Ch 16, 17, 18

A patient diagnosed with schizophrenia is acutely 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 is thrust forward, and the patient is drooling. Which effect is the patient demonstrating? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back; opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies that require immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis; it appears after prolonged treatment. Waxy flexibility is a symptom observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, magical thinking, poor concentration, and perceptual disturbances b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Early prodromal symptoms include social withdrawal and deterioration in functioning, depressive mood, perceptual disturbances, magical thinking, and peculiar behavior. Changes in self-care, sleeping or eating patterns, and changes in school or work performance may also be evidenced. The incorrect options each list the positive symptoms of schizophrenia that are more likely to be apparent during the acute stage of the illness.

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily and has now reported being nauseated. To reduce the nausea, what will the nurse suggest the lithium be taken with? a. Food b. An antacid c. A large glass of juice d. An antiemetic medication

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

A nurse reviewing the laboratory results for a patient diagnosed with bipolar disorder notes the lithium level as 1 mEq/L. How will the nurse interpret this information about the medication level? a. It requires no additional nursing intervention. b. It is below recognized therapeutic serum limits. c. It is above recognized therapeutic serum limits. d. It indicates a need for immediate medical intervention.

ANS: A The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

. Which condition is characterized with apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy? a. Alzheimer's disease b. Wernicke encephalopathy c. Central anticholinergic syndrome d. Acquired immunodeficiency syndrome (AIDS)-related dementia

ANS: A The problems are all aspects of the pathophysiological characteristics of Alzheimer's disease. These characteristics are not noted in any of the other options.

A patient diagnosed with schizophrenia begins to talk about "cracklomers" in the local shopping mall. The term "cracklomers" should be documented using what term? a. Neologism b. Concrete thinking c. Thought insertion d. An idea of reference

ANS: A A neologism is a newly coined word having special meaning to the patient. "Cracklomers" is not a known word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others that are implanted in one's mind. An idea of reference is a type of delusion in which trivial events are given personal significance.

An older adult diagnosed with moderate-stage Alzheimer's disease forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Labeling the bathroom door b. Taking the older adult to the bathroom hourly c. Placing the older adult in disposable adult diapers d. Making sure the older adult does not eat nonfood items

ANS: A A patient with moderate Alzheimer's disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and their role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation.

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment place the patient at risk for injury.

This is the primary reason that the cause of bipolar disorder has not been determined? a. Several factors, including genetics, are implicated. b. Brain structures were altered by trauma early in life. c. Excess norepinephrine is probably a major factor. d. Excess sensitivity in dopamine receptors may exist.

ANS: A At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances. All the remaining options are too narrow in their cope.

An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of which adverse reaction to the medication therapy? a. Delirium b. Dementia c. Amnestic syndrome d. Alzheimer's disease

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol. Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately; therefore, the intramuscular route is best. In this case, the best option given is diphenhydramine.

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the patient and health care provider? a. Use of long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam c. Adjunctive use of an antidepressant, such as amitriptyline d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

ANS: A Medications such as paliperidone, fluphenazine decanoate, and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for nonadherence. The incorrect options do not address the patient's dislike of taking pills.

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patient's sense of humor by telling jokes.

ANS: A Patients with a cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes meaningless.

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

A health teaching plan for a patient taking lithium should include which instructions? a. Maintain normal salt and fluids in the diet. b. Drink twice the usual daily amount of fluids. c. Double the lithium dose if diarrhea or vomiting occurs. d. Avoid eating aged cheese, processed meats, and red wine

ANS: A Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information.

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. "Converses without interrupting; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

Goals and desired outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on what? a. Returning to premorbid levels of function b. Identifying stressors negatively affecting self c. Demonstrating motor responses to noxious stimuli d. Exerting control over responses to perceptual distortions

ANS: A The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium since the condition is usually temporary in nature. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient experiencing delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.

. A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. What is the best initial approach by the nurse to interrupt this behavior without entering into a power struggle? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger.

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient cusses while twirling and shadowboxing. Then 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? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

ANS: A The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patient's mood. A high level of suspicion is not evident.

A patient presenting with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines. b. Allow the patient to telephone a local restaurant to deliver meals. c. Offer to taste each portion on the tray for the patient. d. Begin tube feedings or total parenteral nutrition.

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are considered aggressive and usually promote violence. Patients often perceive foods in sealed containers, packages, or natural shells as being safe.

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. I didn't like how it made me feel." What likely side effects did the patient experience? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance. The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to assault me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's paranoia and feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family to assist in managing these behaviors? (Select all that apply.) a. Provide structure. b. Limit credit card access. c. Encourage group social interaction. d. Limit work to half days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania.

A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such a burden to my family." These statements support which nursing diagnoses? (Select all that apply.) a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? (Select all that apply.) a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress

ANS: A, D Compelling evidence exists that schizophrenia is a neurological disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Stress and family disruption may contribute but are not considered etiological factors. Environmental factors are not recognized as causative variables in schizophrenia.

Which description of patient behavior best applies to a hallucination? a. Looking at shadows on a wall and says, "I see scary faces" b. Stating, "I feel bugs crawling on my legs and biting me" c. Becoming anxious when the nurse leaves his or her bedside d. Trying to hit the nurse when vital signs are taken

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl. The patient is 5 feet 6 inches tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia? b. Weight management strategies. c. Ways to manage constipation. d. Sleep hygiene measures.

ANS: B Lurasidone HCl (Latuda) is an atypical antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management is especially important. The incidence of tardive dyskinesia is low with atypical antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.

A patient diagnosed with stage 1 mild Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Complicated grieving b. Impaired memory c. Self-care deficit d. Caregiver role strain

ANS: B Memory impairment is present and expected in stage 1 mild Alzheimer's disease. Patients diagnosed with early Alzheimer's disease often have difficulty remembering names, so socialization is minimized. Data are not present to support the other diagnoses.

A person diagnosed with schizophrenia has had difficulty keeping a job because of severe paranoia. Today the person shouts, "They're all plotting to destroy me." Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.

When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allowing the patient to act out his or her feelings b. Setting limits on the patient's behavior as necessary c. Providing verbal instructions to the patient to remain calm d. Restraining the patient to reduce hyperactivity and aggression

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to the loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective

During morning care, an assistive personnel asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine. This is the expected reaction to the addition of olanzapine to the medication regimen? a. Minimize the side effects of lithium. b. Bring hyperactivity under rapid control. c. Enhance the antimanic actions of lithium. d. Provide long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug like olanzapine with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium is used for long-term control.

Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Socially withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior

ANS: B Patients with disorganization demonstrate the most regressed and socially impaired behaviors. Communication is often incoherent, with silly giggling and loose associations predominating. Highly suspicious, delusional behavior relates more to paranoia. Extremes of motor activity, from excitement to stupor, relate to catatonia. Severe anxiety and ritualistic behaviors relate to obsessive-compulsive disorder.

A patient diagnosed with schizophrenia is demonstration catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiological c. Self-actualization d. Safety and security

ANS: B Physiological needs must be met to preserve life. A patient who is catatonic may need to be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiological integrity. The assessment findings do not suggest safety concerns. Higher-level needs (psychosocial and self-actualization) are of lesser concern.

A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and been aggressive all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Criteria for seclusion have not been met.

A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest.

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

ANS: B Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. What response supported by research should the nurse provide? a. "A high proportion of patients diagnosed with bipolar disorders are found among creative writers." b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder." c. "Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses." d. "More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission of bipolar disorder.

This nursing diagnosis applies to a patient experiencing mania: imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. What is the most appropriate outcome related to patient behavior? a. Asking staff for assistance with feeding within 4 days b. Drinking six servings of a high-calorie, high-protein drink each day c. Consistently sitting with others for at least 30 minutes at mealtime within 1 week d. Wearing appropriate attire for age and gender within 1 week while in the psychiatric unit

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis.

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 as what classic behavior? a. Echolalia b. An idea of reference c. A delusion of infidelity d. An auditory hallucination

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Which stage of Alzheimer's disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

ANS: B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late), the ability to talk and walk is eventually lost, and stupor evolves.

A patient diagnosed with schizophrenia has taken a first-generation antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine

ANS: B Olanzapine is an atypical antipsychotic medication that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are first-generation (conventional) antipsychotic agents that target only positive symptoms. Diphenhydramine is an antihistamine.

A patient diagnosed with schizophrenia is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patient's ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition.

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 most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider has not already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. The incorrect options offer incorrect or misleading information.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients diagnosed with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid volume.

A patient diagnosed with Alzheimer's disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.

A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars

ANS: B Reorientation may seem like arguing to a patient experiencing cognitive deficits and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation.

A patient experiencing acute mania waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes." What is the nurse's most appropriate intervention? a. Suggesting to the patient to ask a friend to do the shopping and bring purchases to the unit b. Inviting the patient to sit with the nurse and look at new fashion magazines c. Telling the patient that computer use is not allowed until self-control improves d. Asking whether the patient has enough money to pay for the purchases

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to the staff's advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

A patient has taken trifluoperazine 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are observed. These symptoms are frequently not reversible, even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. What select is the best option? a. Extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury.

Consider these health problems: Lewy body disease, Pick disease, and Parkinson's disease. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia

What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit related to altered cerebral function as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes related to medication intoxication as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by hiding from imagined ferocious dogs

ANS: B The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

A patient prescribed lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" What instructions should the nurse provide? a. "Restrict oral fluids for 24 hours and stay in bed." b. "Have someone bring you to the clinic immediately." c. "Drink a large glass of water with 1 teaspoon of salt added." d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patient's symptoms. Restricting oral fluids will make the situation worse.

A nurse observes a 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? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

A nurse prepares the plan of care for a patient experiencing a manic episode. Which nursing diagnoses are most appropriate? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take the time to eat and drink properly. Their high levels of activity consume calories; therefore, deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? (Select all that apply.) a. How to complete an application for employment? b. The importance of correctly taking your medication. c. How to dress when attending community events? d. How to give and receive compliments? e. Ways to quit smoking.

ANS: B, E Stabilization is maximized by the adherence to the antipsychotic medication regimen. Because so many patients with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiological well-being. The other topics are also important but are not priority topics.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.

A patient experiencing acute mania undresses in the group room and dances. What should be the nurse's first intervention? a. Quietly ask the patient, "Why don't you put on your clothes?" b. Firmly tell the patient, "Stop dancing, and put on your clothing." c. Put a blanket around the patient and walk with the patient to a quiet room. d. Allow the patient stay in the group room while moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach.

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

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Asking other patients to talk incorrectly shifts responsibility for intervention from the nurse to other patients.

What is the focus of outcome identification for the treatment plan of a patient presenting with grandiose thinking associated with acute mania? a. Maintaining an interest in the environment b. Developing an optimistic outlook c. Self-control of distorted thinking d. Stabilizing the sleep pattern

ANS: C The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

The nurse is monitoring a patient closely for signs and symptoms of Stevens-Johnson syndrome. Which medication is likely the trigger for such a syndrome? a. Clonazepam b. Risperidone c. Lamotrigine d. Aripiprazole

ANS: C Lamotrigine is a first-line treatment for bipolar depression and is approved for acute and maintenance therapy. It is generally well-tolerated, but there are two concerns with this agent. One is a rare but serious dermatological reaction: a potentially life-threatening rash called Stevens-Johnson syndrome and the other is aseptic meningitis. None of the other options are associated with this complication.

When used for treatment of patients diagnosed with Alzheimer's disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. Donepezil b. Rivastigmine c. Memantine d. Galantamine

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

A patient diagnosed with schizophrenia says, "My coworkers are out to get me. I also saw two doctors plotting to overdose me." What term identifies how this patient is perceiving the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarre

ANS: C The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.

What is the priority nursing intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints

ANS: C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.

A patient receiving lithium should be assessed for which evidence of early toxicity? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diarrhea, thirst, and vomiting d. Ascites, dyspnea, and edema

ANS: C Diarrhea, thirst, and vomiting are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad mood

ANS: C Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania.

What is the priority nursing need for a patient diagnosed with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering

ANS: C In late-stage dementia, the patient has often forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia.

A patient diagnosed with schizophrenia has taken fluphenazine 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a pool cue in one hand and says, "I'll protect myself if anyone comes near me." What is the nurse's first intervention? a. Telling the patient, "You need to be secluded." b. Demanding the patient, "get down from the table." c. Clearing the room of all other patients. d. Assembling staff for a show of force.

ANS: C Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. Making demands or assembling a show of force is likely to anger or frighten the patient and increase this risk for violence.

Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "I know what you're up to; you're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. Phenytoin b. Clonidine c. Carbamazepine d. Chlorpromazine

ANS: C Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes.

Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped cream

ANS: C The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

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

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking "why" does not provide for environmental safety.

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

ANS: D Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as what? a. Need for psychoeducation b. Medication nonadherence c. Chronic deterioration d. Relapse

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is regularly taking his or her medication. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.

A patient receiving risperidone reports severe muscle stiffness at 10:30 am. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 pm, vital signs are body temperature, 102.8° F; pulse, 110 beats/min; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurse's best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, low-fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

ANS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in this scenario are not consistent with the medical problems listed in the incorrect options.

A patient diagnosed with schizophrenia says, "Everyone has skin lice that jump on you and contaminate your blood." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of contamination indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information

Patients diagnosed with schizophrenia who are suspicious and withdrawn generally present with what additional characteristic? a. Universally fear sexual involvement with therapists. b. Are socially disabled by the positive symptoms of schizophrenia. c. Exhibit a high degree of hostility as evidenced by rejecting behavior. d. Avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior.

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." What phenomena is the patient describing? a. Derealization b. Concrete thinking c. Abstract thinking d. Depersonalization

ANS: D Depersonalization: a nonspecific feeling of having lost one's identity; the self is different or unreal. People may be concerned that body parts do not belong to them, or they may have an acute sensation that the body has drastically changed. Derealization is the false perception that the environment has changed. Concrete thinking refers to an overemphasis on specific details and a literal interpretation of ideas. It is contrasted with abstract thinking. People who think in an abstract way look at the broader significance of ideas and information rather than the concrete details.

A patient diagnosed with schizophrenia demonstrates paranoid thinking. The patient angrily tells a nurse, "You are mean and nasty. No one trusts you or wants to be around you." What is the likely motivation behind this behavior? a. Attempting to manipulate the nurse by using negative comments b. The prelude to disorganization and catatonia in the near future c. Jealousy of the nurse's position of power in the relationship d. Identifying another person's shortcomings in order to preserve his or her own self-esteem

ANS: D Patients with paranoid ideation often use disparaging comments to preserve their own self-esteem. There is no evidence the patient is trying to manipulate the nurse or is jealous. This behavior is not predictive of catatonia or disorganization.

Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

ANS: D The 40-year-old patient who has been diagnosed with schizophrenia since 18 years of age could logically be expected to have the lowest overall level of functioning secondary to deterioration associated with frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have a higher-level because schizophrenia of short duration may be less impairing than other types. The patient who has had episodes of catatonia since the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient diagnosed with schizophreniform disorder has been ill for only 6 months, and disability is likely to be minimal.

A patient experiencing acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement? a. Place the patient in the seclusion room. b. Ask if the patient finds clothes bothersome. c. Tell the patient that others feel embarrassed. d. Arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One-on-one supervision may provide the necessary structure. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness. Seclusion is not the appropriate intervention especially since the patient is not a threat to self or others.

Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? a. Keep the patient by the nurse's desk while the patient is awake. Provide restperiods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

ANS: D A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient experiencing cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

A patient diagnosed with stage 2 moderate Alzheimer's disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be characterized using which term? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

ANS: D During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication adherence and preventing a relapse, both of which are fostered by ongoing psychoeducation.

An older adult patient in an intensive care unit is experiencing visual and auditory illusions. Which nursing intervention will be most helpful? a. Keep the room brightly lit at all times. b. Place personally meaningful objects in view. c. Place large clocks and calendars on the wall. d. Assess the patient's for use of glasses and hearing aids

ANS: D Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

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

ANS: D Learning what a command hallucination is telling the patient to do is important; the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

A patient diagnosed with schizophrenia says, "High heat. Last time here. Did you get a coat?" What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of "cheeking" the medication a form of nonadherence to the medication therapy. The prescribed dose is high, so one would not expect a need for the dose to be increased.

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

ANS: D The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on the hallucinatory clue (i.e., the patient's laughter) and then eliciting the patient's observation is best. The incorrect options are less useful in eliciting a response; no joke may be involved, "Why" questions are difficult to answer, and the patient is probably not focusing on what the nurse has said in the first place.

Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Exercise-induced asthma d. Congestive heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Neither arthritis, epilepsy, nor asthma directly involves fluid balance and kidney function.

A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist family members to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two of the incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

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

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.

A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry. I will have someone stay here and brush off the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

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