Behavioral Health

Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)

"Are there others in your family who must do things in a certain way to feel comfortable?" "Is it difficult to keep certain thoughts out of your awareness?" "Do you do certain things over and over again?"

Which of these statements by a nurse suggests that the nurse will display cultural sensitivity when interviewing a patient from a different culture?

"Before the interview I will take a few minutes to review actions that might offend a patient of this culutre."

A nurse is caring for a client who is in restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply).

"Client was offered 8 ounces of water every hour." "Client shouted obscenities at assistive personnel." "Client received chlorpromazine 15 mg by mouth at 1000."

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?

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

A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?

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

A patient has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this patient shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response.

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

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide?

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

A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, "What should we do?" Select the nurse's best response.

"Give your child a kiss before you leave the preschool program."

Which statement demonstrates a well-structured attempt at limit setting?

"Hitting me when you are angry is unacceptable."

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse.

"How do you feel about that?"

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis?

"I am fat and ugly."

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's most therapeutic response.

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

A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?

"I check where my car keys are eight times."

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective?

"I felt empty and wanted to hurt myself, so I called you."

A person's spouse filed charges after repeatedly being battered. The person sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by this person supports an antisocial personality disorder?

"I hit because I am tired of being nagged. My spouse deserves the beating."

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication.

"I notice you keep looking toward the door."

A patient says, "Please don't share information about me with the other people." How should the nurse respond?

"I will not share information with your family or friends without your permission, but I will share information about you with other staff."

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:

"I'd like to talk with you about how you're feeling right now."

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response?

"I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope."

A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be:

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

A client has received a new prescription for paroxetine. Which of the following instructions should the nurse include when working with this client?

"It can take several weeks before you feel like the medication is helping."

A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response.

"Let's consider the advantages of being able to stop and think before acting."

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?

"Let's consider which problems are very important and which are less important."

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization?

"Let's look at one bad thing that happened to see if another explanation exists."

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?

"My fingers are tingly."

A patient asks, "What are neurotransmitters? My doctor said mine are imbalanced." Select the nurse's best response.

"Neurotransmitters are natural chemicals that pass messages between brain cells."

Which instruction has priority when teaching a patient about clozapine?

"Report sore throat and fever immediately."

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response.

"Taking the medication every day helps reduce the risk of a relapse."

A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? (Select all that apply.)

"Tell me how you discipline your children." "How do you stop your baby from crying?" "Caring for four small children must be difficult."

A patient diagnosed with alcohol use disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively?

"Tell me what happened the last time you drank."

A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking?

"The table of contents tells what a book is about."

Which hallucination necessitates the nurse to implement safety measures? The patient says,

"The voices say everyone is trying to kill me."

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate?

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

Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management?

"We spend daily family time talking about experiences and feelings."

A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient:

"What do you eat in a typical day?"

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse?

"You are feeling violated because you thought you could trust your partner."

A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response.

"You don't think you're making progress?"

Which statement shows a nurse has empathy for a patient who made a suicide attempt?

"You must have been very upset when you tried to hurt yourself."

A patient diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient?

"You're wearing a new shirt."

One bed is available on the inpatient eating-disorder unit. Which patient should be admitted to this bed? The patient whose weight decreased from

150 to 100 pounds over a 4-month period. Vital signs are temperature, 96.6° F; pulse, 38 beats/min; blood pressure 60/40 mm Hg

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate?

"Am I correct in understanding that."

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.)

82-year-old white male 17-year-old white female 19-year-old Native American male

Which child demonstrates behaviors indicative of a neurodevelopmental disorder?

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

Which individual in the emergency department should be considered at highest risk for completing suicide?

A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

Select an example of a tort.

A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed.

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care?

A wish for revenge

The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with

ADHD

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for

ADHD

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu?

Ability to provoke interpersonal conflict

Which goal for treatment of alcohol use disorder should the nurse address first?

Achieve physiological stability.

A nurse is providing patient teaching to a patient who has been prescribed Lorazepam (Ativan). What should the patient know about this drug as it relates to central nervous system (CNS) depression? Select all that apply.

Advise the client to avoid driving, and operating heavy equipment. To avoid alcohol and other CNS depressentant when taking this medication. Expect possibility of light-headedness and sedation.

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood?

Affect flat; mood depressed

An older adult diagnosed with Alzheimer's disease lives with family in a rural area. During the week, this adult attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this adult most vulnerable to abuse?

Alzheimer's disease

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely?

Amphetamines

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?

An acute dystonic reaction

Which experiences are most likely to precipitate PTSD? (Select all that apply).

An adolescent was kidnapped and held for 2 years in the home of a sexual predator. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

Which individual with mental illness may need involuntary hospitalization?

An individual with bipolar disorder, manic phase, who has not eaten in 4 days.

In psychiatric nursing, a nurse knows that the assessment of a client refers exclusively to:

An individual, family, group or community

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior?

Anger is an expected emotion in an adjustment disorder.

The nurse has a patient with dissociative disorders. She also recognizes certain medications are often prescribed for the hyperarousal and intrusive symptoms that accompany PTSD and dissociation. What type of medications could the nurse anticipate for the patient to receive? (Select all that apply)

Antidepressants medications Antianxiety medications Antipsychotics

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.)

Appoint a person to clear a path and open, close, or lock doors. Select the person who will communicate with the patient. Remove jewelry, glasses, and harmful items.

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

Aripiprazole

Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy?

As depression lifts, physical energy becomes available to carry out suicide.

Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa?

Assist the patient to identify triggers to binge eating.

A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident?

Associative looseness

Which ethical principle refers to the individual's right to make his or her own decisions?

Autonomy

A nurse has been working in the community with a patient for 6 months to establish a relationship with a delusional and suspicious patient. The patient has no employment, has no money for medications and is decompensating. Should the patient be hospitalized or provided with medications and allowed to remain to home?

Autonomy Beneficence

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD?

Avoidance

A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who begins a new prescription for Lorazepam (Ativan). What information should be included? (Select all that apply.)

Avoidance of alcohol and other sedatives The importance of caffeine restriction Caution in use of machinery

A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group?

Benzodiazepines

An individual hiking in the forest encounters a large poisonous snake on the path. Which change in this individual's vital signs is most likely?

Blood pressure changes from 114/62 to 136/78.

A woman is 5'7", 160 lbs. and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?

Body dysmorphic disorder

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.)

Callous attitude Aggression

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse:

Can be charged with battery.

Which action by the nurse best supports the right of patients to be treated with dignity and respect?

Consistently address patient by title and surname.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "This patient is like one of my grandparents ... so helpless." Which response is the nurse demonstrating?

Counter-transference

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Darting eyes, tilted head, mumbling to self

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

Denial

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?

Diaphoresis, weakness, and nausea

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select?

Distraction: "Let's go to the dining room for a snack."

Which assessment findings are likely for an individual who recently injected heroin?

Drowsiness, constricted pupils, slurred speech

At what point in the nurse-patient relationship should a nurse plan to first address termination?

During the orientation phase

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely?

Emotional

A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse's best first action?

Encourage the victimized child to share feelings about the experience.

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

Euphoric

A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care?

Explain that the physical symptoms are related to the psychological state.

Which intervention by a psychiatric nurse best applies the ethical principle of autonomy?

Explores alternative solutions with a patient, who then makes a choice.

When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action?

External controls are necessary due to failure of internal control.

A nurse is caring for a client who has a psychotic disorder in seclusion over night due to the unit being short-staffed. The nurse's actions are an example of which of the following torts?

False imprisonment

If a nurse is charged with leaving a suicidal client unattended, it is being suggested that the nurse's behavior has violated the ethical principle of

Fidelity

A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier?

Fireworks display on July 4th

An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed?

Fluoxetine

Which medication should the nurse be prepared to educate patients on when they are prescribed a selective serotonin re-uptake inhibitor (SSRI) for panic attacks?

Fluoxetine (Prozac)

A nurse is caring for her patient and she is discussing the importance of washing hands. This would be an example of promoting?

Good

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

Gynecomastia

Which assessment findings present familial risks for a child to develop a psychiatric disorder? (Select all that apply.)

Having a mother diagnosed with schizophrenia Living with an alcoholic parent

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical?

Heart failure

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?

Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.

Help the patient identify incidents that trigger impulsive anger.

Which measure would be considered a form of primary prevention for suicide?

Helping school children learn to manage stress and be resilient

What feelings are most commonly experienced by nurses working with abusive families?

Helplessness regarding the victim and anger toward the abuser

A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive?

History of family violence

Which assessment finding presents the greatest risk for violent behavior directed at others?

History of spousal abuse

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving?

Honeymoon

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care?

Hyperactivity; not eating and sleeping

A patient's history shows drinking 4 to 6 L of fluid and eating more than 6,000 calories per day. Which part of the central nervous system is most likely dysfunctional for this patient?

Hypothalamus

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies?

Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

A patient being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5'4". The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis.

Imbalanced nutrition: less than body requirements related to self-starvation

A child diagnosed with ADHD shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior?

Improved abilities to participate in cooperative play with other children

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

Impulsivity

The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)

Ineffective home maintenance Chronic low self-esteem Risk for injury

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?

Jumping from a railroad bridge located in a deserted area late at night

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically in using restraints to prevent one patient from engaging in self-mutilating behavior while the care plan for another self-mutilating patient calls for one-on-one supervision." Which ethical principle most clearly applies to this situation?

Justice

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply.)

Keep a cell phone fully charged. Have the phone number for the nearest shelter. Secure a supply of current medications for self and children. Assemble birth certificates, Social Security cards, and licenses. Determine a code word to signal children when it is time to leave.

As a patient admitted to the eating-disorder unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5'4" tall. Which term should be documented?

Lanugo

A nurse is teaching the parents of a school-age child about transdermal methylphenidate. Which of the following instructions should the nurse include.

Leave the patch on for 9 hours.

A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first?

Lower the patient's current anxiety.

Which statement is true regarding mail sent to an involuntarily admitted client residing on a psychiatric inpatient unit?

Mail is a form of social interaction and so receiving mail is a client's civil right.

Which nursing interventions will be implemented for a patient who is actively suicidal? (Select all that apply.)

Maintain arm's length, one-on-one direct observation at all times. Check all items brought by visitors and remove risk items.

What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation?

Maintaining consistent limits

The intervention that will be most effective in preventing a nurse from making decisions that will lead to legal difficulties is

Maintaining currency in state laws affecting nursing practice.

A patient diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective?

Make observations.

By which mechanism do SSRI medications improve depression?

Making more serotonin available at the synaptic gap

A nurse will prepare teaching materials for the parents of a child newly diagnosed with ADHD. Information will focus on which medication likely to be prescribed?

Methylphenidate

A patient diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient?

Milk

A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety?

Moderate

A patient diagnosed with bipolar disorder displays aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group?

Mood stabilizers

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed?

Mood stabilizing medication

Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?

Naltrexone

While talking with a patient diagnosed with major depressive disorder, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest. The patient looks at the floor. Which aspect of communication has the nurse assessed?

Nonverbal communication

A fearful patient has an increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter?

Norepinephrine

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority?

Notify the health care provider to obtain a seclusion order.

Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight?

Observe for adverse effects of refeeding.

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?

Olanzapine

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?

Olanzapine

Which actions violate the civil rights of a psychiatric patient? The nurse: You may select more than one answer.

Opens and reads a letter a patient left at the nurse's station to be mailed. Restrains a patient who uses profanity when speaking to the nurse.

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident?

Paranoia

Which clinical scenario predicts the highest risk for directing violent behavior toward others?

Paranoid delusions of being followed by alien monsters

A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?

Patient involvement in decision making increases sense of control and promotes adherence to the plan of care.

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger?

Periodically provide an update and progress report on the patient.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment?

Physical injuries

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

Physiological

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?

Poor judgment and hyperactivity

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

Poor personal hygiene

Which finding constitutes a negative symptom associated with schizophrenia?

Poverty of thought

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident?

Projection

A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?

Pseudoparkinsonism

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend?

Psychoeducational

A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.)

Recent stressful life event Self-imposed isolation Humiliation Shame

The nurse administers a medication that potentiates the action of ã-aminobutyric acid (GABA). Which effect would be expected?

Reduced anxiety

Which issues should a nurse address during the first interview with a patient with a psychiatric disorder?

Relationship parameters, the contract, confidentiality, and termination

A patient begins therapy with a phenothiazine medication. What teaching should the nurse provide related to the drug's strong dopaminergic effect?

Report changes in muscle movement.

The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3. Select the nurse's best action.

Report the results to the health care provider immediately.

What is a nurse's legal responsibility if child abuse or neglect is suspected?

Report the suspicion according to state regulations

A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?

Respiratory

Which technique will best communicate to a patient that the nurse is interested in listening?

Restating a feeling or thought the patient has expressed.

Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa?

Rigidity, perfectionism

A patient tells the nurse, "My doctor prescribed paroxetine for my depression. I assume I'll have side effects like I had when I was taking imipramine." The nurse's reply should be based on the knowledge that paroxetine is a(n)

SSRI

As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response?

Say to the patient, "I must watch you take the medication. Please take it now."

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.)

Schizotypal Borderline Antisocial Obsessive-compulsive

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient?

Sedation and muscle stiffness

A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety?

Severe

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

Silence can provide meaningful moments for reflection.

What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for ADHD?

Sleep disturbances and weight loss

Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan was effective?

Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

A desired outcome for a 12-year-old diagnosed with ADHD is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care?

Social skills group

An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

Social skills training

A nurse in an outpatient mental setting is collecting a health history from a client who is taking paroxetine for depression. The client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine?

St. John's Wort

Which behavior best demonstrates aggression?

Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?

Strong negative feelings interfere with assessment and judgment.

It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.

Supervise the patient 24 hours a day.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment?

Supporting physiological stability

When a 5-year-old diagnosed with ADHD bounces out of a chair and runs over and slaps another child, what is the nurse's best action?

Take the aggressive child to another room.

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action.

Tell the client, "You are in a safe place where you will be helped."

As a nurse you hear a newly licensed nurse talking about a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

Tell the nurse to stop discussing the behavior.

A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis?

The child frequently eats newspapers and magazines.

Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness?

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

The nurse is caring for a client who has been determined to not have the capacity to make his own decisions. The nurse knows that she should ask

The court appoints a guardian to make decision on his behalf.

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient's hand. Select the correct analysis of the nurse's behavior.

The gesture is premature. The patient's cultural and individual interpretation of touch is unknown.

A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed?

The nurse interacts with the patient in a protective fashion.

The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate (amphetamine) to the plan of care for a patient diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team?

The patient's history of substance abuse

The civil rights of persons with mental illness who are hospitalized for treatment are

The same as those for all citizens

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred?

Tolerance has developed.

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

Waxy flexibility

What assessment findings mark the prodromal stage of schizophrenia?

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. Select the priority outcome.

Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute.

A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding?

Word salad

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved?

Working

A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as

a neologism.

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room

accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control."

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will

acknowledge manipulative behavior when it is called to his or her attention.

The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by

acting without thought on urges or desires.

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as

an idea of reference.

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of

anhedonia

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should

arrange for one-on-one supervision.

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should

assess lung sounds and extremities.

When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to

avoid alcoholic beverages.

The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply)

avoids people and places that arouse painful memories. experiences flashbacks or re-experiences the trauma. experiences symptoms suggestive of a heart attack. demonstrates hypervigilance or distrusts others. feels detached, estranged, or empty inside.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with

bipolar I disorder.

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates

boundary blurring.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? It will

bring hyperactivity under rapid control.

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has

bruises on extremities

Priority interventions for a patient diagnosed with major depressive disorder and feelings of worthlessness should include

careful unobtrusive observation around the clock.

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child

continuously rocks in place for 30 minutes.

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for

depression

Which behavior shows that a nurse values autonomy? The nurse

discusses options and helps the patient weigh the consequences.

Termination of a therapeutic nurse-patient relationship has been successful when the nurse

discusses with the patient changes that happened during the relationship and evaluates outcomes

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child

displays resiliency.

A drug causes muscarinic receptor blockade. The nurse will assess the patient for

dry mouth.

A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to

establish trust with the patient.

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is

exhibiting clues to potential aggression.

An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult

expresses frustration verbally instead of physically.

A disheveled patient in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. The nurse will

firmly and neutrally assist the patient with showering.

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include

grandiosity, self-importance, and a sense of entitlement.

Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? The patient

has a high tolerance to alcohol.

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who

have been abused.

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child

holds the parent's hand while walking.

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is

hopelessness

A nurse instructs a patient taking a drug that inhibits MAO to avoid certain foods and drugs because of the risk of

hypertensive crisis.

A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of

hypertensive crisis.

A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will

identify two alternative methods of coping with loneliness.

A nurse can anticipate anticholinergic side effects are likely when a patient takes

imipramine

A nurse caring for a patient taking a SSRI will develop outcome criteria related to

improvement in depression.

The patient says, "My marriage is just great. My spouse and I always agree." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patient's communication is

incongruous.

A nurse worked with a patient diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of

ineffectiveness and frustration.

For which behavior would limit setting be most essential? The patient who

is flirtatious and provocative with staff members of the opposite sex.

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving

lithium

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic?

lorazepam

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should

maintain a normal social interaction distance from the patient.

A health teaching plan for a patient taking lithium should include instructions to

maintain normal salt and fluids in the diet.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should

make sure there is adequate physical space between the nurse and patient.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as

manipulative.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with

meals

A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience as

mild anxiety.

A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will

name two community resources for help.

Symptoms of withdrawal from opioids for which the nurse should assess include

nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient

not to skip meals or restrict food.

A drug blocks the attachment of norepinephrine to α1 receptors. The patient may experience

orthostatic hypotension.

Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are

perfectionist, inflexible.

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will

perform self-care activities with coaching by the end of day 3.

A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis?

persistent thoughts about bacteria, germs, and dirt

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient

presented a clear and present danger to others.

A nurse would anticipate that treatment for a patient with memory difficulties might include medications designed to

prevent destruction of acetylcholine.

Physical assessment of a patient diagnosed with bulimia often reveals

prominent parotid glands.

A nurse conducting group therapy on the eating-disorder unit schedules the sessions immediately after meals for the primary purpose of

promoting processing of anxiety associated with eating.

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate

rapport and trust with the nurse.

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to

reduce loneliness and increase self-esteem.

A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about

reporting increased suicidal thoughts.

A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n)

sedative, such as lorazepam or chlordiazepoxide.

A patient is hospitalized for severe major depressive disorder. Of the medications listed below, the nurse can expect to provide the patient with teaching about

sertraline

The exact cause of bipolar disorder has not been determined; however, for most patients

several factors, including genetics, are implicated.

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as

splitting

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of

substance abuse.

A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes

substance addiction.

A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will

teach the patient strategies to manage postural hypotension.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is

within therapeutic limits.