Exam 1 Recommended NCLEX Qs.

When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize? A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder

ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action? A. The nurse notifies the client's physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room. C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the client's fluid intake to facilitate the digestive process.

ANS: A A client who is scheduled for ECT procedures is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

A client is diagnosed with generalized anxiety disorder. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client's level of anxiety B. Assessing and documenting the client's vital signs C. Assessing suicide risk D. Assessing availability of support systems

ANS: A Anxiety at a moderate or higher level will interfere with the learning process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention? A. Suicide assessment must continue throughout the ECT course. B. Antidepressant medications are contraindicated throughout the ECT course. C. Discourage expressions of hopelessness throughout the ECT course. D. Encourage a high-caloric diet throughout the ECT course.

ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom. Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, "I'm not hungry and just want to stay in bed and sleep." On the basis of this information, which is the most appropriate nursing intervention? A. Allow the client to remain in bed. B. Encourage the client to join the milieu to promote socialization. C. Obtain a physician's order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation.

ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

When an individual's stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate? A. Decreased resistance to disease B. Increased libido C. Decreased blood pressure D. Increased inflammatory response

ANS: A In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at which time the body's compensatory mechanisms no longer function effectively and diseases of adaptation occur. A decreased immune response is seen at this stage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. "What do you think needs to change about how you express anger?" B. "How did you feel after attending the anger management session?" C. "On a scale of 1 to 10, please rate your current level of anger." D. "What bothers you about the actions of others when you get angry?"

ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

Most cultures label behavior as mental illness on the basis of which of the following criteria? A. Incomprehensibility and cultural relativity B. Strength of character and ethics C. Goal directedness and high energy D. Creativity and good coping skills

ANS: A Incomprehensibility and cultural relativity are most often the criteria used to define whether something is labeled mental illness. The other identified behaviors would be more associated with health than illness. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Meditation has been shown to be an effective stress management technique. When meditation is effective, what should a nurse expect to assess? A. An achieved state of relaxation B. An achieved insight into one's feelings C. A demonstration of appropriate role behaviors D. An enhanced ability to problem-solve

ANS: A Meditation produces relaxation by creating a special state of consciousness through focused concentration. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions? A. Neuroleptic malignant syndrome B. Tardive dyskinesia C. Acute dystonia D. Agranulocytosis

ANS: A Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Providing nursing education on drug abuse to a high school class is an example of which level of preventive care? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Primary intervention

ANS: A Providing nursing education on drug abuse to a high school class is an example of primary prevention. Primary prevention services are aimed at reducing the incidence of mental health disorders within the population. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance

Which client statement should alert a nurse that a client may be responding maladaptively to stress? A. "I've found that avoiding contact with others helps me cope." B. "I really enjoy journaling; it's my private time." C. "I signed up for a yoga class this week." D. "I made an appointment to meet with a therapist."

ANS: A Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents? A. Reactions to stress are relative rather than absolute; individual responses to stress vary. B. It is abnormal for identical twins to react differently to similar stressors. C. Identical twins should share the same temperament and respond similarly to stress. D. Environmental influences weigh more heavily than genetic influences on reactions to stress.

ANS: A Responses to stress are variable among individuals and may be influenced by perception, past experience, and environmental factors in addition to genetic factors. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM-5? A. Somatic symptom disorders B. Grief responses C. Psychosis D. Bipolar disorder

ANS: A Somatic symptom disorder is characterized by preoccupation with physical symptoms for which there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety about health concerns or illness. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A mental health technician asks the nurse, "How do psychiatrists determine which diagnosis to give a patient?" Which of these responses by the nurse would be most accurate? A. Psychiatrists use pre-established criteria from the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). B. Hospital policy dictates how psychiatrists diagnose mental disorders. C. Psychiatrists assess the patient and identify diagnoses based on the patient's unhealthy responses and contributing factors. D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from.

ANS: A The DSM-5 is an organized manual describing mental disorders and the criteria that determine whether a given diagnosis is appropriate. It is published by the American Psychiatric Association (APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes nursing rather than medical diagnosis. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. SOLER C. DAR D. PQRST

ANS: A The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each. KEY: Cognitive Level: Comprehension | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment

A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.

ANS: A The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A son who recently brought his extremely confused parent to a nursing home for admission reports feelings of guilt. Which is the appropriate nursing reply? A. "People often have mixed emotions about decisions like this. Support groups are held here on Mondays for children of residents in similar situations." B. "You did what you had to do. I wouldn't feel guilty if I were you." C. "Support groups are available to low-income families." D. "Your parent is doing just fine. We'll take very good care of him."

ANS: A The most appropriate reply by the nurse is to normalize the son's feelings and provide a resource to help the son deal with feelings of guilt by giving information about an available support group. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will this cure Alzheimer's disease (AD)?" Which is the appropriate instructor reply? A. "This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD." B. "This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." C. "This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD." D. "This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."

ANS: A The most appropriate response by the instructor is to explain that donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of AD. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client on the inpatient unit tells a student nurse, "My life has no purpose. I can't think about living another day, but please don't tell anyone about the way I feel. I know you are obligated to protect my confidentiality." Which is the most appropriate reply by the student nurse? A. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care." B. "Let's discuss steps that will resolve negative lifestyle choices that may increase your suicidal risk." C. "You seem to be preoccupied with self. You should concentrate on hope for the future." D. "This information is secure with me because of client confidentiality."

ANS: A The most appropriate response by the student nurse is to explain that sharing the information with the treatment team is critical to the client's care. The nurse's priority is to ensure client safety and to inform others of the client's suicidal ideation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

An elderly client has met the criteria for a diagnosis of major depressive disorder. The client does not respond to antidepressant medications. Which treatment should a nurse anticipate that the physician would prescribe for this client? A. Electroconvulsive therapy (ECT) B. Neuroleptic therapy C. An antiparkinsonian agent D. An anxiolytic agent

ANS: A The nurse should anticipate that ECT will be ordered to treat this client's symptoms of depression. ECT remains one of the safest and most effective treatments for major depressive disorder in older adults. When a client does not respond to antidepressant medications or has been diagnosed with co-morbid disease processes that prohibit the use of antidepressant medications, ECT is considered the treatment of choice. The response to ECT may be slower in older clients, and the effects may be of limited duration. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Which client should the nurse anticipate to be most receptive to psychiatric treatment? A. A Jewish, female journalist B. A Baptist, homeless male C. A Catholic, black male D. A Protestant, Swedish business executive

ANS: A The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely than men to seek treatment for mental health problems. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

The following outcome was developed for a client: "Client will list five personal strengths by the end of day 1." Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considered as a treatment option. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain, which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain, causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

ANS: A The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A newly admitted client asks, "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing reply? A. "Group therapy provides the opportunity to learn and practice new coping skills." B. "Group therapy is mandatory. All clients must attend." C. "Group therapy is optional. You can go if you find the topic helpful and interesting." D. "Group therapy is an economical way of providing therapy to many clients concurrently."

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking.

ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of nursing diagnosis of risk for suicide. Disorganized thoughts and delusional thinking would lead to the development of a nursing diagnosis of altered thought processes. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. "Taking multiple medications may lead to adverse interactions or toxicity." B. "Age-related cognitive changes may lead to alterations in mental status." C. "Lack of rigorous exercise may lead to decreased cerebral blood flow." D. "Decreased social interaction may lead to profound isolation and psychosis."

ANS: A The nurse should identify that taking multiple medications may lead to adverse reactions or toxicity and put an older adult at risk for the development of delirium. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A new psychiatric nurse states, "This client's use of defense mechanisms should be eliminated." Which is a correct evaluation of this nurse's statement? A. Defense mechanisms can be self-protective responses to stress and need not be eliminated. B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

ANS: A The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Immediately after electroconvulsive therapy, in which position should a nurse place the client? A. On his or her side to prevent aspiration B. In semi-Fowler's position to promote oxygenation C. In Trendelenburg's position to promote blood flow to vital organs D. In prone position to prevent airway blockage

ANS: A The nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients' bedside at the appropriate times.

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply. A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder

ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression, acute mania, and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply. A. It informs the nurse of accurate and reliable medical diagnosis. B. It represents progress toward a more holistic view of mind-body. C. It provides a framework for interdisciplinary communication. D. It provides a template for nursing care plans. E. It provides a framework for communication with the client.

ANS: A, B, C The DSM-5 is useful in the practice of psychiatric nursing because it facilitates comprehensive evaluation of the client. In addition, it encourages a holistic view and provides a framework for interdisciplinary communication. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

Which of the following are cultural aspects of mental illness? Select all that apply. A. Local or cultural norms define pathological behavior. B. The higher the social class the greater the recognition of mental illness behaviors. C. Psychiatrists typically see patients when the family can no longer deny the illness. D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion.

ANS: A, B, C The fewer ties that a group has with mainstream society, the greater the likelihood of a negative response by society to mental illness. Coercive treatments and involuntary hospitalizations are more common in this population. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply. A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss

ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated. KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A nurse is working with a client who has recently been under a great deal of stress. Which nursing recommendations would be most helpful when assisting the client in coping with stress? Select all that apply. A. "Enjoy a pet." B. "Spend time with a loved one." C. "Listen to music." D. "Focus on the stressors." E. "Journal your feelings."

ANS: A, B, C, E Focusing on the stressors is more likely to increase stress in the client's life. However, pets, music, journaling feelings, and healthy relationships have all been shown to decrease amounts of stress. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply. A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy

ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential

A nurse is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptoms might the client demonstrate? Select all that apply. A. Fidgeting B. Laughing inappropriately C. Palpitations D. Nail biting E. Extremely limited attention span

ANS: A, B, D The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply. A. Electrocardiographic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results

ANS: A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the client's physician. The client must be medically cleared prior to ECT. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the client's appraisal of the situation? Select all that apply. A. "What resources have you used previously in stressful situations?" B. "Have you ever experienced a similar stressful situation?" C. "Who do you think is to blame for this situation?" D. "Why do you think you were fired from your job?" E. "What skills do you possess that might lead to gainful employment?"

ANS: A, B, E These questions specifically address the client's coping resources and encourage the client to apply learning from past experiences. These questions also encourage the client to consider alternative methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather, encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to communication. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? Select all that apply. A. Assist clients to perform activities of daily living. B. Act as a consultant with other clinicians to provide services for clients and effect system change C. Encourage clients to discuss triggers for relapse D. Use prescriptive authority in accordance with state and federal laws E. Educate families about signs and symptoms of alcohol dependence and withdrawal

ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which of the following statements should a nurse recognize as true about defense mechanisms? Select all that apply. A. They are employed when there is a threat to biological or psychological integrity. B. They are controlled by the id and deal with primal urges.C. They are used in an effort to relieve mild to moderate anxiety. D. They are protective devices for the superego. E. They are mechanisms that are characteristically self-deceptive.

ANS: A, C, E Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity, in an effort to relieve mild to moderate anxiety. Because they redirect focus, they are characteristically self-deceptive. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply. A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms. KEY: Cognitive Level: Comprehension | Integrated Process: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety? A. Diagnostic blood tests B. Awareness of factors creating stress C. Relaxation exercises D. Identifying support systems

ANS: B Although all of the above answers may be useful in the comprehensive management of stress, the initial step is awareness that stress is being experienced and awareness of factors that create stress. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the client's lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply? A. "The cuff has to be placed on the leg because both arms are used for intravenous fluids." B. "The cuff functions to prevent succinylcholine from reaching the foot." C. "The cuff position gives a more accurate blood pressure reading during the treatment." D. "The cuff is placed on the leg so that arms can easily be restrained during seizure."

ANS: B A blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

A 27-year-old client was diagnosed 5 years ago with schizophrenia. What course of treatment should the nurse expect to be implemented? A. Eventual admission for long-term care in a psychiatric facility B. Community-based care with numerous brief hospitalizations C. Case management in the community with few relapses D. Occasional contact with outpatient counselors and psychiatrists

ANS: B Community-based care is the standard of treatment that followed the deinstitutionalization movement. Schizophrenia is a chronic disease that includes both exacerbations and remissions in the course of the illness, leading to numerous brief hospitalizations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which symptom should a nurse identify as typical of the "fight-or-flight" response? A. Pupil constriction B. Increased heart rate C. Increased salivation D. Increased peristalsis

ANS: B During the "fight-or-flight" response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions. OK KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. "During ECT a state of euphoria is induced." B. "ECT induces a grand mal seizure." C. "During ECT a state of catatonia is induced." D. "ECT induces a petit mal seizure."

ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

A client is assigned the nursing diagnosis of impaired social interaction R/T sociocultural differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.

ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A community health nurse is teaching a class to expectant parents. All participants lack infant care knowledge. A student nurse asks, "If you had to assign a nursing diagnosis to this group, what would it be?" What is the best nursing reply? A. "I would assign the nursing diagnosis of cognitive deficit." B. "I would assign the nursing diagnosis of knowledge deficit." C. "I would assign the nursing diagnosis of altered family processes." D. "I would assign the nursing diagnosis of risk for caregiver role strain."

ANS: B Knowledge deficit is defined as the absence or deficiency of cognitive information related to a specific topic. Cognitive deficit would indicate an alteration in the ability to process information, and this evidence is not provided in the question. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Health Promotion and Maintenance

Which psychiatric disorder would a nurse expect to see diagnosed in a client's later life? A. Schizophrenia B. Major depressive disorder C. Phobic disorder D. Dependent personality disorder

ANS: B Major depressive disorder is most likely to be identified later in life. Depression among older adults can be increased by physical illness, functional disability, cognitive impairment, and loss of a spouse. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

The nurse is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction? A. Learning is best when anxiety is moderate to severe. B. Learning is enhanced when anxiety is mild. C. Panic level anxiety helps the nurse teach better. D. Severe anxiety is characterized by intense concentration and enhances the attention span.

ANS: B Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness of the environment. Learning is enhanced. As anxiety increases, attention span decreases and learning becomes more difficult. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Health Promotion and Maintenance

A client states, "My doctor has told me I am a candidate for electroconvulsive therapy (ECT). Where will the treatment take place, and how much time would this entail?" Which is the most accurate nursing reply? A. "Clients typically receive ECT in their hospital room, daily for 1 month." B. "Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting." C. "Clients typically receive an unlimited number of treatments, in the hospital procedure room." D. "Clients typically receive two to three treatments, in either an outpatient or inpatient setting."

ANS: B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures. Treatments are usually administered every other day, three times per week. Treatments are performed on either an inpatient or outpatient basis, depending on the need for client monitoring. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients diagnosed with amnesic disorders? A. Neurocognitive disorders involve disorientation that develops suddenly, whereas amnestic disorders develop more slowly. B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not. C. Neurocognitive disorders include the symptom of confabulation, whereas amnestic disorders do not. D. Both neurocognitive disorders and profound amnesia typically share the symptom of disorientation to place, time, and self.

ANS: B Neurocognitive disorders involve impairment of abstract thinking and judgment. Amnestic disorders are characterized by an inability to learn new information and to recall previously learned information, with no impairment in higher cortical functioning or personality change. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response? A. "Genetics have nothing to do with your temperament." B. "How you reacted to past experiences influences how you feel now." C. "If you're in good physical health, your stress level will be low." D. "Stress can always be avoided if appropriate coping mechanisms are employed."

ANS: B Past experiences are occurrences that result in learned patterns that can influence an individual's current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A school nurse is assessing a distraught female high school student who is overly concerned because her parents can't afford horseback riding lessons. How should the nurse interpret the student's reaction to her perceived problem? A. The problem is endangering her well-being. B. The problem is personally relevant to her. C. The problem is based on immaturity. D. The problem is exceeding her capacity to cope.

ANS: B Psychological stressors to self-esteem and self-image are related to how the individual perceives the situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all the advantages that other adolescents experience. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? A. "Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives." B. "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." C. "Reminiscence therapy is a social group where members chat about past events and future plans." D. "Reminiscence therapy encourages members to share positive memories of significant life transitions."

ANS: B Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution. Stimulation of life memories serves to help older clients work through their losses and maintain self-esteem. Reminiscence therapy can take place in one-on-one or group settings. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health? A. Mental health is the absence of any stressors. B. Mental health is successful adaptation to stressors in the internal and external environment. C. Mental health is incongruence between thoughts, feelings, and behavior D. Mental health is a diagnostic category in the DSM-5.

ANS: B Several definitions of mental health exist, but this definition highlights concepts of successful adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

During the implementation phase of the nursing process, a nurse is teaching an adult depressed patient with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials

ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which should the nurse recognize as a DSM-5 disorder? A. Obesity B. Generalized anxiety disorder C. Hypertension D. Grief

ANS: B The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety disorder, somatic symptom disorder, and dissociative disorders. KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

According to the U.S. Census Bureau criteria, how would a nurse classify a 70-year-old man? A. This man would be classified as "older." B. This man would be classified as "elderly." C. This man would be classified as "aged." D. This man would be classified as "very old."

ANS: B The U.S. Census Bureau classifies a 70-year-old man as "elderly." The U.S. Census Bureau has developed a system for classification of older Americans: older, 55 to 64; elderly, 65 to 74; aged, 75 to 84; very old, 85 years and older. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance

Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services

ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client, including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations.

ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A client diagnosed with schizophrenia is hospitalized because of an exacerbation of psychosis related to antipsychotic medication nonadherence. Which level of care does the client's hospitalization reflect? A. Primary prevention level of care B. Secondary prevention level of care C. Tertiary prevention level of care D. Case management level of care

ANS: B The client's hospitalization reflects the secondary prevention level of care. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nursing instructor is teaching about case management. What student statement indicates that learning has occurred? A. "Case management is a method used to achieve independent client care." B. "Case management provides coordination of services required to meet client needs." C. "Case management exists to facilitate client admission to needed inpatient services." D. "Case management is a method to facilitate physician reimbursement."

ANS: B The instructor evaluates that learning has occurred when a student defines case management as providing coordination of services required to meet client needs. Case management strives to organize client care so that specific outcomes are achieved within allotted time frames. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities

ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the appropriate nursing reply? A. "I'm glad we discussed this. We'll excuse him from the activity groups." B. "The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation." C. "The groups are optional. Only clients at high functioning levels would benefit." D. "If your father doesn't go to these activity groups, he will be at high risk for developing dementia."

ANS: B The most appropriate nursing reply is to educate the family on the purpose of activity groups, which is to provide social interaction, sensory stimulation, and reality orientation. Groups can also serve to increase self-esteem and reduce depression. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. Which information should a nurse include when teaching about the potential side effects of this procedure? A. "You may experience transient tangential thinking." B. "You may experience some memory deficit surrounding the ECT." C. "You may experience avolution for the remainder of the day." D. "You may experience a higher risk for subsequent seizures."

ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

ANS: B The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoia." D. "The client is verbalizing a word salad."

ANS: B The nurse should describe the client's statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity

At what point should the nurse determine that a client is at risk for developing a mental disorder? A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria B. When maladaptive responses to stress are coupled with interference in daily functioning C. When the client communicates significant distress D. When the client uses defense mechanisms as ego protection

ANS: B The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client's ability to communicate distress would be considered a positive attribute. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, "I know she wants me." This statement reflects which defense mechanism? A. Displacement B. Projection C. Rationalization D. Sublimation

ANS: B The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection refers to the attribution of one's unacceptable feelings or impulses to another person. When the client "passes the blame" of the undesirable feelings, anxiety is reduced. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations

ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy response (inference), the contributing factors, and the data that support the inference. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this client's assessment data, which diagnosis would the nurse expect the physician to assign? A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimer's disease

ANS: B The nurse should expect that this client would be diagnosed with vascular neurocognitive disorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abrupt onset. This disease often occurs in a fluctuating pattern of progression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

ANS: B The nurse should focus on the client's feelings rather than attempt to change the client's delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?A. A client rudely complaining about limited visiting hours B. A client exhibiting aggressive behavior toward another client C. A client stating that no one cares D. A client verbalizing feelings of failure

ANS: B The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other, higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

What is the best rationale for including the client's family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors

ANS: B The nurse should include the client's family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

ANS: B The nurse should note escalating behaviors and intervene immediately to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

How should a nurse prioritize nursing diagnoses? A. By the established goal of care B. By the life-threatening potential C. By the physician's priority of care D. By the client's preference

ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse's first priority. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment

A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, "I work hard to provide for my family. I don't see why I can't drink to relax." The nurse recognizes the use of which defense mechanism? A. Projection B. Rationalization C. Regression D. Sublimation

ANS: B The nurse should recognize that the client is using rationalization, a common defense mechanism. The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A homeless client comes to an emergency department reporting cough, night sweats, weight loss, and blood-tinged sputum. What disease that has recently become more prevalent among the homeless community should a nurse suspect? A. Meningitis B. Tuberculosis C. Encephalopathy D. Mononucleosis

ANS: B The nurse should suspect that the homeless client has contracted tuberculosis. Tuberculosis is a growing problem among homeless individuals because of being in crowded shelters, which are ideal conditions for the spread of respiratory tuberculosis. Alcoholism, drug addiction, HIV infection, and poor nutrition also contribute to the increase in cases of tuberculosis. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Which nursing statement about the concept of psychoses is most accurate? A. "Individuals experiencing psychoses are aware that their behaviors are maladaptive." B. "Individuals experiencing psychoses experience little distress." C. "Individuals experiencing psychoses are aware of experiencing psychological problems." D. "Individuals experiencing psychoses are based in reality."

ANS: B The nurse should understand that the client with psychoses experiences little distress, because of his or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is maladaptive or that he or she has a psychological problem. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which nursing statement about the concept of neuroses is most accurate? A. "An individual experiencing neurosis is unaware that he or she is experiencing distress." B. "An individual experiencing neurosis feels helpless to change his or her situation." C. "An individual experiencing neurosis is aware of psychological causes of his or her behavior." D. "An individual experiencing neurosis has a loss of contact with reality."

ANS: B The nurse should understand that the concept of neuroses includes the following characteristics. The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client's problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion

ANS: B The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of hearing things that others do not. A nursing diagnosis describes a client's condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

ANS: B The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A nursing instructor is teaching students about the purpose of using the nursing process in the care of psychiatric patients. Which of the following statements by the student indicates that learning has occurred? A. The nursing process is a method for interviewing the patient in a systematic way. B. The nursing process is used to assist patients to adapt successfully to stressors within the environment. C. The nursing process is used to provide support for the psychiatric diagnosis. D. The nursing process is used primarily to minimize allegations of negligence.

ANS: B The nursing process is a method for nursing care delivery in which the patient's unhealthy responses are identified and interventions are planned, which are designed to assist the patient to adapt more successfully in their environment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.

ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical nursing judgments and plan appropriate care. The nurse should complete a thorough assessment of the client, including information collected from the client, significant others, and health-care providers (consistent with HIPAA laws and the client's right to confidentiality). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time? A. Meditation B. Problem-solving training C. Relaxation D. Journaling

ANS: B The student must assess his or her situation and determine the best course of action. Problem-solving training, by providing structure and objectivity, can assist in decision making. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which statement reflects a student nurse's accurate understanding of the concepts of mental health and mental illness? A. "The concepts are rigid and religiously based." B. "The concepts are multidimensional and culturally defined." C. "The concepts are universal and unchanging." D. "The concepts are unidimensional and fixed."

ANS: B The student nurse should understand that mental health and mental illness are multidimensional and culturally defined. It is important for nurses to be aware of cultural norms when evaluating a client's mental state. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? Select all that apply. A. Respiratory therapist B. Occupational therapist C. Recreational therapist D. Social worker E. Mental health technician

ANS: B, C, D, E The typical interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, dietician, psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. Other disciplines may be included on the basis of resources available in a particular hospital setting and individual patient needs. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? Select all that apply. A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature

ANS: B, C, E A nursing diagnosis is a statement of a client's functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A "risk for" diagnosis does not contain AEB because there is only a potential for the problem; it does not yet exist. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment

Which of the following clients should a nurse recommend for a structured day program? Select all that apply. A. An acutely suicidal teenager who has had three previous suicide attempts B. A chronically mentally ill woman who has a history of medication noncompliance C. An elderly individual with end-stage Alzheimer's disease D. A depressed individual who is able to participate in a safety plan E. A client who is hearing voices that tell him or her to harm others

ANS: B, D The nurse should recommend a structured day program for a chronically mental ill woman who has a history of medication noncompliance and for a depressed individual who is able to participate in a safety plan. Day programs (also called partial hospitalizations) are designed to prevent institutionalization or to ease the transition from inpatient hospitalization to community living. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment: Management of Care

A nursing student finds that she comes down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing? A. Alarm reaction stage B. Stage of resistance C. Stage of exhaustion D. Fight-or-flight stage

ANS: C At the stage of exhaustion, the student's exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient are common initial biological responses to stress? Select all that apply. A. Constricted pupils B. Watery eyes C. Unusual food cravings D. Increased heart rate E. Increased respirations

ANS: B, D, E Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. Since dilated pupils rather than constricted pupils are related to "Fight or Flight" syndrome, this symptom should be assessed for other potential causes. Unusual food cravings have not been identified as a typical biological response to stress. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Which of the following are accurate descriptors of a therapeutic community? Select all that apply. A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs. D. The individual is the sole focus of therapy. E. A democratic form of government exists.

ANS: B, E In a therapeutic community the unit responsibilities are assigned according to client capability, and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client is in the late stage of Alzheimer's disease. To address the client's symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.

ANS: C KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Basic Care and Comfort

A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would impact the feasibility of this treatment option? A. Because the client is extremely suicidal, ECT is an appropriate option. B. Because antidepressant medications have been ineffective, ECT is a good alternative. C. Because informed consent is required for ECT, cognitive deficits could preclude this option. D. Because of the client's cognitive deficits, a signed consent is waived.

ANS: C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the client's level of competency and, if necessary, the judge would appoint a guardian. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions

ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A nursing instructor is teaching students about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act? A. Many perspective clients did not meet criteria for mental illness diagnostic-related groups. B. Zoning laws discouraged the development of community mental health centers. C. States could not match federal funds to establish community mental health centers. D. There was not a sufficient employment pool to staff community mental health centers.

ANS: C A deterring factor to the proper implementation of the Community Mental Health Centers Act of 1963 was that states could not match federal funds to establish community mental health centers. This act called for the construction of comprehensive community mental health centers to offset the effects of deinstitutionalization caused by the closing of state mental health hospitals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

ANS: C Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with major depressive disorder states, "Why should I keep trying to get a job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the content and mood themes in this client's statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred

ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A "risk for" diagnosis does not contain AEB because there is only a potential for the problem; it doesn't yet exist. The client's statement indicates that role performance is altered because fear of failure prevents seeking employment. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A client who is learning about electroconvulsive therapy (ECT) asks a nurse, "Isn't this treatment dangerous?" Which is the most appropriate nursing reply? A. "No, this treatment is side-effect free." B. "There can be temporary paralysis, but full functioning returns within 3 hours of treatment." C. "There are some risks, but a thorough examination will determine your candidacy for ECT." D. "Transient ischemic attacks (TIAs) can occur but are rare."

ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Reduction of Risk Potential

The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. "Appears uncooperative. Exhibits characteristics of depression." B. "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." C. "States 'I don't need to be here' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." D. "Unwilling to respond openly during interview."

ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client's legal record should be objective and based on assessed data. Implications and generalizations should be avoided. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment

An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention? A. Encourage the student to use the alternative coping mechanism of relaxation exercises. B. Complete the problem-solving process for the client. C. Work through the problem-solving process with the client. D. Encourage the client to keep a journal.

ANS: C During times of high anxiety and stress, clients will need more assistance in problem-solving and decision making. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.

ANS: C It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. "Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT." B. "Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration." C. "Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious." D. "Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure."

ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously a short-acting anesthetic such as thiopental sodium (Pentothal). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, "Kill your infant son." D. The client who argued with her boyfriend and inflicted a superficial cut on her arm

ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. These data are prioritized to meet client needs, with an emphasis on safety. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A student nurse asks an instructor which resource is best to use when developing nursing outcomes for clients. Which reply by the instructor most accurately answers the student's question? A. "Use the Nursing Interventions Classification (NIC), as a reference for nursing outcomes." B. "Use the NANDA resource to identify appropriate outcomes." C. "Use the Nursing Outcomes Classification (NOC), as a reference for nursing outcomes." D. "Copy your standard outcomes from a nursing care plan textbook."

ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions. NANDA is a resource for identifying approved nursing diagnoses. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment

A husband accuses his wife of infidelity. Which situation would indicate to the nurse the husband's use of the ego defense mechanism of projection? A. The husband cries and stamps his feet, demanding that his wife be true to her marriage vows. B. The husband ignores the wife's continued absence from the home. C. The husband has already admitted to having an affair with a coworker. D. The husband takes out his marital frustrations through employee abuse.

ANS: C Projection is the attribution of feelings or impulses unacceptable to one's self to another person. In this situation, the husband attributes his infidelity to his wife. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale

ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data? A. The client is experiencing severe distress and is at risk for physical and psychological illness. B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness. C. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports. D. The client may view these losses as challenges and perceive them as opportunities.

ANS: C The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a client's life. However, positive coping mechanisms and strong social support can limit susceptibility to stress-related illnesses. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, "I can't even remember eating breakfast, so I want to stop the ECT." Which is the most appropriate nursing reply? A. "After you begin the course of treatments, you must complete all of them." B. "You'll need to talk with your doctor about what you're thinking." C. "It is within your right to discontinue the treatments, but let's talk about your concerns." D. "Memory loss is a rare side effect of the treatment. I don't think it should be a concern."

ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the client's concerns so that the nurse can provide needed information. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? A. The employee assertively confronts the boss B. The employee leaves the staff meeting to work out in the gym C. The employee criticizes a coworker D. The employee takes the boss out to lunch

ANS: C The client using the defense mechanism of displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

ANS: C The initial nursing action is to assess environmental triggers and potential unmet needs. Due to the cognitive decline experienced in a client diagnosed with neurocognitive disorder, communication skills may be limited. The client may become disoriented and frustrated. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist

ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A newly admitted homeless client diagnosed with schizophrenia states, "I have been living in a cardboard box for 2 weeks. Why did the government let me down?" Which is an appropriate nursing reply? A. "Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless." B. "Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia." C. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success." D. "Your discharge from the state hospital was based on presumed family support, and this was not forthcoming."

ANS: C The most accurate nursing reply is to explain to the client that the resources were not available for successful transitioning out of a state hospital to the community. There are several factors that are thought to contribute to homelessness among the mentally ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable health care, domestic violence, and addiction disorders. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with neurocognitive disorder due to Alzheimer's disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication? A. Discourage attempts at verbal communication because of increased client frustration. B. Increase the volume of the nurse's communication responses. C. Verbalize the nurse's perception of the implied communication. D. Encourage the client to communicate by writing.

ANS: C The most appropriate nursing intervention is to verbalize the nurse's perception of the implied communication. The nurse should also keep explanations simple, use face-to-face interaction, and speak slowly without shouting. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client has recently been placed in a long-term-care facility because of marked confusion and inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the client's self-esteem? A. Leave the client alone in the bathroom to test ability to perform self-care. B. Assign a variety of caregivers to increase potential for socialization. C. Allow client to choose between two different outfits when dressing for the day. D. Modify the daily schedule often to maintain variety and decrease boredom.

ANS: C The most appropriate nursing intervention to maintain this client's self-esteem is to allow the client to choose between two different outfits when dressing for the day. The nurse should also provide appropriate supervision to keep the client safe, maintain consistency of caregivers, and maintain a structured daily routine to minimize confusion. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. I don't hear any voices speaking." D. "The devil only talks to people who are receptive to his influence."

ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, the nurse would most appropriately make which statement? A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Watch your diet and try to engage in some regular physical activity." C. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."

ANS: C The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension. KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse's rationale for this procedure? A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity

ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medication-induced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

Which data-gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful

ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client's orientation. Assessment of the client's orientation to reality is part of a mental status evaluation. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response? A. "It's just a routine part of our assessment. All clients are asked these same questions." B. "Why are you concerned about these types of questions?" C. "Psychological factors, like excessive stress, have been found to affect medical conditions." D. "We can skip these questions, if you like. It isn't imperative that we complete this section."

ANS: C The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Health Promotion and Maintenance

A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist

ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

At what time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications

ANS: C The nurse should determine that clients with Alzheimer's disease exhibit more pronounced symptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the late afternoon and evening. KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client diagnosed with schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

ANS: C The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self. KEY: Cognitive Level: Analysis | Integrated Processes: Communication and Documentation; Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

An elderly client who lives with a caregiver is admitted to an emergency department for a fractured arm. The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect? A. Inability for the client to meet self-care needs B. Alzheimer's dementia C. Abuse, neglect, or both D. Caregiver role strain

ANS: C The nurse should expect that this client is a victim of elder abuse, neglect, or both. Indicators of elder physical abuse include bruises, fractures, burns, and other physical injuries. Neglect may be manifested as hunger, poor hygiene, unattended physical problems, and/or abandonment. KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Safe and Effective Care Environment

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)? A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity

ANS: C The nurse should identify that attention and concentration are impaired in neurocognitive disorder and not in pseudodementia (depression). KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? A. Displacement B. Projection C. Reaction formation D. Sublimation

ANS: C The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?A. Maintaining a long-term, faithful, intimate relationship B. Achieving a sense of self-confidence C. Possessing a feeling of self-fulfillment and realizing full potential D. Developing a sense of purpose and the ability to direct activities

ANS: C The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity

After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimer's disease. What should cause the nurse to question this diagnosis? A. Neurocognitive disorder does not typically occur in African American clients. B. The symptoms presented are more indicative of Parkinsonism. C. Neurocognitive disorder does not develop suddenly. D. There has been no T3 or T4 level evaluation ordered.

ANS: C The nurse should know that neurocognitive disorder (NCD) does not develop suddenly and should question this diagnosis. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed. The disease is generally progressive and debilitating. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

ANS: C The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

An elderly client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen? A. Altered cortical and intellectual functioning B. Altered respiratory and gastrointestinal functioning C. Altered liver and kidney functioning D. Altered endocrine and immune system functioning

ANS: C The nurse should question the use of an antidepressant medication in a client with altered liver and kidney function. Antidepressant medication should be administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity. Because of these changes, medications can reach high levels despite moderate oral dosage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition? A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism

ANS: C The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). In NCD, impairment is evident in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? A. "If only we could have tried again, things might have worked out." B. "I am so mad that the children and I had to put up with him as long as we did." C. "Yes, it was a difficult relationship, but I think I have learned from the experience." D. "I still don't have any appetite and continue to lose weight."

ANS: C The nurse should recognize that the client is in the acceptance stage of grief. During this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team's goals. B. Nursing interventions are directed solely by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.

ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care? A. Teaching an adolescent about pregnancy prevention B. Teaching an elderly client the reportable side effects of a newly prescribed neuroleptic medication C. Teaching a client with schizophrenia to cook meals, make a grocery list, and establish a budget D. Teaching a client about his or her new diagnosis of bipolar disorder

ANS: C The nurse who teaches a client to cook meals, make a grocery list, and establish a budget is implementing care within the parameters of tertiary prevention. Tertiary prevention is services aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by promoting rehabilitation that is directed toward achievement of maximum functioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

An angry client on an inpatient unit approaches a nurse, stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should be addressed only during group therapy.

ANS: C The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The client's sleep habits will improve during hospitalization.

ANS: C The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization" is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A client diagnosed with neurocognitive disorder due to Alzheimer's disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis? A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance

ANS: C The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Reduction of Risk Potential

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve? A. The client will verbalize an understanding of the need for moving slowly after treatment. B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment. C. The client will continue adequate tissue perfusion 1 hour after treatment. D. The client will verbalize an understanding of common side effects of ECT.

ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity

When a home health nurse administers an outpatient's injection of haloperidol decanoate (Haldol decanoate), which level of care is the nurse providing? A. Primary prevention level of care B. Secondary prevention level of care C. Tertiary prevention level of care D. Case management level of care

ANS: C When administering this long-acting antipsychotic medication, the nurse is providing a tertiary prevention level of care. Tertiary prevention services are aimed at reducing the residual effects associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation directed toward achievement of maximum functioning. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

ANS: C When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nurse is evaluating a client's response to stress. What would indicate to the nurse that the client is experiencing a secondary appraisal of the stressful event? A. When the individual judges the event to be benign B. When the individual judges the event to be irrelevant C. When the individual judges the resources and skills needed to deal with the event D. When the individual judges the event to be pleasurable

ANS: C When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign-positive, and stressful. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Which intervention should the nurse consider as primary prevention for an individual who is on the verge of being homeless because of a job layoff? A. Referral to primary care provider to improve general health status B. Encouraging client to recognize reasons for job layoff C. Job training to increase employment options D. Encouraging the use of prn medications to control symptoms

ANS: C When the nurse implements primary prevention interventions, the nurse is providing services aimed at reducing the incidences of mental disorders within the population. In this situation, there is emphasis on providing education and support to unemployed or homeless individuals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which of the following are characteristics of accurately developed client outcomes? Select all that apply. A. Client outcomes are formulated by nurses independent from other team members. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.

ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment

A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response

ANS: D "Verbalizes understanding of the side effects of Prozac" is an example of the response category of focused charting. The response is a description of the client's reaction to any part of medical or nursing care. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment

When a nurse attempts to provide health-care services to the homeless, what should be a realistic concern? A. Most individuals who are homeless reject help. B. Most individuals who are homeless are suspicious of anyone who offers help. C. Most individuals who are homeless are proud and will often refuse charity. D. Most individuals who are homeless relocate frequently.

ANS: D A realistic concern in the provision of health-care services to the homeless is that individuals who are homeless relocate frequently. Frequent relocation confounds service delivery and interferes with providers' efforts to ensure appropriate care. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A client diagnosed with schizophrenia was released from a state mental hospital after 20 years of institutionalization. A nurse should recognize which characteristic that is likely to be exhibited by this client? A. The client is likely to be compliant with treatment because of institutional dependency. B. The client is likely to find a variety of community support services to aid in the transition. C. The client is likely to adjust to the community environment if given sufficient support. D. The client is likely to be admitted at some time to an acute care unit for psychiatric treatment.

ANS: D Because of the chronic nature of this client's diagnosis and commonly occurring medication noncompliance, the nurse would expect recidivism during the course of the illness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nurse is conducting a class on fall prevention at a local senior center. In relationship to the slowed cognitive processing of advanced age, which teaching modification would be most appropriate for the nurse to implement? A. Encouraging the clients to use hearing aids if needed B. Avoiding overarticulation C. Minimizing distractive stimuli D. Providing more time for client feedback

ANS: D Because the elderly require more time to assimilate information, the nurse should modify teaching methods to allow more time for older adults to respond to and pose questions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A distraught, single, first-time mother cries and asks a nurse, "How can I go to work if I can't afford childcare?" What is the nurse's initial action in assisting the client with the problem-solving process? A. Determine the risks and benefits for each alternative. B. Formulate goals for resolution of the problem. C. Evaluate the outcome of the implemented alternative. D. Assess the facts of the situation.

ANS: D Before any other steps can be taken, accurate information about the situation must be gathered and assessed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

When intervening with a married couple experiencing relationship discord, which reflects a nursing intervention at the secondary level of prevention? A. Assessing how the children are coping with the parents' relationship issues B. Supplying the couple with guidelines related to marital seminar leadership C. Teaching the couple about various methods of birth control D. Counseling the couple in relation to open and honest communication skills

ANS: D Counseling the couple in relation to open and honest communication skills is reflective of a nursing intervention at the secondary level of prevention. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which is the most significant consequence of the excessive use of defense mechanisms? A. The superego will be suppressed. B. Emotions will be experienced intensely. C. Learning and the ability to grow will be enhanced. D. Problem-solving will be limited.

ANS: D Defense mechanisms become maladaptive when they are used by an individual to such a degree that there is interference with the ability to deal with reality, effective interpersonal relations, or occupational performance. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nursing instructor is asking students about diseases of adaptation and when they are likely to occur. Which student response indicates that learning has occurred? A. "When an individual has limited experience dealing with stress" B. "When an individual inherits maladaptive genes" C. "When an individual experiences existing conditions that exacerbate stress" D. "When an individual's physiological and psychological resources have become depleted"

ANS: D During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is the time when diseases of adaptation may occur. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance

A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.

ANS: D Forgetfulness is an early symptom of dementia that would alert the nurse to question the client's safety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease. The cause of vascular dementia is related to an interruption of blood flow to the brain. High blood pressure and hypertension are significant factors in the etiology. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a client's electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication? A. Robinul decreases anxiety during the ECT procedure. B. Robinul induces an unconscious state to prevent pain during the ECT procedure. C. Robinul prevents severe muscle contractions during the ECT procedure. D. Robinul decreases secretions to prevent aspiration during the ECT procedure.

ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT procedures to decrease secretions and prevent aspiration. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client's normal sleep pattern.

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

An instructor overhears a student say, "That family seems to disagree more than agree. The family seems to be dysfunctional." To further assess the family's situation, which would be an appropriate instructor reply? A. "Families who disagree can be a challenge to the treatment team." B. "You seem very critical of the family. Do you believe that you are unable to help them?" C. "Let's bring the family in for an educational session to improve their communication." D. "What appears to trigger family disagreements?"

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

During an intake interview, which question would assist the nurse in gathering data about the client's judgment? A. "What brought you to the hospital? Do you know what day and season it is now?" B. "On a scale of 1 to 10, how would you rate your stress level?" C. "What does the phrase 'a rolling stone gathers no moss' mean to you?" D. "If you found a stamped, addressed envelope in the street, what would you do?"

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment on the basis of the client's action choice. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. "If I were in your situation, I would not repeat a behavior that has caused problems." B. "What do you think needs changing, and what do you want to do differently?" C. "What exactly will it take to carry out your plan, and what else do you need to do?" D. "It sounds like you're saying this new approach is working for you."

ANS: D In the evaluation phase of the nursing process, the nurse and the client evaluate progress toward attainment of the expected outcomes. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: "Perhaps this was the best thing to happen. Maybe I'll look into pursuing an art degree." How should the nurse characterize the client's appraisal of the job loss stressor? A. Irrelevant B. Harm/loss C. Threatening D. Challenging

ANS: D The client perceives the situation of job loss as a challenge and an opportunity for growth. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Research undertaken by Miller and Rahe in 1997 demonstrated a correlation between the effects of life change and illness. This research led to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool? A. Specific illnesses are not identified. B. The numerical values associated with specific life events are randomly assigned C. Stress is viewed as only a physiological response. D. Personal perception of the event is excluded.

ANS: D Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance

A client diagnosed with glaucoma is being discharged to an assisted living facility. In what way should the discharge nurse modify teaching to most effectively present information to this client? A. Repeat information at least four times. B. Present discharge teaching to client's spouse. C. Use a taped message that can be repeated as needed. D. Reinforce critical content by providing large-print handouts.

ANS: D Providing large-print materials would address the client's visual alterations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which is an example of the ego defense mechanism of regression? A. A mother blames the teacher for her child's failure in school. B. A teenager becomes hysterical after seeing a friend killed in a car accident. C. A woman wants to marry a man exactly like her beloved father. D. An adult throws a temper tantrum when he does not get his own way.

ANS: D Regression is the retreating to an earlier level of development and the comfort measures associated with that level of functioning. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which should the nurse recognize as an example of the defense mechanism of repression?A. A student aware of the need to study for tomorrow's test goes to a movie instead. B. A woman whose son was killed in Iraq does not believe the military report. C. A man who is unhappily married goes to school to become a marriage counselor. D. A woman was raped when she was 12 and no longer remembers the incident.

ANS: D Repression is the involuntary blocking of unpleasant feelings and experiences from one's awareness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A school nurse is assessing a female high school student who is overly concerned about her appearance. The client's mother states, "That's not something to be stressed about!" Which is the most appropriate nursing response? A. "Teenagers! They don't know a thing about real stress." B. "Stress occurs only when there is a loss." C. "When you are in poor physical condition, you can't experience psychological well-being." D. "Stress can be psychological. A threat to self-esteem may result in high stress levels."

ANS: D Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nursing instructor is teaching students about the differences between partial and inpatient hospitalization. In what way does partial hospitalization differ from traditional inpatient hospitalization? A. Partial hospitalization does not provide medication administration and monitoring. B. Partial hospitalization does not use an interdisciplinary team. C. Partial hospitalization does not offer a comprehensive treatment plan. D. Partial hospitalization does not provide supervision 24 hours a day.

ANS: D The instructor should explain that partial hospitalization does not provide supervision 24 hours a day. Partial hospitalization programs generally offer a comprehensive treatment plan formulated by an interdisciplinary team. This has proved to be an effective method of preventing hospitalization. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

Which nursing statement best describes the current nature of mental health care in the community? A. "All homeless people have a history of institutionalization and are frequently admitted to acute care settings." B. "In the United States, the rate of serious mental illness in the prison population is the same as the general population." C. "The deinstitutionalization movement in the United States was successful in transitioning clients into the community." D. "Today, the majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization."

ANS: D The majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization and reintroduction into the community. Crisis situations can occur because of treatment noncompliance and exacerbations of the chronic mental illness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects

ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client's safety and physiological needs are met within the milieu. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.

ANS: D The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client on an inpatient unit angrily states to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? A. "I'll talk to Peter and present your concerns." B. "Why are you overreacting to this issue?" C. "You should bring this to the attention of your treatment team." D. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

ANS: D The most appropriate nursing response involves restating the client's feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A couple resides in a long-term care facility. The husband is admitted to the psychiatric unit after physically abusing his wife. He states, "My wife is having an affair with a young man, and I want it investigated." Which is the appropriate nursing reply? A. "Your wife is not having an affair. What makes you think that?" B. "Why do you think that your wife is having an affair?" C. "Your wife has told us that these thoughts have no basis in fact." D. "I understand that you are upset. Let's talk about it."

ANS: D The most appropriate reply by the nurse is to empathize with the client regarding his emotional response and to encourage the client to talk about the situation. The nurse should remain nonjudgmental and help maintain orientation and aid in memory and recognition. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors? A. The client's behaviors demonstrate mental illness in the form of depression. B. The client's behaviors are extensive, which indicates the presence of mental illness. C. The client's behaviors are not congruent with cultural norms. D. The client's behaviors demonstrate no functional impairment, indicating no mental illness.

ANS: D The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the client's distress does not indicate a mental illness. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial? A. Hiding liquor bottles in a closet B. Yelling at their son for slouching in his chair C. Burning dinner on purpose D. Saying to the spouse, "I don't drink too much!"

ANS: D The nurse should associate the client statement "I don't drink too much!" with the use of the defense mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the feelings associated with it is using the defense mechanism of denial. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin) D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft)

ANS: D The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the client's social functioning and concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management

ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client's learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with neurocognitive disorder due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

ANS: D The nurse should recognize that this client is in the late stage of Alzheimer's disease. The late stage is characterized by a severe cognitive decline. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client diagnosed with neurocognitive disorder due to Alzheimer's disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the client's room with name and number D. Assist with bathing and toileting

ANS: D The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.

ANS: D The statement "Client will initiate interaction with one peer during free time within 2 days" is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply. A. Apathy B. Social withdrawal C. Anhedonia D. Galactorrhea E. Gynecomastia

ANS: D, E Dopamine blockage, an expected action of antipsychotic medications, also results in prolactin elevation. Galactorrhea and gynecomastia are symptoms of prolactin elevation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

An elderly, emaciated client is brought to an emergency department by the client's caregiver. The client has bruises and abrasions on shoulders and back in multiple stages of healing. When directly asked about these symptoms, which type of client response should a nurse anticipate? A. The client will honestly reveal the nature of the injuries. B. The client may deny or minimize the injuries. C. The client may have forgotten what caused the injuries. D. The client will ask to be placed in a nursing home.

The nurse should anticipate that the client might deny or minimize the injuries. The older client may be unwilling to disclose information because of fear of retaliation, embarrassment about the existence of abuse in the family, protectiveness toward a family member, or unwillingness to bring about legal action. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply. A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity