3). Thought blocking (4) is not the most effective response in this situation.

Alprazolam (Xanax) is prescribed for a patient who has a generalized anxiety disorder. Which of the following instructions is most important for the nurse to give the patient? 1. "Prolonged use can result in dependence." 2. "Take the medication 2 hours after eating." 3. "Take an additional dose if you don't obtain relief." 4. "Return once a month to have your blood level tested."

1. "Prolonged use can result in dependence." Rationale: Alprazolam (Xanax) is addictive and may cause dependence, even after relatively short-term use. Patients who develop dependency will experience withdrawal symptoms, including high risk for seizures. The medication can be taken at any time regardless of food intake (2). The patient should take the prescribed dose as directed (3), and there are no labs to be drawn monthly (4).

A patient keeps repeating that he is scared but cannot verbalize what he fears. Related to this situation, what principle would the nurse use to differentiate between anxiety and fear? 1. Anxiety is nonspecific; fear is specific. 2. Fear is nonspecific; anxiety is specific. 3. Anxiety is always present; fear is not. 4. Anxiety is always less intense than fear.

1. Anxiety is nonspecific; fear is specific. Rationale: Anxiety is a generalized, nonspecific feeling of an impending situation, whereas fear is directed toward a specific object. The other answer options (2, 3, and 4) are incorrect statements regarding anxiety and fear.

A nurse is meeting with a physician in the conference room and is approached by a depressed and withdrawn patient. Which response by the nurse is most appropriate? 1. Ask the patient how she can help. 2. Ask the patient if what she needs is urgent. 3. Tell the patient that she will available to talk with her in 5 minutes. 4. Tell the patient that she will find her when she is finished helping the physician.

1. Ask the patient how she can help. Rationale: The patient is attempting to interact with the nurse, who should not disregard this opportunity for therapeutic intervention, especially because the patient has been withdrawn. The patient's needs are a priority over a conference. In this type of situation, the patient's needs are a priority. The other answer options (2, 3, and 4) are not appropriate responses.

A nurse is assessing a battered woman's methods of coping. Which method would the nurse lease expect to find her using? 1. Assertiveness 2. Self-blame 3. Alcohol 4. Somatization

1. Assertiveness Rationale: The nurse is least likely to find assertiveness in the battered woman. The victim is usually compliant and submissive with the abuser and feels guilt, shame, and some responsibility for the battering. Self-blame (2), alcohol use (3), and somatic complaints (4) are seen in battered women.

A 23-year-old male patient is admitted to a psychiatric emergency unit after having been picked up by the police. He was walking around a residential neighborhood at night without shoes in the snow. The patient appears confused and disoriented. Which nursing action is of highest priority? 1. Assess and stabilize his physical needs. 2. Assess and stabilize his psychiatric needs. 3. Arrange for admission to a medical unit. 4. Attempt to contact a family member to obtain an accurate history.

1. Assess and stabilize his physical needs. Rationale: Because the patient was discovered without shoes in the snow, he should be evaluated for frostbite and hypothermia before psychiatric interventions. The patient's physical needs must be attended to before his psychiatric needs. If the patient is found to need medical attention, admission to a medical unit is appropriate (3); otherwise a more thorough psychiatric assessment should be performed (2). Attempting to contact a family member to obtain an accurate patient history will help with meeting both physical and psychiatric needs (4).

While performing a routine physical assessment on a 16-year-old female high school student, the nurse notices peeling skin on the fingertips and erosion of tooth enamel. Based on these findings the nurse would suspect which of the following conditions? 1. Bulimia nervosa 2. Anorexia nervosa 3. Substance abuse disorder 4. Inflammatory bowel disease

1. Bulimia nervosa Rationale: Frequent self-induced vomiting is a key characteristic of bulimia nervosa and can result in tooth decay and fluid and electrolyte imbalances. Peeling skin on the fingers may come from abrasions by the teeth incurred when stimulating the soft palate with the fingers and from erosion of the skin as a result of coming into contact with gastric contents. Anorexia nervosa (2) may lead to self-starvation in which behaviors of bulimia nervosa may be manifested in the anorexic patient. The stated assessment findings are not symptoms associated with substance abuse disorder (3) or inflammatory bowel disease (4).

A patient severely injured in a car accident tells a nurse about her experience and the long recovery period she expects. As the patient speaks, the nurse notices that her speech lacks affect. Which crisis intervention technique would initially be most therapeutic for the nurse to use? 1. Catharsis 2. Raising self-esteem 3. Positive manipulation 4. Reinforcement of behavior

1. Catharsis Rationale: Catharsis as an initial crisis intervention technique will help this patient relieve feelings as she talks about an emotionally charged area. It is an expression of feelings in a nonthreatening atmosphere that includes negative and positive emotions. Activities that raise self-esteem (2) and reinforce positive behaviors (4) are appropriate after initial crisis intervention. Positive manipulation is not a crisis intervention technique (4).

A patient experiencing delusions of persecution and auditory hallucinations is admitted to the mental health unit for a psychiatric evaluation after assaulting a friend. Later in the shift, a nurse greets the patient by saying, "Good evening. How are you?" The patient answers, "This man is bad." This is an example of which of the following? 1. Dissociation 2. Transference 3. Displacement 4. Reaction formation

1. Dissociation Rationale: The patient is talking in the third person; this reflects poor ego boundaries and dissociation from the real self. The patient's feelings are not transferred to a less threatening object or person as in transference (2) or displacement (3). Nor did the patient assume an attitude or behavior as a reaction to someone or something he rejects, as in reaction formation (4).

A 26-year-old man is reported missing after being the only survivor of a multiple-vehicle car accident. Two months later he is found working in a town 100 miles away from his home. The man does not recognize family members or recall being in an accident. He most likely has which of the following conditions? 1. Dissociative fugue 2. Dissociative amnesia 3. Depersonalization disorder 4. Dissociative identity disorder

1. Dissociative fugue Rationale: Dissociative fugue is sudden flight after a traumatic event. During the episode the person may assume a new identity and not recognize people from his past. In dissociative amnesia (2) the defining symptom is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is often too extensive for ordinary forgetting to explain. In depersonalization disorder (3) persistent or recurrent episodes of feelings of detachment or sensations of being outside of one's own body are manifested. In Dissociative Identity Disorder (4), or DID, two or more distinct identities or personality states are manifested. At least two of the personality states in DID recurrently take control of the person's behavior and the individual is unable to recall important information.

Which nursing intervention is most important when caring for a patient with a diagnosis of Alzheimer's disease? 1. Ensure a safe environment to prevent injury. 2. Make sure the patient receives food she likes to prevent weight loss. 3. Introduce the patient to others to prevent social isolation. 4. Encourage the patient to be involved in self-care to prevent dependence.

1. Ensure a safe environment to prevent injury. Rationale: Providing the patient with safety is the highest priority when caring for any patient but particularly when caring for a patient who is at greater risk for injury due to altered mental functioning. After environmental safety and injury prevention measures are performed, nutrition (2) would be a priority. After nutrition, social (3) and self-care (4) interventions would be appropriate.

A patient with borderline personality disorder is admitted to the mental health unit after lacerating his wrist. Which goal is most important after establishing a safe environment? 1. Establish a therapeutic relationship with the patient. 2. Question the patient as to why he lacerated his wrist. 3. Talk about his acting-out and self-destructive tendencies. 4. Encourage the patient to understand why he blames others.

1. Establish a therapeutic relationship with the patient. Rationale: After establishing patient safety, the nurse should work on developing a trusting relationship with the patient to facilitate the appropriate expression of feelings. A therapeutic relationship must be established before the nurse can effectively work with the patient on self-destructive tendencies. Asking "why" (2, 4) implies blame and should be avoided. Getting the patient to talk about his acting-out and self-destructive tendencies (3) would be a secondary goal after establishing a therapeutic relationship.

What is a priority for the nurse to consider when caring for a patient with a history of substance abuse? 1. Establish boundaries and set firm, consistent limits. 2. Use the same type of communication patterns that the patient uses. 3. Avoid upsetting the patient by calling attention to the drug abuse problem. 4. Realize that interaction with the patient must reflect distance and structure.

1. Establish boundaries and set firm, consistent limits. Rationale: Setting limits gives structure and balance and demonstrates a caring attitude by the nurse. The nurse must establish boundaries; however this does not distance the interaction but helps establish a therapeutic relationship. The other answer options (2, 3, 4) are not appropriate actions to use when caring for a patient with a history of substance abuse.

During a mental status examination, the nurse evaluates a patient's thought content by determining if the patient: 1. Has any delusions. 2. Has slowness or rapidity of speech. 3. Is having visual or auditory hallucinations. 4. Has had a change in appetite or difficulty sleeping.

1. Has any delusions. Rationale: The mental status examination represents a cross section of the patient's present psychological status. Evaluation of thought content refers to the specific meaning expressed in the patient's communication. It is what the patient believes, whether true or false and contradicted by social reality. Speech (2), appetite, and sleeping patterns (4) are not part of the mental status examination. Evaluation of hallucinations (3) is important but does not address thought content.

The psychiatric nurse works toward providing a therapeutic milieu for patients. The primary purpose of managing the milieu on a psychiatric unit is to ensure that the environment: 1. Helps patients to meet their treatment goals. 2. Meets the comfort and social needs of patients. 3. Allows the staff to observe and interact with patients. 4. Remains stress-free for the patients.

1. Helps patients to meet their treatment goals. Rationale: A therapeutic milieu is an environment that helps patients meet treatment goals. The items listed in the other answer options (2, 3, and 4) are secondary benefits of providing a therapeutic milieu for patients in the psychiatric setting.

The nurse is working with the family of a patient with anorexia nervosa. What is most important to include in a family teaching session? 1. How to be supportive 2. How to facilitate managing feelings 3. How to set limits on behavior 4. How to monitor social interactions

1. How to be supportive Rationale: The most important intervention to teach the family is how to be there for the patient and express their support. This is true because low self-esteem and dysfunctional family relationships are major risk factors for anorexia nervosa. Patients with anorexia nervosa need to be encouraged to manage all their feelings (2), behaviors (3), and social interactions (4).

A patient who has bipolar disorder, manic phase, is exhibiting all of the following behaviors. Which behavior should a nurse select as the most important to address first? 1. Impulsiveness 2. Distractibility 3. Rapid speech 4. Pacing the hall

1. Impulsiveness Rationale: An impulsive patient is in need of close supervision, because this specific behavior may result in injury. The nurse must ensure the patient's safety needs are met first. The other answer options (2, 3 and 4) if present may be addressed after safety needs are met.

When a nurse is assessing a patient's risk for self-directed violence, which condition would be the most significant? 1. Lethalness of the plan 2. Degree of depression 3. A family history of suicide 4. Lack of a support system

1. Lethalness of the plan Rationale: A lethal plan, such as gunshot or jumping off a bridge, is considered indicative of a firm intention to commit suicide. Answer options 2, 3, and 4 are related areas to assess with a suicidal patient but are not the most important.

A nurse is preparing a patient for electroconvulsive therapy (ECT) and understands that ECT is most commonly used as a treatment for which condition? 1. Major depression 2. Chronic schizophrenia 3. Acute somatoform disorder 4. Antisocial personality disorder

1. Major depression Rationale: ECT is most commonly used to treat major depression in patients who have not responded to other therapies, such as antidepressant medications. ECT is not used for chronic schizophrenia (2), acute somatoform disorder (3), or antisocial personality disorder (4).

Which therapy or therapeutic behavior would be the least effective initial communication for a patient with obsessive-compulsive disorder (OCD)? 1. Meditation 2. Relaxation exercises 3. Exposure therapy 4. Thought stopping

1. Meditation Rationale: Meditation would not be helpful because of the increased anxiety associated with OCD, which interferes with concentration, thinking, and focusing. Relaxation exercises (2), exposure therapy (3), and thought stopping (4) are potentially therapeutic and beneficial for a patient with OCD.

When planning care for an older adult patient with dementia, the nurse would arrange for increased supervision of the patient at what time of day? 1. Night 2. Noon 3. Morning 4. Afternoon

1. Night Rationale: In the evening and into the night, the older adult patient with dementia, also known as organic brain syndrome (OBS), may experience increasing confusion known as Sundowner's syndrome. During this time, the patient may wander; this is a safety issue, and therefore increased supervision is warranted. Patients with OBS are usually at their best in the morning (3), midday (noon) (2), and early afternoon (4).

Which defense mechanism is most likely to be seen in a patient with borderline personality disorder? 1. Projection 2. Sublimation 3. Displacement 4. Identification

1. Projection Rationale: Patients with borderline personality disorder tend to use projection to blame and project their feelings and inadequacies onto others. Sublimation (2) is the conversion of unwanted aggressive or sexual drives into socially acceptable activities. Displacement (3) is the redirection or transferring of an emotional impulse or feeling from the original source to something that is more acceptable and less threatening. Identification (4) is a defense mechanism that operates unconsciously, by which a person patterns himself or herself after some other person.

A patient reveals that he was late for his appointment and states, "I'm late because of my dumb habit. I had to relace my shoes 35 times! I can't stop until I do it just right." The nurse correctly judges that the patient's behavior most likely represents an effect to: 1. Relieve anxiety. 2. Control his thoughts. 3. Gain attention from others. 4. Express hostility toward others.

1. Relieve anxiety. Rationale: The patient exhibiting obsessive-compulsive behavior is attempting to control his anxiety. The compulsiveness of the behavior is performed to relieve or avoid anxiety. Answer options 2, 3 and 4 do not reflect the behavior that is characteristic of obsessive-compulsive disorder.

The nurse observes a nursing assistant interacting with a patient who engages in prolonged rituals. Which interaction by the nursing assistant would require the nurse to intervene? 1. Rushing the patient through the ritual. 2. Making difficult decisions for the patient. 3. Suggesting an alternative method of dealing with stress. 4. Giving the patient extra time to prepare for scheduled activities.

1. Rushing the patient through the ritual. Rationale: If the patient is hurried through his or her ritual, it is likely that the patient's anxiety will increase and the patient will need to repeat the ritual immediately from the beginning. Making difficult decisions for the patient (2) reduces the patient's sense of responsibility and consequent anxiety. Suggesting an alternative method of dealing with stress (3), such as through social or recreational activities, is appropriate because it may distract the patient from the ritualistic behavior. Giving the patient extra tie to prepare for scheduled activities (4) increases their control over the current situation.

The nurse observes that a male patient is indifferent to the staff and other patients, emotionally constricted, and aloof. He has difficulty establishing eye contact, dresses unattractively, and appears to like being isolated. These traits are most indicative of which personality disorder? 1. Schizoid 2. Antisocial 3. Obsessive-compulsive 4. Passive-aggressive

1. Schizoid Rationale: The schizoid personality likes to stay aloof, withdrawn, and isolated, with as little interaction with others as possible. Individuals with this personality type will never initiate interpersonal communications or relationships. Traits of antisocial personality disorder (2) include a pervasive pattern of disregard for, and violation of, the rights of others that begins and is characterized by deceit and manipulation. Obsessive-compulsive disorder (3) is an anxiety disorder characterized by excessive worrying and persistent ideas, thoughts, or images. The compulsive nature of the disorder includes repetitive impulses to perform a behavior. Passive-aggressive behavior (4) is a pattern of negative attitudes that manifest as learned helpfulness, procrastination, stubbornness, and resentment.

In developing a plan of care for a patient who has a diagnosis of conversion disorder, the nurse should consider that the: 1. Symptom is real to the patient. 2. Patient's symptom has an organic cause. 3. Patient's symptom is the focus of the treatment. 4. Patient will be extremely anxious about the symptom.

1. Symptom is real to the patient. Rationale: Although there is no physical defect to be found to explain the symptoms of a patient with conversion disorder, the nurse should keep in mind that the symptoms are real to the patient. Although the patient may be anxious about the symptom (4), answer options 2 and 3 are incorrect related to conversion disorder.

A nurse assesses severe anxiety in a patient. Which symptom would the nurse expect to see as a response of the sympathetic nervous system to anxiety? 1. Tachycardia 2. Bradycardia 3. Constricted pupils 4. Increased peristalsis

1. Tachycardia Rationale: Tachycardia is the only sympathetic response listed in the choices provided. Bradycardia (2), constricted pupils (3), and increased peristalsis (4) are all parasympathetic responses and do not occur as a result of severe anxiety.

A male patient in the manic phase of bipolar disorder asks his nurse to have sex with him. What is the best action for the nurse to take? 1. Tell the patient no, and offer him an appropriate substitute activity. 2. Ask the patient how having sexual relations with him would help him. 3. Explain that it is unethical for a nurse to have intimate relations with a patient. 4. Ask the patient to explain why he decided to ask the nurse rather than someone else.

1. Tell the patient no, and offer him an appropriate substitute activity. Rationale: Telling the patient no and suggesting another appropriate activity offers the patient an alternative to decrease his activity. The nurse must maintain professional boundaries. The responses in the other answer options (2, 3, and 4) do not set limits and may lead the patient to believe that the nurse is interested in having sexual relations with him.

In an individual therapy session, a patient freely expresses his fears to the nurse. Which response by the nurse would be considered nontherapeutic? 1. The nurse states, "I'm sure everything will turn out fine." 2. The nurse asks, "Are you worried about how long you will be in therapy?" 3. The nurse learns toward the patient and gently touches the patient's arm. 4. The nurse positions herself on the patient's level and makes eye contact.

1. The nurse states, "I'm sure everything will turn out fine." Rationale: The statement, "I'm sure everything will turn out fine" offers false reassurance and is the least therapeutic response, given the available information. The nurse should listen attentively and encourage the patient to verbalize his feelings. Using touch, eye contact, and leaning in towards the client (3, 4) are therapeutic techniques. The question is option 2 is a closed-ended question and will not elicit details regarding the patient's fears.

A 38-year-old female patient has been hospitalized for a manic episode. Which behavior would suggest that the treatment has been effective? 1. The patient is no longer loud and hostile to others. 2. The patient directs anger verbally to the person who annoys her. 3. The patient presents a list of grievances to the nurse manager. 4. The patient attempts to involve other patients in her situations.

1. The patient is no longer loud and hostile to others. Rationale: When a patient is hospitalized for a manic episode, the ability to sit and talk without loud outbursts and hostility would indicate that the treatment was effective. The other options (2, 3 and 4) do not demonstrate effective behavioral responses.

A patient with bipolar disorder is having difficulty sleeping. Which short-term goal is most appropriate for this patient? 1. The patient will develop a nighttime routine. 2. The patient will exercise before bedtime. 3. The patient will write a list of possible solutions. 4. The patient will request a medication for sleep.

1. The patient will develop a nighttime routine. Rationale: A nighttime routine or sleep ritual helps the patient relax and prepare for sleep. Exercise (2) may increase wakefulness. A list of solutions (3), although a good start, is not as effective as the implementation of a nighttime routine, which is also more appropriate than dependence on a sleep medication (4).

A patient with antisocial personality disorder is at high risk for violence directed at others. Which goal would be most appropriate? 1. The patient will discuss the desire to hurt others rather than act. 2. The patient will be given something to destroy to displace anger. 3. The patient will develop a list of resources to refer to when anger escalates. 4. The patient will understand the difference between anger and physical symptoms.

1. The patient will discuss the desire to hurt other rather than act. Rationale: By discussing the desire to be violent toward others, the nurse can help the patient get in touch with the pain associated with the angry feelings. The patient needs to talk about strong feelings in a nonviolent manner and not destroy something to displace anger (2) or refer to a list of crisis references (3). Understanding the difference between anger and physical symptoms (4) would be secondary to the primary goal of having the patient discuss the desire to hurt others rather than acting on that desire.

Which short-term goal would be given highest priority for a patient with depression admitted to a mental health unit due to attempted suicide? 1. The patient will seek out a nurse when feeling self-destructive. 2. The patient will identify and discuss actual and perceived losses. 3. The patient will learn strategies to promote relaxation and self-care. 4. The patient will establish healthy and mutual caring relationships.

1. The patient will seek out a nurse when feeling self-destructive. Rationale: By seeking out the nurse when feeling self-destructive, the patient can feel safe and begin to see that there are coping skills to assist in dealing with self-destructive tendencies. Although important, the goals stated in answer options 2, 3, and 4 would be secondary to option 1, which is a physical safety goal and takes highest priority.

A young patient with bulimia nervosa wants to decrease feelings of powerlessness. Which initial short-term goal is most appropriate? 1. The patient will verbalize newly learned problem-solving skills. 2. The patient will decrease symptoms of anxiety. 3. The patient will perform self-care activities independently. 4. The patient will verbalize how to set limits with others.

1. The patient will verbalize newly learned problem-solving skills. Rationale: Learning effective problem-solving skills gives one a sense of control and power over life. Anxiety (2) is commonly caused by feelings of powerlessness. Verbalizing how to set limits (4) is a necessary life skill, but problem-solving skills take priority. Performing self-care activities independently (3) is secondary to gaining new problem-solving skills.

Which statement is correct regarding the binge-purge cycle that occurs with bulimia nervosa? 1. There are emotional triggers connected to bingeing. 2. Over time, people often grow out of bingeing behaviors. 3. Purging is more the issue to address than bingeing. 4. When a person gets too hungry, there is a tendency to binge.

1. There are emotional triggers connected to bingeing. Rationale: It is important for the patient to understand the emotional triggers related to bingeing, such as disappointment, depression, and anxiety. Answer options 2, 3, and 4 are incorrect statements related to the binge-purge cycle.

How does vascular dementia differ from Alzheimer's disease? 1. Vascular dementia has a more abrupt onset. 2. Vascular dementia is usually brief in duration. 3. Personality change is more common in vascular dementia. 4. The inability to perform motor activities is more common in vascular dementia.

1. Vascular dementia has a more abrupt onset. Rationale: Vascular dementia differs from Alzheimer's dementia in that it has a more abrupt onset. The duration of delirium is usually brief, and personality changes are more common in dementia. The inability to carry out motor activities is common in dementia. Vascular dementia is not brief in duration (2) and has long-lasting effects. Personality changes (3) and the inability to perform motor activities (4) are more common in Alzheimer's disease.

Which statement made by a severely anxious patient to the nurse during a psychiatric admission assessment would indicate the possibility of post-traumatic stress disorder (PTSD)? 1. "I keep reliving the rape." 2. "I'm afraid to go out in public." 3. "I keep washing my hands over and over." 4. "My legs feel weak most of the time."

1."I keep reliving the rape." Rationale: The individual with post-traumatic stress disorder (PTSD) has experienced or witnessed an event or events that involved actual or threatened death or serious injury to the physical integrity of self or others. The response to such experiences may involve fear, helplessness, or panic. Individuals with PTSD reexperience or relive the traumatic event. As a result, the person avoids stimuli associated with the trauma and experiences impairment of general responsiveness. The statement in answer option 2 reflects agoraphobia; in option 3, obsessive-compulsive disorder; and in option 4, conversion disorder.

Family therapy is recommended for a schizophrenic patient. Which statement would best describe the desired outcome of this therapy? 1. "Family therapy focuses totally on the patient." 2. "Family therapy changes interactions within the family." 3. "With family therapy the family helps the patient change." 4. "Withy family therapy the family decides together what the focus will be."

2. "Family therapy changes interactions within the family." Rationale: Each member of the family must care for the patient and realize that the interaction of the whole family must change to facilitate optimal functioning by the patient. Family therapy focuses on the family, not just the patient (1). The family may help the patient change (3), but he patient is part of the process. The family does not decide the focus of the therapy (4).

A patient with dependent personality disorder states, "I'll never be able to take care of myself." Which response by the nurse is best? 1. "How can you say that? You did it this morning." 2. "Let's talk about what is making you feel so fearful." 3. "I think we need to work on identifying your strengths." 4. "Can we talk about this tomorrow at the family meeting?"

2. "Let's talk about what is making you feel so fearful." Rationale: The patient with dependent personality disorder is afraid of abandonment, rejection, and being unable to care for himself. Talking about the patient's fears is a useful strategy. When a patient makes a desperate statement like the one in this situation, the nurse must respond to the patient's feelings rather than insert an opinion. Answer options 1, 3 and 4 are not appropriate for the patient with a dependent personality disorder in this situation.

A patient is experiencing hallucinations and tells a nurse, "The voices are telling me I am not a good person." The patient asks the nurse if she hears the voices. The most appropriate response by the nurse would be: 1. "It is the voice of your conscience, which only you can hear." 2. "No, I do not hear your voices, but I believe you can hear them." 3. "The voices are coming from within you, and only you can hear them." 4. "The voices are a symptom of your illness, so don't pay attention to them."

2. "No, I do not hear your voices, but I believe you can hear them." Rationale: The nurse demonstrates an understanding toward the patient and shows acceptance of the patient's perceptions even though they are hallucinatory. Informing the patient that the nurse does not hear voices reinforces reality. The other answer options (1, 3, and 4) are not appropriate responses.

A patient who has been hospitalized in the psychiatric unit for several weeks walks by the nurse waving her arms in the air and shouting, "Watch out! The president told me something terrible is going to happen." Which statement by the nurse is most appropriate? 1. "Nothing is going to happen to you." 2. "Tell me about what is going to happen." 3. "Let's join in one of the ward activities since you will be safe there." 4. "If you keep verbalizing your thoughts, you will have to go into seclusion."

2. "Tell me about what is going to happen." Rationale: The nurse must address the patient's statement as a symptom of her disease process. Further assessment by exploring her thoughts regarding her statement will provide the nurse with information to develop a plan appropriate to address the patient's safety needs as well as her paranoid thoughts. Offering false reassurance (1, 2) and threats (4) are not appropriate, therapeutic, or safe.

A patient who is being admitted to the psychiatric unit says that he hears voices. Which of the following questions should the nurse ask the patient to obtain information necessary to develop an effective plan of care? 1. "Who is speaking to you?" 2. "What do the voices say?" 3. "How do you explain that?" 4. "When do you hear the voices?"

2. "What do the voices say?" Rationale: On admission, the nurse should attempt to find out if hallucinations are controlling the patient's behavior. This is especially important to know as the plan of care is developed, particularly regarding safety needs if the patient is experiencing fear or displays the risk for aggression and violence or self-harm. The other answer options (1, 3, and 4) are not appropriate until the patient's safety status has been established.

A patient is experiencing sudden, moderate-level anxiety. The nurse would anticipate that the psychiatrist would must likely prescribe which medication? 1. Diazepam (Valium) 2. Alprazolam (Xanax) 3. Fluoxetine hydrochloride (Prozac) 4. Chlordiazepoxide hydrochloride (Librium)

2. Alprazolam (Xanax) Rationale: Alprazolam (Xanax) is a benzodiazepine commonly used as an antianxiety medication that is prescribed or sudden onset of anxiety. Although it is the most commonly prescribed anxiolytic, the drug should be used only on a short-term basis because of its highly addictive nature. Diazepam (Valium) (1) and Chlordiazepoxide hydrochloride (Librium) (4) are both benzodiazepines. Diazepam is used for anxiety, however, it is highly addictive, has a prolonged sedation effect and causes respiratory depression. Chlordiazepoxide hydrochloride is most frequent used for the treatment of alcohol withdrawal. Fluoxetine (Prozac) (3) is a selective serotonin reuptake inhibitor (SSRI), which is used as first-line antidepressant therapy.

A patient with schizophrenia has been hospitalized for 2 days and exhibits a flat affect with little interest in others. The nurse recognizes this as what part of the schizophrenic process? 1. Paranoia 2. Ambivalence 3. Input dysfunction 4. Perceptual deviation

2. Ambivalence Rationale: The four identifying characteristics of schizophrenia are ambivalence, lack of affect, autistic behavior, and loose association of thought processes. One of the key indicators of schizophrenia is the overwhelming attitude of ambivalence toward the environment and any emotional involvement with others. Patients with schizophrenia may demonstrate paranoia (1), perceptual deviation (4), or other dysfunctions (3), but these are not described in this patient.

A 40-year-old woman is seen in the outpatient mental health clinic. She is married with 2 children and is a bank executive who was recently promoted. She complains of anxiety attacks with symptoms of loss of appetite, difficulty sleeping, and palpitations. She attributes the anxiety to her increased work duties infringing on her responsibilities as a wife and mother. Based on this information, which nursing diagnosis is most appropriate? 1. Imbalanced Nutrition: less than body requirements, related to loss of appetite 2. Anxiety (moderate), related to fear of losing control of the environment 3. Decreased Cardiac Output, related to increased heart rate 4. Ineffective Coping, related to decision to accept job promotion

2. Anxiety (moderate), related to fear of losing control of the environment Rationale: Anxiety is the primary nursing diagnosis because the patient is faced with multiple stressors within her environment and is attempting to deal with them. She fears losing control and manifests the anxiety as physical symptoms of loss of appetite, difficulty sleeping, and palpitations. Answer options 1 and 3 are nursing diagnoses related to the patient's moderate-level anxiety. There is not enough information provided that the patient's ineffective coping is related to her decision to accept a job promotion (4).

A patient who is recovering from alcohol abuse tells the nurse, "I feel so depressed about what I've done to my family that I feel like giving up." Which action is the nurse's highest priority? 1. Explore family support systems. 2. Assess if there is a plan for self-harm. 3. Ask about interest in Alcoholics Anonymous. 4. Discuss the patient's ambivalent feelings.

2. Assess if there is a plan for self-harm. Rationale: When a patient talks about "giving up," the nurse must explore the potential for suicidal ideation. Although assessing the areas in the other answer options (1, 3, 4) are important, the priority action is to assess for suicide and plan for safety needs.

Although a patient's physiological response to a crisis is important to health outcomes, what additional nursing interventions must be addressed? 1. Teach the family how to care for the patient. 2. Assist the patient to effectively cope with the crisis. 3. Explain to the patient basic information regarding the disease process. 4. Maintain physiological support such as IV access and medication administration.

2. Assist the patient to effectively cope with the crisis. Rationale: Although all of the choices are important in the care of the patient experiencing a crisis, if the individual is not able to cope with the emotional, spiritual, and psychological aspects of a choice, the other components of care may be ineffective. The interventions in answer options 1, 3, and 4 are important; however their effectiveness will be enhanced once the nurse has taken measures to help the patient to cope.

A 41-year-old male patient desires to undergo a sex change operation because he feels trapped in his male body. Which action is the next most important step the patient should take if he wants to have the operation? 1. Schedule the surgery 2. Attend psychotherapy sessions 3. Begin to dress in female attire 4. Tell his family and friends

2. Attend psychotherapy sessions Rationale: Before having a sexual alteration, the patient should have several years of psychotherapy. The family and friends should be told of the patient's plans. As the psychotherapy sessions progress the patient will be expected to discuss his decision with others (4) and begin to dress in female attire (3). Scheduling the surgery (1) is not done until after completing psychotherapy.

Research conducted on sexual disorders has demonstrated that child victims of sexual abuse have a tendency to experience which result? 1. Have higher than normal hormone levels. 2. Become sex offenders themselves. 3. Experience decreased sex drive throughout their life. 4. Have normal sexual experiences throughout their life.

2. Become sex offenders themselves. Rationale: Research supports that children who have been sexually abused have a predisposition for becoming sex offenders. Research does not show that victims have higher than normal hormone levels (1) or experience a decreased sex drive (3). These individuals do not have normal sexual experiences throughout life (4).

A patient is being interviewed after admission to the psychiatric unit. He is having difficulty remembering important details about his history and begins making up details such as names and dates. This is known as: 1. Flight of ideas 2. Confabulation 3. Loose association 4. Ideas of reference

2. Confabulation Rationale: Confabulation is a common disorder seen when there are gaps in memory. The patient will fill in the gaps with anything that comes to mind at that moment to compensate for the memory loss. Flight of ideas (1) is a shift from one idea to another without completing the previous idea. It is characterized by abrupt changes in topic and rapid flow of speech. Loose associations (3) is a thought disturbance in which the speaker rapidly shifts expression of ideas from one subject to another in an unrelated, fragmented manner. Ideas of reference (4) are incorrect interpretations of incidents and external events as having a particular or special meaning specific to the person.

A patient is being treated on an inpatient psychiatric unit for paranoid schizophrenia. The patient whispers to the nurse, "Communists are hunting me down, but I found a good place to hide in the cave under my bed." This statement reflects which of the following? 1. Neologisms 2. Delusions 3. Hyperactivity 4. Hallucinations

2. Delusions Rationale: Delusions are thoughts, ideas, or beliefs that are false but are held to be true even though there is no basis in reality for them. Neologisms (1) are words made up by the patient that have no meaning. The patient may display hyperactivity (3) due to the delusion. Hallucinations (4) are sensory perceptions.

An agitated patient begins to repeat phrases that others have just said. What is this type of speech known as? 1. Autism 2. Echolalia 3. Neologism 4. Echopraxia

2. Echolalia Rationale: Echolalia is repetition of another person's remarks or statements. It occurs when individuals are fearful of saying their own words and therefore just echo the words of others. Autism (1) is extreme withdrawal; absorption in fantasy, delusions, or hallucinations; and inability to communicate or relate to people. A neologism (3), in this context, is a word invented by a psychotic or delusional patient that is meaningful only to the patient. Echopraxia (4) is the imitation or repetition of the body movements of another person.

The foundation of the therapeutic process is the nurse-patient relationship. What is the essential component that the nurse must bring to this relationship? 1. Humor 2. Empathy 3. Reframing 4. Confrontation

2. Empathy Rationale: To promote the therapeutic process, the nurse must be able to express caring and concern for the patient through the use of empathy. Humor (1) can be therapeutic, but it is not an essential component of the therapeutic relationship. Reframing (3) and confrontation (4) are therapeutic techniques, however they are not foundational to the therapeutic process.

Which instructions should a nurse include when teaching the family of a patient diagnosed with major depression? 1. Explain that depression is a lifelong permanent illness. 2. Explain that depression is an illness that can be treated. 3. Describe how depression changes a person's true feelings forever. 4. Describe how depression causes frequent disorganized thinking.

2. Explain that depression is an illness that can be treated. Rationale: The nurse must help the family understand depression, its effect on the family, and recommended treatments. It is important that the family understand that depression can be successfully treated. In some situations, depression can recur sometime later during the individual's life, but it is not necessarily a lifelong illness (1). Depression does not change a person's true feelings (3), nor is it a direct cause of disorganized thinking (4).

To help a patient with conversion disorder increase her self-esteem, what is the nurse's priority intervention? 1. Set large goals so the patient can see positive gains. 2. Focus attention on the patient as a person rather than on the symptom. 3. Discuss the patient's childhood to link present behaviors with past events. 4. Encourage the patient to use avoidant behaviors rather than assertive patterns.

2. Focus attention on the patient as a person rather than on the symptom. Rationale: Focusing on the patient directs attention away from the symptom. This approach eventually reduces the patient's need to gain attention through physical symptoms. The responses in the other answer options (1, 3, 4) do not focus on the patient's specific needs related to the disorder.

A retired secretary is admitted to the mental health unit. She states to the nurse that she is the president of a corporation and that executives from all over the world will be calling and visiting to seek her business advice. What is this patient exhibiting? 1. Delirium 2. Grandiosity 3. Confabulation 4. Flight of ideas

2. Grandiosity Rationale: Grandiosity is described as the feeling and belief of great importance and is part of delusional thinking. Delirium (1) is a disturbance of consciousness and a change in cognition that develops over a short period of time and fluctuates during the course of day. It is characterized by disorientation, reduction in attention, and incoherent speech. Confabulation (3) is the fabrication of experiences often told in a detailed and plausible way to fill in and cover up gaps in memory. Flight of ideas (4) is a shift from one idea to another without completing the previous idea. It is characterized by an abrupt change in topic and rapid flow of speech.

Patients who experience post-traumatic stress disorder (PTSD) may gain the most benefit from which therapy? 1. Hypnotherapy 2. Group therapy 3. Individual therapy 4. Electroconvulsive therapy (ECT)

2. Group therapy Rationale: Group therapy has been found to be the most effective therapy with patients experiencing post-traumatic stress disorder, especially with survivors of combat trauma. Hypnotherapy (1) may assist in treating phobias, anxiety, or pain; however, it is not used as a first-line treatment with PTSD. Individual therapy (3), although a valid treatment measure, is not the most effective for PTSD. ECT (4) is most effective for depressive disorders followed by medication.

A patient with chronic ongoing stress complains of physical symptoms. The nurse caring for him is aware that the most common chronic problem caused by stress is which of the following? 1. Nausea 2. Headaches 3. Disturbed sleep 4. Depression

2. Headaches Rationale: Frequent headaches are the most common complaint of people who experience chronic stress. Nausea (1) is not usually seen with chronic stress unless tied to a gastrointestinal problem. Disturbed sleep (3) is common with stress; patients are tired and fall asleep but it is frequently not a restful sleep. Depression (4) can occur but it is not as common as headaches and is not categorized as a physical symptom.

A patient with anorexia nervosa tells a nurse, "I'll never have the slim body I want." Which intervention by the nurse is best to address this patient's comment? 1. Call a family meeting to involve the patient's parents. 2. Help the patient work on developing a realistic body image. 3. Make an appointment for the patient to see a nutritionist weekly. 4. Develop an exercise program that the patient can participate in twice a week.

2. Help the patient work on developing a realistic body image. Rationale: With anorexia nervosa, the patient pursues slenderness and has a distorted view of self. Therefore interventions to help the patient work on developing a realistic body image would be most therapeutic. Answer options 1 and 3 do not focus on the patient working on her problems but on outside interventions. Although exercise (4) is health promoting, it does not address the patient's underlying issue.

A 72-year-old patient in an extended-care facility is anxious most of the time and has frequent complaints of a number of vague symptoms that interfere with her ability to eat. These symptoms are most likely related to which disorders? 1. Dissociative disorder 2. Hypochondriasis 3. Severe anxiety 4. Conversion disorder

2. Hypochondriasis Rationale: Hypochondriasis is defined as a morbid fear or belief that one has a serious disease, though none exists. There are no apparent symptoms related to other situations. Dissociative disorder (1) manifests as a separation of an overwhelming event from one's conscious awareness resulting in dual personalities or amnesia. There is no indication that the patient is experiencing severe level anxiety (3). Conversion disorder (4) is a mental disorder that produces symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other medical condition.

Serotonin has been associated with depression because it plays an important role in which of the following? 1. Cerebral function 2. Influence on mood states 3. Release and metabolism of catecholamines 4. Regulation of the sleep-wake cycle

2. Influence on mood states Rationale: Serotonin is widespread throughout the cerebral cortex and plays an important role in mood states that are implicated in depression. It is postulated that low levels of serotonin create abnormal levels of norepinephrine, leading to depression. The other answer options (1, 3, and 4) are not associated with serotonin.

The nurse is evaluating a recently widowed patient who presented to the Emergency Department for depression and anorexia. During the interview, the patient laughs and says in a matter-of-fact way, "I should just put a gun to my head and get it over with." Which nursing intervention is highest priority for the nurse to implement? 1. Administer a sedative to calm the patient. 2. Initiate one-to-one supervision for the patient. 3. Immediately place the patient in four-point restraints. 4. Provide the patient with privacy, and review findings with the physician.

2. Initiate one-to-one supervision for the patient. Rationale: Immediate action is necessary because the patient has verbalized a suicide plan that involves use of a gun. One-to-one supervision is a safety priority, as well as notifying authorities to search the patient for a gun or other items that may be used to cause injury to self or others. Answer options 1, 3, and 4 are not appropriate interventions for this patient as this time.

A 40-year-old woman is admitted to the local women's shelter after being raped by her estranged husband. The patient describes the traumatic event to the nurse. Which response by the nurse is the most appropriate? 1. Change the subject to prevent the patient from crying. 2. Listen attentively while the patient describes the event. 3. Arrange for the patient to tell her story in group therapy. 4. Medicate the patient with a tranquilizer to prevent hysteria.

2. Listen attentively while the patient describes the event. Rationale: Listening attentively is a therapeutic technique that conveys that nurse's concern, respect, and empathy to the patient. Retelling the event is part of the healing process. Changing the subject (1) and giving medication (4) do not allow the patient to integrate the experience into her life. Group therapy may be helpful at a later time (3)

When performing a family assessment, the nurse focuses questions with the understanding that which of the following is the most common cause of child abuse? 1. Lack of discipline of children 2. Low impulse control by parents 3. Mental health disorders of parents 4. Financial difficulties within the family

2. Low impulse control of parents Rationale: Parents who abuse their children are most often frustrated and unable to cope with stress. The feelings of frustration are frequently acted out on their children. The other answer options (1, 3, and 4) may contribute to child abuse but are not primary causes.

The nurse is caring for a patient with delirium. Which nursing intervention would be highest priority? 1. Maintaining consistency in routine 2. Maintaining physiological safety 3. Promoting optimal level of functioning 4. Promoting orientation to person, place, and time

2. Maintaining physiological safety Rationale: Nursing interventions that promote safety and maintain life are a priority for the patient with delirium. Physiologic needs are consistently a priority. Consistency in daily routine (1), optimal functioning (3), and facilitating orientation (4) are less important, whether caring for a patient with delirium or dementia.

The nurse is working with a patient who often threatens suicide to get attention. There is no plan verbalized by the patient. The nurse should interpret this behavior as: 1. Aggression 2. Manipulation 3. Confrontation 4. Hopelessness

2. Manipulation Rationale: All threats of suicide should be explored. However, the patient who repeatedly uses threats of suicide to get attention is manipulating, and this behavior should be confronted. If the patient verbalizes a plan, this indicates a serious threat of suicide, and appropriate safety precautions should be taken. In this situation the patient is not showing indications of aggression (1) or confrontation (3). The patient may feel hopelessness (4) but this is not the present behavior displayed.

A nurse is performing an admission assessment on a patient newly admitted to the psychiatric unit and finds that the patient is coherent but experiencing tachypnea, tachycardia, and voice tremors. What stage of anxiety does the nurse assess this to be? 1. Mild 2. Moderate 3. Severe 4. Panic

2. Moderate Rationale: Patients with moderate levels of anxiety frequently experience the physiological symptoms listed, as well as muscle tremors, toe tapping, and foot swinging in response to increased sympathetic stimulation. In moderate level anxiety vital signs are normal or slightly elevated, the patient feels tense, perceptions are narrowed and focused. The patient feels energized and ready for activity or challenge. In mild levels of anxiety (1), vital signs are normal, muscles are tense, awareness is increased, and thoughts are random but controlled. This patient feels safe and has a calm appearance. Severe anxiety (3) initiates the "fight or flight" response, vital signs are elevated, the patient experiences diaphoresis and difficulty in problem solving. The individual experiencing a panic level (4) of anxiety may have disturbances in cognitive/perceptual processes and may strike out in a random fashion. The sympathetic nervous system is overloaded, and the patient feels threatened, and may startle easily. The panic must be controlled before the nurse can begin to logically reason with the patient.

When caring for a patient with bulimia nervosa, the best means for the nurse to determine if the patient has stopped purging after meals is to: 1. Observe the patient for 30 minutes after every meal. 2. Monitor the patient's serum electrolyte values. 3. Weight the patient before and after each meal. 4. Supervise the patient during and after meals.

2. Monitor the patient's serum electrolyte values. Rationale: Electrolyte values are valid, reliable, and measurable indicators of the patient's physiological status that would be altered by purging. A patient with bulimia nervosa may still purge even if the nurse performs the activities listed in answer options 1, 3, and 4.

A 35-year-old woman tells the nurse she was raped when she was 12 years old but no longer remembers the incident. Which defense mechanism is she using? 1. Projection 2. Repression 3. Displacement 4. Dissociation

2. Repression Rationale: Repression is the unconscious defense mechanism whereby unacceptable thoughts, feelings, ideas, impulses, or memories are pushed from the conscious mind because of their painful guilt association or disagreeable content and are submerged in the unconscious. Traumatic past events, such as rape, are especially susceptible to repression. Projection (1) attributes strong conflicting feelings or faults to another person. Displacement (3) is the redirection or transferring of emotional impulses or feelings from the original source to something that is more acceptable and less threatening. Dissociation (4) is an alteration in an awake state where the person feels detached from his or her surroundings.

Which nursing diagnosis would be the highest priority for a patient with moderately severe (phase 3) Alzheimer's disease? 1. Bathing/Hygiene Self-Care Deficit 2. Risk for Injury 3. Ineffective Coping 4. Imbalanced Nutrition: less than body requirements

2. Risk for Injury Rationale: Safety needs are the highest priority with a patient in this phase of Alzheimer's disease. Because memory is severely affective, judgment is altered and these patients are unable to recognize objects or people, and they display wandering behaviors and an inability to make decisions. The other answer options (1, 3, and 4) are secondary in priority.

Which nursing diagnosis is the highest priority for a patient with dissociative identity disorder (DID)? 1. Disturbed Personal Identity, related to delusion ideation 2. Risk for Self-directed Violence, related to suicidal ideations or gestures 3. Deficient Diversional Activity, related to lack of environmental stimulation 4. Disturbed Sensory Perception (visual hallucinations), related to altered sensory reception

2. Risk for Self-Directed Violence, related to suicidal ideations or gestures Rationale: A common reason patients with DID are admitted to a psychiatric facility is that one of the altered personalities has homicidal ideations about another personality. Therefore safety needs and protection from injury are of highest priority. The nursing diagnoses in answer options 1, 3, and 4 may be appropriate for the patient diagnosed with DID but are secondary to physical safety needs.

According to Maslow's hierarchy of needs, which of the following should a nurse assess regarding a patient's most basic need? 1. Career satisfaction 2. Safety and security 3. Affection and belongingness 4. Feelings of confidence and life importance

2. Safety and security Rationale: According to Maslow's hierarchy of needs, after physiological needs are met, safety and security are a person's next most basic needs because none of the other needs can be met until a person is safe in his or her environment. After safety and security, the next needs to be met are affection and belongingness (3), followed by career satisfaction (1) (self-esteem), and the feelings of confidence and life importance (4) (self-actualization).

What should the priority focus be in the nursing plan of care for a patient with advanced (phase 5) Alzheimer's disease? 1. Psychotherapy 2. Safety measures 3. Palliative measures 4. Assistance with activities of daily living

2. Safety measures Rationale: Mental functioning is impaired with Alzheimer's disease, therefore these patients need constant supervision to assure physical safety. This need for almost constant attention often causes the family to seek assistance and services outside the home. Psychotherapy (1) will not be effective with Alzheimer's disease. Palliative measures (3) and assistance with activities of daily living (ADLs) (4) although important are of lesser priority than physical safety needs.

A 56-year-old woman presents to the crisis center crying uncontrollably, hyperventilating, and exhibiting psychomotor agitation. After meeting with a counselor, it is discovered that her husband of 32 years left her a week ago. She states, "I had nowhere to turn." This patient's level of anxiety is a result of which form of crisis? 1. Bipolar 2. Situational 3. Maturational 4. Adventitious

2. Situational Rationale: A situational crisis results from external stressors such as separation from a spouse of death of a clots family member. The behaviors seen with bipolar disorder (1) contribute to a crisis but alone do not constitute one. A maturational crisis (3) results from internal failure of developmental coping mechanisms, and an adventitious crisis (4) results from unusual, large-scale problems such as natural disasters or war.

Which nursing diagnostic statement would be most appropriate for a patient who is depressed? 1. Defensive coping 2. Situational low self-esteem 3. Disturbed sensory perception 4. Disturbed personal identity

2. Situational low self-esteem Rationale: Patients who are depressed are self-critical and express guilt, which indicates situational low self-esteem. The other answer options (1, 3, and 4) are not appropriate nursing diagnoses for a patient who is depressed.

While interviewing a depressed patient, the nurse would consider the most important physiological assessment to be related to: 1. Bowel habits. 2. Sleep patterns. 3. Leisure activities. 4. Menstruation history.

2. Sleep patterns. Rationale: Disturbed sleep habits, such as early morning awakening, insomnia, or hypersomnia, are indicative of a depressed state. Bowel habits (1) may be affected by depression but are not as important of a physiological function as sleep patterns. Leisure activities (3) are not considered physiological. The menstrual history (4) may also indicate irregularities but is not indicative of a depressed state.

A patient who is delusional refuses to eat because he believes that the food is poisoned. What is the most appropriate action for the nurse to take initially? 1. Taste the food in the patient's presence. 2. State to the patient that the food is not poisoned. 3. Suggest to the patient's family that food be brought in from home. 4. Tell the patient that tube feedings will be started if he does not begin to eat meals.

2. State to the patient that the food is not poisoned. Rationale: Patients cannot be argued out of a delusion, so the best approach is a simple statement of reality. None of the choices are ideal, but option 2 is the best of the choices available. The other answer options (1, 3, and 4) are not appropriate statements.

A nurse would suspect conversion disorder if which condition is found in a patient? 1. Fear of having cancer 2. Sudden loss of eyesight 3. Consistently negative chest x-rays 4. Preoccupation with thoughts of dying of a heart attack

2. Sudden loss of eyesight Rationale: Sudden loss of a body function such as eyesight or paralysis of a limb is symptomatic of conversion disorder. Fear of cancer (1) and preoccupation with thoughts of dying of a heart attack (4) would be related to an anxiety disorder. Consistently negative chest x-rays (3) are not related to a psychological problem.

A patient who is undergoing alcohol detoxification should be observed for which signs of withdrawal? 1. Hypotension and bradycardia 2. Tachycardia and irritability 3. Blurred vision and depression 4. Dilated pupils and abdominal cramps

2. Tachycardia and irritability Rationale: Signs of alcohol withdrawal specifically include tachycardia, irritability, hand tremors, insomnia, nausea or vomiting, seizures, and hallucinations. The signs listed in the other answer options (1, 3, 4) are not specifically associated with alcohol withdrawal.

Which crisis intervention situation would be considered primary prevention? 1. The nurse implements suicide precautions for a newly admitted patient. 2. The nurse instructs a first-time mother about stress-reduction techniques. 3. The nurse assesses the coping skills sed by a patient who attempted suicide. 4. The nurse develops a discharge plan for a patient from a mental health unit to a partial care program.

2. The nurse instructs a first-time mother about stress-reduction techniques. Rationale: Primary prevention interventions include activities that are directed toward decreasing the incidents, probability, or risk for development of a specific illness or dysfunction. Of the choices, teaching the new first-time mother only stress-reduction techniques implies prevention of a problem. Suicide precaution (1) is considered secondary prevention. Information gleaned through assessment of coping skills of a patient who attempted suicide (3) would be used to develop a tertiary prevention plan. Development of a discharge plan for a patient from a mental health unit to a partial care program (4) would also be tertiary prevention.

A male patient with dependent personality disorder has a goal to increase problem-solving skills. Which of the following behaviors demonstrates that the patient has made progress toward this goal? 1. The patient is courteous. 2. The patient asks questions. 3. The patient stops acting out. 4. The patient controls his emotions.

2. The patient asks questions. Rationale: The patient with dependent personality disorder is passive and tries to please others. By asking questions, the patient is beginning to gather information-the first step of decision making and problem solving. The outcomes in answer options 1, 3, and 4 do not reflect progress towards the goal.

A nurse implements a nursing intervention to reorient a male patient to person, place, and time. Which evaluation statement best reflects a positive outcome? 1. The patient asks when dinner will be served. 2. The patient correctly states his birthday and the day of the week. 3. The patient requests spaghetti and meatballs for dinner. 4. The patient states that he is unsure of the date but does know the correct day of the week.

2. The patient correctly states his birthday and the day of the week. Rationale: When the patient correctly states his birthday and the day of the week, it is a direct reflection of the nurse's reorientation intervention being successful. The other answer options (1, 3, and 4) do not necessarily reflect a positive outcome.

Which statement related to care provided by the nurse reflects that priority positive outcome for a patient who displayed aggressive and violent behavior on admission? 1. The patient forms meaningful relationships with others. 2. The patient has remained free of injury to self and others. 3. The patient demonstrates improved coping skills. 4. The patient conveys acceptance and respect in a calm, reassuring manner.

2. The patient has remained free of injury to self and others. Rationale: By stating that the patient remained free of injury to self and others, the nurse is conveying the result of interventions, thus evaluating the care implemented. In this situation safety for the patient and others is a priority. The outcomes stated in answer options 1, 3, and 4 are desirable but not as high a priority as patient and staff safety.

Which behavior in a patient recovering from a major depressive episode would the nurse judge as an improvement in the patient's condition? 1. The patient asks to go home. 2. The patient initiates interactions with others. 3. The patient takes prescribed medications without objecting. 4. The patient has fewer episodes of explosive outbursts.

2. The patient initiates interactions with others. Rationale: Patients who are severely depressed are usually slow moving and withdrawn from others. Initiating interactions with others would be a sign of improvement. Asking to go home (1) and taking prescribed medications without objecting (3) doo not indicate improvement in behavior. Severely depressed patients do not characteristically have explosive outbursts (4).

The nurse directs care toward which outcome for the manipulative patient? 1. The nurse confronts and controls the patient's behavior. 2. The patient recognizes his manipulative behavior. 3. The nurse confronts the patient and sets strict limits. 4. The patient participates in activities as directed by the nurse.

2. The patient recognizes his manipulative behavior. Rationale: Patients who are manipulative have limited self-awareness and do not know what effect their behavior is having on others around them. The first step is to make the person aware of his own behavior to facilitate a change. Answer options 1 and 3 are not patient outcomes, and option 4 does not reflect an increase in self-awareness.

A nurse is planning care for a patient prone to anxiety attacks. Which goal is a priority? 1. The patient will consume 100% of meals and snacks. 2. The patient will verbalize ways to cope with anxiety. 3. The patient will sleep throughout the night. 4. The patient will request antianxiety medications as needed.

2. The patient will verbalize ways to cope with anxiety. Rationale: Verbalizing ways to cope with anxiety is the basis for learning new behaviors to handle anxiety. Requesting antianxiety medications (4) is important, but use of individual coping mechanisms should always be employed first. Answer options 1 and 3 are appropriate goals, but they are not specific to anxiety attacks.

A female patient has been diagnosed with conversion-disorder blindness and displays "la belle indifference." Which statement best describes this term? 1. The patient is suppressing her true feelings. 2. The patient's anxiety has been relieved through her physical symptoms. 3. The patient is acting indifferent because she does not want to show her true fear. 4. The patient's needs are being met through the manifestation of blindness.

2. The patient's anxiety has been relieved through her physical symptoms. Rationale: Conversion-disorder reduces anxiety through production of a physical symptom that is symbolically linked to an underlying conflict. "La belle indifference" means that the patient is not aware of the internal conflict. In this situation the patient does not relate the blindness to possible underlying anxiety and other stressors. Based on this the other answer options (1, 3, 4) are incorrect.

A patient is learning ways to improve coping with stress and anxiety. What is the primary goal of this therapy? 1. To change the patient's lifestyle. 2. To alter the patient's response to stress. 3. The patient will ignore stressful situations. 4. The patient will limit major sources of stress.

2. To alter the patient's response to stress. Rationale: Research shows that it is not the actual stressor that determines the effect of stress, but rather how the individual responds to that stress. Therefore, it is important for the patient to actively work at changing how he responds to stress. After the patient alters his responses to stress, he may begin to work at lifestyle changes (1) to support new coping skills. Ignoring stress-producing situations (3) will not help patients develop positive coping skills. It is unrealistic for a patient to limit major sources of stress; many of these cannot be controlled (4).

Which of the following conditions is seen in patients with a somatoform psychophysiological response? 1. Diabetes mellitus 2. Ulcerative colitis 3. Hyperthyroidism 4. Viral hepatitis

2. Ulcerative colitis Rationale: Ulcerative colitis is one of the psychophysiological responses that may be prompted by psychological stressors. Diabetes mellitus (1), hyperthyroidism (3), and viral hepatitis (4) are not associated with somatoform responses.

A nurse should expect that a patient who is malingering will display what behavior? 1. Preoccupation with pain in the absence of physical disease 2. Voluntary production of a physical symptom for a secondary gain 3. Morbid fear or belief that one has a serious disease when none exists 4. Psychological need in which the patient shows one or more neurological symptoms

2. Voluntary production of a physical symptom for a secondary gain. Rationale: Malingering is defined as a voluntary production of physical or psychological symptoms to accomplish a specific goal or secondary gain. Malingering may also be used to avoid a specific situation such as a jail term or to obtain money in a lawsuit. Preoccupation with pain in the absence of physical disease (1), fear or belief of serious disease when none exists (3), and psychological need in which the patient shows one or more neurological symptoms (4) are all characteristic of somatoform disorders.

A 40-year-old homemaker presents to the triage area of an emergency department with uncontrollable crying and anxiety. She states that her husband of 18 years has recently asked for a divorce. The patient is observed fidgeting in a chair and wringing her hands. Which response by the nurse is most therapeutic? 1. "You must stop crying so we can discuss your feelings about the divorce." 2. "Once you find a job, you will feel better and more secure in your new life." 3. "I can see you are upset. Let's sit here and talk about how you are feeling." 4. "Once you have a lawyer looking out for your interests, you will feel better."

3. "I can see you are upset. Let's sit here and talk about how you are feeling." Rationale: In this response, the nurse validates the patient's distress and provides her with an opportunity to talk about her feelings. Because the patient is in crisis, decision making is difficult, even for simple tasks; therefore the nurse must be directive as well as supportive. The other answer options (1, 2, and 4) do not address the patient's needs and are not therapeutic.

A patient with anorexia nervosa attended educational sessions on principles of adequate nutrition. Which statement by the patient indicates the teaching was effective? 1. "I eat while I'm doing things to distract myself." 2. "I eat all my food at night right before I go to bed." 3. "I eat small amounts of food slowly at every meal." 4. "I eat only when I'm with my family and trying to be social."

3. "I eat small amounts of food slowly at every meal." Rationale: Slowly eating small amounts of food facilitates adequate digestion and prevents distension, which can trigger the patient to want to stop eating. Answer options 1, 2 and 4 are incorrect and indicate the patient requires further teaching.

A 21-year-old woman with anorexia is discharged from the hospital after gaining 10 pounds. Which statement indicates the patient still has a lack of knowledge about her condition? 1. "I plan to eat 6 small meals a day to start." 2. "I'll need to attend therapy for support to stay healthy." 3. "I have to diet because I've gained 10 pounds during my hospitalization." 4. "I feel this is scary and I need to write in my journal about this experience."

3. "I have to diet because I've gained 10 pounds during my hospitalization." Rationale: The patient is still relying on a mental image of herself as being fat. Therefore the nurse should further intervene with this patient, because she expresses a lack of understanding about her condition. Answer options 1, 2, and 4 are appropriate responses and reflect the patient's progress.

A patient who is diagnosed with schizophrenia tells the nurse, "I can't eat because I have snakes in my stomach." Which response by the nurse would be most therapeutic? 1. "Are you afraid of snakes?" 2. "Tell me more about the problems in your stomach." 3. "I know that you believe that, but these thoughts are part of your illness." 4. "I'd like to help you get rid of the snakes, but you'll have to tell me what to do."

3. "I know that you believe that, but these thoughts are part of your illness." Rationale: To avoid encouraging delusions, the nurse states the facts in a nonthreatening way. In this situation, the nurse acknowledges that the patient believes this but indicates that it is part of the illness. The focus is on reality. The responses in the other answer options (1, 2, and 4) are nontherapeutic and inappropriate for this patient.

A patient in the psychiatric unit tells a nurse that his wife's nagging really gets on his nerves. He asks the nurse if, during their family session later in the day, she would talk with his wife about her nagging. Which response by the nurse would be most therapeutic? 1. "Tell me more about her complaints." 2. "Can you think of a reason why she might nag you so much?" 3. "I'll help you think about how to bring this up yourself." 4. "Tell me why you want me to initiate this discussion."

3. "I'll help you think about how to bring this up yourself." Rationale: The patient needs to learn how to communicate directly with his wife about her behavior. The nurse's assistance will enable him to practice a new skill and will communicate the nurse's confidence in his ability to confront this situation. The responses in the other answer options (1, 2, and 4) could cause triangulation among the nurse, the patient, and his wife.

A male patient with antisocial personality disorder is attempting to convince the nurse that he deserves special privileges and that exceptions to unit rules should be made for him. Which response by the nurse is most appropriate? 1. "I believe we need to sit down and talk about this." 2. "Don't you know better than to try to bend the rules?" 3. "What you're asking me to do for you is unacceptable." 4. "Why don't you bring this request to the unit community meeting?"

3. "What you're asking me to do for you is unacceptable." Rationale: Patients with antisocial personality disorder often try to manipulate the nurse to get special privileges or get the nurse to make exceptions to the rules on their behalf. By informing the patient directly when actions are inappropriate, the nurse helps the patient learn to control unacceptable behaviors and set limits. The responses in answer options 1, 2, and 4 are all nontherapeutic and may provide the patient with a sense that the nurse supports the antisocial behaviors.

Which statement made by a patient in a psychiatric unit is the best example of a patient's use of "splitting"? 1. "I'm here because I have a split personality." 2. "I thought the men and women would be in separate units." 3. "You're the only one who understands me. Everyone else is mean to me." 4. "There are too many rules here. I'm going to run away the first chance I get."

3. "You're the only one who understands me. Everyone else is mean to me." Rationale: The person with a borderline personality disorder has a conflict with dependence and independence and tends to see others as all good or all bad, hence the statement by the patient that the nurse understands and the others are mean. The other answer options (1, 2, 4) are not examples of splitting.

Which statement is true regarding an amnesic disorder? 1. Short-term memory is affected. 2. Personality is grossly affected. 3. Abstract thinking and judgment remain intact. 4. There are no identifiable physical or psychological causes.

3. Abstract thinking and judgment remain intact. Rationale: With regard to amnesic disorder, the patient's thinking, judgment, and personality usually remain intact. There is usually loss of short-term (1) or long-term memory. Amnesic disorder usually results from an identifiable physical cause or psychological stress (4). The personality (2) usually remains intact.

According to Maslow's hierarchy of needs theory, which of the following represents an individual's ultimate achievement in the area of self-actualization? 1. Acceptance of self 2. Physical comfort 3. Acceptance of death and dying 4. Positive interpersonal relationships

3. Acceptance of death and dying Rationale: Maslow proposed that an individual's final life achievement is that of accepting death, on the individual's own terms. This final step is self-actualization. Within Maslow's hierarchy acceptance of self (1) relates to self-esteem, physical comfort (2) relates to the basic physiological needs, and positive interpersonal relationships (4) relates to love and belonging.

An airliner carrying 90 people crashed in a residential community near a municipal airport. The survivors, families, and community will experience a(n): 1.Situational crisis 2. Ineffective crisis 3. Adventitious crisis 4. Adjustment disorder

3. Adventitious crisis Rationale: An adventitious crisis involves a crisis that is not part of everyday life. They are unplanned and accidental in nature and encompass natural disasters and crimes of violence such as sexual assaults and mugging. A situational crisis (1) is unexpected and arises suddenly in response to an external event or a conflict concerning a specific circumstance. The symptoms are transient and the episode is usually brief. Adjustment disorder (4) is a temporary disorder that occurs as an acute reaction to an overwhelmingly stressful situation. Anxiety associated with an adjustment disorder and any other symptoms usually decrease and disappear as the stress diminishes. Ineffective crisis (2) is not a term used to describe a crisis.

During a mental status examination, the nurse assesses a patient's level of consciousness. Appropriate responses the nurse would explore include: 1. Recent and remote memory 2. Mood and emotional state 3. Alertness and ability to respond 4. Articulation and rate of speech

3. Alertness and ability to respond Rationale: Evaluation of the level of consciousness determines if the patient is awake, the level of alertness, and the ability to respond to questions. Exploration of recent and remote memory (1) demonstrates the patient's ability to recall, focus, and concentrate. Mood and emotional state (2) are not part of the level of consciousness assessment. Articulation and rate of speech (4) reflect speech and language ability.

Which of the following constitutes a crisis for an individual? 1. An identified stressful event 2. An event with a pathological outcome 3. An overwhelming emotional response to an event 4. Important life events such as marriages or deaths

3. An overwhelming emotional response to an event Rationale: A crisis is defined as an overwhelming emotional reaction to an event, and not necessarily as the threatening situation or event itself. A crisis creates a temporary state of disequilibrium in which a person's usual coping mechanism or problem solving methods fail. Answer options 1 and 2 are incorrect statements. Important life events such as marriages or death (4) are stressful, but they do not in themselves result in a crisis. Rather, a crisis depends on the individual's emotional reaction and ability to cope.

A nurse says to a patient, "Tell me more about the pain you have been having." This statement is an example of: 1. Restating 2. Exploring 3. Asking for clarification 4. Providing feedback

3. Asking for clarification Rationale: Asking for clarification encourages the patient to attempt to put into word vague ideas or unclear thoughts. This is accomplished by directly asking the patient to explain what is meant. The value of clarification is to clarify feelings, ideas, and perceptions. Restating (1) is the same as paraphrasing another's message more briefly using one's own words. Exploring (2) may be used as a technique of asking relevant questions. Providing feedback (4) is the measure by which the effectiveness of a message is gauged.

A male patient has attended assertiveness training. Which behavior would indicate that he benefited from the training? 1. Sporadically attends the group therapy 2. Angrily confronts a nurse about a physician's order 3. Asks to meet with his physician to discuss his treatment plan 4. States that he is beginning to understand what is wrong in his life

3. Asks to meet with his physician to discuss his treatment plan Rationale: Asking the physician to discuss the treatment plan is something that many may find difficult to do. This single act would suggest that the patient benefited from the assertiveness training. Sporadically attending group therapy (1) does not reflect a commitment by the patient to changing his behavior. Angry behavior (2) is not assertive behavior. The patient stating that he is beginning to understand what is wrong in his life (4) does reflect positive change but is not the best behavioral outcome in this situation.

A patient is admitted to the Emergency Department after being sexually assaulted. She is physiologically stable but emotionally distraught. The nurse realizes that several important tasks should be performed in caring for this patient. Which nursing action should receive priority? 1. Assist with medical treatment. 2. Collect and prepare evidence for the police. 3. Attempt to reduce the patient's anxiety level. 4. Provide anticipatory guidance about normal responses to sexual assault.

3. Attempt to reduce the patient's anxiety level. Rationale: Reducing anxiety will help the patient more effectively participate in medical, forensic, and legal follow-up activities. Routine medical treatment (1) should begin as soon as the patient's anxiety decreases. Collecting and preparing evidence (2) and providing anticipatory guidance (4) are not high-priority interventions initially.

Which nursing diagnosis would be considered specific for a patient with catatonic schizophrenia? 1. Anxiety 2. Powerlessness 3. Bathing self-care deficit 4. Impaired physical mobility

3. Bathing self-care deficit Rationale: Individuals with catatonic schizophrenia are usually unable to care for their most basic needs, including bathing, dressing, grooming, feeding, and toileting. Anxiety (1), powerlessness (2), or impaired physical mobility (4) may or may not be a concern with a catatonic schizophrenic patient.

A patient is admitted to an inpatient psychiatric unit for a phobia of crowds and open public spaces. What therapeutic approach by the nurse would be most effective? 1. Group therapy 2. Reality testing 3. Behavioral therapy 4. Crisis intervention

3. Behavioral therapy Rationale: Behavioral therapy is very effective at helping patients resolve phobias by using positive reinforcement and desensitizing techniques. Group therapy (1) helps the patient with problem-solving skills, setting goals, social interactions, and medication education.. Groups usually consist of 6-8 people with enough reality testing to participate meaningfully. Reality testing (2) involves the individual's attempt to evaluate and understand the real world and his or her relation to it. Crisis intervention (4) is a problem-solving activity intended to correct or prevent continuation of a crisis situation.

What is the most appropriate nursing intervention to assist a patient with borderline personality disorder to identify appropriate behaviors? 1. Schedule a family meeting. 2. Place the patient in seclusion. 3. Develop a behavioral contract. 4. Perform a mental status assessment.

3. Develop a behavioral contract. Rationale: The use of a behavioral contract establishes a framework for healthier functioning and places responsibility for actions on the patient. Answer options 1, 2, and 4 are not priority interventions for a patient with borderline personality disorder as described in this situation.

A patient with anorexia nervosa tells the nurse she always feels fat. Which of the following interventions is best for this patient? 1. Talk to her about how important she is to her family. 2. Encourage her to look at herself in a mirror. 3. Discuss with her the dynamics of the disorder. 4. Talk about her positive attributes.

3. Discuss with her the dynamics of the disorder. Rationale: The patient can benefit from understanding the underlying dynamics of the eating disorder. The patient with anorexia nervosa has low self-esteem and will not believe positive statements about her even though they are true (1, 4). Encouraging the patient to look at herself in the mirror (2) is not as effective an intervention as first discussing the facts about anorexia nervosa.

A nurse is implementing the technique of reframing in therapy with a patient who is depressed. What is the primary purpose of reframing? 1. Force the patient to view things in a different way. 2. Help the patient forget the past and look toward the future. 3. Encourage the patient to seek alternative ways of looking at situations. 4. Suggest that the patient see things from another's point of view.

3. Encourage the patient to seek alternative ways of looking at situations. Rationale: Reframing is an effective therapeutic technique often used to encourage a patient to see his or her behavior from different perspectives. Reframing helps the patient change his or her viewpoint of a situation and replace it with another that fits the facts well but changes the meaning. The therapist should not force a patient in any way (1) or help a patient to forget experiences (2). Suggesting that the patient see things from another person's point of view (4) is not a client-focused approach.

Which intervention would most likely promote a positive self-image in a patient with depression and low self-esteem? 1. Encouraging the patient to pray 2. Involving the patient in playing cards 3. Encouraging the patient to write poetry 4. Teaching the patient about effects of medications

3. Encouraging the patient to write poetry Rationale: Writing poetry or engaging the patient in some other creative outlet will enhance the patient's self-esteem. Along with the positive feedback of the nurse, this provides a means of expressing positive aspects of one's self and life. Encouraging the patient to pray (1) may not provide as creative an outlet as other activities because praying is a solitary activity. Involving the patient in playing cards (2) may or may not build positive self-esteem, depending on who is playing cards and the patient's experience and ability with the card game. Teaching the patient about the effects of medications (4) does not provide an opportunity for the patient to be creative.

A patient who is diagnosed with bipolar disorder is admitted to an inpatient mental health unit in the manic phase. What is the priority in the initial plan of care? 1. Place the patient in seclusion. 2. Place the patient on one-to-one supervision. 3. Ensure a calm and quiet environment. 4. Medicate the patient with a sedative.

3. Ensure a calm and quiet environment. Rationale: During the manic phase, a calm and quiet environment should be provided to meet safety and security needs and he physiological need for rest, because this patient does not need additional stimuli from the environment. There is no indication that seclusion (1) or one-to-one supervision (2) is necessary for this patient. Medicating the patient with a sedative (4) would be used as a last resort if other interventions were unsuccessful.

What is the initial most effective nursing intervention to lower a patient's risk for suicide? 1. Use a calm, caring approach toward the patient. 2. Develop a strong, therapeutic relationship with the patient. 3. Establish a suicide contract to ensure the patient's safety. 4. Encourage the patient to avoid overstimulating activities.

3. Establish a suicide contract to ensure the patient's safety. Rationale: Establishing a suicide contract with the patient demonstrates the nurse's concern for the patient's safety is a priority and that the patient's life is of value. When a patient agrees to a suicide contract, it decrease the risk for a successful attempt. Using a calm, caring approach (1), developing a strong therapeutic relationship with the patient (2), and avoiding overstimulating activities (4) are all important nursing interventions for a suicidal patient but not as high a priority as establishing a suicide contract for safety.

The patient with obsessive-compulsive disorder (OCD): 1. Experiences mood swings. 2. Is paralyzed by fear of an object or situation. 3. Experiences persistent thoughts and repeated behaviors. 4. Is disoriented and out of touch with reality.

3. Experiences persistent thoughts and repeated behaviors. Rationale: OCD is characterized by persistent and intrusive thoughts and repeating ritualistic behaviors. Mood swings (1) may be related to a bipolar disorder, fear of an object or situation (2) is characteristic of a phobia, and being disoriented and out of touch with reality (4) represents a psychosis.

A patient who has been in therapy for 2 weeks is becoming increasingly dependent on the nurse and the staff. Which action by the nurse would be most therapeutic? 1. Fulfill the patient's needs. 2. Deny what the patient wants. 3. Facilitate insight regarding behavior. 4. Encourage coping with disappointments.

3. Facilitate insight regarding behavior. Rationale: The dependent patient often rationalizes and is not aware of behavior. Insight therapy will focus on developing increase self-awareness. Awareness of inappropriate behavior is the first step to changing it. Answer options 1, 2, and 4 are not appropriate interventions for a patient who is showing signs of becoming increasingly dependent on the nurse.

An adolescent male patient tells the nurse he hates his parents because they focus attention on his older sister. What therapeutic intervention might benefit this patient the most? 1. Play therapy 2. Art therapy 3. Family therapy 4. Occupational therapy

3. Family therapy Rationale: The premise of family therapy is that the transactions within the family system determine the stability and later social adaptations of its members. The major goal of family therapy is to change the dysfunctional patterns in the family into more functional patterns, thereby improving functioning and quality of life for all members. Play therapy (1), art therapy (2), and occupational therapy (4) focus on the individual, not the family system.

A patient is being discharged from a crisis center after a domestic abuse episode. She agrees to meet with the nurse the following week. Before the nurse terminates the meeting with the patient, what action is most important? 1. Ask the patient what she could do to deescalate the situation at home. 2. Advise the patient to pack up her personal belongings and leave her husband. 3. Give the patient the telephone number of a shelter or safe house and the crisis center. 4. Tell the patient not to do anything that could upset her husband and trigger another incident.

3. Give the patient the telephone number of a shelter of safe house and the crisis center. Rationale: The nurse would provide the patient with resources or support systems to turn to when (or if) the next battering incident occurs. It is inappropriate to advise the patient to leave her husband (2), and the patient should not be pushed or coerced into leaving her husband until she is ready. She should be told to do what she needs to do to keep herself and her children safe. She should also be informed of the potential for further and escalating abuse. Asking her what she could do to deescalate the situation in the home (1) or telling her not to do anything to upset her husband (4) places blame for the violent on the patient.

The Emergency Department nurse is caring for a sexual assault victim. What emotional response is the patient most likely to display? 1. Anger 2. Fear 3. Guilt 4. Depression

3. Guilt Rationale: Guilt and anxiety are the predominant feelings expressed by victims of sexual assault initially after the event. Anger (1), fear (2), and depression (4) may develop at a later time.

The family of a patient with paranoid personality disorder is trying to understand the patient's behavior. Which intervention would be most helpful to the family? 1. Assist the family and find ways to handle stress. 2. Explore the possibility of finding respite care. 3. Help the family manage the patient's eccentric behavior. 4. Encourage the family to focus on the patient's strengths.

3. Help the family manage the patient's eccentric behavior. Rationale: The family needs to know how to handle the patient's symptoms and eccentric behaviors. Although focusing on the patient's strengths (4) is a positive action, in this situation the family must learn how to manage the patient's behavior. Assisting the family to find ways to handle stress (1) and exploring the possibility of finding respite care (2) are possible secondary interventions.

Which intervention is most appropriate for a patient diagnosed with a schizoid personality disorder? 1. Assist the patient to enter a group recreation activity. 2. Convince the patient that the nursing staff is trying to be helpful. 3. Help the patient learn to trust the staff through selected experiences. 4. Arrange the unit environment so that contact with other patients is limited.

3. Help the patient learn to trust the staff through selected experiences. Rationale: Demonstrating that the staff can be trusted is a vital initial step in the therapy for a patient with a schizoid personality disorder. This is done slowly by exposing the patient to experiences that demonstrate the staff's consistent behavior. Assisting the patient to enter a group recreation activity (1) may be attempted after trust is established. Convincing the patient of the staff trying to be helpful (2) is less of a priority than gaining trust. Arranging the unit environment so that contact with other patients is limited (4) is an inappropriate action.

Which outcome should a nurse expect when a woman who has been submissive to her husband increases her assertiveness after attending an assertiveness workshop for women? 1. Her husband will have increased respect for her. 2. The family unit will have a greater sense of wellness. 3. Her husband will display behavioral changes. 4. The patient will become aware of intrapsychic motives.

3. Her husband will display behavioral changes. Rationale: When a person changes the way in which he or she interacts with others, the others will respond in new ways. The changes may be positive or negative, depending on the situation. Answer options 1 and 2 are positive outcomes that may occur as a result of the husband's behavioral changes. Answer option 4 is irrelevant.

A patient is going through acute opiate withdrawal. The nurse would monitor the patient closely for which potentially severe symptom? 1. Diarrhea 2. Hypothermia 3. Hypertension 4. Irritability

3. Hypertension Rationale: Withdrawal responses from opioids include hypertension, which can lead to physiologic crisis and therefore should be monitored closely. Although the patient can exhibit diarrhea (1) and anxiety or irritability (4), these would not be considered a priority over hypertension. Patients experiencing opioid withdrawal may experience an elevated temperature rather than hypothermia (4).

A college student frequently visits the college health center with multiple vague complaints of gastrointestinal symptoms before examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typical of which of the following disorders? 1. Conversion disorder 2. Depersonalization 3. Hypochondriasis 4. Somatization disorder

3. Hypochondriasis Rationale: Hypochondriasis in this situation is displayed by the patient's belief that she has a serious illness although pathological causes have been eliminated. The disturbance usually affects the GI system, with exacerbations often associated with identifiable life stressors that, in this case, can be related to the college student's examinations. Conversion disorder (1) is a mental disorder that produces symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other medical condition. Depersonalization (2) is the persistent or recurrence of feelings of detachment or sensations of being outside of one's own body. Somatization (4) is the process of expressing a mental condition as a disturbed bodily function.

The nurse is assessing an adolescent patient with symptoms of bulimia nervosa. Review of lab chemistries would reveal which abnormality? 1. Hypocalcemia 2. Hyperglycemia 3. Hypokalemia 4. Hyperkalemia

3. Hypokalemia Rationale: Patients who are bulimic will have decreased serum potassium, or hypokalemia, caused by purging behaviors and the subsequent loss of gastric secretions. Hypocalcemia (1), hyperglycemia (2), and hyperkalemia (4) are not problems associated with bulimia nervosa.

A nurse would expect which of the following in the history of a patient with dissociative identity disorder (DID)? 1. A close relationship with his or her mother 2. A history of performing poorly in school 3. Inability to recall certain events or experiences 4. Consistency in the performance of certain tasks or skills

3. Inability to recall certain events or experiences Rationale: Patients with Dissociative Identity Disorder (DID) often experience occurrences of amnesia when alternate personalities are in control. Patients with DID frequently have a history of difficult relationships with parental figures (1). Intelligence is not a feature of DID (2), and performance of certain skills or tasks (4) can vary with DID.

A patient is experiencing a combined situational and maturational crisis. What would be the best intervention for a nurse to use? 1. General support 2. Generic debriefing 3. Individual approach 4. Environmental manipulation

3. Individual approach Rationale: An individual approach intervention involves the diagnosis and treatment of a specific problem in a specific patient. The individual approach is effective with all types of crisis and in a combination of crises, or when homicidal or suicidal risks exist. The interventions in the other answer options (1, 2, and 4) are not appropriate during a situational/maturational crisis.

An older adult patient who lives with her daughter is seen in the emergency department for the second time in a month. She is noted to have unexplained bruising on both arms. When a nurse questions the patient about the bruises, the patient says to the nurse, "Please don't say anything. It's not my daughter's fault. I just bruise easily." Which action would be most appropriate for the nurse to take after assessing the patient? 1. Report the situation as possible elder abuse, and inform the patient and her daughter of your intention. 2. Spend time with the daughter and her mother, and observe their interaction together before documenting. 3. Inform the patient and her daughter of your intention to document and report findings while continuing to observe their interactions for further signs of elder abuse/neglect. 4. Request a social worker to interview the patient, then document and report findings only when they are substantiated by further indications of elder abuse.

3. Inform the patient and her daughter of your intention to document and report findings while continuing to observe their interactions for further signs of elder abuse/neglect. Rationale: Besides the nurse's obligation to provide physical care and emotional support in elder abuse situations, the nurse has a legal responsibility and is mandated in most states to report suspected elder abuse. Immunity from criminal or civil liability is provided when reporting is mandated. In this situation, the nurse does not have enough information as presented in the question; therefore further assessment is indicated. The other answer options (1, 2, and 4) are incorrect actions until further information is obtained.

The daughter of a 75-year-old female patient who is admitted to the mental health unit informs the nurse that her mother has recently become confused and is unmanageable at home. The admission assessment reveals that the patient's mood is labile, and she demonstrates periodic disorientation. When the nurse approaches the patient, she says of the nurse, "Here she comes again." Further questioning finds that she has confused the nurse with a neighbor and believes she is at a Fourth of July picnic. At this moment, what is the best nursing intervention? 1. Ask the patient why she thinks she is at a picnic. 2. Introduce yourself as the nurse and tell her she is confused. 3. Introduce yourself as a nurse and tell her she is in the hospital. 4. Agree with her idea that she is at a picnic so her self-esteem is not lowered.

3. Introduce yourself as a nurse and tell her she is in the hospital. Rationale: The best action for the nurse to take at this point is to begin to build a therapeutic relationship and attempt to orient the patient to current person, place, and time. The other answer options (1, 2, 4) are incorrect and nontherapeutic interventions. Asking "why" (1) can be interpreted by the patient as confrontational. Telling the patient she is confused (2) may cause the patient to become frustrated. Agreeing with a patient who is delusional (4) does not help the patient.

A 32-year-old male patient is experiencing severe anxiety over a recent failed relationship. What nursing intervention should be given highest priority? 1. Give the patient an antianxiety agent immediately. 2. Offer him psychotherapy to calm him down. 3. Isolate the patient in a quiet environment. 4. Place him in supervised seclusion immediately.

3. Isolate the patient in a quiet environment. Rationale: The patient should be isolated in a quiet environment where supportive care can be most effective to decrease anxiety and facilitate coping. The patient should be medicated (1) only if other interventions are not effective. Psychotherapy (2), although appropriate, would not be of highest priority while the patient is experiencing severe anxiety. Supervised seclusion (4) is not necessary for severe anxiety unless the patient escalates and demonstrates a safety risk to himself or others.

Parents of a patient with anorexia nervosa inquire about the risk factors for this disorder. Which of the following facts is most accurate for the nurse to discuss with the parents? 1. It involves the inability to tolerate structure. 2. It involves high levels of anxiety and disorganized behavior. 3. It involves low self-esteem and problems with family relationships. 4. It involves a lack of experience and limited opportunities to learn life skills.

3. It involves low self-esteem and problems with family relationships. Rationale: There are several risk factors for eating disorders, including low self-esteem, history of depression, substance abuse, and dysfunctional family relationships. The patient with anorexia nervosa tends to display perfectionist behaviors and is not able to tolerate structure (1). Anxiety may be experienced but patients with anorexia nervosa usually do not display disorganized behavior (2). These behaviors are often demonstrated by the anorexic patient as a means of establishing control. A lack of life experience and absence of opportunities to learn life skills (4) may be a result of anorexia nervosa but is not a risk factor.

Which of the following is considered an effective therapeutic communication technique? 1. Advisement 2. Asking why 3. Listening attentively 4. Using technical language

3. Listening attentively Rationale: Listening attentively is the active process of receiving information and examining one's reaction to messages received. An example of this therapeutic technique is to maintain eye contact and receptive nonverbal communication, conveying to the patient the nurse's interest and acceptance. Advisement (1), asking why (2), or using technical language (4) diminishes the ability to form a therapeutic relationship.

A patient with a diagnosis of alcoholic amnesic disorder resulting from chronic alcoholism is admitted to the mental health unit. When the patient uses confabulation, the nurse should realize that this is precipitated by the patient's: 1. Ideas of grandeur. 2. Need to get attention. 3. Marked loss of memory. 4. Difficulty in accepting the truth.

3. Marked loss of memory. Rationale: Patients have loss of memory and adapt to this by unconsciously filling in with false information from those area they cannot remember. This process is known as confabulation. Answer options 1, 2, and 4 are incorrect aspects of confabulation.

A patient's family is asking about Alzheimer's disease. The nurse should explain that a classic sign of Alzheimer's is an alteration in: 1. Gait 2. Speech 3. Mentation 4. Emotions

3. Mentation Rationale: Intellectual function is impaired in Alzheimer's disease because it is a degenerative disorder affecting the brain cells, memory recall, and cognitive processing. Gait (1), speech (2), and emotional changes (4) may be affected later in the Alzheimer's disease process.

Which symptom is most characteristic of a conduct disorder in adolescents? 1. Obsessive thoughts 2. Auditory hallucinations 3. Negativism 4. Self-induced vomiting

3. Negativism Rationale: Disobedient behavior, negativism, and destructive acts are the most common clinical manifestations of conduct disorder in adolescents. Obsessive thoughts (1) and behaviors are characteristic of OCD. Auditory hallucinations (2) are not characteristic of conduct disorders. Self-induced vomiting (4) is characteristic of eating disorders.

In assessing an older adult patient, a nurse is aware that the most common type of elder abuse is: 1. Physical 2. Psychological 3. Neglect 4. Financial

3. Neglect Rationale: Neglect is one of the most common forms of abuse in the older adult. The lack of attention by the responsible care provider and the older adult's own mental status may complicate the issue. Physical (1), psychological (2), and financial (4) abuse may also be seen in elders, although not as frequently as neglect.

Which of the following symptoms are most distinguishing between post-traumatic stress disorder (PTSD) and other anxiety-related disorders? 1. Severe depression 2. Suspiciousness of others 3. Nightmares and flashbacks 4. Lack of interest in family and activities

3. Nightmares and flashbacks Rationale: The individual with PTSD has experienced, or witnessed, an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others. The response to such experiences may involve feelings of fear, helplessness, or panic, which may manifest as nightmares and flashbacks. A major symptom of PTSD is that of avoiding stimuli associated with the trauma and experiencing impairment of general responsiveness. Some of these may include behaviors associated with depression (1), suspiciousness (2), and lack of interest (4) which may be manifested throughout most other anxiety-related disorders.

During an initial interview with parents, a nurse suspects child abuse. What behavior displayed by the parents would lead the nurse to be suspicious? 1. Guilt 2. Apathy 3. Overconcern 4. Ignoring the child

3. Overconcern Rationale: Parents who abuse their children most commonly display overconcern as a compensation so as not to draw attention to the evidence of abuse or neglect. Overconcern is often exhibited in inappropriate behaviors, such as anger at the nurse for having to wait to be seen by the health care provider. Guilt (1), apathy (2), or ignoring the child (4) are not typical behaviors of an abusive parent.

What is the most important factor in rehabilitation of a patient addicted to alcohol? 1. Availability of community resources 2. Accepting attitude of patient's family 3. Patient's emotional or motivational readiness 4. Physical condition of the patient

3. Patient's emotional or motivational readiness Rationale: Intrinsic motivation, stimulated from within the learner, is essential if rehabilitation is to be successful. Often patients are most emotionally ready for help when they have exhausted all other resources. Only then are patients motivationally ready to face reality and put forth the necessary energy and effort to change behavior. Availability of community resources (1) and an accepting attitude of the patient's family (2) are important but not as important as the patient's readiness for treatment. Poor physical condition (4) or health in general may improve with rehabilitation.

In planning care for a patient who has a mood disorder in the manic phase, which intervention is most important? 1. Encouraging self-expression 2. Providing reality orientation 3. Reducing environmental stimuli 4. Facilitating attendance at group meetings

3. Reducing environmental stimuli Rationale: Reducing environmental stimuli may have a calming effect on a patient who is hypermanic. The other answer options (1, 2, and 4) are not appropriate at this time.

A patient asks a nurse, "What do you think I should do about asking my boss for a raise?" The nurse replies, "What do you think about asking your boss for a raise?" The nurse is using which therapeutic communication technique? 1. Focusing 2. Restating 3. Reflecting 4. Suggesting

3. Reflecting Rationale: Reflection directs a patient's ideas, feelings, questions, and content back to the patient. This technique validates the nurse's understanding of what the patient is saying and conveys empathy, interest, and respect for the patient. Focusing (1) centers on key elements or concepts of a message. Restating (2) is the same as paraphrasing another's message more briefly using one's own words. Suggesting (4) can be therapeutic depending on the situation. If it is professional advice, then it is therapeutic, whereas personal opinion is nontherapeutic.

Which intervention is most appropriate for a newly admitted male patient with schizophrenia? 1. Allow the patient quiet time alone in his room. 2. Allow the patient to watch TV with other patients. 3. Reinforce reality of orientation to person, place, and time. 4. Maintain physical restraints on the patient's bed in case he becomes violent.

3. Reinforce reality of orientation to person, place, and time. Rationale: Reinforcing the reality of person, place, and time is a basic therapeutic nursing intervention with a newly admitted schizophrenic patient. Allowing the patient quiet time alone in his room (1) or to watch TV with other patients (2) may be acceptable if not disruptive, but they are not priority interventions for a newly admitted patient with schizophrenia. Physical restraints (4) are used only if indicated, and the patient would not be left alone on admission for safety reasons.

What is a nurse's responsibility when a patient is suspected of being abused or neglected? 1. Report to child protective services with a physician's order. 2. Parents must be informed before reporting to child protective services. 3. Reporting of suspected abuse or neglect is required by law in each state. 4. The nurse should consult a social worker before reporting to any authority.

3. Reporting of suspected abuse or neglect is required by law in each state. Rationale: Each state requires that any suspected child abuse or neglect is reported. The report does not require that the nurse inform the child's parent(s) (2). The nurse is responsible for reporting without regard to the direction or advice of other health professionals, such as a physician (1), or social worker (4).

The nurse is working with a patient who appears to be responding to voices. The patient yells out at intervals, "No, no, I didn't kill him. You know the truth. Please help me!" The nurse should: 1. Sit quietly and not respond at all to the patient's statements. 2. Respond to the patient by asking, "Whom are they saying you killed?" 3. Respond by saying, "I want to help you, and I realize that you must be very scared." 4. Respond by saying, "Don't become so upset. No one is talking to you. The accusing voices are part of your illness."

3. Respond by saying, "I want to help you, and I realize that you must be very scared." Rationale: This response demonstrates an understanding of the patient's feelings and encourages the patient to share feelings and focus on reality, which is an immediate need. Answer options 1 and 4 negate the patient's distress. Answer option 2 does not address the here and now and feeds the hallucination.

Which characteristic is most typical of how patients with an antisocial personality disorder would perceive themselves? 1. Exploited, unappreciated, and undervalued 2. Assertive, sensitive, warm, and fair-minded 3. Self-sufficient, powerful, and superior to others 4. Competitive, flexible, interdependent, and empathic

3. Self-sufficient, powerful, and superior to others Rationale: Antisocial personality patients see themselves are very confident and powerful in relationships with others. There is a lack of self-awareness of their own behavior and interpersonal relationships. The other answer options (1, 2, 4) are not characteristics of antisocial personality disorder.

A patient with Alzheimer's disease becomes verbally abusive and physically aggressive toward the nursing staff. What is the most appropriate action for the nurse to take? 1. Administer diazepam (Ativan) to calm the patient. 2. Apply four-point restraints to physically control the patient. 3. Speak in a calm, caring tone of voice, and attempt to divert the patient's attention. 4. Advise the patient that unit privileges will be withheld if the behavior continues.

3. Speak in a calm, caring tone of voice, and attempt to divert the patient's attention. Rationale: Patients with Alzheimer's disease need patience, clam reassurance, and diversion when becoming physically and verbally abusive. Diazepam (Valium) (1) and other barbiturates should be avoided with these patients, because they may cause a paradoxical effect such as agitation. Restraints (2) and withholding unit privileges (4) in Alzheimer's patients are not appropriate.

A 30-year-old married homemaker is referred to the mental health clinic because she is depressed. The nurse sees the patient for the first time, notices bruises on her upper arms, and questions the patient about them. The patient denies any problem and begins to cry, saying, "He didn't really mean to hurt me, but I hate the kids to see. I'm so worried about them." During the intake interview, what would be most important for the nurse to determine? 1. The resources available to the patient. 2. The type and extent of abuse in the family. 3. The potential of immediate danger to the patient and her children. 4. Whether the patient wants to be separated from her husband.

3. The potential of immediate danger to the patient and her children. Rationale: The safety of the patient and her children is the immediate concern. If there is immediate danger, action must be taken to protect them. The availability of resources (1), the level of abuse in the family (2), and the patient's plans for separation (4) are also important considerations in developing a treatment plan, but they are not the most important immediate concern.

A patient with depersonalization disorder tells the nurse, "I feel like my arm isn't attached to my body." Which of the responses would be most appropriate? 1. "Do you know where you are?" 2. "What makes you feel that way?" 3. "Don't worry, I can see that your arm is attached to your body." 4. "Feeling that your body parts are unattached is part of the disorder."

4. "Feeling that your body parts are unattached is part of the disorder." Rationale: Reinforcing that what the patient feels is an expected result of the disease process would be most appropriate. Answer options 1, 2, and 3 are inappropriate responses to the patient's statement and are not therapeutic.

A nurse is caring for a patient diagnosed with conversion disorder who has developed paralysis of her legs. Diagnostic tests fail to detect a physiological cause. During the working phase of the nurse-patient relationship, the patient says to the nurse, "You think I could walk if I wanted to, don't you?" What is the best response by the nurse? 1. "Yes, if you really wanted to walk, you could." 2. "Tell me why you are concerned about what I think." 3. "Do you think you could walk if you wanted to?" 4. "I think you are unable to walk now, whatever the cause."

4. "I think you are unable to walk now, whatever the cause." Rationale: This response answers the patient's question honestly and nonjudgmentally. It also helps preserve the patient's self-esteem. The other answer options (1, 2, and 3) do not directly focus on the patient's self-esteem and do not answer the patient's questions.

A patient with bipolar disorder becomes verbally aggressive during a group session. Which response by the nurse is most therapeutic? 1. "If you continue to talk like that, no one will want to be around you." 2. "You're behaving in an unacceptable manner and need to control yourself." 3. "You're frightening everyone. I want you to leave the group now and go to your room." 4. "Other people are disturbed by your profanity. Let's walk down the hall to help you release some energy."

4. "Other people are disturbed by your profanity. Let's walk down the hall to help you release some energy." Rationale: The response informs the patient that even though his behavior is unacceptable, he is still worthy of help. The responses in the other answer options (1, 2, and 3) indicate that the patient is in control of his behavior but do not focus on assisting the patient.

Which intervention is least appropriate for a nurse to use with a rape victim? 1. Never leave the woman alone. 2. Encourage expression of feelings. 3. Emphasize that she did the right thing in order to save her life. 4. Allow the patient to shower and brush her teeth before an examination.

4. Allow the patient to shower and brush her teeth before an examination. Rationale: Victims of sexual assault should not bathe, brush their teeth, change their clothes, douche, or eat or drink anything before the sexual assault examination. Performing any of these may destroy evidence such as semen, skin, and hair specimens from the assailant. Sexual assault victims may be left alone (1), although this is not advised. The responses in answer options 2 and 3 are appropriate interventions by the nurse.

During a meeting on an inpatient addictions unit, a newly admitted patient asks what defines drug abuse. The best response by the nurse is that drug abuse is: 1. A physiological need for a drug. 2. A psychological dependence on a drug. 3. A compulsion to take a drug on either a continual or periodic basis. 4. An excessive drug use inconsistent with accepted medical purposes.

4. An excessive drug use inconsistent with accepted medical purposes. Rationale: In drug abuse, the drug is not taken for medical reasons but for the favorable, pleasant, or desirable effects it produces. It is often taken in doses that would be fatal in a person who has not established tolerance to the drug. Answer options 1 and 2 may be a component of drug abuse but do not define drug abuse. Answer option 3 is an incorrect statement related to drug abuse.

Which measure is most effective and should be included when teaching a patient strategies to help her sleep? 1. Keep the room warm. 2. Eat a meal with a glass of milk before bedtime. 3. Schedule bedtime when you feel tired. 4. Avoid alcohol or stimulants before bedtime.

4. Avoid alcohol or stimulants before bedtime. Rationale: Caffeine, excessive fluid intake, and alcohol act as stimulants. The patient with sleeping difficulty should be advised to avoid them to promote sleep. Having a warm room (1) or eating before going to bed (2) will not promote a full night's sleep. Scheduling bedtime when tired (3) is also a good intervention to promote sleep but not as high a priority as refraining from stimulants.

A patient is displaying reaction formation when he: 1. Substitutes an activity for one that is more desirable. 2. Redirects sexual drive into socially acceptable channels. 3. Transforms mental conflict into a physical symptom. 4. Behaves in an opposite way to what he truly feels.

4. Behaves in an opposite way to what he truly feels. Rationale: Reaction formation is also known an overcompensation. With this defense mechanism, unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion. Substitution of an activity for one that is more desirable (1) is a form of displacement. Redirecting sexual drives into socially acceptable channels (2) is a form of sublimation. Transforming mental conflict into a physical symptom (3) describes a somatoform disorder, which converts anxiety into physical symptoms.

During a therapy session, a patient discusses his problems, cries openly, and expresses feelings of anger. At the end of the session, the patient states that he feels a sense of relief. The nurse recognizes this as: 1. Ventilation 2. Reframing 3. Sublimation 4. Catharsis

4. Catharsis Rationale: Catharsis is the sudden release of emotional energy from activities such as talking or exercise, resulting in a sense of relief and improved emotional well-being. Ventilation (1) is what occurred during the session. Reframing (2) is a technique of changing the viewpoint of a situation and replacing it with another that fits the facts well but changes the meaning. Sublimation (3) would not involve patients discussing their problems openly.

Which of the following is most characteristic of cognitive disorders? 1. Catatonia 2. Depression 3. Feeling of dread and doom 4. Deficit in memory

4. Deficit in memory Rationale: Cognitive disorders represent a significant change in cognition or memory from a previous level of functioning. Catatonia (1) is a type of schizophrenia. Depression (2) is a feeling of sadness and apathy and is part of major depressive and other mood disorders. Feelings of dread and doom (3) are characteristics of an anxiety disorder.

What is the most appropriate therapeutic intervention to use with a patient who has agoraphobia? 1. Have the patient go outdoors alone. 2. Advise the patient to use relaxation techniques. 3. Allow the patient to stay in his room as long as desired. 4. Discuss the patient's fear of his/her feelings or sensations rather than the situation.

4. Discuss the patient's fear of his/her feelings or sensations rather than the situation. Rationale: Discussing with the patient the concept that fear is caused by feelings or sensations and not the object or situation is the most therapeutic intervention for any phobia. Having the patient go outdoors alone (1) will cause acute exacerbation of the phobia and increase levels of anxiety. Although use of relaxation techniques (2) may be helpful to relieve anxiety associated with the phobia, it does not work on resolving the cause of the phobia. Allowing the patient to stay in his or her room (3) is nontherapeutic.

A man gets angry with his boss and goes home and yells at his wife. Which of the following defense mechanisms is he using? 1. Identification 2. Substitution 3. Undoing 4. Displacement

4. Displacement Rationale: Displacement is a release or redirection of feelings and impulses upon a safe object or person as a substitute for that which aroused the feeling. Identification (1) is a defense mechanism of operating unconsciously, by which a person patterns him or herself after some other person. Substitution (2) is a defense mechanism of turning from an obstructed desire to one whose gratification is socially acceptable. Undoing (3) is not a defense mechanism.

The nurse is working with a patient who is trying to overcome a phobia related to a fear of flying. The nurse will most likely observe which defense mechanism displayed by this patient? 1. Projection 2. Denial 3. Suppression 4. Displacement

4. Displacement Rationale: Displacement is the redirection or transferring of an emotional impulse or feelings from the other source to something that is more acceptable and less threatening. Projection (1) attributes strong conflicting feelings or faults to another person. Denial (2) is the unconscious refusal to acknowledge a painful reality or subjective experience that others identify. Suppression (3) is avoiding thinking about the problem areas intentionally, unlike repression which is unintentional.

Which action would be most appropriate for a nurse to take when a newly admitted patient is observed performing a ritualistic pattern of behavior? 1. Isolate the patient so that he will not disturb others. 2. Observe the patient closely for marked changes in behavior. 3. Remind the patient that he can control his behavior if he desires. 4. Enable the patient to continue so that he will not become more anxious.

4. Enable the patient to continue so that he will not become more anxious. Rationale: It is best to accept compulsive behavior in a comparatively permissive manner. The patient may become more restless and anxious if he is denied ritualistic activity. The behavior would be stopped only if it is harmful to the patient. The other answer options (1, 2, and 3) are not appropriate nursing interventions in this situation.

A 15-year-old female patient refuses to participate in scheduled activities on the adolescent mental health unit. She pushes another patient, causing her to fall. Which approach by the nursing staff would be most therapeutic? 1. Permit the patient to refuse participation. 2. Coax the patient to gain compliance. 3. Offer the patient rewards in advance. 4. Establish firm limits with the patient.

4. Establish firm limits with the patient. Rationale: Setting limits will help a patient learn appropriate and desirable behaviors; identify the rules, guidelines, and standards of acceptable behaviors; and define the consequences of violating those boundaries or limits. The consequences must be clear, consistently enforced, and reasonable. The nurse should speak slowly and clearly, behave politely, and listen uncritically. The other answer options (1, 2, and 3) do not identify clear boundaries for the patient and are not therapeutic.

Which of the following interventions would a nurse most likely use in a cognitive-behavioral approach for a patient experiencing low self-esteem? 1. Classical conditioning 2. Analysis of free associations 3. Use of unconditional positive regard 4. Examination of negative thought patterns

4. Examination of negative thought patterns Rationale: Popular cognitive-behavioral approaches examine the validity of habitual patterns of thinking and belief systems that influence feelings and behaviors. The other answer options (1, 2, and 3) are not appropriate with a cognitive behavioral approach.

The nurse initiating a therapeutic relationship with a patient understands that the main purpose of this intervention is to: 1. Alleviate stressors in life. 2. Establish a meaningful relationship. 3. Maximize the effects of medications. 4. Facilitate a positive behavior change.

4. Facilitate a positive behavior change. Rationale: When a patient enters therapy, the patient is in effect expressing displeasure with life situations and the desire for change. The nurse can facilitate this decision to change through developing a professional therapeutic relationship. Alleviating life stressors (1) is a possible outcome of the relationship. Establishing a meaningful relationship (2) is desired but is not the main purpose. Therapeutic relationships do not directly maximize the effects of medication (3), but through discussion and education the patient may gain understanding and improve medication compliance.

Which behavior by a patient with antisocial personality disorder would alert the nurse to the need for teaching related to interpersonal relationship skills? 1. Frequently crying 2. Having panic attacks 3. Avoiding social activities 4. Failing to follow social norms

4. Failing to follow social norms Rationale: Failure to abide by social norms influences the patient's ability to interact in a healthy manner with peers. Answer options 1, 2, and 3 are not behaviors frequently seen in a patient with antisocial personality disorder.

Buspirone (BuSpar) offers several advantages over barbiturates and benzodiazepines. However, one disadvantage of Buspirone is that it: 1. Appears to cause less sedation. 2. Does not potentiate the effects of alcohol. 3. Has no apparent abuse potential. 4. Has a delayed anxiolytic effect.

4. Has a delayed anxiolytic effect. Rationale: Buspirone (BuSpar) does not have an immediate antianxiety effect and is therefore not indicated for acute anxiety or panic attacks. Buspirone take 1-2 weeks to achieve desired antianxiety effect. Buspirone (BuSpar) causes less sedation (1), does not potentiate the effects of alcohol (2), and has less potential for addiction (3).

Which nursing intervention is most appropriate for a patient with memory impairment? 1. Speak to the patient slowly, and limit eye contact. 2. Offer low-dose sedative or hypnotic medications. 3. Ask a series of questions when obtaining information. 4. Identify yourself, and make direct eye contact with the patient.

4. Identity yourself, and make direct eye contact with the patient. Rationale: Patients with memory impairment need to have important information such as the nurse's identification constantly reestablished and reinforced. Although speaking slowly to a patient with memory impairment is acceptable, the remaining information in answer options 1, 2, and 3 is inaccurate.

Which statement best describes the key advantage for using groups in psychotherapy? 1. It decreases the focus and stress on the individual. 2. It fosters the physician-patient relationship. 3. It confronts individuals with their weaknesses and phobias. 4. It fosters a learning environment with interpersonal feedback.

4. It fosters a learning environment with interpersonal feedback. Rationale: In a group, an individual has the opportunity to learn that others have the same problems, concerns, and needs. The group can also provide a forum in which new methods of relating to others can be practiced. In psychotherapy, focus remains on the individual even though in a group setting (1). A group fosters the relationship with the therapist regardless of his or her title (2). Individuals may be confronted with their weaknesses in a group, but it is not a key advantage of a group (3).

The daughter of a 70-year-old male patient with dementia is attending a caretaker support meeting and asks a nurse for a definition of dementia. The nurse would respond that dementia is best defined as: 1. A personal neglect in self-care. 2. Poor judgment, especially in social situations. 3. Memory loss occurring as a natural consequence of aging. 4. Loss of intellectual abilities sufficient to impair self-care.

4. Loss of intellectual abilities sufficient to impair self-care. Rationale: The ability to perform self-care is an important measure of the progression of dementia. Personal neglect (1), poor judgment (2), and memory loss (3) typically occur in dementia but are not considered defining characteristics.

A nurse is developing a plan of care for a patient diagnosed with catatonic schizophrenia. Which action would the nurse consider to be highest priority? 1. Provide at least 1 hour of psychotherapy per day. 2. Introduce the patient to each member of the staff. 3. Administer medications to keep the patient clam in the first 24 hours. 4. Minimize demands on the patient during the initial course of therapy.

4. Minimize demands on the patient during the initial course of therapy. Rationale: Patients with schizophrenia have major difficulty coping with the external environment and communicating with others, and are unable to handle demands during the early phase of therapy. Any potentially stressful or highly structured/complex activities such as psychotherapy (1) or introduction to staff (2) should be avoided, especially early in the hospitalization. Patients with catatonic schizophrenia do not manifest agitation or hyperactivity, therefore administering medications to keep the patient calm (3) would not be appropriate.

A nurse is closely monitoring a newly admitted patient who is anxious. At what anxiety level might this patient become assaultive and a potential threat to himself and others? 1. Mild 2. Moderate 3. Severe 4. Panic

4. Panic Rationale: The individual experiencing a panic level of anxiety may have disturbances in cognitive/perceptual processes and may strike out in a random fashion. The sympathetic nervous system is overloaded, and the patient feels threatened, and may startle easily. The panic must be controlled before the nurse can begin to logically reason with the patient. The nurse must follow facility guidelines to protect her or himself. In mild levels of anxiety (1), vital signs are normal, muscles are tense, awareness is increased, and thoughts are random but controlled. This patient feels safe and has a calm appearance. In moderate level anxiety (2), vital signs are normal or slightly elevated, the patient feels tense, perceptions are narrowed and focused. The patient feels energized and ready for activity or challenge. Severe anxiety (3) initiates the "fight or flight" response, vital signs are elevated, and the patient experiences diaphoresis and difficulty in problem solving.

Touch may be used as an effective means of nonverbal communication. The nurse is aware, however, that when using touch with a patient, it is most important to consider which of the following factors? 1. Blocking 2. Hygiene 3. Body language 4. Personal space

4. Personal space Rationale: It is most important for the nurse to be sensitive to the patient's personal space preference and cultural differences in terms of touch, because most people have a well-defined personal space. A gentle touch of the shoulder, back of the hand, or arm can be tremendously therapeutic in terms of demonstrating genuine interest and concern. Blocking (1) is not a term used related to the nurse's use of touch as a means of nonverbal communication. Hygiene (2) should not prevent the nurse from using touch. If there are concerns with possible infectious exposure then standard precautions should be used. After personal space, the nurse should be observant for the patient's body language (3) to determine comfort level and the effect that touch has as a therapeutic intervention.

Which of the following measures should be included in the nursing plan of care when the patient is experiencing delirium tremens? 1. Restrain the patient, and keep the room quiet. 2. Approach the patient by touching a limb before saying anything. 3. Tell the patient he or she is having nightmares that will soon cease. 4. Place the patient on one-to-one supervision, and keep a light on in the room.

4. Place the patient on one-to-one supervision, and keep a light on in the room. Rationale: For safety purposes, the patient with delirium tremens should not be left unattended. Unintentional suicide is a possibility when these patients attempt to get away from the hallucinations. Shadows created by dim lights are likely to causes illusions and fear. Answer options 1, 2 and 3 are inappropriate actions for the patient experiencing delirium tremens.

A 22-year-old woman is seen in the outpatient mental health clinic complaining of frequent nightmares, feelings of guilt, and poor concentration. During the intake assessment, the nurse learns that the patient was physically abused as a child. These symptoms and this situation are most consistent with which anxiety disorder? 1. Panic attack 2. Phobic reaction 3. Obsessive-compulsive disorder 4. Post-traumatic stress disorder

4. Post-traumatic stress disorder Rationale: Post-traumatic stress disorder (PTSD) involves an individual reexperiencing a psychologically traumatic event, manifesting as flashbacks and other psychological and physiological symptoms. The other answer options (1, 2, and 3) do not exhibit symptoms as described in the question.

In planning care for a patient experiencing sleep deprivation, what is most important to consider? 1. Sleep is influenced by biological rhythms. 2. The natural body clock follows a 24-hour cycle. 3. The longer a person sleeps, the more rapid-eye-movement periods are experienced. 4. Prolonged periods of sleep deprivation can lead to hallucinations and delusions.

4. Prolonged periods of sleep deprivation can lead to hallucinations and delusions. Rationale: Sleep deprivation can lead to ego disorientation and include hallucinations and delusions. Uninterrupted sleep is an important nursing consideration in planning care. Answer options 1, 2, and 3 are correct; however they are not the most important when developing a plan of care for the patient experiencing sleep deprivation.

Which intervention would help a male patient diagnosed with Alzheimer's disease perform activities of daily living? 1. Have the patient perform all basic care without help. 2. Tell the patient morning care must be done by 9 o'clock. 3. Give the patient a written list of activities he is expected to do. 4. Provide encouragement and ample time to complete basic tasks.

4. Provide encouragement and ample time to complete basic tasks. Rationale: Clients with Alzheimer's disease respond to the affect of those around them. A gentle calm approach is comforting and nonthreatening, whereas a tense, hurried approach may agitate the patient and may lead to frustration. Answer options 1, 2 and 3 place excess demands on the patient, which the patient may not be able to achieve. Patients with Alzheimer's disease can become combative when pressured.

What defense mechanism is being used when a nurse responds to a rude and offensive patient in a pleasant, friendly tone? 1. Repression 2. Displacement 3. Projection 4. Reaction formation

4. Reaction formation Rationale: Reaction formation, also known as overcompensation, is the process of keeping unacceptable feelings or behaviors out of awareness by developing the opposite emotion or behavior. This involves the development of conscious attitudes and behavior patterns that are opposite to what a person really feels or would like to do. Repression (1) is the unconscious defense mechanism whereby unacceptable thoughts, feelings, ideas, impulses, or memories are pushed from the conscious mind because of their painful guilt association or disagreeable content and are submerged in the unconscious. Traumatic past events, such as rape, are especially susceptible to repression. Displacement (2) is the redirection or transferring of emotional impulses or feelings from the original source to something that is more acceptable and less threatening. Projection (3) attributes strong conflicting feelings or faults to another person.

Which statement best describes the major goal of crisis intervention? 1. Identify the participating event. 2. Decrease the effects of the stressful event. 3. Facilitate personality change and adaptation. 4. Reestablish psychological equilibrium.

4. Reestablish psychological equilibrium. Rationale: The goals of crisis intervention are to apply external controls for protection of the person in crisis who potentially is suicidal or homicidal and to employ anxiety-reduction techniques to allow inner psychological resources to restore equilibrium. Identifying the precipitating event (1) and facilitating personality change and adaptation (3) would be part of the plan of care after the initial crisis intervention. Decreasing the effects of the stressful event (2) is not a major goal of crisis intervention because the stressful event may have already passed.

A nurse is providing psychotherapy to a patient who is having difficulty recognizing her problems. Which quality must the nurse possess to be most therapeutic with this patient? 1. Values 2. Sympathy 3. Understanding 4. Self-awareness

4. Self-awareness Rationale: A helping relationship is most effective when the nurse has come to terms with the patient's issues and problems through his or her own process of self-awareness. Values (1) and understanding (3) are important qualities but not more important than self-awareness. Sympathy is not a therapeutic quality.

The most appropriate nursing intervention that would encourage a withdrawn, noncommunicative patient to talk would be to: 1. Focus on nonthreatening subjects. 2. Try to get the patient to discuss feelings. 3. Ask simple questions that require answers. 4. Sit with the patient for short periods of time.

4. Sit with the patient for short periods of time. Rationale: Sitting with a patient and not demanding conversation helps engender trust, which will facilitate the patient to talk. Focusing on nonthreatening subjects (1) is appropriate after trust has been established in a nonthreatening manner. Trying to get the patient to discuss feelings (2) will be perceived as threatening. Asking simple questions that require answers (3) could be nonthreatening; however if trust is not established it is less likely that patient will engage in conversation. Additionally the answers may be too complex.

Which clinical manifestation is least likely to be found in a patient with delirium? 1. Hallucinations 2. Recent memory loss 3. Disorientation to place and time 4. Slow, insidious onset of symptoms

4. Slow, insidious onset of symptoms Rationale: Delirium has an abrupt onset, which should cause the nurse to suspect the disorder. Hallucinations (1), recent memory loss (2), and disorientation to place and time (3) are all clinical manifestations of delirium.

While a nurse is speaking with a patient, another female patient approaches and yells, "I hate you. You're talking about me again," and throws a glass of juice at the nurse. What would be the best approach by the nurse? 1. State to the patient, "You hate me? Tell me more about this." 2. Remove the patient to an isolation room because she needs to have limits placed on her behavior. 3. Ignore both the behavior and the patient, clean up the spilled juice, and talk to her when she is in a better mood. 4. Verbalize feelings of disapproval as an example to the patient that it is more appropriate to verbalize feelings than to act them out.

4. Verbalize feelings of disapproval as an example to the patient that it is more appropriate to verbalize feelings than to act them out. Rationale: The nurse's response provides an example to the patient that feelings can be expressed by words rather than action. This response also demonstrates that the nurse cares enough to set limits. The other answer options (1, 2 and 3) are not appropriate or therapeutic.

Side effects of tricyclic antidepressants

Anticholinergic effects: -Dry mouth -Blurry vision -Dry mucous membranes -Urinary retention -Constipation -Change in temperature Other symptoms: -Irregular heartbeat -Restlessness -Change in weight -Hypotension -Sexual dysfunction

Drug therapy for delirium

Caused by an underlying issue which needs to be treated in order to decrease symptoms of delirium.

Signs and symptoms of depression

Changes in mood: -Sadness and despair -a sense of emptiness -Anhedonia (loss of ability to enjoy pleasure) -Low self-esteem -Excessive emotional sensitivity -Pessimistic thinking -Irritability -Excessive guilt -Indecisiveness -Often, suicidal thoughts Vegetative symptoms -Disturbance of sleep -Increase/decrease in appetite -Weight gain/loss -Lack of motivation -Difficulty functioning in all aspects of life

Diagnostics for schizophrenia

Clinical exam based on the DSM diagnostic criteria

Cluster C personality disorders

Comprises anxious or scared behaviors such as avoidant, dependent, or obsessive-compulsive personality disorder

Cluster A personality disorders

Consists of odd behaviors such as paranoid, schizoid, and schizotypal personality disorders

Contraindications to MAOIs

Contraindicated with many medications and can cause a serious complication known as hypertensive crisis

Which food choices are best for a bipolar patient in the manic phase? (Select all that apply.) 1. Roast beef and asparagus 2. Spaghetti and meatballs 3. Cheeseburger 4. Ham and eggs 5. Peanut butter and jelly sandwich

Correct answer: 3 and 5 Rationale: Manic patients are too hyperactive to sit and eat but require a balanced diet with increased calories. They are more likely to eat finger foods that can be carried such as a cheeseburger (3) or sandwiches (5), which also offer increased calories that manic patients need due to their activity level. Although nutritious, roast beef (1), spaghetti and meatballs (2), and ham and eggs (4) are not finger foods and therefore not good food choices for bipolar patients.

A nurse needs to be familiar with all the stages of psychosocial development and understand which stage goes with the correct age group. What is the correct sequence for Erikson's stages of psychosocial development? (Arrange in order from infancy to older adult.) 1. Autonomy vs. Shame and Doubt 2. Integrity vs. Despair 3. Intimacy vs. Isolation 4. Initiative vs Guilt 5. Industry vs. Inferiority 6. Trust vs. Mistrust 7. Identity vs. Role Confusion 8. Generativity vs. Stagnation

Correct answer: 6, 1, 4, 5, 7, 3, 8, 2 Rationale: The correct order of Erikson's psychosocial development is: 6. Trust vs. Mistrust (birth to 1 year) 1. Autonomy vs Shame and Doubt (1-3 years) 4. Initiative vs. Guilt (3-6 years) 5. Industry vs. Inferiority (6-11 years) 7. Identity vs. Role Confusion (puberty) 3. Intimacy vs. Isolation (young adult) 8. Generativity vs Stagnation (middle age) 2. Integrity vs. Despair (old age)

The nurse is aware that which symptoms are included as a part of borderline personality disorder? (Select all that apply.) 1. Unstable self-image 2. Impulsivity 3. Stable sense of reality 4. Anger control issues 5. Strong sense of identity 6. Long-lasting relationships

Correct answers: 1, 2, and 4 Rationale: Patients who have the diagnosis of borderline personality disorder have an unstable self-image (1), are very impulsive (2), and have difficulty controlling their emotions (4) . The other answer options are incorrect, as these patients have an unstable sense of reality (3), an identity disturbance (5), and unstable, short-lived relationships (6).

What is characteristic of schizophrenic disorders? (Select all that apply.) 1. Physiological dysfunctions 2. An elevated, euphoric mood 3. Regression to previous behavior levels 4. Ability to continue to provide self-care 5. Withdrawal from social relationships 6. Changes in affect

Correct answers: 3, 4, 5, and 6 Rationale: Schizophrenic disorders involve regression to a previous level of behavior (3) and withdrawal from social relationships (5) as a means to be safe and secure. The ability to continue to provide self-care is usually disturbed in the schizophrenic patient (4). The schizophrenic patient demonstrates aloof and indifferent behavior along with altered affect (6). Physiological dysfunctions may or may not be present (1) in schizophrenic disorders. An elevated, euphoric mood (2) is seen in the manic phase of bipolar disorder.

A nurse observes a patient with narcissistic personality disorder. Which behavior would the nurse recognize as most characteristic of this disorder? (Select all that apply.) 1. A lifelong pattern of passive-aggressive behavior 2. Refusal to enter into relationships for fear of rejection 3. Belief in entitlement to special privileges 4. Belief in a "sixth sense" and knowing what others are thinking 5. A tendency to be seductive and manipulative 6. A pattern of impulsive, erratic behavior

Correct answers: 3, 5, and 6 Rationale: People who display narcissistic personality traits are overemotional, dramatic, erratic, and impulsive (6), displaying arrogance, a need for admiration and special privileges (3), and a lack of empathy. They tend to be seductive and manipulative (5) and possess a grandiose sense of self-importance. The other answer options (1, 2, 4) are incorrect characteristics regarding narcissistic personality disorder.

Diagnostics for personality disorders

DSM-IV criteria

Pharmacokinetics for SSRIs and SNRIs

Given PO with food to decrease GI upset

Pharmacokinetics of cognitive enhancers

Given orally and with food to decrease GI upset.

Cluster B personality disorders

Includes emotional or erratic behavior such as antisocial, borderline, histrionic, and narcissistic personality disorders

Cognitive enhancers

Inhibit cholinesterase to improve cognition in patients with Alzheimer's disease and dementia.

Signs and symptoms of bipolar disorder

Mania: -Euphoria -Irritability -Grandiosity -Increased self-esteem -Decreased need for sleep -Racing thoughts and pressured speech -Increased activity -Poor judgment involving spending sprees, promiscuity, gambling, or other behaviors. -Depressive symptoms are the same as in depression.

Contraindications to Antianxiety medications

Patients taking other CNS depressants or antipsychotics should consult a physician before taking benzodiazepines.

Contraindications to mood stabilizers

Patients who take MAOIs, diuretics, non-steroidal anti-inflammatory drugs, or other CNS depressants should use caution when taking mood stabilizers, especially lithium.

Contraindications to antipsychotics

Patients with a history of cardiac problems are advised to use meds with caution.

Contraindications to cognitive enhancers

Patients with renal and liver disease should use caution when taking these medications.

Side effects of SSRIs and SNRIs

SSRIs have the fewest side effects of all the antidepressants: -GI upset -HA -Dizziness -CNS effects -Fatigue -Weight changes -Appetite changes -Photosensitivity -Sexual dysfunction -Nervousness SNRIs: -Urinary retention -Dry mouth -Dry eyes -Orthostatic hypotension -Disruption of sleep

Types of SSRIs and SNRIs

SSRIs: -Citalopram (Celexa) -Escitalopram (Lexapro) -Fluoxetine (Prozac) -Fluvoxamine (Luvox) -Paroxetine (Paxil) -Sertraline (Zoloft) SNRIs: -Duloxetine (Cymbalta) -Venlafaxine (Effexor) -Desvenlafaxine (Pristiq)

Pharmacokinetics of tricyclic antidepressants

Taken orally and given with food to decrease GI upset

Pharmacokinetics of mood stabilizers

Taken orally with food to decrease GI upset

Types of antipsychotics

Two types: typical (changes dopamine levels) and antitypical (changes dopamine/serotonin). Typical: -Chlorpromazine (Thorazine) -Haloperidol (Haldol) -Fluphenazine (Prolixin) -Thiothixene hydrochloride (Navane) -Loxapine (Loxitane) -Trifluoperazine (Stelazine) -Molindone (Moban) -Perphenazine (Trilafon) Atypical: -Risperidone (Risperdal) -Quetiapine (Seroquel) -Clozapine (Clozaril) -Olanzapine (Zyprexa) -Aripiprazole (Abilify) -Ziprasidone (Zeldox)

Tricyclics antidepressants

Used to treat both depression and anxiety by inhibiting serotonin and norepinephrine