Test 1

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Drugs commonly used to treat epilepsy that suppress the rapid and excessive firing of neurons and are used as mood stabilizers

anticonvulsant drugs

A syndrome in which a person lacks the capacity to relate to others, does not experience discomfort in inflicting or observing pain in others, and may manipulate others for personal gain

antisocial personality disorder

An intentional threat designed to make the victim fearful; produces reasonable apprehension of harm

assault

A client with schizophrenia is having an acute exacerbation of symptoms. The client states, "Black cats and black hats. Where does the time go?" What symptom of schizophrenia is the client demonstrating?

associative looseness

Physical attempts and verbal threats of rape

attempted rape

A personality disorder in which the central characteristics are an extreme sensitivity to rejection and robust avoidance of interpersonal situations

avoidant personality disorder

The emergency room nurse is performing an assessment on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the assessment procedures. Which assessment finding would most likely assist in verifying the suspicion? a) poor hygiene b) bald spots on the scalp c) lacerations in the anal area d) swelling of the genitals

b - bald spots on the scalp

The wrong or improper use of action toward another individual that results in injury, damage, maltreatment, or corruption

abuse

When directed towards another, includes acts of misuse, deceit, or exploitation

abuse

A reduction in the expression, range, and intensity of affect

affective blunting

A reduction in spontaneity or volume of speech, represented by a lack of spontaneous comments and overly brief responses.

alogia, or poverty of speech

A student nurse is learning about different theories of management. Which of the following is a correct description of a management theory? A. Behavioral: Manager sets strict rules, with defined rewards and punishments for action Incorrect B. Bureaucratic: Manager decides how procedures will be done on a unit C. Contingency: Manager makes decisions after considering what motivates people D. Systems: Manager makes decisions without considering the impact on the entire facility

Involves severe muscle spasms, particularly of the back, neck, tongue, and face

Acute dystonia

Believing that one's thoughts or actions can affect others

magical thinking, a positive symptom of schizophrenia

A disorder characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy for others

narcissistic personality disorder

Are poor thought processes positive or negative symptoms of schizophrenia?

negative

Is anhedonia a positive or negative symptom of schizophrenia?

negative

Is apathy as positive or negative symptom of schizophrenia?

negative

Is little or no functional speech a positive or negative symptom of schizophrenia?

negative

Is poor judgment a positive or negative symptom of schizophrenia?

negative

Is the lack of ability to perform ADLs a positive or negative symptom of schizophrenia?

negative

Symptoms associated with a loss of normal functioning

negative

made-up words (or idiosyncratic uses of existing words) that have meaning for the patient but a different or nonexistent meaning to others

neologisms

a term used to denote drugs that have effects on the nervous system, especially those that have Parkinson-like adverse effects on posture and body movement

neuroleptic

Those who initiate violence

perpetrator

An enduring pattern of experience and behavior that deviates significantly from the expectations within the individual's culture.

personality disorder

A syndrome characterized by an acute phase and a long-term reorganization process that occurs after an actual or attempted sexual assault. Each phase has separate symptoms.

rape-trauma syndrome

Hearing is controlled by the a) occipital lobe b) brain stem c) temporal lobe d) frontal lobe

temporal lobe

A client ashamedly tells the nurse that he hit his wife while intoxicated and asks the nurse if his wife will ever forgive him. The nurse should reply to the client by saying: a) "You seem to have some feelings about hitting your wife." b) "Perhaps you could ask her and find out." c) "It would depend on how much she really cares for you." d) "That's something you can explore in family therapy."

"You seem to have some feelings about hitting your wife." Explanation: The client is feeling remorse about hitting his wife. It is best to make a comment that will help him focus on his feelings and express them. Reflecting what the client has said is a good technique to accomplish these goals. Suggesting the client ask his wife or explore the issue in family therapy is inappropriate because it gives advice and ignores the client's underlying feelings. Saying, "It would depend on how much she really cares for you," is inappropriate because it ignores the client's feelings and reinforces the negative aspects, such as the shamefulness, of the behavior.

The nurse is leading a medication group in a psychiatric unit. Which information should the nurse discuss with the clients concerning antipsychotic medications after discharge? Select all that apply. 1. chew sugarless gum to help dry mouth 2. teach the client about orthostatic hypotension 3. explain that medication may cause drowsiness 4. discuss that these medications may cause sexual dysfunction 5. instruct the client to call the HCP if flulike symptoms occur

1, 2, 4, and 5. 1. Antipsychotic drugs produce varying degrees of muscarinic cholinergic blockade, including dry mouth, blurred vision, and photophobia. Chewing sugarless gum may help dry mouth. 2. Antipsychotic meds promote orthostatic hypotension by blocking alpha-adrenergic receptors on blood vessels. Therefore, the nurse should teach the client about orthostatic hypotension. 3. The sedative effects of the antipsychotic meds should have subsided by the time the client is discharged. Therefore, this is not an appropriate teaching for discharge. Sedation is common during the early days of treatment, but it subsides within a week or so. 4. Antipsychotics can cause sexual dysfunction in women and men, so this should be discussed by the nurse. 5. Flulike symptoms are a sign of agranulocytosis, which is a rare but serious reaction to antipsychotic meds. In agranulocytosis, the body loses its ability to fight infection.

The staff nurse answers the telephone on a medical unit and the caller tells the nurse that he has planted a bomb in the facility. Which actions should the nurse implement? Select all that apply. 1. Do not touch any suspicious object. 2. Call 911, the emergency response system. 3. Try to get the caller to provide additional information. 4. Immediately pull the red emergency wall lever. 5. Write down exactly what the caller says.

1, 3, and 5. 1. The nurse should begin a systematic search of the unit after activating the bomb scare emergency plan, and if any suspicious objects are found the nurse should not touch and should notify the bomb squad. 2. The nurse should notify the house supervisor and administration because they are responsible for notifying the police department. 3. The nurse should stay calm and try to keep the caller on the telephone. The nurse should attempt to get as much information from the caller as possible. The nurse can jot a note to someone nearby to initiate the bomb scare procedure. 4. The red emergency levers in hospitals are to notify the ﬁre departments of a ﬁre, not a bomb scare. 5. The nurse should try to transcribe exactly what the caller says; this may help identify who is calling and where a bomb might be placed. MAKING NURSING DECISIONS: The nurse must be knowledgeable of hospital emergency preparedness. Students as well as new employees receive this information in hospital orientations and are responsible for implementing procedures correctly. The NCSBN NCLEX-RN blueprint includes questions on safe and effective care environment.

Barbara believes that the birds sing when she walks down the street just for her. Which type of delusion is Barbara experiencing?

Ideas of reference

The male client diagnosed with schizophrenia is prescribed ziprasidone (Geodon), an atypical antipsychotic. Which statement to the nurse indicates the client understands the medication teaching? 1. "I need to keep taking this medication even if I become impotent." 2. "I should not go out in the sun without wearing protective clothing." 3. "This medication may cause my breast size to increase." 4. "I may have trouble sleeping when I take this medication."

1. Atypical antipsychotic meds have a lower risk of sexual dysfunction than conventional antipsychotic meds; therefore, if the client experiences impotency, he should call his HCP. This statement does not indicate he understands the medication teaching. 2. Atypical antipsychotic meds DO NOT cause photosensitivity (unlike conventional antipsychotic drugs) This statement does not indicate he understands the medication teaching. 3. Atypical antipsychotics DO NOT cause gynecomastia (inlike conventional antipsychotic drugs). 4. Geodon is well-tolerated, but the most common side effect is difficulty sleeping, perhaps because of the histamine antagonist blockade effect of the drug. This comment indicates the client understands the teaching.

Which information should the nurse discuss with the client diagnosed with schizophrenia who is prescribed an antipsychotic medication? 1. drink decaffeinated coffee and tea 2. decrease the dietary intake of salt 3. eat six small, high-protein meals a day 4. limit alcohol intake to one glass of wine a day

1. Caffeine-containing substances will negate the effects of antipsychotic medication; therefore, the client should drink caffeine-free beverages such as decaffeinated coffee and tea and caffeine-free colas.

The client diagnosed with schizophrenia is prescribed clozapine (Clozaril), an atypical antipsychotic. Which information should the nurse discuss with the client concerning this medication? 1. discuss the need for regular exercise 2. instruct the client to monitor for weight loss 3. tell the client to take the medication with food 4. explain to the client the need to decrease alcohol intake

1. Clozaril can promote significant weight gain; therefore, the client should exercise regularly, monitor weight, and reduce caloric intake. 2. Clozaril promotes weight gain, not weight loss. 3. Clozaril does not cause GI distress and can be taken with food OR on an empty stomach. 4. The client should not DECREASE alcohol intake; the client should AVOID alcohol intake COMPLETELY.

The development of which symptom (s) in a client taking an antipsychotic must be reported immediately? 1. Fever, tachycardia, stupor, and incontinence 2. Suddenly occurring muscle spasms, especially in the neck and back 3. Sexual dysfunction 4. Leg pains, pacing, an inability to sit still

1. Fever, tachycardia, stupor, and incontinence are sx of neuroleptic malignant syndrome (NMS), a potentially fatal adverse effect of antipsychotics that must be diagnosed and treated immediately. Options 2, 3, and 4 are possible adverse reactions, but are not life threatening, and therefore do not need to be reported with the same urgency as sx of NMS.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. using open-ended questions and silence 2. sharing personal preferences regarding food choices 3. documenting reasons why the client does not want to eat 4. offering opinions about the necessity of adequate nutrition

1. Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express his feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. Test-Taking Strategy: Use knowledge of therapeutic communication techniques. First eliminate options that do not support the client's expression of feelings. Any option that is not client-centered should be eliminated next. Focusing on the client's feelings will direct you to the correct option.

The psychiatric nurse is working in an outpatient mental health clinic. Which client should the nurse intervene with ﬁrst? 1. The client who had a baby 2 months ago and who is sitting alone and looks dejected. 2. The client whose wife just died and who wants to go to heaven to be with her. 3. The client whose mother brought her to the clinic because the mother thinks the client is anorexic. 4. The client who is rocking compulsively back and forth in a chair by the window.

1. The client who is depressed would be expected to look dejected; therefore, the nurse would not need to assess this client ﬁrst. 2.This client who says he wants to go to heaven to be with his wife may be suicidal and should be assessed ﬁrst to see whether he has a plan. 3. This client needs to be assessed for anorexia but not before a client who may be suicidal. 4. The nurse should not interrupt a client who is acting compulsively. The nurse should wait until the client ﬁnishes the behavior before talking to the client.

The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take ﬁrst? 1. Tell the man the client needs to go to the x-ray department. 2. Notify hospital security and have the man removed from the room. 3. Explain that the man must leave the room while the nurse checks the client. 4. Give the client a brochure with information about a woman's shelter.

1. The nurse needs to remove the man from the room so that the nurse can talk to the client and discuss probable abuse. Taking the client to the x-ray department may not rouse suspicion in the man and may allow the client to discuss the situation. 2. This may be needed, but it is not the ﬁrst intervention. This action may cause the man to get angrier in the emergency room department, or it may cause more problems for the woman if she goes home with him. 3. The nurse could demand the man leave the room, but this action may cause the man's anger to escalate; therefore, the ﬁrst intervention is to remove the client from the room. 4. The nurse should not allow the man to see the nurse discussing a woman's shelter with the client or providing a client with a brochure. This could cause further anger in the man, especially if the woman goes home with the man.

The charge nurse received laboratory data for clients in the psychiatric unit. Which client data warrants notifying the psychiatric health-care provider? 1. The client on lithium (Eskalith) whose serum lithium level is 1.0 mEq/L. 2. The client on clozapine (Clozaril) whose white blood cell count is 13,000. 3. The client on alprazolam (Xanax) whose potassium level is 3.7 mEq/L. 4. The client on quetiapine (Seroquel) whose glucose level is 128 mg/dL.

1. The therapeutic serum level for lithium is0.6 to 1.5 mEq/L. Because the client's1.0 mEq/L level is within normal limits, the charge nurse would not need to notify the psychiatric HCP. 2.The WBC count is elevated, which may indicate that the client is experiencing agranulocytosis, a life-threatening com-plication of clozapine. This laboratory data would warrant notifying the psychiatric health-care provider. 3. The client's serum potassium level is within normal limits; therefore, this laboratory data does not warrant notifying the psychiatric health-care provider. 4. This glucose level is slightly elevated but would not warrant notifying the psychiatric health-care provider.

The male client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the day room are becoming angry. Which action should the nurse take ﬁrst? 1. Obtain a restraint order from the HCP. 2. Escort the other clients from the day room. 3. Administering an intramuscular (IM) antipsychotic medication. 4. Approach the client calmly along with two MHWs

1. The ﬁrst intervention should be to talk to the client and remove him from the day room to the least restrictive environment.Restraining the client is the most restrictive environment. 2. The nurse should ﬁrst attempt to talk to the client and remove the client from the day room area, not try to remove all the other clients. 3. The client will probably need a prn medication to calm the behavior, but it is not the nurse's ﬁrst intervention. An intramuscular medication takes at least 30 minutes to become effective. 4. The ﬁrst intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not approach the agitated client alone but should be accompanied by other personnel.

A young child, Joey, was admitted to the pediatric unit with a fractured jaw, bruises, and multiple cigarette burns to the arms. The mother reported the father hurt the child. A man comes to the nurse's station saying, "I am Joey's father, can you tell me how he is doing?" Which statement is the nurse's best response? 1. "Your son has a fractured jaw and some bruises but he is doing ﬁne." 2. "I am sorry I cannot give you any information about your son." 3. "You should go talk to your wife about your son's condition." 4. "The social worker can discuss your son's condition with you."

1. This child has been abused, and until Child Protective Services have been notiﬁed, the nurse should not share any information with the child's father. 2. The Health Insurance Portability and Accountability Act (HIPAA) considers parents the "personal representative" of the minor child with the right to information. However, there are exceptions to this rule, including when the provider reasonably believes that the minor may be a victim of abuse or neglect by the parents/guardians. This statement is the nurse's best response. 3. Because the mother is accusing the father of the abuse, this is not an appropriate response 4. The social worker must adhere to HIPAA regulations; therefore; referring the father to the social worker will not help the father ﬁnd out how is son is doing. MAKING NURSING DECISIONS: The nurse is responsible for knowing and complying with local, state, and federal standards of care

The psychiatric nurse overhears an MHW telling a client diagnosed with schizophrenia, "You cannot use the phone while you are here on the unit." Which action should the psychiatric nurse take? 1. Praise the MHW for providing correct information to the client. 2. Tell the MHW this is not correct information in front of the client. 3. Explain to the MHW that the client does not lose any rights. 4. Discuss this situation at the weekly multidisciplinary team meeting.

1. This is not correct information; there fore; the nurse should not praise the MHW. 2. The psychiatric nurse should not correct the MHW in front of the client because it will compromise the MHW's authority with the client. 3. The nurse should explain to the MHW that the mental health client retains all of the civil rights afforded to all per-sons, except the right to leave the hospital in the case of involuntary commitments. The client may have phone calls restricted if that is included in the care plan—for example, if the client is calling and threatening the president. 4. This situation does not need to be dis-cussed at the weekly team meeting. The psychiatric nurse can discuss this on a one-to-one basis with the MHW.

The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)? 1. The client diagnosed with dementia who is confused and disoriented. 2. The client diagnosed with schizophrenia who is experiencing tardive dyskinesia. 3. The client diagnosed with bipolar disorder who has a lithium level of 2.0 mEq/L. 4. The client diagnosed with chronic alcoholism who is experiencing delirium tremens

1.The client diagnosed with dementia would be expected to have confusion and disorientation; therefore, the LPN could be assigned this client. This client is not experiencing any potentially life-threatening complication of dementia. 2. The client is experiencing tardive dyskinesia, a potentially life-threatening com-plication of antipsychotic medication. An experienced RN should be assigned to this client. 3. The therapeutic serum level for lithium is0.6 to 1.5 mEq/L. The client's level is toxic, and an experienced RN should care for the client.4. This client is experiencing a potentially life-threatening complication of alcohol withdrawal. An experienced RN should be assigned to this client. MAKING NURSING DECISIONS: The test taker must determine which client is the most stable, which makes this an "except" question. Three clients are either unstable or have potentially life-threatening conditions

The male client in the psychiatric unit asks the MHW to mail a letter to his family for him. Which action would warrant intervention by the psychiatric nurse? 1. The MHW tells the client to place the letter in the mailbox. 2. The MHW informs the client he cannot send mail to his family. 3. The MHW takes the letter and places it in the unit mailbox. 4. The MHW reports the client mailed a letter at the team meeting.

The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call ﬁrst? 1. The female client diagnosed with histrionic personality who needs to talk to the nurse about something very important. 2. The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother. 3. The male client diagnosed with major depression whose wife called and said he was talking about killing himself. 4. The client diagnosed with bipolar disorder who is manic and has not slept for the last 2 days

2 - The nurse should contact this client ﬁrst because the client realizes the voices are telling him to hurt his mother. The nurse should inform this client to come to the clinic immediately, and he should be admitted to a psychiatric unit. 1. The client with a histrionic personality has excessive emotionality and seeks attention. Her saying "something important" must be understood within this context and would not warrant the psychiatric nurse's calling this client ﬁrst 3. Because the wife called the clinic, the client is being watched and should be safe from killing himself. The nurse should call this client immediately but not before a client who made the phone call and who may be by himself and hearing voices. 4. The nurse should expect the client who is manic not to be sleeping; therefore, this is expected behavior. The nurse should call this client immediately but not before the client who is hearing voices telling him to hurt his mother.

The client admitted to the psychiatric unit diagnosed with schizophrenia is prescribed clozapine (Cloazaril), an atypical antipsychotic. Which laboratory data should the nurse evaluate? 1. the client's clozapine therapeutic level 2. the client's white blood cell count 3. the client's red blood cell count 4. the client's arterial blood gases

2 - WBC count.

The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment

2, 3, and 5. False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statement about the client. **Focus on the SUBJECT, legal ramifications of nursing actions r/t hospital admission. Noting the words ADMITTED VOLUNTARILY will assist you in selecting the options r/t inappropriately preventing the client from leaving the hospital; a right to which a voluntarily committed client is entitled. The remaining options do not relate to acts that prevent the client from leaving the hospital.

Nursing implications of the administration of haloperidol (Haldol) to a client exhibiting psychotic behavior include which of the following? Select all that apply. 1. Take 1 hour or 2 hours after antacids. 2. The incidence of extrapyramidal symptoms is high. 3. It is therapeutic if ordered on an as-needed basis. 4. Haldol is contraindicated in Parkinson's disease, seizure disorders, alcoholism, and severe mental depression. 5. Crush the sustained release form for easier swallowing.

2, and 4. EPS occurs frequently, especially at the beginning of therapy with haloperidol. A person with Parkinson's disease, seizure disorders, alcoholism, or severe mental depression should not take haloperidol because they are all conditions that affect the CNS. Dementia, seizures, depression, and severe CNS depression are known to occur with the use of haloperidol in these clients. Options 1, 3, and 5 are incorrect. Haloperidol and antacids may be given simultaneously; there are no known interactions between these 2 meds. Haloperidol must be taken as ordered, on a regular schedule. Taking the drug prn will not reduce sx of psychosis because it takes several weeks of regular administration before therapeutic levels are reached. Sustained-release meds should NEVER be crushed. If client cannot take the med, another form should be used.

A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests that the nurse move away from the window. The nurse recognizes that doing as the client requested is contraindicated for which of the following reasons? 1. The action will make the client feel that the nurse is humoring him 2. The action indicates nonverbal agreement with the client's false ideas 3. The client will think that he will have his way when he wishes 4. The nurse will be demonstrating a lack of composure over the situation

2. The nurse's nonverbal behavior, moving away from the window as the client requests, indicates agreement with the client's false ideas. The client's behavior is likely to be reinforced if the nurse takes steps to agree with the false ideas the client holds.

The client diagnosed with paranoid schizophrenia has been taking haloperidol (Haldol), a conventional antipsychotic, for several years. Which statement indicates the client needs additional teaching concerning this medication? 1. "I know that if I have any rigidity or tremors I must call my HCP." 2. "I eat high-fiber foods and drink extra water during the day." 3. "I am more susceptible to colds and the flu when taking this medication." 4. "This medication will make my hallucinations and delusions go away."

The clinical manager assigned the psychiatric nurse a client diagnosed with major depression who attempted suicide and is being discharged tomorrow. Which discharge instruction by the psychiatric nurse would warrant intervention by the clinical manager? 1. The nurse provides the client with phone numbers to call if needing assistance. 2. The nurse makes the client a follow-up appointment in the psychiatric clinic. 3. The nurse gives the client a prescription for a 1-month supply of antidepressants. 4. The nurse tells the client not to take any over-the-counter medications.

The client admitted to the psychiatric unit experiencing hallucinations and delusions is prescribed risperidone (Risperdal), an atypical antipsychotic. Which intervention should the nurse implement? 1. Provide the client with a low tyramine diet 2. Assess the client's respiration for 1 full minute 3. Instruct the client to change positions slowly 4. Monitor the client's intake and output

3 - Change position slowly.

The psychiatric charge nurse is making shift assignments for the admission unit. The staff includes one registered nurse (RN), two LPNs, four MHWs, and a unit secretary. Which assignment would be most appropriate to assign to the LPN? 1. Update the client's individualized care plans. 2. Stay in the lobby area and watch the clients. 3. Administer routine medications to the clients. 4. Transcribe the admission orders for a client.

3 - administer routine meds

The client with paranoid schizophrenia is prescribed ariprpazole (Abilify), a dopamine system stabilizer (DDS). Which statement best describes the scientific rationale for administering this medication? 1. it decreases the anxiety associated with hallucinations and delusions 2. it increases the dopamine secretion in the brain tissue to improve speech 3. it reduces positive symptoms of schizophrenia and improves negative symptoms 4. it blocks the cholinergic receptor sites in the diseased brain tissue

3 - reduces positive symptoms and improves negative symptoms

Which task would be inappropriate for the psychiatric charge nurse to delegate to the MHW? 1. Instruct the MHW to escort the client to the multidisciplinary team meeting. 2. Ask the MHW to stay in the day room and watch the clients. 3. Tell the MHW to take care of the client on a 1-to-1 suicide watch. 4. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.

3 or 4?

The male client diagnosed with major depression is returning to the psychiatric unit from a weekend pass with his family. Which intervention should the nurse implement ﬁrst? 1. Ask the wife for her opinion of how the visit went. 2. Determine whether the client took his medication. 3. Ask the client for his opinion of how the visit went. 4. Check the client for sharps or dangerous objects

Which task would be most appropriate for the psychiatric nurse to delegate to the MHW? 1. Request the MHW to take the client with lithium toxicity to the emergency room. 2. Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal. 3. Encourage the MHW to teach the client how to express his or her anger in a positive way. 4. Ask the MHW to sit with the client while the client talks to his mother on the telephone.

The nurse is discussing the prescribed antipsychotic medication with a family member of a client diagnosed with schizophrenia. Which information should the nurse discuss with the family members? 1. explain the need for the family member to give the client the medication 2. encourage the family member to learn cardiopulmonary resuscitation (CPR) 3. discuss the need for the client to participate in a community support group 4. teach the family member what to do in case the client has a seizure

4 - Antipsychotic meds lower the seizure threshold, even if the client does not have a seizure disorder. Therefore, the nurse should discuss what to do if the client has a seizure.

Which assessment data indicates the atypical antipsychotic quetiapine (Seroquel) is effective for the client diagnosed with paranoid schizophrenia? 1. the client does not exhibit any tremors or rigidity 2. the client reports a "2" on an anxiety scale of 1-10 3. the family reports the client is sleeping all night 4. the client denies having auditory hallucinations

4 - the client denies having auditory hallucinations

Research has indicated that the antisocial personality may be characterized by A. social isolation. B. lack of remorse. C. learning difficulties. D. difficulty with reality testing.

B. Individuals with an antisocial personality exhibit a lack of remorse when confronted with the results of their thoughtless, irresponsible behavior toward others.

Playing one staff member against another is an example of A. devaluation. B. splitting. C. impulsiveness. D. social ineptitude.

B. Splitting involves setting up individuals or groups to disagree. While the two parties are busy disagreeing, they are too busy to maintain consistent limits for the manipulative client. The client can enjoy the spectacle and do as he or she pleases.

A newly admitted client describes her mission in life as one of saving her son by eliminating the "provocative sluts" of the world. There are several attractive young women on the unit. What should the nurse do first? 1. Ask the client for her definition of "provocative sluts" 2. Ask the young female clients on the unit to dress less provocatively 3. Ask the client to discuss her concerns in the next group session 4. Ask the client to inform the staff if she has negative thoughts about other clients

4. It is critical for the nurse to ensure the safety of others by knowing who the client might think needs elimination. Asking the client to explain what she means or discuss her concerns at the group session are possible interventions for later in the client's hospital stay. Wearing appropriate clothing while hospitalized is generally a unit expectation for all clients.

When a client diagnosed with a cognitive deficit experiences a catastrophic reaction, the priority intervention is to A. decrease sensory stimuli. B. smile and call the client by name. C. take the client to the bathroom. D. calmly ask the client what's wrong.

B. Smile and call the client by name. Getting the client's attention by calling his or her name is necessary. Smiling is necessary to convey the lack of a threat.

A client diagnosed with obsessive-compulsive personality disorder takes the nurse aside and mentions, "I've observed you interacting with that new patient. You are not approaching him properly. You should be more forceful with him." The best response for the nurse would be A. "I will be continuing to follow the care plan for the patient." B. "I see you are trying to control that patient's therapy as well as your own." C. "Your eye for perfection extends even to my nursing interventions." D. "That patient's care is really of no concern to you or to other clients."

A " I will be continuing to follow the care plan for the patient." Obsessive-compulsive personality disorder has the key factor of perfectionism with a focus on orderliness and control. These individuals get so preoccupied with details and rules that they may not be able to accomplish the tasks. Guard against engaging in power struggles with a client with obsessive-compulsive disorder.

A new nurse in the psychiatric unit is administering medication, and a client yells at the nurse, "You are a spy with poison pills!" Which response is best? a) "I am a new nurse." b) "This is your medication, which you have to take." c) Is it your feeling that I am trying to poison you?" d) "I am not a spy."

A - "I am a new nurse." Reality orientation addresses a client's concern without reinforcing delusion. Nontherapeutic defensiveness will reinforce the delusion and should be avoided. b - Does not address the client's concern about who the nurse is. May be interpreted as a threat c - Inappropriate use of reflection. Reinforces delusion.

A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? a) "I need to keep my appointment here at the clinic this week for a blood test." b) "I can drink alcohol with this medication." c) "I can take over-the-counter sleeping medication if I have trouble sleeping." d) "I need to call my doctor in 2 weeks for a checkup."

A - "I need to keep my appointment here at the clinic this week for a blood test." Mandatory weekly white blood cell counts are used to detect developing agranulocytosis, which can be fatal and occurs in 1% to 2% of clients taking clozapine. This medication is associated with a risk of seizures; this risk is dose-dependent, meaning that it increases with moderate to high doses (600 to 900 mg/day). While the need to call the doctor in 2 weeks may be true, it does not reflect an understanding of the medication. Use of alcohol is contraindicated. Use of over-the-counter medications is contraindicated.

A client is admitted to the psychiatric unit with schizophrenia. The client verbalizes that, "Someone wants to kill me tonight." Which response is best? a) "It must feel frightening to think someone is trying to hurt you." b) Someone does not know that you have been admitted." c) "Why do you think that?" d) "No one wants to kill you."

A - "It must feel frightening to think someone is trying to hurt you." The nurse should encourage the patient to focus on the feelings the delusions generate; avoid arguing about the content of the delusion. "Why" questions will make the client defensive. Delusions are persistent false beliefs. Nurses should not encourage discussion of delusions.

A client with borderline personality disorder becomes angry when he is told that his psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse is most helpful in dealing with the client's anger? a) "You had to wait. Can we talk about how this is making you feel right now?" b) "If it had been your emergency, I would have made the other client wait." c) "I know it's frustrating to wait. I'm sorry this happened." d) "I really care about you, and I'll never let this happen again."

A - "You had to wait. Can we talk about how this is making you feel right now?" This response may defuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Telling the client that if the situation was an emergency involving him other clients would have to wait wouldn't address the client's anger. Apologizing is incorrect because a client with a borderline personality disorder blames others for things that happen; apologizing reinforces his misconception that someone is at fault. The nurse can't promise that a delay will never occur again because such matters are beyond her control.

A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid: a) has a more predictable onset of action. b) has a longer duration of action. c) produces fewer drug interactions. d) produces fewer anticholinergic effects.

A - A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

Every day for the past 2 weeks, a client with schizophrenia has stood during group therapy and screamed, "Get out of here right now! The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond? a) "I know you think there are bombs in the elevator, but there aren't." b) "Why do you think there is a bomb in the elevator?" c) "That is the same thing you said in yesterday's session." d) "If you have something to say, you must do it according to our group rules."

A - Acknowledging the client's statement and then telling him that bombs aren't in the elevator is the most therapeutic response because it orients the client to reality. Asking why the client thinks a bomb is in the elevator and stating that the client said the same thing the day before are condescending responses. Telling the client to follow group rules sounds punitive and could embarrass the client.

A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." The nurse should next: a)Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol). b)Place the client in temporary seclusion before he has a chance to hurt others. c)Call the primary health care provider for a prescription for restraints. d)Ask the other clients to leave the immediate area.

A - Administer lorazepam or haloperidol The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the Ativan and Haldol will help the anxiety and delusions. He is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary

A nursing manager notices discord among the nursing staff on the unit. Which action would be most helpful? A. Compile data on the different generations working on the unit. B. Have a series of staff meetings focusing on professionalism at work. Incorrect C. Single some nurses out as informal leaders to set a good example. D. Try to separate the conflicting groups from each other, if possible.

A - As many as four different generations are in the workplace today. Each generation has its own way of responding to the work environment, and they have different expectations of their employer and co-workers. To determine the cause of conflict, the manager should assess the generational characteristics of the nurses employed on the unit to see if this is a possible contributing factor. The other options might occur at some point, but without understanding the nature of the problem is unlikely to resolve it.

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They'll see you!" Which of the following responses by the nurse would be best? a) "Who are 'they'?" b) "You have no reason to be afraid." c) "What will happen if they do see me?" d) "No one will see me."

A - Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client. The client is unlikely to accept statements that indicate that no one will see the nurse. The client is unlikely to accept statements that there is no reason to be afraid. Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion.

Which is true of pharmacological therapies for treatment of personality disorders? A. Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. B. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. C. Patients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors. D. Patients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these patients.

A - At this time in the United States, there are no specifically FDA-approved medications for treating personality disorders. Prescribers are using the medications "off- label" until evidence-based pharmacotherapies are proven to be safe and effective. There is evidence that mood stabilizers, antidepressants, and atypical antipsychotics are helpful in specific personality disorders. Pharmacologic evidence is lacking for the treatment of persons with narcissistic and obsessive-compulsive personality disorders. Although patients with personality disorders usually do not like taking medicine unless it calms them down and are fearful about taking something over which they have no control, providers do attempt to mediate symptoms with psychotropic agents for improved quality of life.

A nurse who is idealized by a client is at risk for A. becoming overinvolved and being protective and indulgent. B. becoming indecisive about planned interventions. C. developing a prejudicial, blaming orientation. D. stringent enforcement of boundaries and limits.

A - Becoming overinvolved and being protective and indulgent Finding an approach for helping clients with personality disorders who have overwhelming needs can be challenging for caregivers. For example, a borderline female client may briefly idealize her male nurse on the inpatient unit, telling staff and clients alike that she is "the luckiest client because she has the best nurse in the hospital." The rest of the team initially realizes that this behavior is an exaggeration, and they have a neutral response. But after days of constant dramatic praise, some members of the team may start to feel inadequate and jealous of the nurse. They begin to make critical remarks about minor events to prove that the nurse is not perfect. Open communication in staff meetings and ongoing clinical supervision are important aspects of self-care for the nurse working with these clients to maintain objectivity.

A desired outcome for a client diagnosed with schizophrenia who has a nursing diagnosis of Disturbed sensory perception: auditory hallucinations related to neurobiological dysfunction would be that the client will A. ask for validation of reality. B. describe content of hallucinations. C. demonstrate a cool, aloof demeanor. D. identify prodromal symptoms of disorder.

A - Beginning to question his or her own altered perceptions by seeking input from staff is highly desirable.

The nurse is admitting a client to the psychiatric unit. Suddenly, the client states, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response? a) "Please explain that to me." b) "What reason would people have to want to destroy you?" c) "People here are trying to help you if you will let them." d) "That doesn't make any sense; nurses are helpers, not murderers."

A - Clients with fixed false beliefs truly believe the content of the delusion. Arguing or explaining will not help as in the other options. Initially the nurse needs to know the content and depth of the delusion while the client is being admitted. Then the nurse needs to focus on how the client feels about the delusion or distract the client from the delusion during the conversation.

During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The nurse interprets these findings to indicate that the client needs? a) Immediate medical evaluation. b) A sleep aid. c) An increase in medication. d) A clinic appointment.

A - The client is exhibiting symptoms of becoming catatonic and unable to care for himself, and needs immediate evaluation and possible hospitalization. A sleep aid is not sufficient to treat this client. The client's worsening condition dictates action without waiting for a clinic appointment. An increase in medication may be indicated, but hospitalization is required first for safety.

A nurse is caring for a client with bruises on her face and arms. Her husband refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? a) Collaborate with the physician to make a referral to social services. b) Question the woman in front of her husband. c) Tell the husband that he must leave because he is intimidating the client. d) Contact hospital security to escort the husband from the hospital.

A - Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her spouse does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security.

The parent of a young adult client diagnosed with schizophrenia is asking questions about his son's antipsychotic medication, ziprasidone. Which of the following statements by the father reflects a need for further teaching? a) "I should give him benztropine to help prevent constipation from the ziprasidone." b) "If he experiences restlessness or muscle stiffness, he should tell the doctor." c) "If he becomes dizzy, I'll make sure he doesn't drive." d) "The ziprasidone should help him be more motivated and less withdrawn."

A - Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the primary health care provider. Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition.

Which intervention strategy should be avoided by staff working with a client who is shouting and flailing his arms? A. Defusing the situation by laughing or making a joke of the challenge B. Saying "Let's go to your room to talk about this" C. Moving a few staff close together as a group to provide a show of force Incorrect D. Allowing one staff person to speak to the client while others provide support

A - Defusing the situation by laughing or making a joke of the challenge. Ridiculing a client should always be avoided. The other options are constructive approaches to deescalation.

When providing care for a client diagnosed with borderline personality disorder, the nurse will need to consider strategies for dealing with the client's A. mood shifts, impulsivity, and splitting. B. grief, anger, and social isolation. C. altered sensory perceptions and suspicion. D. perfectionism and preoccupation with detail.

A - Mood shifts, impulsivity, & splitting Borderline personality disorder has the central characteristic of instability in affect, identity, and relationships. Borderline individuals desperately seek relationships to avoid feeling abandoned, but they often drive others away with excessive demands, impulsive behavior, or uncontrolled anger. Their frequent use of the defense of splitting strains personal relationships and creates turmoil in health care settings.

A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in her? a) "I get upset once in a while, too." b) "I know just how you feel. I'd feel the same way in your situation." c) "At times, it's normal not to trust anyone." d) "I worry, too, when I think people are talking about me."

A - Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport with the client and encourages the client to confide in her. The nurse can't know how the client feels. Telling the client otherwise would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. The nurse stating that she worries when people talk about her is incorrect because the statement focuses on the nurse's feelings, not the client's. Saying it's normal not to trust anyone wouldn't help establish rapport or encourage the client to confide in the nurse.

Which effects do most antipsychotic medications exert on the central nervous system (CNS)? a) They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. b) They stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors. c) They sedate the CNS by stimulating serotonin at the synaptic cleft. d) They depress the CNS by stimulating the release of acetylcholine.

A - The exact mechanism of antipsychotic medication action is unknown, but these drugs appear to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. Antipsychotics don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.

A nurse caring for a client with schizophrenia goes into the client's room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? a) "How do you feel when you see the creatures?" b) "You are delusional." c) "It is time for your medication now." d) "The creatures will not hurt you."

A - The most appropriate response by the nurse is "How do you feel when you see the creatures?" The client is experiencing a delusion, a false belief that has no basis in reality. When the client experiences a delusion, it is important to acknowledge the delusion and to ask the client to describe it and how it makes them feel. These actions help identify the type of delusions so that the correct intervention can be implemented while establishing trust. If asked, the nurse should point out that they are not experiencing the same stimuli but should not argue with the client

When assessing a hospitalized client diagnosed with Major Depression and Borderline Personality Disorder, the nurse should ask the client about which of the following first? a) Suicidal thoughts. b) Access to pills and weapons. c) Suicidal plans. d) Seriousness of the client's intent to die.

A - The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. When assessing the client on admission, the nurse should first ask the client: a) If he is thinking about hurting himself. b) How he feels about himself. c) How he sleeps at night. d) About recent stresses.

A - The nurse's highest priority is to ask the client if he is thinking about hurting himself or to assess for suicide. Questioning the client about his sleep pattern, questioning the client about recent stresses, and questioning the client about his feelings about himself are important areas of assessment for the depressed client but not as immediate a priority as assessing the Risk for suicide

Which effects do most antipsychotic medications exert on the central nervous system (CNS)? B a) They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. b) They stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors. c) They sedate the CNS by stimulating serotonin at the synaptic cleft. d) They depress the CNS by stimulating the release of acetylcholine.

A - They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. Explanation: The exact mechanism of antipsychotic medication action is unknown, but these drugs appear to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. Antipsychotics don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.

The primary care provider prescribes risperidone 1 mg orally, two times a day for a client from a group home admitted to the hospital with severe anti-social behavior.The nurse determines that this dose is: a) Typical when initiating therapy. b) Too high for the client. c) Typical when initiating therapy but it should be tapered down in 1 week. d) Too low for the client.

A - Treatment with risperidone typically begins with 1 milligram twice a day for an adult and 0.5 milligram twice a day for an elderly client. Recommended dosages range from 4 to 6 milligrams/day. This dosage is not too high for the client. This dosage is not too low for initial treatment. It is typical for initiation, but the dosage will be increased, not decreased, over 1 week.

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called: a) flight of ideas b) looseness of association c) tangential thoughts d) circumstantial thinking

A - flight of ideas Flight of ideas describes a thought pattern in which a client moves rapidly from one topic to the next with some connection. Looseness of association describes a pattern in which ideas lack an apparent logical connection to one another. Tangential thoughts seem to be related but miss the point. A client who talks around a subject and includes a lot of unnecessary information is exhibiting circumstantial thinking.

The primary goal of milieu therapy for clients diagnosed with personality disorders is A. to manage the effect the behavior has on the entire group. B. to provide one-on-one therapy for each member of the milieu. C. to help the client remain uninvolved with other patients. D. to promote a laissez-faire attitude among the staff members.

A. The primary goal of milieu therapy is affect management in a group context.

The more a nurse's intervention is prompted by emotion A. the less likely it is to be therapeutic. B. the less likely it is to be aggressive. C. the more likely it is to be effective. D. the more likely it is to be empathetic.

A - the less likely it is to be therapeutic. One study reported in the text found that the nurse's response to anger from a client varied according to the interpretation given to the client's anger and to the nurse's self-appraised ability to manage the situation. Only when self-efficacy was perceived as adequate did the nurse move to help the client. When self-efficacy was not seen as adequate, nurses showed a decreased ability to process the client's message and a decreased ability to problem-solve.

A client with schizophrenia is taking the atypical antipsychotic medication clozapine. Which signs and symptoms indicate the presence of adverse effects associated with this medication? Select all that apply. a) Pill-rolling movements b) Sore throat c) Polyuria d) Fever e) Polydipsia f) Orthostatic hypotension

A and B - Sore throat and fever Sore throat, fever, and sudden onset of other flulike symptoms are signs of agranulocytosis, a condition in which an insufficient number of granulocytes (a type of white blood cell [WBC]) causes the individual to be susceptible to infection. The client's WBC count should be monitored at least weekly throughout the course of treatment. Pill-rolling movements can occur in clients experiencing adverse extrapyramidal effects associated with antipsychotic medication that has been ordered for much longer than a medication, such as clozapine. Polyuria and polydipsia are common adverse effects of lithium therapy. Orthostatic hypotension is an adverse effect of tricyclic antidepressant therapy.

What are contusions usually associated with?

A closed head injury

acquaintance (or date) rape

A rape in which the perpetrator is known to, and presumably trusted by, the person who is raped

The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply. a) "If I am having trouble sleeping or eating, I will call the mental health center." b) "Anxiety and worry causes me to have more voices." c) "Possible bad effects from the pills only last a few days." d) "I can't drink even one or two beers." e) "I can skip a pill when I am feeling too tired from them."

A, B, and D. • "Anxiety and worry causes me to have more voices." • "I can't drink even one or two beers." • "If I am having trouble sleeping or eating, I will call the mental health center." In schizophrenia, the client and the family need to be given teaching in order to manage the illness and to prevent a relapse. In the initial phase of the illness, teaching will need to be continued at the physician's office or the local mental health center. The client needs to understand that difficulty with eating or sleeping or increased anxiety can increase symptoms. Alcohol even in small amounts depresses the CNS and can interfere with pharmacological actions of medications. Reactions to the client's medications like tardive dyskinesia, dystonia, or the other extra-pyramidal side effects may take longer periods of time. The client needs to report any unusual symptoms.

Alicia, a 31-year-old patient, is flirting with a peer. She is overheard asking him to convince staff to give her privileges to leave the inpatient mental health unit. Later she offers you a backrub in exchange for receiving her 10:00 p.m. Xanax an hour early. Which response(s) to such behaviors would be most therapeutic? Select all that apply. a. Label the behavior as undesirable, and explore with Alicia more effective ways to meet her needs. b. By role-playing, demonstrate other approaches Alicia could use to meet her needs. c. Advise the other patients that Alicia is being manipulative and that they should ignore her when she behaves this way. d. Bargain with Alicia to determine a reasonable compromise regarding how much of such behavior is acceptable before she crosses the line. e. Explain that such behavior is unacceptable, and give Alicia specific examples of consequences that will be enacted if the behavior continues. f. Ignore the behavior for the time being so Alicia will find it unrewarding and in turn seek other, and hopefully more adaptive, ways to meet her needs.

A, B, and E a) Label the behavior as undesirable, and explore with Alicia more effective ways to meet her needs. b) By role-playing, demonstrate other approaches Alicia could use to meet her needs. e) Explain that such behavior is unacceptable, and give Alicia specific examples of consequences that will be enacted if the behavior continues.

The nurse is monitoring a client who appears to be hallucinating. The client displays paranoid speech content, seems agitated, and gestures at a figure on the television. Which of the following nursing interventions is appropriate? Select all that apply. a) Reinforce that the client is not in any danger. b) In a firm voice, instruct the client to stop the behavior. c) Immediately implement physical restraint procedures. d) Use a calm voice and simple commands. e) Acknowledge the presence of the hallucinations. f) Instruct other team members to ignore the client's behavior.

A, D, and E • Reinforce that the client is not in any danger. • Use a calm voice and simple commands. • Acknowledge the presence of the hallucinations. Using a calm voice, the nurse should reassure that the client is safe. The nurse should not challenge the client; rather, he or she should acknowledge the hallucinatory experience. It is not appropriate to request that the client stop the behavior. Implementing restraints is not warranted at this time. Although the client is agitated, no evidence exists that the client is at risk for harming self or others.

A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: a) unpredictable behavior and intense interpersonal relationships. b) coldness, detachment, and lack of tender feelings. c) inability to function as a responsible parent. d) somatic symptoms.

A. A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. His interpersonal relationships may be intense and unstable, and his behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect his parenting skills, his inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders

Characteristics the nurse will assess in the client diagnosed with antisocial personality disorder are A. deceitfulness, impulsiveness, and lack of empathy. B. perfectionism, preoccupation with detail, and verbosity. C. avoidance of interpersonal contact and preoccupation with being criticized. D. a need for others to assume responsibility for decision making and seeking nurture.

A. Antisocial clients have no conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others.

A client arrested for an assault in which he savagely beat a classmate states, "The guy deserved everything he got." The behaviors described are most consistent with the clinical picture of A. antisocial personality disorder. B. borderline personality disorder. C. schizotypal personality disorder. D. narcissistic personality disorder.

A. Clients with antisocial personality act out feelings without consideration for the rights of others. They feel no remorse for their antisocial acts.

Which statement is descriptive of clients with a personality disorder? A. They are resistant to behavioral change. B. They have an ability to tolerate frustration and pain. C. They usually seek help to change maladaptive behaviors. D. They have little difficulty forming satisfying and intimate relationships.

A. Personality disorders are deeply ingrained and pervasive. Clients with personality disorders find it very difficult, if not nearly impossible, to change. Change proceeds very slowly.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: a) a calming effect from which the client is easily aroused. b) greater sedation than CNS depressants. c) deeper sleep than CNS depressants. d) more prolonged sedative effects, making the client more difficult to arouse.

A. Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

A patient becomes frustrated and angry when trying to get his MP3 player and headset to function properly and angrily throws it across the room, nearly hitting a peer with it. Which intervention(s) would be the most therapeutic? Select all that apply. a. Place the patient in seclusion for 1 hour to allow him to de-escalate. b. Tell the patient that any further outbursts will result in a loss of privileges. c. Offer to help the patient learn how to operate his music player and headset. d. Explore with the patient how he was feeling as he worked with the music player. e. Point out the consequences of such behavior and note that it cannot be tolerated. f. Limit the patient's exposure to frustrating experiences until he attains improved coping skills. g. Encourage the patient to recognize signs of mounting tension and seek assistance.

A., D, E, and G a) Place the patient in seclusion for 1 hour to allow him to de-escalate. d) Explore with the patient how he was feeling as worked with the music player. e) Point out the consequences of such behavior and note that it cannot be tolerated. g) Encourage the patient to recognize signs of mounting tension and seek assistance.

A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When's he going to come get me out of here?" The nurse interprets the client's statements as indicative of which of the following? A. Ambivalence B. Autistic thinking C. Associative looseness D. Auditory hallucinations

A: Ambivalence refers to strong conflicting attitudes or feelings toward an object, person, goal, or situation evidenced in one instance by the client stating she is going to divorce her husband then stating that she misses and loves him. Autistic thinking is preoccupation with self with little concern for external reality. For example, a client's attention cannot be diverted from examining his hands. Associative looseness is characterized by simultaneous expression of unrelated, or only slightly related, ideas or thoughts. For example, a client states, "We went to a basketball game. Where is my father?" Auditory hallucinations involves hearing sounds, words, or voices not heard by others.

The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position? 1. Evaluate the job performance of the staff. 2. Be the sole decision-maker for the unit. 3. Take responsibility for the staff nurse's actions. 4. Attend the medical staff meetings.

ANSWER = 1. One of the many jobs of a manager is to see that performance evaluations are completed on the staff. 2. The manager should receive input from many sources to make decisions. Some decisions are made for the manager by administration based on costs or any number of other reasons. 3. The nurses retain responsibility for their own actions because they practice under the state's nursing practice act. The manager retains responsibility for the functioning of the unit. 4. The nurse manager attends many meetings pertaining to nursing but attends medical committee meetings only when a nursing issue is being discussed.

Which staff nurse should the charge nurse in the critical care unit send to the medical unit? 1. The nurse who has worked in the unit for 18 months. 2. The nurse who is orienting to the critical care unit. 3. The nurse who has been working at the hospital for 2 months. 4. The nurse who has 12 years' experience in this ICU unit.

ANSWER = 1. This nurse should be sent to the medical unit because, with 18 months' experience, the nurse is familiar with the hospital routine and would be helpful to the medical unit but is not the most experienced ICU nurse on duty. 2. The nurse who is still orienting to the unit should not be sent to the medical unit. The nurse in orientation should be kept with the nurse preceptor. 3. The nurse who is new to the hospital should not be sent to a new unit with which he or she is unfamiliar. 4. The nurse with 12 years' experience should be kept on in the ICU because his or her expertise would be more helpful for client care than a nurse with 18 months' experience.

Which situation should the charge nurse in the critical care unit address ﬁrst after receiving the shift report? 1. Talk to the family member who is irate over their loved one's nursing care. 2. Complete the 90-day probationary evaluation for a new ICU graduate intern. 3. Call the laboratory concerning the type and cross match for a client who needs blood. 4. Arrange for a client to be transferred to the telemetry step-down unit

ANSWER = 1. This situation should be addressed ﬁrst because the charge nurse is responsible for family/client complaints. If the family contacts the administration, the charge nurse must be aware of the situation. 2. The evaluation needs to be completed, but it does not take priority over handling an irate family member. 3. The charge nurse could assign this task to another nurse or ward clerk. Dealing appropriately with an irate family member takes priority over calling the laboratory. 4. The charge nurse could assign this task to another nurse or ward clerk. Dealing appropriately with an irate family member takes priority over transferring a client.

The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement ﬁrst? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

ANSWER = 2. The night supervisor or the unit manager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation. 1. The new graduate must work under this charge nurse; confronting the nurse would not resolve the issue because the nurse can choose to ignore the new graduate. Someone in authority over the charge nurse must address this situation with the nurse. 3. The new graduate is bound by the nursing practice acts to report potentially unsafe behavior regardless of the position the nurse holds. 4. The nurse educator would not be in a position of authority over the charge nurse. MAKING NURSING DECISIONS: When the nurse is deciding on a course of action involving other staff members, a rule of thumb is this: If the individual the nurse is concerned about is superior in job title to the nurse, then go through the chain of command to the next level of superior. If the individual is subordinate in job title to the nurse, then the nurse should confront the individual.

The experienced male nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he ﬁnds that the stafﬁng is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? 1. Immediately give a 2-week notice and ﬁnd a different job. 2. Discuss the situation with the manager who interviewed him. 3. Talk with the other employees about the stafﬁng situation. 4. Tell the charge nurse the stafﬁng is not what was explained to him.

ANSWER = 2. The nurse should give the manager a chance to discuss the situation before quitting. A temporary problem, such as illness, may be affecting stafﬁng. 1. The nurse should leave if he determines that the stafﬁng is not now or ever will be as it was relayed to him in the interview; however, there may be a temporary situation that can be resolved. 3. This action could cause the manager to think of the new nurse as a troublemaker. 4. The nurse should not discuss this with the charge nurse because this may cause a rift between the charge nurse and the new nurse. The nurse should clarify the stafﬁng situation with the unit manager.

The male visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse's best initial response? 1. "If you don't stop shouting, I will have to call security." 2. "I hear that you are frustrated. Can we discuss the issues calmly?" 3. "Sir, you are disrupting the unit. Calm down or leave the hospital." 4. "This type of behavior is uncalled for and will not resolve anything."

ANSWER = 2. The nurse should remain calm and try to allow the client to vent his frustrations in a more acceptable manner. The nurse should repeat calmly in a low voice any instructions given to the client. 1. This might be the second statement for the nurse to make if the client does not calm down and discuss the problems with the nurse. Because it could escalate the anger, it should not be the ﬁrst statement. 3. This statement will escalate the situation and could cause the visitor to lash out at the nurse. 4. This statement will escalate the situation and could cause the visitor to lash out at the nurse.

The confused client in the critical care unit is attempting to pull out the IV line and the indwelling urinary catheter. Which action should the nurse implement ﬁrst? 1. Ask a family member to stay with the client. 2. Request the UAP to stay with the client. 3. Place the client in a chest restraint. 4. Notify the HCP to obtain a restraint order.

ANSWER = 2. The nurse should ﬁrst ensure the client's safety by having someone stay at the bedside with the client, and then call the HCP, and ﬁnally apply mitt restraints. 1. The family may or may not be able to control the client's behavior but the nurse should not ask a family member ﬁrst. The CCU usually has mandated visiting hours. 3. This is a form of restraint and is against the law unless the nurse has a health care provider's order. This is the least restrictive form of restraint but would not be helpful if the client is pulling at tubes. 4. The nurse must notify the healthcare provider before putting the client in restraints; restraints must be used only in an emergency situation, for a limited time, and for the protection of the client.

The charge nurse observes two UAPs arguing in the hallway. Which action should the nurse implement ﬁrst in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

ANSWER = 2. The ﬁrst action is to stop the argument from occurring in a public place. The charge nurse should not discuss the UAPs' behavior in public. 1. The nurse should stop the behavior occurring in a public place. The charge nurse can discuss the issue with the UAPs and determine whether the manager should be notiﬁed. 3. The second action is to have the UAPs go to a private area before resuming the con- versation. 4. The charge nurse may need to mediate the disagreement; this would be the third step.

The critical care unit is having problems with staff members clocking in late and clocking out early from the shift. Which statement by the male charge nurse indicates he has a democratic leadership style? 1. "You cannot clock out 1 minute before your shift is complete." 2. "As long as your work is done you can clock out any time you want." 3. "We are going to have a meeting to discuss the clocking in procedure." 4. "The clinical manager will take care of anyone who clocks out early."

ANSWER = 3. A democratic manager is people oriented and emphasizes efﬁcient group functioning. The environment is open and communication ﬂows both ways, and this includes having meetings to discuss concerns. 1. Autocratic managers use an authoritarian approach to direct the activities of others. 2. Laissez-faire managers maintain a permissive climate with little direction or control. 4. This statement reﬂects shirking of responsibility, thus letting someone else address the problem, and is not characteristic of a democratic manager.

The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system? 1. It guarantees that unions will not be able to come into the hospital. 2. It makes the manager responsible for sharing information with the staff. 3. It involves staff nurses in the decision-making process of the unit. 4. It is a system used to represent the nurses in labor disputes.

ANSWER = 3. Shared governance is an organizational framework in which the nurse has autonomy over his or her own practice. The nurse is given direct input into the working of the unit. 1. Under shared governance, some nurses become so involved with the management of facilities that they are no longer eligible for representation by a bargaining agent (union), but there are no guarantees. 2. The manager is responsible for disseminating information under a centralized system of organization. 4. Shared governance is a system in which the nurse represents himself or herself

A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. What typically occurs in reaction formation? a) The client assumes an attitude that contradicts an impulse he harbors. b) The client believes his thoughts can control other people and events. c) The client persistently thinks and talks about a particular idea or subject. d) The client uses a specific act to negate a previous act.

ANSWER = A Reaction formation is a defense mechanism in which a person assumes an attitude that contradicts an impulse or a wish that he harbors. The belief that one's thoughts can control other people and events is called "magical thinking." Persistent thoughts and discussion of a particular idea or subject are called "rumination." Use of an act to negate a previous act is called "undoing."

The client in the critical care unit tells the day shift primary nurse that the night nurse did not answer the call light for almost 1 hour. Which statement would be most appropriate by the day shift primary nurse? 1. "The night shift often has trouble answering the lights promptly." 2. "I am sorry that happened and I will answer your lights promptly today." 3. "I will notify my charge nurse to come and talk to you about the situation." 4. "There might have been an emergency situation so your light was not answered."

ANSWER = 3. The nurse should have someone come talk to the client who is in a position to then investigate what happened on the night shift and determine why this happened. The day shift primary nurse does not have this authority. 1. This statement is not supporting the night shift and makes the unit look bad. The nurse should not "bad-mouth" the night shift. 2. The nurse has no idea what happened that delayed answering the call light, it could have been a code or other type of life-threatening situation. The day shift primary nurse may not be able to answer the light in some certain situations and should not falsely reassure the client. 4. This is negating the client's feeling, and theclient does not need to know what wasgoing on in the critical care unit

The 18-year-old client is admitted to the critical care unit after a serious motor vehicle accident resulting from driving under the inﬂuence. The mother comes to the unit and starts yelling at her son about "driving drunk." Which action should the nurse implement? 1. Allow the mother to continue talking to her son. 2. Notify the hospital security to remove the mother. 3. Escort the mother to a private area and talk to her. 4. Tell the mother if she wants to stay, she must be quiet.

ANSWER = 3. The nurse should remove the mother from the room and allow her to ventilate her feelings about the accident her son sustained while he was under the inﬂuence. 1. The nurse must diffuse the situation and remove the mother from the client's room because a seriously ill client does not need to be yelled at. 2. Hospital security does not need to be called unless the mother refuses to leave the client's room in the critical care unit. 4. The nurse should remove the mother because she is upset and let her ventilate. Telling the mother she must be quiet is condescending, and when someone is upset, telling the person to be quiet is not helpful.

A woman comes to the emergency department (ED) and tells the triage nurse she was raped by two men. The woman is crying, disheveled, and has bruises on her face. Which action should the triage nurse implement ﬁrst? 1. Ask the client whether she wants the police department notiﬁed. 2. Notify a Sexual Assault Nurse Examiner (SANE) to see the client. 3. Request an ED nurse to take the client to a room and assess for injuries. 4. Assist the client to complete the emergency department admission form.

ANSWER = 3. The triage nurse's ﬁrst intervention is to address the client's physiologic needs, which means to assess for any type of trauma or injury. 1. The client may or may not want the police notiﬁed, but this is not the triage nurse's ﬁrst intervention. The triage nurse should ﬁrst care for the client. 2. The SANE nurse is a nurse who is specialized in caring for clients who have been raped. The SANE nurse is able to spend time with the client, is knowledgeable of legal issues, and would be an appropriate intervention, but it is not the triage nurse's ﬁrst intervention 4. The client can complete the admission form while in the room; the triage nurse's ﬁrst intervention should be to care for the client, not paperwork. MAKE NURSING DECISIONS: When the question asks which intervention to implement ﬁrst, the test taker should determine whether any of the options concern the physiologic needs of the client and then apply Maslow's Hierarchy of Needs to ﬁnd the correct answer. Remember, physiologic needs take priority over all other needs

The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening the staff members. The charge nurse determines the client is at imminent risk for harming the staff/clients and instructs the staff to place the client in seclusion. Which intervention should the charge nurse implement ﬁrst? 1. Document the client's behavior in the nurse's notes. 2. Instruct the MHWs to clean up the day room area. 3. Obtain a restraint/seclusion order from the HCP. 4. Ensure that none of the other clients were injured.

ANSWER = 3. The use of restraints and seclusion requires a HCP's order every 24 hours. The nurse must obtain this order ﬁrst after placing the client in the seclusion room. The nurse can place the client in seclusion for the safety of the client/staff/other clients, but the nurse must then immediately obtain a HCP's order. 1. The nurse must document the client's behavior that prompted the need for seclusion, but it is not the ﬁrst intervention.2. The day room area should be cleaned up, but it is not the nurse's ﬁrst intervention. 2. The day room area should be cleaned up, but it is not the nurse's ﬁrst intervention. 4. The charge nurse should make sure the other clients are not injured, but the ﬁrst intervention is to keep the client who is acting out safe and legally put into seclusion.

A client diagnosed with AIDS dementia is angry and yells at everyone entering the room. None of the critical care staff wants to be assigned to this client. Which intervention would be most appropriate for the nurse manager to use in resolving this situation? 1. Explain that this attitude is a violation of the client's rights. 2. Request the HCP to transfer the client to the medical unit. 3. Discuss some possible options with the nursing staff. 4. Try to ﬁnd a nurse who does not mind being assigned to the client.

ANSWER = 3. This would be the most appropriate intervention because it allows the staff to have input into resolving the problem. When staff have input into resolving the situation, then there is ownership of the problem. 1. The feelings of the staff are not a violation of the client's rights. Refusing to care for the client is a violation of the client's rights. 2. Transferring the client to the medical unit solves the problem for the critical care unit, but the client's behavior should be addressed by the health-care team. This is not the most appropriate intervention for the nurse manager. 4. One nurse cannot be on duty 24 hours a day. The nurse manager should try to allow the staff to identify options to address the client's behavior.

The nurse is assigned to care for a client admitted with depression as well as a dependent personality disorder. Which of the following statements by the client is indicative of this personality disorder? a) "I don't want to go in there. Don't want to talk to anyone because anything I say makes them think I'm stupid." b) "Please don't forget to wait for me to go to dinner. I don't want to go by myself." c) "It is hard for me to go and eat dinner when everyone wants to be with me. They all love me!" d) "When I walked out the door, there were all of these people that were staring at me and talking about me."

ANSWER = B. A client with a dependent personality disorder does not like to be alone and attaches themselves to others emotionally as well as physically. This client can be in relationships in which they are the submissive party. A - The statement regarding not wanting to talk to anyone because the client feels stupid is an example of an avoidant personality disorder. C - When client states, "They all love me!" they are displaying a narcissistic personality disorder. D - A paranoid personality disorder is demonstrated by the comment regarding people staring and talking about them.

A nurse caring for a client diagnosed with schizophrenia should perform which of the following interventions when the client becomes suspicious and refuses to take his medication? a) Document that the client is noncompliant b) Wait for a short time and then attempt to administer the medication c) Tell the client he must take the medication now d) Attempt to coax the client into taking the medication by calling him honey

ANSWER = B. Wait for a short time and then attempt to administer the medication Explanation: A flexible care plan is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and at different times and is sometimes in control of himself, the nurse must be able to adjust nursing care as the situation warrants, such as offering the medication again after waiting for a short period of time. Forcing the client to take the medication now and calling the client honey may anger the client.

Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: a) increasing the level of acetylcholine in the CNS. b) decreasing the anxiety causing muscle rigidity. c) blocking cholinergic activity in the central nervous system (CNS). d) increasing norepinephrine in the CNS.

ANSWER = C, blocking cholinergic activity in the CNS. Benztropine blocks cholinergic activity in the CNS. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS

The client's arterial blood gas results are pH 7.48, PaO2 98, PCO2 30, and HCO3 24. Which action would be most appropriate for this client? 1. Administer oxygen 10L/min via nasal cannula 2. Administer an antianxiety medication 3. Administer 1 amp of sodium bicarbonate IVP 4. Administer 30 mL of an antacid

Administer antianxiety agent. This client is in respiratory alkalosis, which is caused by hyperventilating and could be the result of anxiety, elevated temperature, or pain. The nurse should administer the appropriate medication. Oxygen would not be helpful in treating this client. Sodium bicarbonate is the drug of choice for metabolic acidosis and is an alkaline substance that would increase the client's alkalosis. An antacid would not help treat respiratory alkalosis because it is also an alkaline substance.

Survival rate of DAI

Approximately 90% of patients with DAI remain in a persistent vegetative state

Belinda is a 24-year-old patient with borderline personality disorder (BPD). She is admitted to the inpatient psychiatric unit following a suicide attempt. You are caring for Belinda. Which of the following statements by Belinda illustrates a primary coping style of persons with BPD? A. "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" B. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." C. "I will never again speak to any of my messed up family members. I know that this will help me be more functional." D. "I promise I am not feeling suicidal. I won't hurt myself."

B B A primary coping style used by patients with BPD is called splitting. Splitting is the inability to incorporate positive and negative aspects of oneself or others into a whole image. The individual may tend to idealize another person (friend, lover, health care professional) at the start of a new relationship and hope that this person will meet all of his or her needs. At the first disappointment or frustration, however, the individual quickly shifts to devaluation, despising the other person. The other options do not describe splitting, which is a primary coping style of patients with BPD.

A client receiving fluphenazine decanoate therapy develops pseudoparkinsonism. A physician is likely to order which drug to control this extrapyramidal effect? a) Diphenhydramine b) Amantadine c) Benztropine d) Phenytoin

B - An antiparkinsonian agent such as amantadine may be used to control pseudoparkinsonism; diphenhydramine or benztropine may be used to control other extrapyramidal effects. Phenytoin is used to treat seizure activity.

A client is admitted to the psychiatric emergency department. His significant other reports that he has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. He reports being a special messenger from the Messiah. He has a history of depressed mood for which he has been taking an antidepressant. Which diagnosis should the nurse suspect? a) Obsessive-compulsive disorder (OCD) b) Bipolar disorder c) Paranoid personality d) Schizophrenia

B - Bipolar disorder is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur accompanied by pressured speech are common symptoms of the manic phase of bipolar disorder. Schizophrenia does not manifest as mood swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is usually accompanied by grandiosity. OCD is a preoccupation with rituals and rules.

A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate? a) Ask the client to describe what the voices are saying. b) Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. c) Approach the client and touch him to get his attention. d) Encourage the client to go to his room where he'll experience fewer distractions.

B - By acknowledging that the client hears voices, the nurse conveys her acceptance of him. By letting the client know that she doesn't hear the voices, the nurse avoids reinforcing his hallucination. The nurse shouldn't touch a client with schizophrenia without advance warning. A hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings rather than the content of the hallucination.

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: a) although uncomfortable, this reaction isn't serious. b) the client must take benztropine as ordered to prevent a return of symptoms. c) results of treatment are rapid and dramatic but may not last. d) the client shouldn't buy drugs on the street.

B - Client must take benztropine as ordered to prevent sx from returning. An oral anticholinergic agent such as benztropine is commonly ordered to control and prevent the return of symptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when airway patency is compromised. Lecturing the client about buying drugs on the street isn't appropriate.

Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement? a) Amenorrhea is irreversible. b) Continue previous contraceptive use even if you're experiencing amenorrhea. c) Incidence of dysmenorrhea may increase while taking this drug. d) This medication may result in heightened libido.

B - Continue previous contraceptive use even if you're experiencing amenorrhea. Women may experience amenorrhea, which is reversible, while taking antipsychotics because amenorrhea doesn't indicate cessation of ovulation the client who experiences amenorrhea can still become pregnant. She should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and the depressant effect generally decreases libido.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction? a) Akinesia b) Dystonia c) Akathisia d) Tardive dyskinesia

B - Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements, particularly around the mouth.

Which condition or characteristic is related to the cluster of symptoms associated with disorganized schizophrenia? a)Odd beliefs b)Flat affect c)Waxy flexibility d)Systematized delusions

B - Flat affect (the lack of facial or behavioral manifestations of emotion) is related to disorganized schizophrenia. Other characteristics of disorganized schizophrenia include incoherence, loose associations, and disorganized behavior. Paranoid residual type schizophrenia is characterized by odd beliefs, unusual perceptions, and systematized delusions. Waxy flexibility, or maintaining the position the client is placed in, is seen in catatonic schizophrenia.

In working with a rape victim, which of the following is most important? a) Recommending that the client resume sexual relations with her partner as soon as possible. b) Periodically reminding the client that she did not deserve and did not cause the rape. c) Telling the client that the rapist will eventually be caught, put on trial, and jailed. d) Continuing to encourage the client to report the rape to the legal authorities.

B - Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the rapist will be caught, tried, and jailed. Most rapists are not caught or convicted.

Which neurotransmitter imbalance has been shown to be related to impulsive aggression? A. Low levels of ã-aminobutyric acid B. Low levels of serotonin C. High levels of dopamine D. High levels of acetylcholine

B - Low serotonin levels have been implicated in several research studies as being a factor in impulsive aggression.

A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be to A. set firm limits on behavior. B. respect need for social isolation. C. encourage expression of feelings. D. involve in milieu and group activities.

B - Respect need for social isolation. Schizoid personality disorder has the primary feature of emotional detachment. Individuals do not seek out or enjoy close relationships. They are reclusive, avoidant, and uncooperative. They do not do well with resocialization.

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action should be to: a) administer an as-needed dose of haloperidol. b) administer an as-needed dose of benztropine I.M. as ordered. c) reassure the client and administer as-needed lorazepam I.M. d) administer an as-needed dose of benztropine as ordered.

B - The client is most likely suffering from muscle rigidity caused by haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would intensify the severity of the client's reaction.

A client is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: a) obsessive-compulsive personality disorder. b) antisocial personality disorder. c) borderline personality disorder. d) narcissistic personality disorder.

B - This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.

When obtaining a nursing history from parents who are suspected of abusing their child, which of the following characteristics about the parents should the nurse particularly assess? a) Ability to relate the child's developmental achievements. b) Difficulty with controlling aggression. c) Attentiveness to the child's needs. d) Self-blame for the injury to the child.

B - difficulty controlling aggression Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information.

After months of counseling, a client abused by her husband tells the nurse that she has decided to stop treatment. There has been no abuse during this time, and she feels better able to cope with the needs of her husband and children. In discussing this decision with the client, the nurse should: a) Remind the client of her duty to protect her children by continuing treatment. b) Find out more about the client's rationale for her decision to stop treatment. c) Warn the client that abuse commonly stops when one partner is in treatment, only to begin again later. d) Tell the client that this is a bad decision that she will regret in the future.

B - find out more about the client's rationale for her decision to stop treatment. The nurse needs more information about the client's decision before deciding what intervention is most appropriate. Judgmental responses could make it difficult for the client to return for treatment should she want to do so. Telling the client that this is a bad decision that she will regret is inappropriate because the nurse is making an assumption. Warning the client that abuse commonly stops when one partner is involved in treatment may be true for some clients. However, until the nurse determines the basis for the client's decision, this type of response is an assumption and therefore inappropriate. Reminding the client about her duty to protect the children would be appropriate if the client had talked about episodes of current abuse by her partner and the fear that her children might be hurt by him.

A nurse is aware that antipsychotic medications may cause: a) increased coagulation time. b) lower seizure threshold. c) increased risk of heart failure. d) increased insulin production.

B - low seizure threshold Explanation: Antipsychotic medications affect brain neurotransmitters in a way that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect of antipsychotic agents.

Which instructions should the nurse include when teaching a client about quetiapine therapy? Select all that apply. a) Report dry mouth immediately. b) Avoid becoming overheated or dehydrated during therapy. c) Change positions slowly to prevent orthostatic hypotension. d) Contact the prescriber before taking over-the-counter preparations. e) Have an annual eye examination to check for cataract formation.

B, C, and D • Contact the prescriber before taking over-the-counter preparations. • Change positions slowly to prevent orthostatic hypotension. • Avoid becoming overheated or dehydrated during therapy. The nurse should instruct the client to avoid becoming overheated or dehydrated during therapy to prevent neuroleptic malignant syndrome. He or she also should tell the client to contact the prescriber before taking over-the-counter preparations and to change positions slowly to prevent orthostatic hypotension. The client should have an eye examination every 6 months to check for cataract formation. Dry mouth is a common adverse effect of therapy that can be alleviated with ice chips, drinks, or sugarless hard candy; this effect does not need to be reported immediately.

An angry client frequently loses patience with the nurses and shouts at them while they perform a complicated dressing change. Which plan could they create to intervene effectively in this behavior? A. Tell him they will not change his dressing if he is going to abuse them. B. When the client begins to become abusive, leave the room promising to return in 20 minutes when he has regained control. C. Assure him they will complete the dressing change as quickly as possible. D. Explain that they are professionals and unused to being shouted at by people they are trying to help.

B. When the client begins to become abusive, leave the room promising to return in 20 minutes when he has regained control. The nurse is using behavioral techniques to reinforce desirable behavior (spending time with the client when he is calm) and limit reinforcement of undesirable behavior (leaving when he is acting out anger).

While examining a female client who comes to the emergency department complaining of a fever and a sore throat, the nurse assesses many bruises in various stages of healing. The client states, "This fever made me so confused and clumsy, I fell several times." Suspecting abuse, the nurse interprets this statement as indicating behavior most probably due to which of the following? A. Gaining pleasure from being abused. B. Fearing she is to blame for her plight. C. Believing her illness will end the abuse. D. Thinking she can handle the problem when feeling better

B: Battered women commonly deny being abused because they are afraid that they are somehow to blame or deserving of their situation. It is a myth that battered women are masochistic and gain pleasure from abuse. Most battered women want to believe that the abuse will stop, especially during the honeymoon phase when the abuser is apologetic. Handling the problem when she is feeling better is an oversimplification of the dynamics of partner abuse and is not what the victim is concerned with or expressing in her statement. The statement in the scenario reflects denial of the abuse.

A client with this type of personality disorder exhibits mood instability, poor self-image, identity disturbance, and labile effect.

Borderline personality disorder

A staff nurse on the unit has a great deal of influence on others' opinions and actions. What type of power does this nurse have? A. Information B. Legitimate C. Referent D. Reward

A nurse caring for a client with schizophrenia goes into the client's room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? a) "It is time for your medication now." b) "The creatures will not hurt you." c) "How do you feel when you see the creatures?" d) "You are delusional."

C - "How do you feel when you see the creatures?" Explanation: The most appropriate response by the nurse is "How do you feel when you see the creatures?" The client is experiencing a delusion, a false belief that has no basis in reality. When the client experiences a delusion, it is important to acknowledge the delusion and to ask the client to describe it and how it makes them feel. These actions help identify the type of delusions so that the correct intervention can be implemented while establishing trust. If asked, the nurse should point out that they are not experiencing the same stimuli but should not argue with the client.

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate? a) "There is no need to be concerned about a man who isn't even real." b) "Describe the man who's out to get you. What does he look like?" c) "This subject seems to be troubling you. Let's walk to the activity room." d) "There is no reason to be afraid of that man. This hospital is very secure."

C - "This subject seems to be troubling you. Let's walk to the activity room." This remark distracts the client from the delusion by engaging him in a less-threatening or more-comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the client's false belief. The other options focus on the content of the delusion rather than on the meaning, feeling, or distress it evokes.

The priority nursing intervention for a client diagnosed with borderline personality disorder is to A. protect other clients from manipulation. B. respect the client's need for social isolation. C. assess for suicidal and self-mutilating behaviors. D. provide clear, consistent limits and boundaries.

C - Assess for suicidal and self-mutilating behaviors One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress.

A client with schizophrenia tells the nurse that he doesn't go out much because he doesn't have anywhere to go and he doesn't know anyone in the apartment where he's staying. Which of the following actions is most beneficial for the client at this time? a) Thinking about the need for rehospitalization for the client. b) Encouraging him to call his family to visit more often. c) Arranging for the client to attend day treatment at the clinic. d) Making an appointment for the client to see the nurse daily for 2 weeks.

C - Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time. Family visits and daily nursing visits do not encourage the client to do this. Making an appointment for 2 weeks later puts the client's needs off. Lack of social relationships is not a sufficient reason for rehospitalization.

Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: a) increasing the level of acetylcholine in the CNS. b) increasing norepinephrine in the CNS. c) blocking cholinergic activity in the central nervous system (CNS). d) decreasing the anxiety causing muscle rigidity.

C - Benztropine blocks cholinergic activity in the CNS. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.

The nurse is teaching a group of unlicensed personnel new to psychiatry about balance in a therapeutic milieu. Which of the following statements by a member of the group indicates the need for further teaching? a) "Balance includes safe and effective treatment for all clients." b) "We need to think of patients' rights when working with clients." c) "Controlling clients helps them feel more comfortable." d) "We don't fix clients but help them solve their problems."

C - Controlling clients helps them feel more comfortable. The statement, "Controlling clients helps them feel more comfortable," does not reflect an understanding of the concept of balance in a therapeutic milieu. Balance is the careful negotiation of the conflict between dependency and independency in a therapeutic milieu. Clients are dependent when admitted to care but are allowed and encouraged to become independent as they are able to assume responsibility for self. Staff may find it easier to care for the client when they can control the client and may feel needed when the client is dependent on them. In a therapeutic milieu, staff do not solve the clients' problems for them. Rather, they work with the clients to gradually allow independent behaviors and decision making. Understanding clients' rights, legal issues, and ethical concerns is crucial for the skilled use of balance.

Clients demonstrating characteristics of personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that addresses this sort of interpersonal dysfunction is A. spiritual distress. B. defensive coping. C. impaired social interaction. D. disturbed sensory perception.

C - Impaired social interaction For a client who has difficulty in relationships and is very manipulative, the nursing diagnosis of impaired social interaction would be used.

The client with a diagnosis of schizophrenia walks into group naked. The nurse should: a) Ask a male client to take off his sweater and wrap it around the client's waist. b) Instruct the client to go to his room and to put on some clothes. c) Lead the client to his room and help him dress if he needs assistance. d) Wrap a blanket around him and tell him to be seated for the remainder of group.

C - Lead client to his room and help him dress if he needs assistance. The best nursing action is to lead the client to his room and assist him with putting on his clothes. The client with disorganized behavior needs the nurse's assistance to protect his self-esteem and dignity and to avoid embarrassment. Instructing the client to go to his room to put on his clothes may not be effective because the client may be too disorganized to follow directions. Wrapping a blanket around the client is helpful. Instructing him to be seated for the remainder of group is inappropriate and demeaning. Asking another client to remove his sweater and wrap it around the other client's waist is inappropriate

A nurse is planning care for a client with a diagnosis of schizophrenia who has been admitted to the psychiatric unit. Which nursing diagnosis should receive the highest priority? a) Impaired verbal communication b) Imbalanced nutrition: Less than body requirements c) Risk for other-directed violence d) Compromised family coping

C - Risk for other-directed violence Such characteristics as suspiciousness, anxiety, and hallucinations put the client with schizophrenia at risk for violence toward himself or others. Imbalanced nutrition: Less than body requirements, Compromised family coping, and Impaired verbal communication are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him has been established. **NURSING DIAGNOSES THAT, IF UNTREATED, RESULT IN HARM TO THE PATIENT OR OTHERS HAVE THE HIGHEST PRIORITIES!!!

A nurse is caring for a client with schizophrenia. The nurse identifies which is the primary problem? a) split personality b) acting in a compulsive way c) difficulty forming relationships d) acting-out behaviors

C - Schizophrenia is associated with difficulty forming relationships with a marked inability to trust others a (split personality) is a failure to integrate various aspects of one's identity, memory, and consciousness b - compulsion is an irrational drive d (acting-out behaviors) expressing unconsciousness feelings or conflicts through actions

The client with a diagnosis of schizophrenia is acutely psychotic and exhibits religious delusions and hallucinations, loose associations, and concrete thinking. When the nurse offers the client her medication, the client states, "I don't need that. God will heal me." The nurse should respond to the client by saying: a) "This medicine will help clear your thoughts and decrease anxiety." b) "God wants you to take your medicine." c) "God is important in your life, but the medicine will help you too." d) "God helps those who help themselves."

C - Stating that God is important in the client's life recognizes the client's cognitive and perceptual disturbances and level of anxiety and acknowledges the client's message in a respectful and neutral manner, while adding that the medicine also will help, clearly and directly states the need for medication. Stating, "God helps those who help themselves" challenges the client. Stating, "God wants you to take your medicine" is deceitful. Stating, "Medicine will help clear your thinking and decrease anxiety" would be helpful to the client later when she is less acutely psychotic and anxious.

During an extremely busy shift on the psychiatric unit, a newly graduated nurse approaches the charge nurse and states, "I'm having a hard time taking care of mentally ill people. What can I do to handle this stress?" The charge nurse's best response is: a) "Try to take some deep breaths whenever you feel anxious." b) "Just ignore situations you can't change." c) "Maybe we could schedule a time to discuss this further." d) "Maybe you should attend some stress-reduction courses."

C - Suggesting to set a time for a more detailed discussion acknowledges that the charge nurse is concerned about what the new graduate has told her and provides an opportunity to explore and address the problem at a more appropriate time. Telling the new nurse to breathe deeply when she feels anxious doesn't help her address the underlying issue. Although stress-reduction courses may ultimately prove useful, suggesting them at this time is impersonal and doesn't respond to the nurse's needs. Telling the new nurse to ignore situations that she can't change discounts the fact that the new nurse has identified a problem and is seeking an answer.

A nurse is providing care to a client with schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should: a) prepare the client ahead of time for the activity. b) negotiate a time when the client will perform activities. c) tell the client specifically and concisely what needs to be done. d) ask the client which activity he would prefer to do first.

C - The client must be informed of the activity and when it will occur. Giving choices isn't desirable because the client can be manipulative or refuse to do anything. Negotiation and preparation wouldn't be therapeutic because this type of client might not want to perform the activity.

The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought process does this indicate? a) Idea of reference. b) Idea of influence. c) Delusion of persecution. d) Delusion of grandeur.

C - The client's thought process is best defined as a delusion of persecution. An idea of reference assumes that the remarks and behavior of others apply to oneself. An idea of influence refers to the belief that people or objects have control over one's behavior. A delusion of grandeur involves an exaggerated idea of one's importance or identity.

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which of the following questions by the nurse is most important to ask? a) "When do you hear the voices?" b) "Why are the voices starting again?" c) "Are you going to hurt yourself?" d) "How long have you heard the voices?"

C - The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to cope with the voices and to assess the client's impulse control. The nurse's assessment will then determine the course of action to take regarding the client's safety. Asking when the client hears the voices and how long the client has heard them is important but not as important as determining whether the client will act on what the voices are saying. Asking "Why are the voices starting again?" would be inappropriate because the client may not know why and may not be able to answer the nurse.

Which of the following approaches is most appropriate to use with a client diagnosed with a narcissistic personality disorder when discrepancies exist between what the client states and what actually exists? a) Limit setting. b) Consistency. c) Supportive confrontation. d) Rationalization.

C - The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self. Limit setting and consistency also may be used. However, limit setting helps the client control unacceptable behavior and consistency helps reduce the frequency of negative behaviors; they do not point out discrepancies. Rationalization is typically used by the client, not the nurse, to blame others, make excuses, and provide alibis for self-centered behaviors.

A nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: a) haloperidol. b) diphenhydramine. c) benztropine. d) propranolol.

C - benztropine Benztropine, trihexyphenidyl, or amantadine are ordered for treatment of Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms

A client is admitted with paranoid schizophrenia. The client's wife says that he has not slept in 4 nights. Which action by the nurse is most correct? a) introduce the client to other clients on the unit b) encourage the client to sleep c) establish a trusting nurse/client relationship d) assign the client to straighten up the day room

C - establish a trusting nurse/client relationship

The client at highest risk for violence directed at others is one who A. has a history of recurrent severe depression. B. is in an alcohol rehabilitation program. C. has delusions of persecution. D. who has somatic symptoms for which no organic basis is found.

C - has delusions of persecution The client who perceives others to be against him may lash out if he feels threatened.

When working with an angry client, it is best to A. encourage the client to fully explore and express his or her anger. B. help the client deny and repress the feelings of anger. C. help the client reframe the anger-producing situation. D. ignore the client's anger and change the subject.

C - help the client reframe the anger-producing situation De-escalation occurs more quickly with this strategy than when other approaches are used.

A delusional client approaches a nurse, stating, "I am the Easter Bunny," and insisting that the nurse refer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply. a) Logically point out why the client couldn't be the Easter Bunny. b) Provide an as-needed medication. c) Consistently use the client's name in the interaction. d) Provide the client with structured activities. e) Smile at the humor of the situation. f) Agree that the client is the Easter Bunny.

C and D. • Consistently use the client's name in the interaction. • Provide the client with structured activities. Continued reality-based orientation is necessary, so it's appropriate to use the client's name in any interaction. Structured activities can help the client refocus and resolve his delusion. The nurse shouldn't contribute to the delusion by going along with the situation. Logical arguments and an as-needed medication aren't likely to change the client's beliefs.

The client diagnosed with a personality disorder who is most likely to be admitted to a psychiatric unit is one who has A. paranoid personality disorder and is suspicious of his neighbors. B. narcissistic personality disorder and is highly self-important. C. borderline personality disorder and is impulsive. D. dependent personality disorder and clings to her husband.

C. Clients with borderline disorder can decompensate into psychotic states under stress. Hospitalization is needed at these times.

A nurse attempts to intervene verbally when an angry client initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the client shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the client deescalate by A. continuing to manage the situation personally. B. telling the client, "It isn't safe for me to leave the room." C. moving to the rear of the staff group. D. apologizing for upsetting the client.

C. Moving to the rear of the staff group. There is no need for the nurse to stand her ground to save face. The goal is to deescalate the situation. When the client makes a request that can be met without compromising safety, granting the request is acceptable.

Characteristic behaviors the nurse will assess in the narcissistic client are A. dramatic expression of emotion, being easily led. B. perfectionism and preoccupation with detail. C. grandiose, exploitive, and rage-filled behavior. D. angry, highly suspicious, aloof, withdrawn behavior.

C. Narcissistic clients give the impression of being invulnerable and superior to others to protect their fragile self-esteem.

A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit A. frequent episodes of psychosis. B. constant involvement with the needs of significant others. C. inflexible and maladaptive responses to stress. D. abnormal ego functioning.

C. Personality patterns persist unmodified over long periods of time. Inflexible and maladaptive responses to stress are characteristic of individuals with a personality disorder.

Which of the following expected outcomes would the nurse judge as therapeutic and realistic for a female client with major depression and borderline personality disorder who is hospitalized for self-mutilation and threats of suicide? A. The client will stay in her room when overwhelmed by feelings. B. The client will leave the group to pace when feeling anxious and angry. C. The client will appropriately verbalize anger and sad feelings to the nurse. D. The client asks the nurse for a prescribed medication when feeling out of control

C: The client needs to ventilate and discuss feelings of anger and sadness with the nurse to decrease behaviors of self-harm. Other alternatives such as punching the pillow may be helpful to the client in expressing anger and rage. Staying in her room when feeling overwhelmed is inappropriate because it will not help the client understand herself or her feelings. Additionally, doing so will not foster growth in autonomy and responsibility for self. Leaving the group to pace when anxious and angry is inappropriate because it will not help the client understand herself or her feelings. Additionally, doing so will not foster growth in autonomy and responsibility for self. Asking for prescribed medications when feeling out of control will not help the client to understand herself or her feelings and will not foster growth in autonomy and responsibility for self.

When providing a therapeutic milieu for clients, which of the following would be most appropriate? A. Using psychotropic drugs primarily. B. Fostering dependent client behavior. C. Accepting behavior as meaningful and motivated. D. Meeting one's own needs while helping clients meet their needs

C: The milieu should provide an atmosphere that fosters growth, change, and self-responsibility. Therefore, the nurse needs to accept behavior as meaningful and motivated. Staff interventions should also be flexible, open, and encourage clients to achieve their own potential. Using psychotropic drugs is only one component of therapeutic milieu. Other components include nurse-client interaction, therapeutic groups, recreation, and client-staff treatment meetings. Independent, not dependent, behavior is fostered and supported to promote the client to assume responsibility for self. Meeting one's own needs while helping clients meet their needs is inappropriate for the nurse or the staff in a therapeutic milieu. The nurse focuses on the client's needs without expecting personal needs to be met.

In which of the following instances would the nurse anticipate that a client who has been sexually assaulted will have future adjustment problems and the need for additional counseling? A.When she becomes upset when talking about the rape to anyone. B. When she seeks support from formerly ignored relatives and friends. C. When her parents show shame and suspicion about her part in the rape. D. When her life becomes focused on helping other rape victims like herself.

C: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.

Brian covered his apartment walls with aluminum foil to block governmental efforts to control his thoughts. Which type of delusion is Brian experiencing?

Control

The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which of the following responses by the nurse would be most appropriate? a) "Do you hear these voices very often?" b) "Do you have a plan for getting away from the voices?" c) "Try to ignore them and play cards with the others." d) "I do not hear any voices. What are you hearing?"

D - A hallucination is a false sensory perception. It involves all five senses and bodily sensations. Initially, the nurse needs to assess what kind of voices are being heard. That is, are they friendly, commanding, or controlling voices? Acknowledging that the client is experiencing the voices but telling the client that the nurse does not may assist the client to realize that the voices are not real. Then the nurse can focus on the client's feelings or redirect the client on reality by initiating a simple task with the client as coloring as well as other options. When the voices are less severe, then the nurse can do a more thorough assessment of the client's hallucinations and begin to assist the client in learning to deal with the voices.

A client is becoming agitated during a discussion group. She states, "I know that all of you hate me." She leaves the group and goes to her room. Which action by the nurse is most therapeutic for the client? a) Ask the client to return to group and share her feelings. b) Ask the group members to apologize to the client individually. c) Explain to group members about the client's problems. d) After group, ask the client to talk to the nurse about her concerns.

D - After group, ask the client to talk to the nurse about her concerns. Explanation: It is appropriate to talk alone with this client about her feelings. A suspicious client is unlikely to agree to talk about feelings in a group. It is a violation of the client's privacy to reveal a client's problems to group members. The other clients in the group have no reason to apologize, and the nurse should not ask them to do so.

For the client with catatonic behaviors, which of the following should the nurse use to determine that the medication administered as needed has been most effective in the long term? a) The client can move all extremities occasionally. b) The client walks with the nurse to her room. c) The client responds to verbal directions to eat. d) The client initiates simple activities without directions.

D - Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. Moving all extremities occasionally, walking with the nurse to the client's room, and responding to verbal directions to eat represent single steps toward the client initiating her own actions.

While conducting a home visit for a client diagnosed with schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I'm gone?" Which of the following problems related to the caregiver would be the most inclusive one for the nurse to incorporate into the client's plan of care? a) Disturbed sleep pattern. b) Fear. c) Anxiety. d) Caregiver role strain.

D - Caregiver role strain The nurse recognizes the mother's feelings of being overwhelmed with the issues concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support of other family members or friends, continue with psychoeducation, and help the family connect with the Alliance for the Mentally Ill for support, reassurance, and education.

When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem? a) The family is poor and the mother and father aren't married. b) The parents offer consistent explanations for the injury. c) The parents are argumentative and demanding with personnel. d) The injury isn't consistent with the child's history or age.

D - When the child's injuries are inconsistent with the history given or if the injuries couldn't have occurred naturally or accidentally because of the child's age and developmental stage, the emergency department nurse should suspect child abuse. Consistent explanations for the injury typically don't indicate child abuse. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of their child's injury.

A client is being successfully treated with clozapine. Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects? a) "I need to take the medicine with food to avoid nausea." b) "I have to get up slowly so I don't get dizzy." c) "Sometimes I have to push myself because I'm sleepy." d) "If I eat too many fruits, I'll get constipated."

D - Clozapine is the one atypical antipsychotic associated with severe anticholinergic adverse effects such as constipation. Consuming fruits would not be the cause of the client's constipation. The client should take clozapine with food to avoid nausea. Getting up slowly indicates that the client understands that postural hypotension may occur with clozapine. The statement about sleepiness indicates that the client understands that sedation may occur with this drug.

A client claims to have a "special mission from God". The nurse incorporates this religious delusion of grandeur into the client's plan of care based on the understanding that the primary purpose of such a delusion is to provide which of the following? a) Comfort. b) Safety. c) Sexual outlet. d) Self-esteem.

D - Delusions of grandeur provide the client with an exaggerated sense of self-esteem that is unrelated to the client's actual achievements. Other, less grandiose, religious delusions may provide comfort or meaning for the client. Delusions of persecution are frequently related to safety issues. Delusions may also be related to sexual issues.

A client with a head injury begins to have clear drainage from the nose. The nurse should: a) Tilt the head back at a 30-degree angle. b) Compress the nares for 10 seconds. c) Administer an antihistamine for postnasal drip. d) Document the presence and amount of fluid.

D - Document the presence and amount of fluid The clear drainage (cerebrospinal rhiorrhea) may result from a basal skull fracture caused by leakage of cerebrospinal fluid. The nurse should document the finding. Most leaks will close spontaneously. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat. It is not necessary to administer an antihistamine because the drainage may not be from postnasal drip

Which statement about dementia is accurate? a. The majority of people over age 85 are affected by dementia. b. Disorientation is the dominant and most disruptive symptom of dementia. c. People with early dementia do not tend to be distressed by symptoms. d. Hypertension, diminished activity levels, and head injury increase the risk of dementia.

D - HTN, diminished activity levels, and head injury increase the risk of dementia.

A client is hearing voices that are telling her to kill herself. She is demanding a knife to use on her wrists. Which of the following is most appropriate at this time? a) Search the client's room for potential weapons after locking the unit kitchen. b) Put the client in restraints after giving an I.M. dose of p.r.n. medication. c) Ask the client to talk about her anger and what is causing it. d) Give oral p.r.n. doses of haloperidol and lorazepam as ordered.

D - Haloperidol and lorazepam together decrease hallucinations and agitation, thus decreasing the risk of self-harm. Putting the client in restraints is premature because danger is not imminent. Asking the client to talk about her anger is inappropriate because the client is beyond rational conversation. A room search is appropriate only after the crisis with the client is handled.

Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of ineffective coping? A. Difficulty in relationships B. High levels of anxiety C. Manipulation D. Interdependence

D - Interdependence The characteristics for the diagnosis of ineffective coping include crisis, high levels of anxiety, anger, and aggression; child, elder, or spouse abuse; and difficulty in relationships and manipulation. Interdependence would not be considered a symptom for ineffective coping.

A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client's disturbed thought process? a) "I'd like you to come to group with me right now." b) "I don't see any foreign agents." c) "I don't know what you mean." d) "I think these thoughts are frightening to you."

D - The client's disturbed thought process likely reflect this client's paranoid delusions. The nurse should acknowledge that the thoughts are frightening the client. Telling the client the nurse does not see any foreign agents is an appropriate nursing response if the client is having disturbed visual sensory perception and is having visual hallucinations. Telling the client the nurse does not understand what the client means is an appropriate response if the client has impaired verbal communication. Suggesting that a client participate in group activities would be appropriate if the client had a nursing diagnosis of social isolation and was staying in his room.

A nurse is caring for a 17-year-old adolescent brought to the hospital by police in an agitated state after attempting to stab his mother. He is diagnosed with schizophrenia. After receiving haloperidol LA, the client stabilizes. His mother states that he is been troubled in the past, but is basically a good boy. She asks if she may take her son home now that he is better. Which response by the nurse is appropriate? a) "You'll need to discuss your concerns with the physician on duty." b) "A legal decision must be made before your son may go home." c) "The physician has determined that your son may be a danger to other people." d) "Your son is taking a very powerful medication and needs careful monitoring."

D - The mother's behavior does not indicate that she understands the seriousness of her son's condition; she must be educated about her son's diagnosis and how his illness is managed. The nurse is in a key position to provide such education by explaining about the client's medication and the need for careful monitoring. Telling the mother that she must talk with the physician dismisses the mother's concerns and deflects an opportunity to develop a therapeutic relationship. Stating that the son is a danger to other people might unnecessarily alarm the mother and does not provide sufficient information about his diagnosis. There is no indication that any legal restrictions or orders are in place.

A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique? a)Presenting reality b)Making observations c)Restating d)Exploring

D - The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.

"This food is garbage! I'll fight anyone who says it's not!" The nurse's most relevant assessment is that the client A. is upset with the quality of the food. B. is getting rid of tension in a harmless way. C. is frustrated by limits imposed by hospitalization. D. has a high potential for other-directed violence.

D - has a high potential for other-directed violence The client's offers to fight are suggestive of a high potential for violence. Clients may have coping skills that are adequate for day-to-day events in their lives but are overwhelmed by the stresses of illness or hospitalization. Other clients may have a pattern of maladaptive coping, which is marginally effective and consists of a set of coping strategies that have been developed to meet unusual or extraordinary situations.

Nurses coping with angry clients may find it helpful to remember that anger and aggression begin as feelings of A. isolation. B. confidence. C. competence. D. vulnerability.

D - vulnerability The progression is vulnerability, perception of event as a threat, arousal, and then uneasiness and anxiety.

A physician starts a client on the antipsychotic medication haloperidol-LA. The nurse is aware that this medication has adverse extrapyramidal effects. Which nursing measures should be taken during haloperidol administration? Select all that apply. a) Monitor blood glucose levels. b) Review subcutaneous (subQ) injection technique. c) Monitor the client for signs and symptoms of urticaria. d) Provide the client with the opportunity to pace. e) Closely monitor vital signs, especially temperature. f) Provide the client with hard candy.

D, E, F. • Closely monitor vital signs, especially temperature. • Provide the client with the opportunity to pace. • Provide the client with hard candy. Neuroleptic malignant syndrome is a life-threatening adverse extrapyramidal effect of antipsychotic medications such as haloperidol. It is associated with a rapid increase in temperature. The most common adverse extrapyramidal effect, akathisia, is a form of psychomotor restlessness that can often be relieved by pacing. Haloperidol and the anticholinergic medications that are provided to alleviate its extrapyramidal effects can result in dry mouth. Providing the client with hard candy to suck on can help alleviate this problem. Haloperidol is not given subQ and does not affect blood glucose level. Urticaria is not usually associated with haloperidol administration.

Which of the following are true of antisocial personality disorder (APD)? (select all that apply): A. It is the least studied of the personality disorders. B. It is characterized by rigidity and inflexible standards of self and others. C. Persons with APD display magical thinking. D. Persons with APD are concerned with personal pleasure and power. E. It is characterized by deceitfulness, disregard for others, and manipulation. F. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. G. Frontal lobe dysfunction is a brain change identified in APD.

D, E, and G. APD is the most studied and researched personality disorder. Rigidity and inflexible standards describe obsessive-compulsive personality disorder. Magical thinking describes schizotypal personality disorder. People with APD usually present with depression or because of the consequences of their behaviors, not because they care about the effects of their actions on others.

The client rushes out of the day room where he has been watching television with other clients. He is hyperventilating, flushed, and his fists are clenched. He states to the nurse, "That bastard! He's just like Tom. I almost hit him." Which of the following would be the nurse's best response? a) "I'm glad you left the situation. Why don't you go to your room and calm down. I'll come in soon to talk." b) "I can see you're angry. Let me get you some Ativan to help you calm down. Then we'll talk about what happened." c) "Even if you're angry, you can't use that language here." d) "You're angry and you did well to leave the situation. Let's walk up and down the hall while you tell me about it."

D. "You're angry and you did well to leave the situation. Let's walk up and down the hall while you tell me about it." The nurse acknowledges and labels the client's emotion and acknowledges his appropriate behavior. Recognizing the client's physiologic arousal, the nurse suggests an activity to decrease anxiety and stays with him. Setting limits on the client's language does not acknowledge his control and does not help the client manage his anxiety. The client needs to engage in physical activity to decrease muscle tension and anxiety. Offering the client medication suggests that he cannot control his behavior. Medication would be used only if other interventions failed to reduce the anxiety level.

A client waiting to see the physician is pacing and looking both angry and tense. When it's determined that the client won't be seen for another 30 minutes, the nurse addresses the client's agitation by A. telling the client that pacing will not help the rate at which clients are seen. B. adjusting the appointment schedule to allow the client to be seen next. C. empathizing with the long wait and asking the client if he would mind sitting down until his turn comes. D. explaining to the client what caused the back-up and suggesting that he has time to go to the coffee shop.

D. explaining to the client what caused the back-up and suggesting that he has time to go to the coffee shop. Taking time to explain to clients and offering measures that will provide comfort can be helpful in reducing tension and anger associated with waiting.

rape

Defined in the context of nonconsensual activity and involving any penetration of the vagina or anus with any object or body part or the oral penetration by a sex organ of another person

A client with a chronic mental illness who does not always take her medications is separated from her husband and receives public assistance funds. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and also receives public assistance benefits. The client's sister works outside the home, and the client's father is dead. Which of the following issues should the nurse address first? a) Family. b) Medication. c) Marital. d) Financial.

Medication noncompliance is a primary cause of exacerbation in chronic mental illnesses. Of the issues listed, medications should be addressed first. Other issues, such as family, marriage, and finances can be addressed as client stabilization is maintained.

Classifications of brain injury

Minor (GCS 13-15) Moderate (GCS 9-12) Severe (GCS 3-8)

echopraxia

The mimicking of movements of another, a positive symptom in schizophrenia

Which symptoms of schizophrenia tend to be more crippling, the positive or negative symptoms?

The negative symptoms tend to be more persistent and crippling because they reduce motivation and limit social and vocational success. They often prevent a patient with schizophrenia from living independently, holding down a job, & enjoying life.

A client receiving dialysis directs profanities at the nurse and then abruptly hangs his head and pleads, "Please forgive me. Something just came over me. Why do I say those things?" The nurse interprets this as which of the following? a) Confabulation. b) Neologism. c) Emotional lability. d) Flight of ideas.

This type of behavior illustrates emotional lability, which is a readily changeable or unstable emotional affect. Neologism is using a word when it can have two or more meanings, or a play on words. Confabulation involves replacing memory loss by fantasy to hide confusion; it is unconscious behavior. Flight of ideas refers to a rapid succession of verbal expressions that jump from one topic to another and are only superficially related.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? a) Granulocytopenia b) Hepatitis c) Systemic dermatitis d) Infection

a - granulocytopenia Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions to clozapine therapy.

motor retardation

a pronounced slowing of movement, a positive symptom of schizophrenia

The harmful or offensive touching of another person

battery

A disorder characterized by disordered images of self, impulsive and unpredictable behavior, marked shifts in mood, and instability in relationships with others.

borderline personality disorder

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. The nurse should: a) Notify the primary care provider. b) Administer the ordered fluids. c) Verify that the infant has urinated. d) Have the potassium level redrawn.

c - Verify that the infant has urinated. Reason: Normal serum potassium levels are 3.5-4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4Meq/l is not unexpected and should be corrected with the ordered fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.

The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes? a)Coordinate documentation of the incident. b)Resolve negative feelings and attitudes. c)Improve the use of restraint procedures. d)Calm down before returning to the other clients.

c) Improve the use of restraint procedures. Reason: Although coordinating documentation, resolving negative feelings, and calming down are goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.

Including unnecessary and often tedious details in one's conversation

circumstantiality

choosing words based on their sound rather than their meaning, often rhyming or having a similar beginning sound ("On the track .... have a Big Mac"; "Click, clack, clutch, close").

clang association

An injury to parts of the brain located on the side opposite that of the primary injury

contrecoup

The bruising of the brain tissue within a focal area

contusion

The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective? a) Abnormal thought form. b) Hallucinations and delusions. c) Bizarre behavior. d) Asocial behavior and anergia.

d - Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. Abnormal thought form is a positive symptom of schizophrenia. Hallucinations and delusions are positive symptoms of schizophrenia. Bizarre behavior is a positive symptom of schizophrenia.

A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: a)delusion. b)looseness of association. c)illusion. d)hallucination.

d - Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.

A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: a) delusion. b) looseness of association. c) illusion. d) hallucination.

d) hallucination. Reason: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.

Sally wrongly accused her spouse of going out with other women. Her proof was that he twice came home from work late (even though his boss explained that everyone had worked late). Is Sally experiencing a delusion and if so, which type?

jealousy

Believing that one's mate is unfaithful

jealousy, a type of delusion

avolition

loss of motivation

The term for a generalized brain injury

diffuse

A decreased LOC, increased ICP, decortication or decerebration, and global cerebral edema are clinical signs of what?

diffuse axonal injury (DAI)

Widespread axonal damage occurring after a mild, moderate, or severe TBI

diffuse axonal injury (DAI)

Depriving an individual of a nurturing atmosphere in which he or she can thrive, learn, and develop

emotional abuse

collection of blood between the dura and the inner surface of the skull, producing compression of the dura matter and thus of the brain

epidural hemotoma

The term for a localized brain injury

focal

The client diagnosed with late-stage Alzheimer's disease is agitated and having delusions. Which medication should the nurse anticipate the health-care provider prescribing? 1. the cholinesterase inhibitor donepezil (Aricept) 2. the antipsychotic medication haloperidol (Haldol) 3. the selective serotonin reuptake inhibitor fluoxetine (Prozac) 4. the tricyclic antidepressant amitriptyline (Elavil)

haloperidol Delusions and agitation respond to antipsychotic medications. Haldol has been used and has proven to be effective in treating these symptoms, so the nurse should anticipate this prescription. (Aricept is prescribed in the early stages of Alzheimer's disease but would not be effective in the late stages.

catatonia

A pronounced increase or decrease in the rate and amount of movement, a positive symptom of schizophrenia

A nursing intervention designed to help a schizophrenic client manage relapse is to A. schedule the client to attend group therapy that includes those who have relapsed. B. teach the client and family about behaviors associated with relapse. C. remind the client of the need to return for periodic blood draws to minimize the risk for relapse. D. help the client and family adapt to the stigma of chronic mental illness and periodic relapses.

ANSWER = B By knowing what behaviors signal impending relapse, interventions can be quickly invoked when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted.

A reduction in spontaneity or volume of speech

alogia, or poverty of speech, a positive symptom of schizophrenia

Reduced motivation and spontaneous activity

avolition

an irrational fear of others, ranging from mild to profound

paranoia, a positive symptom of schizophrenia

The overall goal for the acute phase of schizophrenia

patient safety and stabilization

A nurse caring for a client diagnosed with schizophrenia should perform which of the following interventions when the client becomes suspicious and refuses to take his medication? a) Attempt to coax the client into taking the medication by calling him honey b) Wait for a short time and then attempt to administer the medication c) Document that the client is noncompliant d) Tell the client he must take the medication now

ANSWER = B A flexible care plan is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and at different times and is sometimes in control of himself, the nurse must be able to adjust nursing care as the situation warrants, such as offering the medication again after waiting for a short period of time. Forcing the client to take the medication now and calling the client honey may anger the client

A client diagnosed with residual schizophrenia is uninterested in community activities. He lacks initiative, demonstrates both poverty of content of speech and poverty of speech, and seems unable to follow the schedule for taking his antipsychotic medication. The case manager continues to direct his care with the knowledge that his behavior is most likely prompted by A. chronic uncooperativeness. B. personality conflict. C. neural dysfunction. D. dependency needs.

ANSWER = C Schizophrenia is considered a neurobiological disorder. The course of schizophrenia involves recurrences. With each relapse further deterioration is noted. Residual schizophrenia refers to the disorder when active phase symptoms are no longer present and the individual is left with two or more of the following symptoms: lack of initiative, social withdrawal, impaired role function, marked speech deficits, and odd beliefs.

A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. A therapeutic response for the nurse would be A. "You are safe here in the hospital; nothing bad will happen to you." B. "The voices are wrong about the hospital food. It is not contaminated." C. "I understand that the voices are very real to you, but I do not hear them." D. "Other people are eating the food, and nothing is happening to them."

ANSWER = C This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing.

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take? a) Suggest that the client drink warm beverages and rest. b) Have the client decrease the daily amount of clozapine by half. c) Obtain an order for the client to have a white blood cell count drawn. d) Encourage the use of saline mouth rinses until the sore throat is gone.

C - Obtain an order for the client to have a white blood cell count drawn. Explanation: The report of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. The way to determine this is by obtaining a white blood cell count. The other options do not get to the cause of the client's concern

A false perception that the environment has changed

derealization

alogia

poverty of thought

schizophasia

word salad, a positive symptom of schizophrenia

misperceptions or misinterpretations of a real experience

illusions

anhedonia

inability to experience pleasure or joy

A client has reached the stable plateau phase of schizophrenia. An appropriate clinical focus for planning would be A. safety and crisis intervention. B. acute symptom stabilization. C. stress and vulnerability assessment. D. social, vocational, and self-care skills.

ANSWER = D During the stable plateau phase of schizophrenia, planning is geared toward client and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community.

The preferred drugs for psychosis

second-generation (atypical) antipsychotics because they result in a lower incidence of serious adverse effects

another name for the atypical antipsychotics

second-generation antipsychotics

When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be A. "You are safe here. This is a locked unit, and no one can get in." B. "I do not believe I understand the word volmers. Tell me more about them." C. "Why do you think someone or something is going to harm you?" D. "It must be frightening to think something is going to harm you."

ANSWER = D This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. Option A gives global reassurance. Option B encourages elaboration about the delusion. Option C asks for information that the client will likely be unable to answer.

Extrapyramidal symptoms

Acute dystonia Akathisia Parkinsonism Tardive dyskinesia

While looking out the window at trees, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which term best describes what the creatures represent? a) Delusion b) Anxiety attack c) Hallucination d) Projection

A - Delusion Explanation: A delusion is a false belief that has no basis in reality. Although anxiety can increase delusional responses, it isn't considered the primary symptom. Projection is falsely attributing one's unacceptable feelings to another person. Hallucinations, which characterize most psychoses, are perceptual disorders of the five senses; the client may see, taste, feel, smell, or hear something in the absence of external stimulation

The nurse is working with a client with depression in a mental health clinic. During the interaction, the nurse uses the technique of self-disclosure. In order for this technique to be therapeutic, which of the following steps must be a priority for the nurse? a) Ensuring relevance to, and quickly refocusing upon, the client's experience b) Asking for the client's perception of what the nurse has revealed c) Allowing the client time to ask questions about the nurse's experience d) Discussing the nurse's experience in detail

A - Ensuring relevance to, and quickly refocusing upon, the client's experience. Explanation: The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, the discussion should not dwell on the nurse's own experience.

The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the physician? a) The changes suggest that the adolescent's intracranial pressure is increasing. b) The adolescent may be developing a severe infection from the head injury. c) The physician should be notified of any changes in a client's condition. d) Too much pain medication can cause the changes observed by the nurse

A - The changes suggest that the adolescent's intracranial pressure is increasing. Explanation: Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure, which indicates that the teen's condition is deteriorating

A client diagnosed with schizophrenia and alcohol abuse decides to drink alcohol with his buddies. The nurse interprets this behavior, recognizing which of the following as an underlying dynamic of the client's alcohol use? a) The decision to use alcohol is a wish to feel accepted by others. b) The client abused alcohol before developing a mental illness. c) The client is compelled to drink because of cognitive difficulties. d) The decision to drink increases the client's guilt and shame.

A - The decision to use alcohol is a wish to feel accepted by others. Explanation: The client's decision to drink results in feeling accepted by his peers which increases his self-esteem. Guilt or shame may result later because the client is aware that he should not use alcohol because of his mental illness. The combination of a mental illness and substance abuse results in increased recidivism and treatment complications. It may not be true that the client abused alcohol before developing a mental illness or that the client is compelled to drink because of cognitive difficulties. The client may be predisposed to developing a substance abuse problem and a mental illness because of heredity and biologic factors.

A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as A. a neologism. B. clang association. C. blocking. D. a delusion.

ANSWER = A A neologism is a newly coined word that has meaning only for the client.

ANSWER = A Beginning to question his or her own altered perceptions by seeking input from staff is highly desirable.

A client, who has been receiving antipsychotic medication for 6 weeks, tells the nurse that the hallucinations are nearly gone and that concentration has improved. When the client reports flulike symptoms including a fever and a very sore throat, the nurse should A. suggest that the client take something for her fever and get extra rest. B. advise the physician that the client should be admitted to the hospital. C. arrange for the client to have blood drawn for a white blood cell count. D. consider recommending a change of antipsychotic medication.

C - Antipsychotic medications may cause agranulocytosis, the first manifestation of which may be a sore throat and flulike symptoms.

The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to: a) control inappropriate impulses. b) explain one's psychiatric diagnosis. c) understand the nature of one's problem or situation. d) make appropriate choices.

C - understand the nature of one's problem or situation. Explanation: Insight is the ability to understand a situation or problem and its effect on one's life. Judgment is the ability to make appropriate choices and behave in an appropriate manner. A client may be able to explain the psychiatric diagnosis but may lack the insight to understand the underlying problem and how it's affecting his life.

A client with schizophrenia is having an acute exacerbation of symptoms. The client states, "Black cats and black hats. Where does the time go?" Which of the following would be most important for the nurse to say? a) "Halloween is getting close, isn't it." b) "Time certainly does go faster these days." c) "Do you have a black cat?" d) "What's the connection between cats, hats, and time?"

D - "What's the connection between cats, hats, and time?" Explanation: The client is demonstrating loose associations. Therefore, the nurse needs to clarify the meaning of and the connection between ideas. The nurse's statement about Halloween makes the assumption that the client is talking about Halloween from the mention of black cats and black hats. Asking if the client has a black cat is not helpful. The statement about time going faster ignores the client's statement entirely.

represented by a lack of spontaneous comments and overly brief responses

alogia, or poverty of speech, a positive symptom of schizophrenia

represented by delays in responding to questions or difficulty finishing one's thoughts

cognitive retardation

A generalized slowing in the pace of thinking

cognitive retardation, a positive symptom of schizophrenia

An individual hearing voices that direct the person to take action

command hallucinations

refers to an impaired ability to think abstractly

concrete thinking, a positive symptom of schizophrenia

In this type of delusion a person believes that another person, group of people, or external force controls thoughts, feelings, impulses, or behavior

control

false fixed beliefs that cannot be corrected by reasoning

delusions

A feeling that one is somehow different or unreal or has lost his identity

depersonalization

People experiencing this may feel that body parts do not belong to them or may sense that their body has drastically changed

depersonalization

Repeating of the last words spoken by another

echolalia

mimicry or imitation of the speech of another person

echolalia, a positive symptom of schizophrenia

Although he barely knew her, Patti insisted that Eric would marry her if only his current wife would stop interfering. What type of delusion is Patti experiencing?

erotomanic

Believing that another person desires you romantically

erotomanic

the ability to set priorities or make decisions

executive functioning

Moving rapidly from one thought to the next, making it difficult for others to follow the conversation

flight of ideas, a positive symptom in schizophrenia

involve perceiving a sensory experience for which no external stimulus exists

hallucinations

With this type of delusion, a person perceives events as relating to them when they are not

ideas of reference

The false impression that outside events have special meaning for oneself

ideas of reference, a type of delusion

This disorder of thinking that can occur in people with schizophrenia is common in children

magical thinking, a positive symptom of schizophrenia

Is alogia a positive or negative symptom of schizophrenia?

negative

The absence of something that should be present

negative symptoms

Peter believed that the Secret Service was planning to kill him by poisoning his food; therefore, he would eat only prepackaged food. Which type of delusion is Peter experiencing?

persecution

this belief often takes the form of a plot by people in power

persecution

Believing that one is being singled out for harm by others

persecution, a type of delusion

Classes of conventional antipsychotics

phenothiazines and nonphenothiazines

Are abnormal movements a positive or negative symptom of schizophrenia?

positive

Are agitation and anxiety positive or negative symptoms of schizophrenia?

positive

Are delusions a positive or negative symptom of schizophrenia?

positive

Are disorganized thoughts and speech considered positive or negative symptoms of schizophrenia?

positive

Are hallucinations a positive or negative symptom of schizophrenia?

positive

Is associative looseness a positive or negative symptom of schizophrenia?

positive

Is bizarre behavior a positive or negative symptom of schizophrenia?

positive

Is paranoia a positive or negative symptom of schizophrenia?

positive

The presence of something that is not normally present

positive symptoms

An excessive preoccupation with religious themes

religiosity, a positive symptom of schizophrenia

Which antipsychotics are more effective at resolving negative psychotic symptoms?

second-generation (atypical) antipsychotics

David said his heart had stopped and was rotting away. What is David experiencing?

somatic delusion

Believing that the body is changing in unusual ways

somatic delusions

Repeated motor behaviors that do not serve a logical purpose

stereotyped behaviors

Leaving the main topic to talk about less important information

tangentiality

These antipsychotics result in a lower incidence of serious adverse effects

the second-generation (atypical) antipsychotics

A reduction in the amount of thinking

thought blocking, a positive symptom of schizophrenia

an abrupt stoppage of thought that derails conversation

thought blocking, a positive symptom of schizophrenia

A belief that one's thoughts have been taken or are missing

thought deletion, a positive symptom of schizophrenia

feeling that one's thoughts are not one's own or that they were inserted into one's mind

thought insertion, a positive symptom of schizophrenia

a jumble of words that is meaningless to the listener—and perhaps to the speaker as well—because of an extreme level of disorganization

word salad

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