Exam 3 Practice Questions (Varcarolis Chapters 16,17,19,24)

Delusions:Grandeur

False belief that one is an important, powerful person

Tactile

feeling touch sensations in absence of stimuli

Depressive & Other mood symptoms

-Dysphoria -Suicidal -Hopelessness

Language and Communication Disturbances: Clang associations

Repetition of words or phrases similar in sound but in no other way

Gustatory

Experiencing taste in absence of stimuli

Cognitive Symptoms

-Inattention, easily distracted -Impaired memory -Poor problem solving and decision making skills -illogical -impaired judgement

Visual

Seeing things that aren't there

Jealousy

False belief that ones partner is going out with other persons

Abnormal Motor Behavior

-Echolalia: Repeating speech of another person -Echopraxia: Repeating movements of another person -Waxy Flexibility: Having arms or legs in certain position and holding that same position for hours.

13. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.

2. Discontinue the fluoxetine and rethink the client's diagnosis.

14. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

2. Empowerment of the consumer

Abnormal Thought Process: Cirumstantiality

Before getting to the point or answering a question, client gets caught up in countless details and explanations

Thought Blocking

Cessation of thought in the middle of a sentence; unable to continue train of thought; Often new thoughts come up unrelated to the topic.

Hallucinations: Auditory

Hearing voices that are not present

Flight of Ideas

Jumping rapidly from one topic to another; seen in manic states.

Olfactory

Smells that do not exist

Pressured Speech

Speaking as if words are forced out too quickly

A client with a history of alcohol abuse tells the nurse that he refuses to take his vitamins. What is the most appropriate response by the nurse? 1. " It's important to take vitamins to stop your craving." 2. " Prolonged use of alcohol can cause vitamin depletion." 3. " For every vitamin you take, you'll help your liver heal." 4. " By taking vitamins, you don't need to worry about your diet." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15957-15962). Lippincott Williams & Wilkins. Kindle Edition.

13. 2. Chronic alcoholism interferes with the metabolism of many vitamins. Vitamin supplements can prevent deficiencies from occurring. Taking vitamins won't stop a person from craving alcohol or help a damaged liver heal. A balanced diet is essential in addition to taking multivitamins. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15963-15965). Lippincott Williams & Wilkins. Kindle Edition.

14. The nurse determines further teaching about nutrition is necessary when an alcoholic client makes which statement? 1. " I should avoid foods high in fat." 2. " I should eat only one balanced meal per day." 3. " I should take vitamin and mineral supplements." 4. " I should eat large portions of food containing fiber."

14. 2. If the client eats only one adequate meal each day, there will be a deficit of essential nutrients. It's appropriate for the client to take vitamin and mineral supplements to prevent deficiency in these nutrients. Avoiding foods high in fat content and consuming large portions of foods containing fiber indicate the client has good knowledge about nutrition. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15972-15975). Lippincott Williams & Wilkins. Kindle Edition.

A client tells the nurse, "I have been drinking ever since they told me I had learning disabilities." How does the nurse interpret this response? 1. The client is self-medicating. 2. The client has an excuse to drink. 3. The client isn't a productive person. 4. The client will be unable to stop drinking.

15. 1. A client with learning disabilities may experience frustration, depression, or overall feelings of low self-esteem and may self-medicate with alcohol. Many people with learning disabilities don't resort to alcohol but develop other coping skills to handle the disability. People with learning disabilities can be very productive. A person with a learning disability can successfully recover from alcohol addiction. CN: Psychosocial integrity; CNS: None; CL: Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15982-15986). Lippincott Williams & Wilkins. Kindle Edition.

9. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Risky Activity" tool 2. "FIND" tool 3. "Consensus Committee" tool 4. "Monotherapy" tool

2. "FIND" tool Rationale: The nurse should use the "FIND" tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

The nurse is facilitating a family meeting for a client who abuses alcohol. During the meeting, the nurse observes the communication and determines an unhealthy pattern of: 1. use of descriptive jargon. 2. disapproval of behaviors. 3. avoidance of conflicting issues. 4. unlimited expression of nonverbal communication. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16166-16170). Lippincott Williams & Wilkins. Kindle Edition.

3. The interaction pattern of a family with a member who abuses alcohol often revolves around denying the problem, avoiding conflict, or rationalizing the addiction. Health care providers are more likely to use jargon. The family might have problems setting limits and expressing disapproval of the client's behavior. Nonverbal communication often gives the nurse insight into family dynamics. CN: Psychosocial integrity; CNS: Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16171-16175). Lippincott Williams & Wilkins. Kindle Edition.

A family tells the nurse that they are concerned about a family member who stopped using amphetamines 3 months ago and is now acting paranoid. What is the best response by the nurse? 1. " A person gets symptoms of paranoia with polysubstance abuse." 2. " When a person uses amphetamines, paranoid tendencies may continue for months." 3. " Sometimes, family dynamics and a high suspicion of continued drug use make a person paranoid." 4. " Amphetamine abusers may have severe anxiety and paranoid thinking." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16496-16501). Lippincott Williams & Wilkins. Kindle Edition.

2. After a client uses amphetamines, there may be long-term effects that exist for months after use. Two common effects are paranoia and ideas of reference. Even with polysubstance abuse, the paranoia comes from the chronic use of amphetamines. The third option blames the family when the paranoia comes from the drug use. Severe anxiety isn't typically manifested in paranoid thinking. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16502-16505). Lippincott Williams & Wilkins. Kindle Edition.

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

The nurse is caring for a client struggling with alcohol dependence. It is most important for the nurse to do which of the following? 1. Speak briefly and directly. 2. Avoid blaming or preaching to the client. 3. Confront feelings and examples of perfectionism. 4. Determine if nonverbal communication will be more effective. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16070-16074). Lippincott Williams & Wilkins. Kindle Edition.

2. Blaming or preaching to the client causes negativity and prevents the client from hearing what the nurse has to say. Speaking briefly to the client may not allow time for adequate communication. Perfectionism doesn't tend to be an issue. Determining if nonverbal communication will be more effective is better suited for a client with cognitive impairment. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16075-16077). Lippincott Williams & Wilkins. Kindle Edition.

A nurse is caring for a client recovering from cocaine abuse. The priority intervention for this client would be? 1. Skin care 2. Suicide precautions 3. Frequent orientation 4. Nutrition consultation

2. Clients recovering from cocaine use are prone to "postcoke depression" and have a likelihood of becoming suicidal if they can't take the drug. Frequent orientation and skin care are routine nursing interventions but aren't the most immediate considerations for this client. Nutrition consultation isn't the most pressing intervention for this client. CN: Safe, effective care environment; CNS: Management Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16355-16359). Lippincott Williams & Wilkins. Kindle Edition.

A client with a history of alcohol abuse has been diagnosed with nutritional deficits. What is the best intervention for the nurse to implement? 1. Encourage the client to eat a diet high in calories. 2. Help the client recognize and follow a balanced diet. 3. Have the client drink liquid protein supplements daily. 4. Have the client monitor the calories consumed each day.

2. Clients who abuse alcohol are usually malnourished and need help to follow a balanced diet. Increasing calories may cause the client to just eat empty calories. The client must be involved in the decision to supplement the daily dietary intake. The nurse can't force the client to drink liquid protein supplements. Having the client monitor calorie intake could be done only after the client recognizes the need to maintain a balanced diet. Calorie counts usually aren't needed in most recovering clients who begin to eat from the basic food groups. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15951-15955). Lippincott Williams & Wilkins. Kindle Edition.

The nurse is assessing a client who repeatedly abuses cocaine. It is important for the nurse to observe the client for which of the following? 1. Panic attacks 2. Bipolar cycling 3. Attention deficits 4. Expressive aphasia

2. Clients who frequently use cocaine will experience the rapid cycling effect of excitement and then severe depression. They don't tend to experience panic attacks, expressive aphasia, or attention deficits. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16364-16366). Lippincott Williams & Wilkins. Kindle Edition.

A client who formerly used lysergic acid diethylamide (LSD) is seeking counseling. The nurse anticipates that the assessment of the client will include which finding? 1. Lack of trust 2. Panic attacks 3. Recurrent depression 4. Loss of ego boundaries

2. Clients who used LSD typically have a history of panic attacks or psychotic behavior. This is often referred to as a "bad trip." Loss of ego boundaries, recurrent depression, and lack of trust don't tend to be problems for this type of client. CN: Psychosocial integrity; CNS: None; CL: Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16402-16405). Lippincott Williams & Wilkins. Kindle Edition.

The nurse anticipates that a client undergoing nicotine withdrawal may make which statement? 1. " I sometimes feel like I'm seeing things." 2. " I feel lousy, and I'm grumpy with everybody." 3. " I can't believe I feel fine after just having stopped smoking." 4. " I'm always yawning now." .

2. During nicotine withdrawal, the client is typically irritable and nervous. Seeing things (hallucinations) isn't linked to nicotine withdrawal. A client going through nicotine withdrawal is unlikely to "feel fine." Yawning is associated with withdrawal from opioids, not nicotine. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16594-16596). Lippincott Williams & Wilkins. Kindle Edition.

When investigating biologic theories related to schizophrenia, which of the following neuroanatomic findings would be consistent with this mental health disorder? 1. Enlarged hippocampus 2. Enlarged lateral ventricle 3. Smaller third ventricle 4. Enlarged brain volume

2. Enlarged lateral ventricle The lateral and third ventricles are somewhat larger, and total brain volume is somewhat smaller, in persons with schizophrenia compared with those without schizophrenia. The thalamus and the medial temporal lobe structures, including the hippocampus, superior temporal, and prefrontal cortices, also tend to be smaller

The nurse is caring for a client with a history of chronic alcoholism and is aware that the client may be predisposed to which of the following? 1. Arteriosclerosis 2. Heart failure 3. Heart valve damage 4. Pericarditis

2. Heart failure is a severe cardiac consequence associated with long-term alcohol use. Arteriosclerosis, heart valve damage, and pericarditis aren't medical consequences of alcoholism. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15933-15934). Lippincott Williams & Wilkins. Kindle Edition.

18. What is the most important short-term goal for a client with a knowledge deficit about the effects of alcohol on the body? 1. Test blood chemistries daily. 2. Verbalize the results of substance use. 3. Talk to a pharmacist about the substance. 4. Attend a weekly aerobic exercise program.

2. It's important for the client to talk about the health consequences of the continued use of alcohol. Testing blood chemistries daily gives the client minimal knowledge about the effects of alcohol on the body and isn't the most useful information in a teaching plan. A pharmacist isn't the appropriate health care professional to educate the client about the effects of alcohol use on the body. Although exercise is an important goal of self-care, it doesn't address the client's knowledge deficit about the effects of alcohol on the body. CN: Safe, effective care environment; Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16012-16017). Lippincott Williams & Wilkins. Kindle Edition.

A nurse is caring for a client addicted to heroin who is experiencing withdrawal symptoms. The nurse is aware that the withdrawal symptoms may be affected by which factor? 1. Ego strength 2. Liver function 3. Seizure history 4. Kidney function

2. Liver function status is an important variable that can be used to indicate the severity of a client's drug withdrawal. Ego strength, seizure history, and kidney function aren't variables that can be used to predict the severity of withdrawal symptoms.

8. A client who is withdrawing from alcohol is being given lorazepam (Ativan). The client's family asks the nurse about the medication. What is the best response by the nurse? 1. " Short-term use of lorazepam can lead to dependence." 2. " The lorazepam will reduce the symptoms of withdrawal." 3. " The lorazepam will make him forget about symptoms of withdrawal." 4. " The lorazepam will also help with his heart disease."

2. Lorazepam is a short-acting benzodiazepine usually given for 1 week to help the client in alcohol withdrawal. Long-term (not short-term) use of lorazepam can lead to dependence. The medication isn't given to help forget the experience; it lessens the symptoms of withdrawal. It isn't used to treat coexisting cardiovascular problems. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15912-15914). Lippincott Williams & Wilkins. Kindle Edition.

A client tells a nurse, "I'm not going to have problems from smoking marijuana." What is the most appropriate response by the nurse? 1. " Evidence shows it can cause major health problems." 2. " Marijuana can cause reproductive problems later in life." 3. " Smoking marijuana isn't as dangerous as smoking cigarettes." 4. " Some people have minor or no reactions to smoking marijuana." .

2. Marijuana causes cardiac, respiratory, immune, and reproductive health problems. Most people who smoke marijuana don't have major health problems. All people who smoke marijuana have symptoms of intoxication. The residues from marijuana are more toxic than those from cigarettes. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16236-16238). Lippincott Williams & Wilkins. Kindle Edition.

What is the most important teaching information for the nurse to provide a client who abuses prescription drugs? 1. Herbal substitutes are safer to use. 2. Medication should be used only for the reason prescribed. 3. The client should consult a physician before using a drug. 4. Consider if family members influence the client to use drugs.

2. People often take prescribed drugs for reasons other than those intended, primarily to self-medicate or experience a sense of euphoria. The safety and efficacy of most herbal remedies haven't been established. Sometimes, over-the-counter medications are necessary for minor problems. There may be a family history of substance abuse, but it isn't a priority when planning nursing care. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16307-16310). Lippincott Williams & Wilkins. Kindle Edition.

16. A nurse is caring for a client undergoing treatment for acute alcohol dependence. The client tells the nurse, "I don't have a problem. My wife made me come here." Which defense mechanism does the nurse interpret the client's statement as representing? 1. Projection and suppression 2. Denial and rationalization 3. Rationalization and repression 4. Suppression and denial Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15987-15992). Lippincott Williams & Wilkins. Kindle Edition.

2. The client is using denial and rationalization. Denial is the unconscious disclaimer of unacceptable thoughts, feelings, needs, or certain external factors. Rationalization is the unconscious effort to justify intolerable feelings, behaviors, and motives. The client isn't using projection, suppression, or repression. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15993-15995). Lippincott Williams & Wilkins. Kindle Edition.

A client withdrawing from alcohol tells the nurse that he is worried about periodic hallucinations. What is the most appropriate intervention by the nurse? 1. Point out that the sensation doesn't exist. 2. Allow the client to talk about the experience. 3. Encourage the client to wash the body areas well. 4. Determine if the client has a cognitive impairment.

2. The client needs to talk about the periodic hallucinations to prevent them from becoming triggers to acting out behaviors and possible self-injury. The client's experience of sensory-perceptual alterations must be acknowledged; therefore, denying that the client's hallucinations exist isn't a helpful strategy. Determining if the client has a cognitive impairment and encouraging the client to wash the body areas well don't address the problem of periodic hallucinations. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16033-16036). Lippincott Williams & Wilkins. Kindle Edition.

A client experiencing alcohol withdrawal tells the nurse she is upset about going through detoxification. What is the most important goal for this client? 1. The client will commit to a drug-free lifestyle. 2. The client will work with the nurse to remain safe. 3. The client will drink plenty of fluids on a daily basis. 4. The client will make a personal inventory of strengths. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16050-16055). Lippincott Williams & Wilkins. Kindle Edition.

2. The priority goal is for client safety. Although drinking enough fluids, identifying personal strengths, and committing to a drug-free lifestyle are important goals, the nurse's first priority must be to promote client safety. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16056-16058). Lippincott Williams & Wilkins. Kindle Edition.

The nurse is performing an assessment of a client with a history of polysubstance abuse. What is the most important information for the nurse to obtain? 1. Oral administration of any drug 2. Time of last use of each drug 3. How the drug was obtained 4. The place the drug was used

2. The time of last use gives information about expected withdrawal symptoms of the drugs and what immediate treatment is necessary. How the drugs were obtained and the places the drugs were used aren't essential information for treatment, nor is administration. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16246-16247). Lippincott Williams & Wilkins. Kindle Edition.

31. A client recovering from alcohol abuse tells the nurse, "I get nothing out of Alcoholics Anonymous (AA) meetings." What is the best response by the nurse? 1. " What were you told about going to AA meetings?" 2. " What do you want to get out of the AA meetings?" 3. " When do you think you'll stop going to the meetings?" 4. " Do you think you can control what happens in a meeting?"

2. This response puts some of the responsibility for staying sober on the client and encourages the client to take a more active role. Asking what the client was told about AA meetings opens up a discussion that allows the client to continue to discuss disappointments rather than taking a proactive stand to support the value of AA meetings. The third option condones the client's desire to stop going to the meetings. The fourth option changes the issue from being responsible for staying sober to focusing on what the client can't control. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16149-16152). Lippincott Williams & Wilkins. Kindle Edition.

56. The nurse determines that teaching about cocaine has been effective when the client makes which statement? 1. " I wasn't using cocaine to feel better about myself." 2. " I started using cocaine more and more until I couldn't stop." 3. " I'm not addicted to cocaine because I don't use it every day." 4. " I'm not going to be a chronic user; I only use it on holidays." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16386-16391). Lippincott Williams & Wilkins. Kindle Edition.

2. This statement reflects the trajectory or common pattern of cocaine use and indicates successful teaching. The first option reflects the client's denial. People gravitate to the drug and continue its use because it gives them a sense of well-being, competency, and power. Cocaine abusers tend to be binge users and can be drug free for days or weeks between use, but they still have a drug problem. The fourth option indicates the client is in denial about the drug's potential to become a habit. Effective teaching didn't occur. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16392-16395). Lippincott Williams & Wilkins. Kindle Edition.

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2. Valproic acid (Depakote)

An alcoholic client tells the nurse, "I feel so depressed about what I've done to my family that I feel like giving up." It is most important for the nurse to assess the client for which of the following? 1. Family support 2. A plan for self-harm 3. A sponsor for the client 4. Other ambivalent feelings

2. When a client talks about giving up, the nurse must explore the potential for suicidal behavior. Although questioning the client about family support, the availability of a sponsor, or ambivalent feelings is important, the priority action is to assess for suicide. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16024-16026). Lippincott Williams & Wilkins. Kindle Edition.

A client recovering from cocaine abuse is participating in group therapy. The nurse determines that the client has benefited from the therapy when the client makes which statement? 1. " I think the laws about drug possession are too strict in this country." 2. " I'll be more careful about talking about my drug use to my children." 3. " I finally realize the short high from cocaine isn't worth the depression." 4. " I can't understand how I could get all these problems that we talked about in group." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16484-16489). Lippincott Williams & Wilkins. Kindle Edition.

3. This is a realistic appraisal of a client's experience with cocaine and how harmful the experience is. The first option indicates the client was distracting self from personal issues and isn't working on goals in the group setting. Talking about drugs to children must be reinforced with nonverbal behavior, and not talking about drugs may give children the wrong message about drug use. The fourth option indicates the client is in denial about the consequences of cocaine use. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16491-16494). Lippincott Williams & Wilkins. Kindle Edition.

The nurse is trying to determine if a client who abuses heroin has any drug-related problems. What is the most appropriate question for the nurse to ask? 1. " When did your spouse become aware of your use of heroin?" 2. " Do you have a probation officer that you report to periodically?" 3. " Have you experienced any legal violations while being intoxicated?" 4. " Do you have a history of frequent visits with the employee assistance program manager?"

3. This question focuses on obtaining direct information about drug-related legal problems. When a spouse becomes aware of a partner's substance abuse, the first action isn't necessarily to institute legal action. Even if the client reports to a probation officer, the offense isn't necessarily a drug-related problem. Asking if the client has a history of frequent visits with the employee assistance program manager isn't useful. It assumes any visit to the employee assistance program manager is related to drug issues.

A client who abuses alcohol tells a nurse, "I'm sure I can become a social drinker." What is the most appropriate response by the nurse? 1. " When do you think you can become a social drinker?" 2. " What makes you think you'll learn to drink normally?" 3. " Does your alcohol use cause major problems in your life?" 4. " How many alcoholic beverages can a social drinker consume?"

3. This question may help the client recall the problematic results of using alcohol and the reasons the client began treatment. Asking when he believes he can become a social drinker will only encourage the addicted person to deny the problem and develop an unrealistic, self-defeating goal. Asking how many alcoholic beverages a social drinker can consume and why the client thinks he can drink normally will encourage the addicted person to defend himself and deny the problem. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15852-15855). Lippincott Williams & Wilkins. Kindle Edition.

The nurse has just completed an assessment of a client recovering from alcohol addiction who has limited coping skills. During the assessment, the nurse also identified that the client is experiencing relationship problems. This assessment is supported by which finding? 1. The client is prone to panic attacks. 2. The client doesn't pay attention to details. 3. The client has poor problem-solving skills. 4. The client ignores the need to relax and rest. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16091-16096). Lippincott Williams & Wilkins. Kindle Edition.

3. To have satisfying relationships, a person must be able to communicate and problem solve. Relationship problems don't predispose people to panic attacks more than other psychosocial stressors. Paying attention to details isn't a major concern when addressing the client's relationship difficulties. Although ignoring the need for rest and relaxation is unhealthy, it shouldn't pose a major relationship problem. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16097-16100). Lippincott Williams & Wilkins. Kindle Edition.

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

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

7. A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

3. "Weight gain is a common, but troubling, side effect."

A client who abuses alcohol is admitted to an outpatient drug and alcohol treatment facility. The nurse determines that which of the following is the most objective way to determine if the client is still using alcohol? 1. Having the client walk a straight line 2. Smelling the client's breath 3. Giving the client a breath alcohol test 4. Asking the client if he has been drinking

3. A breath alcohol test is the most objective way to determine if the client is still using alcohol. Having him walk a straight line and smelling his breath aren't objective tests. Asking him if he has been drinking may not elicit an honest answer (many clients who abuse alcohol deny alcohol use). Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16584-16586). Lippincott Williams & Wilkins. Kindle Edition.

Which of the following would the nurse expect to administer to a client with schizophrenia who is experiencing a dystonic reaction? 1. Risperidone (Risperdal) 2. Trihexyphenidyl (Artane) 3. Benztropine (Cogentin) 4. Aripiprazole (Abilify)

3. Benztropine (Cogentin) A client experiencing a dystonic reaction should receive immediate treatment with benztropine (Cogentin). Risperidone (Risperdal) and aripiprzole (Abilify) are antipsychotics that may cause dystonic reactions. Trihexyphenidyl (Artane) is used to treat Parkinsonism due to antipsychotic drugs

25. A nurse is working with a client on recognizing the relationship between alcohol abuse and interpersonal problem. Which of the following is the priority intervention? 1. Help the client identify personal strengths. 2. Help the client decrease compulsive behaviors. 3. Examine the client's use of defense mechanisms. 4. Have the client work with peers who can serve as role models.

3. Defense mechanisms can impede the development of healthy relationships and cause the client pain. After identifying barriers to relationship problems, it would be appropriate to identify or clarify personal strengths. Compulsive behavior doesn't tend to be a problem for alcoholic clients who struggle with interpersonal problems. Working with peers who are role models would be useful after the client recognizes and gains some insight into the problems. It isn't the priority intervention. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16085-16089). Lippincott Williams & Wilkins. Kindle Edition.

12. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.

A group of teenagers tell the school nurse they used cocaine because they were bored. What is the most important goal for the nurse? 1. Prepare a drug lecture. 2. Restrict school privileges. 3. Establish an activity schedule. 4. Report the incident to their parents. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16376-16380). Lippincott Williams & Wilkins. Kindle Edition.

3. Having an activity schedule enables the adolescents to develop coping skills to make better choices about what to do with their free time. Preparing a drug lecture or restricting school privileges won't be seen as useful by the adolescents and may inadvertently contribute to their inappropriate behavior. As the nurse works with the adolescents, it would be more effective to have the children talk to their parents about their drug use. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16381-16384). Lippincott Williams & Wilkins. Kindle Edition.

A 20-year-old client is admitted with bone marrow depression. He tells the nurse he's been abusing drugs since age 13. The nurse reviews the client's history for use of which drug? 1. Amphetamines 2. Cocaine 3. Inhalants 4. Marijuana

3. Inhalants cause severe bone marrow depression. Marijuana, cocaine, and amphetamines don't cause bone marrow depression. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16272-16273). Lippincott Williams & Wilkins. Kindle Edition.

The family of an adolescent who smokes marijuana asks a nurse if the use of marijuana leads to abuse of other drugs. What is the most appropriate response by the nurse? 1. " Use of marijuana is a stage your child will go through." 2. " Many people use marijuana and don't use other street drugs." 3. " Use of marijuana can lead to abuse of more potent substances." 4. " It's difficult to answer that question as I don't know your child."

3. Marijuana is considered a "gateway drug" because it tends to lead to the abuse of more potent drugs. People who use marijuana tend to use or at least experiment with more potent substances. Marijuana isn't a part of a developmental stage that adolescents go through. It isn't important that the nurse knows the child. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16318-16320). Lippincott Williams & Wilkins. Kindle Edition.

Negative Symptoms

-Blunted affect -Poverty of thought(Alogia) -Loss of motivation(Avolition) -Inability to experience pleasure or joy(Anhedonia)

Positive symptoms

-Hallucinations -Delusions -Disorganized speech -Bizzare Behavior

A pregnant client is thinking about stopping cocaine use. The nurse determines that teaching about drug use and pregnancy has been effective when the client makes which statement? 1. " Right after birth, I'll give the baby up for adoption." 2. " I'll help the baby get through the withdrawal period." 3. " I don't want the baby to have withdrawal symptoms." 4. " It's scary to think the baby may have Down syndrome."

3. Neonates born to mothers addicted to cocaine have withdrawal symptoms at birth. If the client says she'll give the baby up for adoption after birth or help the baby get through the withdrawal period, the teaching was ineffective because the mother doesn't see the impact of her drug use on the child. Use of cocaine Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16328-16330). Lippincott Williams & Wilkins. Kindle Edition.

A client diagnosed with schizophrenia is having delusions that he is being plotted against by the government. This would be documented as which of the following types of delusion? 1. Somatic 2. Grandiose 3. Persecutory 4. Nihilistic

3. Persecutory A persecutory delusion is a belief that one is being watched, ridiculed, harmed, or plotted against. The belief that one has exceptional powers, wealth. skill, influence, or destiny is a grandiose delusion. A nihilistic delusion is the belief that one is dead or a calamity is impending. A somatic delusion is the belief about abnormalities in bodily functions or structures

A client asks the nurse, "Why does it matter if I talk to my peers in group therapy?" What is the most appropriate response by the nurse? 1. " Group therapy lets you see what you're doing wrong in your life." 2. " Group therapy acts as a defense against your disorganized behavior." 3. " Group therapy provides a way to ask for support as well as to support others." 4. " In group therapy, you can vent your frustrations and others will listen." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16154-16159). Lippincott Williams & Wilkins. Kindle Edition.

3. The best response addresses how group therapy provides opportunities to communicate, learn, and give and get support. Group members will give a client feedback, not just point out what a client is doing wrong. Group therapy isn't a defense against disorganized behavior. People can express all kinds of feelings and discuss a variety of topics in group therapy. Interactions are goal oriented and not just vehicles to vent one's frustrations. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16161-16164). Lippincott Williams & Wilkins. Kindle Edition.

A client recovering from alcohol abuse needs to develop effective coping skills to handle daily stressors. What is the most appropriate nursing intervention for this client? 1. Determine the client's level of verbal skills. 2. Help the client avoid areas that cause conflict. 3. Discuss examples of successful coping behavior. 4. Teach the client to accept uncomfortable situations. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16060-16064). Lippincott Williams & Wilkins. Kindle Edition.

3. The client needs help to identify successful coping behavior and develop ways to incorporate that behavior into daily functioning. There are many skills for coping with stress, and determining the client's level of verbal skills may not be important. Encouraging the client to avoid conflict prevents him from learning skills to handle daily stressors. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16065-16068). Lippincott Williams & Wilkins. Kindle Edition.

A client has received chlordiazepoxide (Librium) to control the symptoms of alcohol withdrawal. The chlordiazepoxide has been ordered as needed. The nurse assesses the client and determines an additional dose of medication is needed when the client displays which symptoms? Select all that apply. 1. Tachycardia 2. Mood swings 3. Elevated blood pressure and temperature 4. Piloerection 5. Tremors 6. Increasing anxiety

1, 3, 5, and 6. Benzodiazepines are usually administered based on elevations in heart rate, blood pressure, and temperature as well as on the presence of tremors and increasing anxiety. Mood swings are expected during the withdrawal period and are not an indication for further medication administration. Piloerection is not a symptom of alcohol withdrawal. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16639-16641). Lippincott Williams & Wilkins. Kindle Edition.

A nurse has developed a relationship with a client who has an addiction problem. The nurse determines that the therapeutic interaction is in the working stage when the client does what? Select all that apply. 1. The client addresses how the addiction has contributed to family distress. 2. The client reluctantly shares the family history of addiction. 3. The client verbalizes difficulty identifying personal strengths. 4. The client discusses financial problems related to the addiction. 5. The client expresses uncertainty about meeting with the nurse. 6. The client acknowledges the addiction's effects on the children.

1, 3, and 6. These statements are indicative of the nurse- client working phase, in which the client explores, evaluates, and determines solutions to identified problems. The remaining statements address what happens during the introductory phase of the nurse- client interaction.

A client with schizophrenia is prescribed second-generations antipsychotic. The client's mother asks, "About how long will it take until we see any changes in his symptoms?" Which response by the nurse would be most appropriate? 1. "Generally, it takes about one to two weeks to be effective in changing symptoms" 2. "You should see improvement in about 36 to 48 hours" 3. "His symptoms should subside almost immediately" 4. "It will take about 6 to 12 weeks until the drug is effective"

1. "Generally, it takes about one to two weeks to be effective in changing symptoms" Generally, it takes about one to two weeks for antipsychotic drugs to effect a change in symptoms. During the stabilization period, the selected drug should be given an adequate trial, generally 6 to 12 weeks, before considering a change in the drug prescription. If treatment effects are not seen, another antipsychotic agent may be tried

1. Family members of an alcoholic client ask the nurse to help them intervene. Which action is essential for a successful intervention? 1. All family members must tell the client they're powerless. 2. All family members must describe how the addiction affects them. 3. All family members must come up with their share of financial support. 4. All family members must become caregivers during the detoxification period.

1. 2. After the family is taught about addiction, they must write down examples of how the addiction has affected each of them and use this information during the intervention. It isn't necessary to tell the client the family is powerless. The family is empowered through this intervention experience. In many cases, a third-party payer will help with treatment costs. Doing an intervention doesn't make family members responsible for financial support or providing care and support during the detoxification period. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15840-15844). Lippincott Williams & Wilkins. Kindle Edition.

A client who smoked marijuana daily for 10 years tells a nurse, "I don't have any goals, and I just don't know what to do." What is the most appropriate nursing intervention for this client? 1. Focus the interaction. 2. Use nonverbal methods. 3. Use reflection techniques. 4. Ask open-ended questions.

1. A client with amotivational syndrome from chronic use of marijuana tends to talk in tangents and needs the nurse to focus the conversation. Nonverbal communication or reflection techniques wouldn't be useful as this client must focus and learn to identify and accomplish goals. Using only open-ended questions won't allow the client to focus and establish specific goals. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16420-16423). Lippincott Williams & Wilkins. Kindle Edition.

A client who uses cocaine finally admits he also abused other drugs to equalize the effect of cocaine. The nurse is aware that the client's drug history may include which substance? 1. Alcohol 2. Amphetamines 3. Caffeine 4. Phencyclidine

1. A cocaine addict will commonly use alcohol to decrease or equalize the stimulating effects of cocaine. Caffeine, phencyclidine, and amphetamines aren't used to equalize the stimulating effects of cocaine. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16373-16374). Lippincott Williams & Wilkins. Kindle Edition.

When assessing a client with prolonged, chronic alcohol intake, the nurse would expect to find which of the following? 1. Enlarged liver 2. Nasal irritation 3. Muscle wasting 4. Limb paresthesia

1. A major effect of alcohol on the body is liver impairment, and an enlarged liver is a common physical finding. Nasal irritation is commonly seen with clients who snort cocaine. Muscle wasting and limb paresthesia don't tend to occur with clients who abuse alcohol. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15881-15883). Lippincott Williams & Wilkins. Kindle Edition.

7. A client who abuses alcohol tells a nurse, "Alcohol helps me sleep." What is the most appropriate response by the nurse? 1. " Alcohol doesn't help promote sleep." 2. " Continued alcohol use causes insomnia." 3. " One glass of alcohol at dinnertime can induce sleep." 4. " Sometimes, alcohol can make one drowsy enough to fall asleep."

1. Alcohol use may initially promote sleep, but with continued use, it causes insomnia. Evidence shows that alcohol doesn't facilitate sleep. One glass of alcohol at dinnertime won't induce sleep. The last option doesn't give information about how alcohol affects sleep. It makes the client think alcohol use to induce sleep is an appropriate strategy to try. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15901-15903). Lippincott Williams & Wilkins. Kindle Edition.

Types of Schizophrenia

1. Catatonic 2. Paranoid 3. Residual 4.Disorganized 5.Undifferentiated

A client is receiving chlordiazepoxide (Librium) as needed for signs and symptoms of alcohol withdrawal. The nurse assesses the client and determines the need for medication when the client displays: 1. mild tremors, hypertension, tachycardia. 2. bradycardia, hyperthermia, sedation. 3. hypotension, decreased reflexes, drowsiness. 4. hypothermia, mild tremors, slurred speech.

1. Chlordiazepoxide is given during alcohol withdrawal. Symptoms that indicate a need for this drug include tremors, hypertension, tachycardia, and elevated body temperature. Bradycardia, sedation, hypotension, decreased reflexes, hypothermia, and slurred speech aren't symptoms of alcohol withdrawal. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15891-15893). Lippincott Williams & Wilkins. Kindle Edition.

A client who has been drinking alcohol for 30 years asks a nurse if permanent damage has occurred to his immune system. What is the best response by the nurse? 1. " There is often less resistance to infections." 2. " Sometimes, the body's metabolism will increase." 3. " Put your energies into maintaining sobriety for now." 4. " Drinking puts you at high risk for disease later in life."

1. Chronic alcohol use depresses the immune system and causes increased susceptibility to infections. A nutritionally well-balanced diet that includes foods high in protein and B vitamins will help develop a strong immune system. The potential damage to the immune system doesn't increase the body's metabolism. The third option negates the client's concern and isn't an appropriate or caring response. Drinking alcohol may put the client at risk for immune system problems at any time in life. CN: Psychosocial integrity; CNS: None; CL: Analysis Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16045-16049). Lippincott Williams & Wilkins. Kindle Edition.

A polyaddicted client is hospitalized for withdrawal complications. What is the most important goal for this client? 1. The client will remain safe during the detoxification period. 2. The client will develop an accurate perception of his drug problem. 3. The client will abstain from mood-altering drugs. 4. The client will learn coping strategies to help him stop relying on drugs.

1. Client safety takes highest priority during detoxification. During this time, it's unrealistic to expect clients to perceive their drug problems accurately; typically, they experience cognitive impairment or deny their addiction. In the hospital, the client usually doesn't have access to drugs and should be drug free; the goal of abstaining from mood-altering drugs takes highest priority after discharge. Learning coping strategies is an appropriate goal immediately after withdrawal and when medical care is completed. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16603-16607). Lippincott Williams & Wilkins. Kindle Edition.

Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by hyperactivity of which neurotransmitter? 1. Dopamine 2. Norepinephrine 3. Acetylcholine 4. Epinephrine

1. Dopamine Positive symptoms of schizophrenia, such as delusions and hallucinations, are thought to be caused by dopamine hyperactivity in the mesolimbic tract at the D2 receptor site in the striatal area, where memory and emotion are regulated. Hyperactivity of acetylcholine, norepinephrine, and epinephrine are not associated with schizophrenia

17. During a family therapy session, an alcoholic client tells a family member, "You made it easy for me to use alcohol. You always made excuses for my behavior." What should the nurse encourage the family to do? 1. Give up enabling behaviors 2. Manage the client's self-care 3. Deal with negative behaviors 4. Evaluate the home environment Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15997-16002). Lippincott Williams & Wilkins. Kindle Edition.

1. Enabling the behaviors of family members allows the client to continue the addiction by rationalizing, denying, or otherwise excusing the problem. Managing the client's self-care isn't an issue that needs to be addressed based on the client's statement. Dealing with negative behaviors and evaluating the home environment don't address the client's statement about the family's enabling behavior. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16002-16005). Lippincott Williams & Wilkins. Kindle Edition.

4. The nurse is caring for a client who is experiencing alcohol withdrawal. The nurse would be most concerned if the client exhibited which of the following? 1. Hallucinations 2. Nervousness 3. Diaphoresis 4. Nausea

1. Hallucinations are a sign of late alcohol withdrawal. The nurse should stay with the client, have someone notify the physician, and institute seizure precautions. Nervousness, diaphoresis, and nausea are signs of early withdrawal. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15873-15875). Lippincott Williams & Wilkins. Kindle Edition.

A client with schizophrenia is prescribed clozapine (Clozaril). The nurse would monitor the client closely for specific signs of which of the following? 1. Infection 2. Hypotension 3. Nausea 4. Weight loss

1. Infection Agranulocytosis can develop with the use of all antipsychotic drugs, but it is most likely to develop with clozapine use. Therefore, the nurse needs to be alert for signs of infection, particularly bacterial infection. Hypotension may occur with any antipsychotic drug. Nausea is a common side effect of many drugs. Weight gain, not loss, can occur with olanzapine and clozapine

A nurse is caring for a client who is experiencing amphetamine withdrawal. The nurse should assess the client for which of the following? 1. Disturbed sleep 2. Increased yawning 3. Psychomotor agitation 4. Inability to concentrate

1. It's common for a person withdrawing from amphetamines to experience disturbed sleep and unpleasant dreams. Increased yawning is seen with clients withdrawing from opioids. Psychomotor agitation is seen in cocaine withdrawal, and the inability to concentrate is seen in caffeine withdrawal. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16289-16291). Lippincott Williams & Wilkins. Kindle Edition.

A nurse suggests to a client struggling with alcohol addiction that keeping a journal may be helpful. The goal of this nursing intervention is to help the client do what? 1. Identify stressors and responses to them. 2. Understand the diagnosis. 3. Help others by reading the journal to them. 4. Develop an emergency plan for use in a crisis. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16102-16106). Lippincott Williams & Wilkins. Kindle Edition.

1. Keeping a journal enables the client to identify problems and patterns of coping. From this information, the difficulties the client faces can be addressed. A journal isn't necessarily kept to promote better understanding of the client's illness, but it helps the client understand himself better. Journals aren't read to other people unless the client wants to share a particular part. Journals aren't typically used for identifying an emergency plan for use in a crisis. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16107-16110). Lippincott Williams & Wilkins. Kindle Edition.

A nurse is assessing a client with a history of substance abuse who has pinpoint pupils, a heart rate of 56 beats/ minute, a respiratory rate of 6 breaths/ minute, and temperature of 96.4 ° F. The nurse determines that which is the most likely cause of the client's symptoms? 1. Opioids 2. Amphetamines 3. Cannabis 4. Alcohol

1. Opioids, such as morphine and heroin, can cause pinpoint pupils and a reduced heart rate, respiratory rate, and body temperature with intoxication. Amphetamine intoxication can lead to tachycardia, euphoria, and irritability. Cannabis (marijuana) intoxication can cause slowed reflexes, lethargy, and tachycardia. Alcohol intoxication leads to slurred speech, unsteady gait, and uncoordination. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16345-16348). Lippincott Williams & Wilkins. Kindle Edition.

11. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

1. Provide client with high-calorie finger foods throughout the day.

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1. Risk for suicide R/T hopelessness

46. A client has been admitted to the emergency department and states he just used cocaine. The nurse monitors the client for which condition? 1. Tachycardia 2. Hyperthermia 3. Hypotension 4. Bradypnea

1. Tachycardia is common because cocaine increases the heart's demand for oxygen. Cocaine doesn't cause hyperthermia (elevated temperature), hypotension (decreased blood pressure), or bradypnea (decreased respiratory rate). CN: Psychosocial integrity; Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16298-16301). Lippincott Williams & Wilkins. Kindle Edition.

A client addicted to alcohol is scheduled to begin individual therapy with the nurse. What is the most important nursing intervention for the client? 1. Learn to express feelings. 2. Establish new roles in the family. 3. Determine strategies for socializing. 4. Decrease preoccupation with physical health. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16176-16180). Lippincott Williams & Wilkins. Kindle Edition.

1. The client must address issues, learn ways to cope effectively with life stressors, and express his needs appropriately. After the client establishes sobriety, the possibility of taking on new roles can become a reality. Determining strategies for socializing isn't the priority intervention for an addicted client. Usually, these clients need to change former socializing habits. Clients addicted to alcohol don't tend to be preoccupied with physical health problems. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16181-16184). Lippincott Williams & Wilkins. Kindle Edition.

What is the priority nursing intervention for a client recovering from cocaine addiction? 1. Help the client find ways to be happy and competent. 2. Foster the creative use of self in community activities. 3. Teach the client to handle stresses in the work setting. 4. Help the client acknowledge the current level of dependency.

1. The major component of a treatment program for a client with cocaine addiction is to have the client feel happy and competent. Cocaine addiction is difficult to treat because the drug actions reinforce its use. There are often perceived positive effects. Clients often credit the drug with giving them creative energy instead of looking within themselves. Fostering the creative use of self may inadvertently reinforce the client's drug use. Teaching the client to handle stresses is appropriate but isn't the most immediate nursing action. Examining the client's level of dependency isn't the immediate choice, as the client needs to work on remaining drug free. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16449-16454). Lippincott Williams & Wilkins. Kindle Edition.

A client who abused alcohol for more than 20 years is diagnosed with cirrhosis of the liver. The nurse determines that teaching about the disease has been successful when the client makes which statement? 1. " If I decide to stop drinking, I won't kill myself." 2. " If I watch my blood pressure, I should be okay." 3. " If I take vitamins, I can undo some liver damage." 4. " If I use nutritional supplements, I won't have problems."

1. This statement reflects the client's perception of the severity of the condition and the life-threatening complications that can result from continued use of alcohol. Aggressive treatment is required, not merely watching one's blood pressure. At this point in the illness, there is little likelihood that liver damage from cirrhosis can be altered. The fourth option denies the severity of the problem and negates the life-threatening complications common with a diagnosis of cirrhosis. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16225-16228). Lippincott Williams & Wilkins. Kindle Edition.

A client tells the nurse that he used amphetamines to be productive at work. The nurse is aware that abrupt discontinuation of the drug will produce which symptom? 1. Severe anxiety 2. Increased yawning 3. Altered perceptions 4. Amotivational syndrome

1. When amphetamines are abruptly discontinued, the client may experience severe anxiety or agitation. Increased yawning is a symptom of opioid withdrawal. Altered perceptions occur when a client is withdrawing from hallucinogens. Amotivational syndrome is seen with clients using marijuana.

A client addicted to alcohol tells a nurse, "Making friends used to be hard for me." The nurse determines that client teaching about relationships has been successful when the client makes which statement? 1. " I've set limits on my behaviors toward others." 2. " I need to be judgmental of others." 3. " I won't become intimately involved with others." 4. " I can't bear to see myself hurt again in a relationship." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16208-16212). Lippincott Williams & Wilkins. Kindle Edition.

1. When the client can set personal limits and maintain boundaries, the ability to have successful interpersonal relationships can occur. Being judgmental is contraindicated if a client wants to have successful relationships. Setting arbitrary limits on relationships indicates the client needs to learn more interpersonal relationship skills. The universal truth about relationships is that they bring both joy and pain. The last statement indicates a need to learn more about relationships. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16213-16217). Lippincott Williams & Wilkins. Kindle Edition.

10. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."

4. "Treatment is compromised when clients choose not to take their medications."

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

78. A client with an alcohol addiction requests a prescription for disulfiram (Antabuse). To determine the client's ability to take the drug appropriately, the nurse should assess which of the following? 1. Whether the client will take a prescription drug 2. Whether the client's family accepts the use of this treatment strategy 3. Whether the client is willing to follow the necessary dietary restrictions 4. Whether the client is motivated to stay sober .

4. A client with a strong craving for alcohol (and a lack of impulse control) isn't a good candidate for disulfiram therapy. Disulfiram is a prescription drug. Accepting the treatment strategy is a decision that the client and health care provider make; although family input may be welcome, family members don't make the final decision. Significant dietary restrictions aren't necessary during disulfiram therapy (except for alcohol and foods prepared or cooked in it). Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16615-16618). Lippincott Williams & Wilkins. Kindle Edition.

A client with a history of cocaine abuse exhibits behavior changes following return from an inpatient treatment facility. The nurse anticipates that the physician will order which test? 1. Antibody screen 2. Glucose screen 3. Hepatic screen 4. Urine screen

4. A urine toxicology screen would show the presence of cocaine in the body. Glucose, hepatic, or antibody screening wouldn't show the presence of cocaine in the body. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16337-16338). Lippincott Williams & Wilkins. Kindle Edition.

The nurse is preparing a teaching plan for a client who abused alcohol. What is the most important information for the nurse to include? 1. Personal needs 2. Illness exacerbation 3. Cognitive distortions 4. Communication skills Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16113-16116). Lippincott Williams & Wilkins. Kindle Edition.

4. Addicted clients typically have difficulty communicating their needs in an appropriate way. Learning appropriate communication skills is a major goal of treatment. Next, behavior that focuses on the self and meeting personal needs will be addressed. The identification of cognitive distortions would be difficult if the client has poor communication skills. Teaching about illness exacerbation isn't a skill, but it is essential for relaying information about relapse. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16117-16121). Lippincott Williams & Wilkins. Kindle Edition.

The nurse is developing interventions to prevent a client who abused alcohol from relapsing. What is the most important intervention for the client? 1. Avoid taking over-the-counter medications. 2. Limit monthly contact with the family of origin. 3. Refrain from becoming involved in group activities. 4. Avoid people, places, and activities from the former lifestyle. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16131-16136). Lippincott Williams & Wilkins. Kindle Edition.

4. Changing the client's old habits is essential for sustaining a sober lifestyle. Certain over-the-counter medications that don't contain alcohol will probably need to be used by the client at certain times. It's unrealistic to have the client abstain from all such medications. Contact with the client's family of origin may not be a trigger to relapse, so limiting contact wouldn't be useful. Refraining from group activities isn't a good strategy to prevent relapse. Going to Alcoholics Anonymous and other support groups will help prevent relapse. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16137-16140). Lippincott Williams & Wilkins. Kindle Edition.

A client asks a nurse not to tell his parents about his alcohol problem. What is the most appropriate response by the nurse? 1. " How can you not tell them? Is that being honest?" 2. " Don't you think you'll need to tell them someday?" 3. " Do alcohol problems run in either side of your family?" 4. " What do you think will happen if you tell your parents?"

4. Clients who struggle with addiction problems often believe people will be judgmental, rejecting, and uncaring if they are told that the client is recovering from alcohol abuse. The first option challenges the client and will put him on the defensive. The second option will make the client defensive and construct rationalizations as to why his parents don't need to know. The third option is a good assessment question, but it isn't an appropriate question to ask a client who's afraid to tell others about his addiction. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15863-15866). Lippincott Williams & Wilkins. Kindle Edition.

A client says, "I started using cocaine as a recreational drug, but now I can't seem to control the use." The nurse interprets the client's statement as most consistent with which drug behavior? 1. Toxic dose 2. Dual diagnosis 3. Cross-tolerance 4. Compulsive use Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16250-16253). Lippincott Williams & Wilkins. Kindle Edition.

4. Compulsive drug use involves taking a substance for a period of time significantly longer than intended. A toxic dose is the amount of a drug that causes a poisonous effect. Dual diagnosis is the coexistence of a drug problem and a mental health problem. Cross-tolerance occurs when the effects of a drug are decreased and the client takes larger amounts to achieve the desired drug effect.

The nurse is caring for a client who uses cocaine and has been admitted to an intensive outpatient rehabilitation program. It is most important for the nurse to assess the client for which finding? 1. GI distress 2. Blurred vision 3. Perceptual distortions 4. Increased appetite .

4. Increased appetite is typical during cocaine or nicotine withdrawal. GI distress (especially nausea and vomiting) occurs during alcohol or opioid withdrawal. Blurred vision isn't typical in cocaine withdrawal. Perceptual distortions are common during withdrawal from phencyclidine (PCP, or "angel dust"), amphetamines, and hallucinogens. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16574-16576). Lippincott Williams & Wilkins. Kindle Edition.

What is the most important assessment for a nurse to implement before starting a teaching session for a client who abuses alcohol? 1. Sleep patterns 2. Decision making 3. Note-taking skills 4. Readiness to learn Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16123-16126). Lippincott Williams & Wilkins. Kindle Edition.

4. It's important to know if the client's current situation helps or hinders the potential to learn. Decision making and sleep patterns aren't factors that must be assessed before teaching about addiction. Note-taking skills aren't a factor in determining whether the client will be receptive to teaching. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16127-16129). Lippincott Williams & Wilkins. Kindle Edition.

A young, depressed adult woman with a history of alcohol abuse is admitted to the hospital after a motor vehicle accident. The nurse performs the admission assessment of the client and anticipates that the history will include which of the following? 1. Defiant responses 2. Infertility 3. Memory loss 4. Sexual abuse

4. Many women diagnosed with substance abuse problems also have a history of physical or sexual abuse. Alcohol abuse isn't a common finding in a young woman showing defiant behavior or experiencing infertility. Memory loss isn't a common finding in a young woman experiencing alcohol abuse. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15941-15943). Lippincott Williams & Wilkins. Kindle Edition.

A client recovering from alcohol addiction asks the nurse how to talk to his children about the impact of addiction on them. What is the best response by the nurse? 1. " Try to limit references to the addiction and focus on the present." 2. " Talk about all the hardships you've had in working to remain sober." 3. " Tell them you're sorry and emphasize that you're doing so much better now." 4. " Talk to them by acknowledging the difficulties and pain your drinking caused." Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16186-16191). Lippincott Williams & Wilkins. Kindle Edition.

4. Part of the healing process for the family is to acknowledge the pain, embarrassment, and overall difficulties the client's drinking problem caused family members. The first option facilitates the client's ability to deny the problem. The second option prevents the client from acknowledging the difficulties the children endured. The third option leads the client to believe only a simple apology is needed. The addiction must be addressed and the children's pain acknowledged. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16192-16196). Lippincott Williams & Wilkins. Kindle Edition.

Which of the following extrapyramidal side effects is noted by the client having bradykinesia and a shuffling gait? 1. Tardive dyskinesia 2. Akathisia 3. Acute dystonia 4. Pseudoparkinsonism

4. Pseudoparkinsonism Pseudoparkinsonism is noted by resting tremor, rigidity, a masklike face, and a shuffling gait. Akathisia occurs when the client has motor restlessness evidenced by pacing, rocking, or shifting from foot to foot. Symptoms of acute dystonia are intermittent or fixed abnormal postures of the eyes, face, tongue, neck, trunk, and extremities

8. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

4. Symptoms indicate lithium carbonate toxicity.

The nurse is preparing a client with the diagnosis of alcohol dependency for discharge from the hospital. What is the most important goal for the client? 1. Find a way to drink socially. 2. Allow self to grieve recent losses. 3. Work to bring others into treatment. 4. Develop relapse-prevention strategies. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16198-16202). Lippincott Williams & Wilkins. Kindle Edition.

4. The primary goal for a client in outpatient treatment is to focus on strategies that prevent relapse. Finding ways to drink socially and working to bring others into treatment aren't goals of outpatient therapy. Allowing self to grieve the losses the addiction caused is a part of the early work of inpatient therapy and may be continued in outpatient therapy. CN: Safe, effective care environment; CNS: Management of care; CL: Analysis Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16203-16207). Lippincott Williams & Wilkins. Kindle Edition.

A client who uses cocaine denies that drug use is a problem. What is the best intervention by the nurse? 1. State ways to cope with stress. 2. Repeat the drug facts as needed. 3. Identify the client's ambivalence. 4. Use open-ended, factual questions.

4. The use of open-ended, factual questions will help the client acknowledge that a drug problem is present. Stating ways to cope with stress and identifying the client's ambivalence won't be effective for breaking through a client's denial. Repeating drug facts won't be effective, as the client will perceive it as preaching or nagging. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16533-16535). Lippincott Williams & Wilkins. Kindle Edition.

A client who abuses alcohol tells the nurse that everyone in his family has an alcohol problem and nothing can be done about it. What is the most appropriate response by the nurse? 1. " You're right; it's much harder to become a recovering person." 2. " This is just an excuse for you so you don't have to work on becoming sober." 3. " Sometimes, nothing can be done, but you may be the exception in this family." 4. " Alcohol problems can occur in families, but you can decide to take the steps to become and stay sober."

4. This statement challenges the client to become proactive and take the steps necessary to maintain a sober lifestyle. The first option agrees with the client's denial and isn't a useful response. The second option confronts the client and may make him more adamant in defense of this position. The third option agrees with the client's denial and isn't a useful response. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 15923-15926). Lippincott Williams & Wilkins. Kindle Edition.

A nurse is assessing a client with a history of cocaine abuse. The nurse is aware that the assessment may include which finding? 1. Glossitis 2. Pharyngitis 3. Bilateral ear infections 4. Perforated nasal septum

4. When cocaine is snorted frequently, the client often develops a perforated nasal septum. Bilateral ear infections, pharyngitis, and glossitis aren't common physical findings for a client with a history of cocaine abuse.

A nurse is performing a physical assessment on a client who uses heroin. It is most important for the nurse to assess the client for which of the following? 1. Hepatitis 2. Peptic ulcers 3. Hypertension 4. Chronic pharyngitis Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16425-16428). Lippincott Williams & Wilkins. Kindle Edition.

60. 1. Hepatitis is the most common medical complication of heroin abuse. Peptic ulcers are more likely to be a complication of caffeine use, hypertension is a complication of amphetamine use, and chronic pharyngitis is a complication of marijuana use. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16429-16431). Lippincott Williams & Wilkins. Kindle Edition.

61. The family of a client in rehabilitation following heroin withdrawal asks a nurse why the client is receiving naltrexone (ReVia). What is the best response by the nurse? 1. To help reverse withdrawal symptoms 2. To keep the client sedated during withdrawal 3. To take the place of detoxification with methadone 4. To decrease the client's memory of the withdrawal experience Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16433-16438). Lippincott Williams & Wilkins. Kindle Edition.

61. 1. Naltrexone is an opioid antagonist and helps the client stay drug free. Keeping the client sedated during withdrawal isn't the reason for giving this drug. The drug doesn't decrease the client's memory of the withdrawal experience and isn't used in place of detoxification with methadone. Lisko, Susan (2013-10-01). NCLEX-RN Questions and Answers Made Incredibly Easy (Nclexrn Questions & Answers Made Incredibly Easy) (Kindle Locations 16439-16441). Lippincott Williams & Wilkins. Kindle Edition.

64. A client discusses with the nurse how drug addiction has made life unmanageable. The nurse determines that information to assist the client with coping would include: 1. how peers have committed to sobriety. 2. how to accomplish family of origin work. 3. the addiction process and tools for recovery. 4. how environmental stimuli serve as drug triggers.

64. 3. When the client admits life has become unmanageable, the best strategy is to teach about the addiction, how to obtain support, and how to develop new coping skills. Information about how peers committed to sobriety would be shared with the client as the treatment process begins. Identification of how environmental stimuli serve as drug triggers would be a later part of the treatment process and family of origin work. Initially, the client must commit to sobriety and learn skills for recovery.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the day room. While following the patient into the day room, the nurse should: a. make sure there is adequate physical space between the nurse and patient. b. move into a position that places the patient close to the door. c. maintain one arm's-length distance from the patient. d. begin talking to the patient about appropriate behavior.

A

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

A

Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that, or any other, medication you try to give me."

A

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or anti-anxiety medication.

A

Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? Select all that apply. a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

A, C, D

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? Select all that apply. a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

A, C, E

A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? Select all that apply. a. Stating the expectation that the patient will stay in control b. Asking the patient, "Do you want to go into seclusion?" c. Telling the patient, "You are behaving inappropriately." d. Offering to provide the patient with medication to help e. Speaking in a firm but calm voice

A, D, E

Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Prefrontal cortex

A, D, E

A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lbs by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

A. Provide client with high-calorie finger foods throughout the day.

Select the outcomes most appropriate for a client in phase III of treatment of schizophrenia who displays many negative symptoms of the disorder. The client will (select all that apply) A. take medication as ordered. B. maintain a regular sleep pattern. C. use alcohol and caffeine as desired. D. participate in self-care skills training.

ANS: A, B, D Rationale: The stabilization phase of schizophrenia is seen when the client is well enough to be maintained in the community. It is a time for consolidating gains, learning relapse prevention (options A and B), and promoting adaptation to deficits that still exist (option D). Option C: Use of alcohol, caffeine, and other recreational drugs should be discouraged because these substances interfere with therapeutic medication effects. DIF: Cognitive Level: Application REF: Text Page: 398 TOP: Nursing Process: Planning (Outcome Identification) MSC: NCLEX: Psychosocial Integrity

A client with schizophrenia begins to talk about "volmers" hiding in the warehouse where he works and undoing his work each night. The term "volmers" should be assessed as a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the client. "Volmer" is not a known word. Option B: Concrete thinking refers to the inability to think abstractly. Option C: Thought insertion refers to the idea that the thoughts of others are being planted in one's mind. Option D: Ideas of reference are a type of delusion in which trivial events are given personal significance. DIF: Cognitive Level: Application REF: Text Page: 392, Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A client with many positive symptoms of schizophrenia whose behavior is disorganized and who is highly anxious tells the nurse in the psychiatric emergency department "You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun." The client, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend a. acute hospitalization for 4 to 5 days. b. partial hospitalization for 2 weeks. c. day treatment for 4 weeks. d. home treatment for 6 weeks.

ANS: A A short-term hospital stay would probably serve the client best. Medication can be started, the inpatient milieu can provide structure, observation can be ongoing, interpersonal support can be provided, physical needs can be met, and the safety of client and others preserved. The client has no support system to provide care at home, and both partial hospitalization and day treatment would leave the client without structure and support for at least 12 hours daily. DIF: Cognitive Level: Analysis REF: Text Page: 399, Text Page: 400 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

A client with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds, the nurse notices the client has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he is drooling. He appears severely anxious. The client has a. a dystonic reaction. b. tardive dyskinesia. c. waxy flexibility. d. akathisia.

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Option B: Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Option C: Waxy flexibility is a symptom seen in catatonic schizophrenia. Option D: Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting. DIF: Cognitive Level: Analysis REF: Text Page: 405, Text Page: 406, Text Page: 407, Text Page: 408, Text Page: 409, Text Page: 410, Text Page: 411 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights.

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

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

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

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury. REF: Pages: 288-289

A client is admitted to the in-patient unit in the withdrawn phase of catatonic schizophrenia. He is completely stuporous. While giving care to the client, the nurse must a. explain care activities in simple, explicit terms as though expecting a response. b. maintain a quiet, nonstimulating atmosphere, speaking as little as possible to the client. c. provide high levels of sensory stimulation by using conversation, the radio, and television. d. address negativism by asking the client to do exactly the opposite of what is desired.

ANS: A Although the withdrawn, catatonic client may appear stuporous, he may be aware of everything going on around him. The client should be treated as though he can see and hear and as though he will respond normally. Option B: The client needs contact with the nurse on a frequent basis. Option C: Excessive auditory stimulation can be a disorganizing influence. Option D: This is nontherapeutic. DIF: Cognitive Level: Application REF: Text Page: 414 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment;

11. Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.

ANS: A Anger has a strong cognitive component; therefore using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

9. The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

ANS: A At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances.

8. The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

ANS: A At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances. REF: Pages: 281-282

Family members of a client newly diagnosed with paranoid schizophrenia state that they do not understand what caused the client's illness. The nurse's response should be predicated on the a. neurobiological-genetic model. b. stress model. c. family theory model. d. developmental model.

ANS: A Compelling evidence exists that schizophrenia is a neurological disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Options B, C, and D: Stress, family disruption, and developmental influences may contribute but are not considered single etiologies. DIF: Cognitive Level: Application REF: Text Page: 386, Text Page: 387 TOP: Nursing Process: Implementation MSC: NCLEX: Physiologic Integrity

A client was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, two nursing diagnoses the nurse should consider are a. disturbed thought processes and risk for other-directed violence. b. spiritual distress and social isolation. c. risk for loneliness and deficient knowledge. d. disturbed personal identity and noncompliance.

ANS: A Delusions of persecution and ideas of reference support a nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the client's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or may attempt self-harm to get away from persecutors. Data are not present to support the diagnoses in the other options. DIF: Cognitive Level: Analysis REF: Text Page: 396, Text Page: 397 TOP: Nursing Process: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity

The nurse who observes a client prescribed haloperidol who has his head rotated to one side in a stiff, fixed position with his lower jaw thrust forward and drool coming from his mouth should intervene by a. obtaining an order to administer diphenhydramine (Benadryl) 50 mg IM. b. reassuring the client that the symptoms will subside if he relaxes. c. administering trihexyphenidyl (Artane) 5 mg orally. d. administering atropine 2 mg subcutaneously.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias, but because the client is drooling the nurse must assume swallowing is difficult, if not impossible. Therefore oral medication is not an option. Medication should be administered intramuscularly. In this case the option given is diphenhydramine. DIF: Cognitive Level: Application REF: Text Page: 409 TOP: Nursing Process: Implementation MSC: NCLEX: Physiologic Integrity

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

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

A newly admitted client diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. The nurse may correctly assess this behavior as a. an idea of reference. b. a delusion of infidelity. c. an auditory hallucination. d. echolalia.

ANS: A Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, seeing two people talking, the individual assumes they are talking about him or her. The other behaviors do not correspond with the scenario. DIF: Cognitive Level: Application REF: Text Page: 392 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

9. The staff development coordinator plans to teach the use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

ANS: A Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

6. A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

The nurse spends several sessions with a client with paranoid schizophrenia and the client's family to help them understand the importance of the client regularly taking antipsychotic medication. The client repeatedly states he does not like taking pills, and family members say they feel helpless to foster his compliance. The treatment strategy the nurse should discuss with the physician is a. use of an antipsychotic decanoate preparation. b. adjunctive use of amitriptyline (Elavil). c. use of benzodiazepines such as diazepam (Valium). d. use of chlordiazepoxide (Librium).

ANS: A Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medication. They are given by depot injection every 2 to 4 weeks, thus reducing daily opportunities for noncompliance. The other options do not address the client's dislike of taking pills. DIF: Cognitive Level: Application REF: Text Page: 407 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment;

The wife of a client with schizophrenia is worried about her 17-year-old daughter and asks the nurse what symptoms mark the prodromal stage of schizophrenia. The nurse should respond by listing behaviors such as a. withdrawal, misinterpreting, poor concentration, and preoccupation with religion. b. auditory hallucinations, ideas of reference, thought insertion, and broadcasting. c. stereotyped behavior, echopraxia, echolalia, and waxy flexibility. d. loose associations, concrete thinking, and echolalia neologisms.

ANS: A Options B, C, and D each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness. Prodromal symptoms, the symptoms that are present before the development of florid symptoms, are listed in option 1. DIF: Cognitive Level: Application REF: Text Page: 389 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A client with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. The client's needs of priority importance are a. physical. b. psychosocial. c. safety and security. d. self-actualization.

ANS: A Physical needs must be met to preserve life. A client who is semistuporous must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Safety needs rank second to physical needs. Higher level needs are of lesser concern. DIF: Cognitive Level: Analysis REF: Text Page: 414 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

To establish a relationship with a severely withdrawn schizophrenic client being cared for at home by a supportive family, the most realistic plan would be for the community mental health nurse to a. visit daily for 4 days, then every other day for 1 week; stay with client for 20 minutes, accept silence; state when the nurse will return. b. arrange to spend 1 hour each day with the client, with the focus on asking questions about what the client is thinking or experiencing; avoid silences. c. visit twice daily; sit beside the client with hand on the client's arm; leave if the client does not respond within 10 minutes. d. visit every other day; remind the client of the nurse's identity; tell the client he may use the time to talk or the nurse will work on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in option A, yet important principles can be used. A severely withdrawn client should be met "at the client's own level," with silence accepted. Short periods of contact are helpful to minimize both the client's and the nurse's anxiety. Predictability in returning as stated will help build trust. Option B: An hour may be too long to sustain a home visit with a withdrawn client, especially if the nurse persists in leveling a barrage of questions at the client. Option C: Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Option D: Working on reports suggests the nurse is not interested in the client. DIF: Cognitive Level: Application REF: Text Page: 399, Text Page: 400 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

19. A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information. REF: Page: 296

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

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

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

19. A patient with bipolar disorder, who is being treated on an outpatient basis, takes lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals b. an antacid c. an antiemetic medication d. a large glass of juice

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

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

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

18. A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful. REF: Page: 296

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

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

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

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

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

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

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior. REF: Pages: 299-300

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

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

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

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger. REF: Page: 290 | Pages: 292-293

12. A nurse receives this laboratory result: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

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

11. A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

ANS: A The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L. REF: Pages: 294-295

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 considering 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.

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

ANS: A The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

A 16-year-old-client diagnosed with paranoid 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.

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.

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.

2. A patient with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

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

2. A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

ANS: A The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patient's mood. A high level of suspicion is not evident. REF: Pages: 282-284

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

ANS: A, B, C The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.

2. A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

ANS: A, B, D Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

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

ANS: A, B, D, E 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.

1Which suggestions are appropriate for the family of a patient with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Provide structure. b. Limit credit card access. c. Encourage group-social interaction. d. Suggest limiting work to half days. e. Monitor the patient's sleep patterns.

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

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

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania. REF: Pages: 290-291 | Page: 298

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

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

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

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses. REF: Page: 288

5. Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics are the primary focuses of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

ANS: A, C, D The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective.

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.

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe

ANS: A, D The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations.

4. Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

ANS: A, D, E Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.

1. A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

12. Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of spousal abuse. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

ANS: B A history of prior aggression or violence is the best predictor of patients who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

7. An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male nursing assistant and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."

ANS: B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort.

The family of a client with acute symptoms of schizophrenia knows nothing about the client's illness and the role the family can play in his recovery. The nurse should recommend that they attend a. psychoanalytic group therapy. b. a psychoeducational group. c. transactional therapy. d. family therapy.

ANS: B A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a schizophrenic person. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation. DIF: Cognitive Level: Application REF: Text Page: 402, Text Page: 403 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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

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

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

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest. REF: Pages: 290-293

Which client with schizophrenia would be expected to have the lowest score in global assessment of functioning? a. Client A, aged 39 years, who had paranoid ideation develop at age 35 years b. Client B, aged 40 years, who has had disorganized schizophrenia since age 18 years c. Client C, diagnosed as catatonic at age 24 years, who has been stable for 3 years d. Client D, aged 19 years, diagnosed with undifferentiated schizophrenia at age 17 years

ANS: B Disorganized schizophrenia represents the most regressed and socially impaired of all the schizophrenias. Client B could logically be expected to have the lowest global assessment of functioning. In addition, the client has been ill for a number of years. Option A: Client A could be expected to have the highest score because paranoid schizophrenia of short duration may be less impairing than other types. Option C: Client C has been stable more than 3 years, suggesting higher functional ability. Option D: Client D has been ill only 2 years, and disability in undifferentiated schizophrenia remains fairly stable over time. DIF: Cognitive Level: Application REF: Text Page: 412, Text Page: 414, Text Page: 415, Text Page: 416 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

25. A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.

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

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

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

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission of bipolar disorder. REF: Pages: 281-282

5. This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis. REF: Page: 291

6. This nursing diagnosis applies to a patient with mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

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

17. A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety.

ANS: B Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice.

7. A patient with mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

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

6. A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium is used for long-term control. REF: Page: 294

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

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

A client with schizophrenia has received standard antipsychotics for a year. His hallucinations are less intrusive, but the client remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might expect the psychiatrist to prescribe a. haloperidol (Haldol). b. olanzapine (Zyprexa). c. diphenhydramine (Benadryl). d. chlorpromazine (Thorazine).

ANS: B Olanzapine is an atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Options A and D are standard antipsychotics that target only positive symptoms. Option C is an antihistamine. DIF: Cognitive Level: Application REF: Text Page: 405 TOP: Nursing Process: Planning MSC: NCLEX: Physiologic Integrity

Which findings listed in the medical record of a client with schizophrenia indicate a neurological origin for schizophrenia? a. A hostile, overinvolved parent and a weak, uninvolved parent b. Enlarged or asymmetrical ventricles, cortical atrophy c. Presence of ambivalence and flattened affect d. Presence of delusions and hallucinations

ANS: B Only option B relates to neurological findings. Options C and D refer to symptoms. Option A refers to family dynamics. DIF: Cognitive Level: Analysis REF: Text Page: 387 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

A client with catatonic schizophrenia is semistuporous, demonstrating little spontaneous movement and waxy flexibility. The client's self-care activities of daily living have been assessed as severely compromised. An appropriate outcome would be that the client will a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of week 1. c. gradually assume the initiative in self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. Option A is not directly related to self-care activities. Option C is difficult to measure. Option D is related to maintenance of nutrition. DIF: Cognitive Level: Application REF: Text Page: 414 TOP: Nursing Process: Planning (Outcome Identification) MSC: NCLEX: Psychosocial Integrity

30. A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider has not already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. The incorrect options offer incorrect or misleading information. REF: Page: 295

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

A patient with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance.

21. Which nursing diagnosis would most likely apply to both a patient with depression and one with acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

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

20. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.

ANS: B Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse's presence and concerns. The incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

When a client diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine) 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a "zombie." The common side effects the nurse should validate with the client include a. sweating, nausea, and diarrhea. b. sedation and muscle stiffness. c. headache, watery eyes, and runny nose. d. mild fever, sore throat, and skin rash.

ANS: B Phenothiazines often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him feel like a "zombie." The side effects mentioned in the other options are usually not associated with phenothiazine therapy or would not have the effect described by the client. DIF: Cognitive Level: Application REF: Text Page: 405, Text Page: 407 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

A client with schizophrenia who has received chlorpromazine (Thorazine) 200 mg po 4 times daily for 3 weeks has symptoms of a shuffling, propulsive gait, a masklike face, and drooling. These symptoms should be assessed as a. hepatocellular effects. b. pseudoparkinsonism. c. tardive dyskinesia. d. akathisia.

ANS: B Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Tardive dyskinesia produces involuntary tonic muscular spasms. Akathisia produces symptoms of motor restlessness. DIF: Cognitive Level: Application REF: Text Page: 405, Text Page: 406, Text Page: 407, Text Page: 408, Text Page: 409, Text Page: 410, Text Page: 411 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

A patient with acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

16. A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

ANS: B Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

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

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

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

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to the staff's advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response. REF: Page: 284 | Page: 289

A client received maintenance doses of trifluoperazine (Stelazine) 30 mg po daily for 1.5 years. The clinic nurse notes the client is grimacing and seems to be constantly smacking her lips. Her neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of a. agranulocytosis. b. tardive dyskinesia. c. Tourette's syndrome. d. anticholinergic effects.

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Option A: Agranulocytosis is a blood disorder. Option C: Tourette's syndrome is a condition in which tics are present. Option D: Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes. DIF: Cognitive Level: Application REF: Text Page: 409 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

A newly admitted client diagnosed with paranoid schizophrenia believes co-workers are "out to get" him and has stated he thinks two doctors on the unit are plotting to kill him. How does the client perceive the environment? a. Supportive b. Dangerous c. Disorganized d. Bizarre

ANS: B The client sees his world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the client. Data are not present to support any of the other options. DIF: Cognitive Level: Analysis REF: Text Page: 392 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

10. An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."

ANS: B The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation.

23. Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. developing an optimistic outlook b. self-control of distorted thinking c. maintaining an interest in the environment d. stabilizing the sleep pattern

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

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

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

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

ANS: B The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury. REF: Pages: 289-291

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

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

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.

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.

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 paranoid delusion." 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.

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.

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.

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

A college student has quit attending classes, isolates self due to 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 should be risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicates a potential for violence, and this potential safety issue should be prioritized.

13. A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

ANS: B The patient's threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

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

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patient's symptoms. Restricting oral fluids will make the situation worse. REF: Pages: 294-295

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

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

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

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

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

14. When a hyperactive patient with acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

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

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

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to the loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective. REF: Pages: 290-291

A catatonic client admitted in a stuporous condition begins to demonstrate increased motor activity. He sometimes walks slowly around the unit without interacting. One day the nurse observes him standing immobile, facing the wall with one arm bent behind his back and the other extended in a Nazi-like salute. He remains immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. This phenomenon is termed a. echolalia. b. waxy flexibility. c. depersonalization. d. thought withdrawal.

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Option A: Echolalia is a speech pattern. Option C: Depersonalization refers to a feeling state. Option D: Thought withdrawal refers to an alteration in thinking. DIF: Cognitive Level: Application REF: Text Page: 394 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

23. A patient with burn injuries has had good coping skills for several weeks. Today, a newly assigned nurse is poorly organized. The patient's usual schedule was not followed. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization, and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

ANS: B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patient's feelings, validating them as understandable, apologizing as necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

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

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

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

ANS: B When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Criteria for seclusion have not been met. REF: Pages: 289-290

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

ANS: B, C People with mania are hyperactive and often do not take the time to eat and drink properly. Their high levels of activity consume calories; therefore deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic. REF: Page: 288

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

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

A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions 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.

18. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."

ANS: C Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness.

The nurse is told that a client with disorganized schizophrenia is being admitted to the unit. The nurse should expect the client to demonstrate a. highly suspicious, delusional behavior. b. extremes of motor activity and excitement to stupor. c. social withdrawal and ineffective communication. d. severe anxiety and ritualistic behavior.

ANS: C Clients with disorganized schizophrenia demonstrate the most regressed and socially impaired behaviors of the schizophrenias. Communication is often incoherent, with silly giggling and loose associations predominating. Option A relates more to paranoid schizophrenia. Option B relates to catatonic schizophrenia. Option D is seen with obsessive-compulsive disorder. DIF: Cognitive Level: Application REF: Text Page: 413 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

4. A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care worker's behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

ANS: C Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

29. A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy. REF: Pages: 294-295

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

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

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

ANS: C Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania. REF: Pages: 282-287

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

3. A person is directing traffic on a busy street and rapidly shouting, "To work, you jerk, for perks," and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, provocative behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

5. A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

ANS: C Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patient's feelings and concerns, which leads to the next step of planning an intervention.

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.

19. Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

ANS: C Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or for those who are borderline bipolar.

The physician is considering changing the antipsychotic medication for a client with schizophrenia who is troubled by the extrapyramidal symptoms of his current medication, haloperidol, and who seems to be becoming less motivated and more withdrawn. For planning purposes the nurse can assume that the physician will probably choose a. chlorpromazine (Thorazine). b. clozapine (Clozaril). c. olanzapine (Zyprexa). d. fluoxetine (Prozac).

ANS: C Olanzapine is an atypical antipsychotic that produces few extrapyramidal side effects and is effective in treating both positive and negative symptoms of schizophrenia. Option A: This drug often produces EPS. It is not effective in treating negative symptoms. Option B: Clozapine would not be the drug of choice because of the danger of agranulocytosis. Option D: Fluoxetine is a selective serotonin reuptake inhibitor antidepressant. DIF: Cognitive Level: Application REF: Text Page: 412 TOP: Nursing Process: Planning MSC: NCLEX: Physiologic Integrity

17. A patient with acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

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

16. A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach. REF: Page: 285 | Pages: 290-291

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

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

22. A patient with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.

A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of symptoms of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly "They're all plotting to destroy me. Isn't that true?" An appropriate response for the nurse would be a. "No, that is not true. People here are trying to help you if you will let them." b. "Everyone here is trying to help you. No one wants to harm you." c. "Thinking that people want to destroy you must be very frightening." d. "That is absurd. Staff are health care workers, not members of the mob."

ANS: C Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and the tenacity with which the client holds to the delusion. The other options focus on content and provide opportunity for argument. DIF: Cognitive Level: Application REF: Text Page: 401 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

27. A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.

ANS: C Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence. REF: Pages: 288-291

A client, newly diagnosed with paranoid schizophrenia, is delusional, withdrawn, and aloof. One of her nursing diagnoses is deficient diversional activity. An activity that would be appropriate to plan for the client early in the course of her hospital stay is a. a basketball game. b. ping-pong with another client. c. a paint-by-number project. d. a card game with three other clients.

ANS: C Solitary, noncompetitive activities that require concentration are best while the client is overtly psychotic. Having to concentrate minimizes hallucinatory and delusional preoccupation. Options A, B, and D are all competitive. DIF: Cognitive Level: Application REF: Text Page: 400 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment;

8. A patient with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

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

7. A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

ANS: C Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes. REF: Pages: 295-297

A newly admitted client with schizophrenia approaches the unit nurse and says "The voices are bothering me. They are yelling and telling me I am bad. I have got to get away from them." The most helpful reply for the nurse to make would be a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other clients to play cards with you."

ANS: C Staying with a distraught client who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Option A is not particularly relevant at this point. Option B is relevant for assessment purposes but is less helpful than option C. Option D shifts responsibility for intervention from the nurse to the client and other clients. DIF: Cognitive Level: Application REF: Text Page: 401 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A highly suspicious client who has delusions of persecution about being poisoned has refused all hospital meals for 3 days. Assuming all interventions listed are possible, the one likely to be most acceptable to the client is a. allowing the client to contact a local restaurant to deliver his meals. b. offering to taste each portion on the tray for the client. c. allowing the client supervised access to lobby food machines. d. providing tube feedings or total parenteral nutrition.

ANS: C The client who is delusional about his food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Clients perceive foods in sealed containers, packages, or natural shells as being safer. DIF: Cognitive Level: Application REF: Text Page: 414 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

A client with schizophrenia tells the nurse "Everyone must listen to me. I am the redeemer. I will bring peace to the world." From this the nurse can determine that an appropriate nursing diagnosis to be completed is a. disturbed sensory perception: auditory. b. risk for other-directed violence. c. chronic low self-esteem. d. noncompliance: medication.

ANS: C The client's grandiose delusion is based on reaction formation to actual feelings of low self-esteem. The scenario does not provide sufficient data to support the other diagnoses. DIF: Cognitive Level: Analysis REF: Text Page: 391, Text Page: 392, Text Page: 396, Text Page: 397 TOP: Nursing Process: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by alien monsters d. Completing alcohol withdrawal and beginning a rehabilitation program

ANS: C The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distracters have better reality-testing ability.

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

ANS: C The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils. REF: Page: 291

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients." Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. Wish for revenge d. Preoccupation with the incident

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distracters are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.

22. Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. maintaining an interest in the environment. b. developing an optimistic outlook. c. self-control of distorted thinking. d. stabilizing the sleep pattern.

ANS: C The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes. REF: Pages: 288-289

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. The devil is not talking to you. This is part of your illness." 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. Reminding the client that "the voices" are a part of his or her illness is a way to help the client accept that the hallucinations are not real.

Parents ask a nurse how they should reply when their child, diagnosed with paranoid 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.

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 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.

A client diagnosed with paranoid 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.

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).

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.

A client diagnosed with psychosis NOS (not otherwise specified) 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.

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.

13. Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

12. Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. REF: Page: 297

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

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

A frightened, delusional client tells the nurse "I can't go to activities. When I am in a room with a lot of people I can feel them sucking my thoughts out of my head." The nurse can correctly assess this as a. anhedonia. b. concrete thinking. c. thought withdrawal. d. associative looseness.

ANS: C Thought withdrawal is defined as a delusional belief that someone or something is removing thoughts from the client's mind. Option A: Anhedonia is the inability to experience pleasure. Option B: Concrete thinking refers to the inability to use abstraction. Option D: Associative looseness refers to a lack of ties between thoughts, leading to jumbled thinking.

15. A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse should say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Was your husband angry if you did not have dinner ready on time?"

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The other options do not validate patient feelings.

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.

5. A patient with bipolar disorder is hyperactive after discontinuing lithium and has not slept for 3 days. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The first response does not offer appropriate assistance to the patient. The second response threatens the patient with seclusion as punishment. The fourth response asks a rhetorical question.

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

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking "why" does not provide for environmental safety. REF: Pages: 290-293

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

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

26. A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proved successful, considering the behavior has continued. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness. REF: Pages: 290-293

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a client with schizophrenia who demonstrates auditory hallucinations, apathy, anhedonia, and poor social functioning. The client is overweight and has hypertension. Bearing these facts in mind, the drug the nurse should advocate would be a. clozapine (Clozaril). b. ziprasidone (Geodon). c. olanzapine (Zyprexa). d. aripiprazole (Abilify).

ANS: D Aripiprazole is a new atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity or heart disease. Option A: Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Option B: Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease. Option C: Olanzapine fosters weight gain. DIF: Cognitive Level: Analysis REF: Text Page: 406 TOP: Nursing Process: Planning MSC: NCLEX: Physiologic Integrity

A male client diagnosed with paranoid schizophrenia angrily tells the male nurse "You act like a homosexual. None of the men trust you or want to be around you." The nurse, who is heterosexual, is perplexed by the client's statements and discusses the event with his mentor. The most likely analysis of the event is a. the client was unleashing unconscious, hostile feelings toward the nurse. b. the client was demonstrating reaction formation in response to feelings of abandonment. c. dwelling on others' shortcomings puts them on the defensive. d. the client was projecting homosexual urges.

ANS: D Clients with paranoid ideation unconsciously use the defense mechanism projection to deal with unacceptable, anxiety-producing ideas and impulses, in this case homosexual urges. Option A: Although the behavior seems hostile, the projection is homosexual urges rather than hostility. Option B: Clients who exhibit paranoid ideation usually fear abandonment, but this situation does not represent reaction formation to abandonment feelings. Option C: Although this statement about defensive behavior is true, it is not the correct analysis of the behavior described in the scenario. DIF: Cognitive Level: Analysis REF: Text Page: 414 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A client's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the client may be hallucinating include a. aloofness, haughtiness, and suspicion. b. elevated mood, hyperactivity, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, tilted head, and mumbling to self.

ANS: D Clues to hallucinations include eyes looking around the room as though to find the speaker; tilting the head to one side as though listening intently; and grimacing, mumbling, or talking aloud as though responding conversationally to someone. DIF: Cognitive Level: Application REF: Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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

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

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

ANS: D During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation. REF: Page: 296 | Page: 298

A client with schizophrenia who admits to auditory hallucinations anxiously tells the nurse "The voice is telling me to do things." The priority assessment question the nurse should ask is a. "Do you recognize the voice speaking to you?' b. "How long has the voice been directing your behavior?" c. "Does what the voice tell you to do frighten you?" d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the client to do is important because the command often places the client or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The other queries are of lesser importance than identifying the command. DIF: Cognitive Level: Application REF: Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment;

A client with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says "It's beat, it's eat. No room. The cat." The nurse can correctly assess this verbalization as a. neologisms. b. ideas of reference. c. thought broadcasting. d. associative looseness.

ANS: D Looseness of association refers to jumbled thoughts that are often incoherently expressed to the listener. Option A: Neologisms are newly coined words. Option B: Ideas of reference are a type of delusion. Option C: Thought broadcasting is the belief that others can hear one's thoughts. DIF: Cognitive Level: Application REF: Text Page: 392, Text Page: 393 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

When a client with paranoid schizophrenia has a recurrence of positive symptoms after stopping his antipsychotic medication to be free of its orthostatic side effect, he is readmitted to the mental health unit. The physician orders the resumption of medication. The nurse adds the nursing diagnosis of "noncompliance with antipsychotic medication regimen related to side effects" to the client's care plan. What measure should the nurse suggest to the client? a. Ask the physician about prescribing an anticholinergic drug such as trihexyphenidyl (Artane). b. Chew sugarless gum or use sugarless hard candy to moisten oral mucous membranes. c. Reduce dosage by 5 mg daily if side effects recur. d. Wear elastic support hose, stay hydrated, and rise slowly from the lying or sitting position.

ANS: D Orthostasis produces dizziness or fainting when moving from a lying or seated position to a standing position. This can be effectively combated by rising slowly. The use of support hose may also be helpful to prevent pooling of blood in the lower extremities. Options A and B are unnecessary. Anticholinergic side effects are not the problem. Option C The client should be taught not to discontinue or adjust the dose of the medication, but rather to report annoying side effects to the physician or nurse. DIF: Cognitive Level: Application REF: Text Page: 409 TOP: Nursing Process: Implementation MSC: NCLEX: Physiologic Integrity

The family of a client with schizophrenia who has been stable for a year reports to the community mental health nurse that the client reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about "volmers" hiding in the warehouse where he works and undoing his work each night. The nurse can correctly assess this information as an indication of a. medication noncompliance. b. the need for psychoeducation. c. chronic deterioration. d. relapse.

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Option A: Medication noncompliance may not be implicated. Relapse can occur even when the client is taking medication regularly. Option B: Psychoeducation is better delivered when the client's symptoms are stable. Option C: Chronic deterioration is not the most viable explanation. DIF: Cognitive Level: Application REF: Text Page: 399, Text Page: 400 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

24. When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient's affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

ANS: D Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the preaggressive phase but is less effective during escalation.

A client receiving risperidone (Risperdal) reports severe muscle stiffness mid-morning. During lunch he has difficulty swallowing food and is noted to drool. When vital signs are taken at 4 PM he is noted to be diaphoretic, with a temperature elevation of 38.4° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect a. agranulocytosis and institute reverse isolation. b. cholestatic jaundice and begin a high-protein, high-cholesterol diet. c. tardive dyskinesia and withhold the next dose of medication. d. neuroleptic malignant syndrome and notify physician stat.

ANS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms such severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation) suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in options A, B, or C. DIF: Cognitive Level: Analysis REF: Text Page: 409 TOP: Nursing Process: Assessment MSC: NCLEX: Physiologic Integrity

A client with schizophrenia anxiously describes seeing the left side of her body merge with the wall as she walked down the corridor and of seeing her face appear and disappear in the bathroom mirror. As the nurse listens she should a. sit close to the client on the bed. b. place an arm protectively around the client's shoulders. c. place a hand on the client's arm and exert light pressure. d. maintain the normal social interaction distance from the client.

ANS: D The client is describing phenomena that indicate personal boundary difficulties. The nurse should maintain appropriate social distance from the client and not touch her because the client is anxious about her inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic. DIF: Cognitive Level: Application REF: Text Page: 393, Text Page: 394 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

The nurse is sitting with a client diagnosed as having schizophrenia, disorganized type, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say a. "Please share the joke with me." b. "Why are you laughing?" c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

ANS: D The client is likely laughing in response to inner stimuli such as hallucinations or fantasy. Moller suggests focusing on the hallucinatory clue (the client's laughter) and eliciting the client's observation. The other options are less useful in eliciting a response. Option A: No joke may be involved. Option B: "Why" questions are difficult to answer. Option C: The client is probably not focusing on what the nurse said in the first place. DIF: Cognitive Level: Application REF: Text Page: 393, Text Page: 401 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

3. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Posttrauma response c. Disturbed thought processes d. Risk for other-directed violence

ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

14. A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

ANS: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia? 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.

A nurse is assessing a client diagnosed with paranoid 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. Paranoid delusions 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.

A client diagnosed with chronic schizophrenia 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 and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat 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.

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on 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.

21. Information from a patient's record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. chemical dependence.

ANS: D The nurse should suspect marginal coping skills in a patient with chemical dependence. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.

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

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

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

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of "cheeking" the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. REF: Pages: 294-295

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

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

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

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

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function. REF: Pages: 294-295

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

ANS: D When a client's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the client that she is having difficulty understanding what the client is saying. If a theme is discernable, ask the client to talk about the theme. The other options tend to place blame for the poor communication with the client. Option D places the difficulty with the nurse rather than being accusatory. DIF: Cognitive Level: Application REF: Text Page: 401, Text Page: 402 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

The nurse attempting to establish a relationship with a severely withdrawn schizophrenic client tells a preceptor that her frustration level is rising daily because the client turns his head away each time she sits down near him. The nurse states "I am beginning to wonder what is wrong with me as a nurse." The preceptor could be most helpful by explaining that withdrawn clients with schizophrenia a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility by demonstrating rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a client, the client's anxiety rises until trust is established. The truth of option A is not borne out by the evidence. Options B and C: These options are not considered true in most cases. DIF: Cognitive Level: Application REF: Text Page: 394, Text Page: 395 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

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

ANS: a. Acute dystonic reaction

An acutely violent patient with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated?

ANS: a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

What assessment findings mark the prodromal stage of schizophrenia?

ANS: a. Withdrawal, misinterpreting, poor concentration, & preoccupation with religion

A patient has taken trifluoperazine (Stelazine) 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

ANS: b. Tardive dyskinesia

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

ANS: b. Waxy flexibility

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

ANS: b. olanzapine (Zyprexa)

A newly admitted patient with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply.

ANS: c. "I'll stay with you. Focus on what we are talking about, not the voices."

A patient with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

ANS: c. Poor personal hygiene

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

ANS: d. "I am having difficulty understanding what you are saying."

A patient with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question.

ANS: d. "What is the voice telling you to do?"

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient has difficulty swallowing and is drooling. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. The patient is diaphoretic. Select the nurse's best analysis and action.

ANS: d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

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

ANS: d. Paranoia

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

ANS: d. aripiprazole (Abilify)

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

ANS: d. maintain a normal social interaction distance from the patient.

Mutism

Absence of verbal speech

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient's medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained

B

A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. a. Teach the patient about herbal preparations that reduce anger. b. Help the patient identify incidents that trigger impulsive anger. c. Explain that restraint and seclusion will be used if violence occurs. d. Offer one-on-one supervision to help the patient maintain control.

B

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolded nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. b. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia. c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. d. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

B

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "The other patient started the fight."

B

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the dayroom. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your health care provider prescribed for you?" b. accompanied by 3 staff members and say, "Please come to your room so I can give you some medication that will help you regain control." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male security guard and tell the patient, "Come to your room willingly so I can give you this medication, or the guard and I will take you there."

B

Which assessment finding presents the greatest risk for violent behavior directed at others? a. Severe agoraphobia b. History of spousal abuse c. Bizarre somatic delusions d. Verbalized hopelessness and powerlessness

B

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. "I can't stop my sexual urges. They have led me to numerous affairs." B. "I'm the world's most perceptive attorney." C. "My wife is distraught about my overspending." D. "The FBI has tapped my room and are out to get me.

B. "I'm the world's most perceptive attorney."

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Your husband gets angry if you do not have dinner ready on time?"

C

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "What is going on?" b. "Please be quiet and sit down in this chair immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

C

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by: a. gently touching the patient's arm. b. asking the patient, "What do you need?" c. saying to the patient, "This is a safe place." d. directing the patient to cease the behavior.

C

A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "This dressing change is needed so your wound will not get infected." d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your health care provider ordered this dressing change."

C

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

C

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient's condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patient's treatment is complete.

C

Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking leading to cognitive distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

C

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium (Eskalith) b. Trazodone (Desyrel) c. Olanzapine (Zyprexa) d. Valproic acid (Depakene)

C

Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performs many rituals c. Paranoid delusions of being followed by alien monsters d. Completed alcohol withdrawal; beginning a rehabilitation program

C

A client on an inpatient unit is diagnosed with bipolar disorder: manic phase. During a discussion in the dayroom about weekend activities, the client raises voice, becomes irritable, and insists that plans change. What should be the nurse's initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems

C. Assist the client to move to a calmer location.

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem solving to cope adequately after discharge.

C. The client will remain safe throughout the hospitalization.

Neologisms

Client makes up words with own meaning

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled nursing facilities increases an individual's tendency toward violence. c. The patient learned violent behavior by watching other patients act out. d. The patient interpreted the UAP's behavior as potentially harmful.

D

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working though angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

D

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Risk for other-directed violence

D

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient: a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.

D

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of: a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse.

D

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

D. Symptoms indicate lithium carbonate toxicity

Confabulation

Filling a memory gap with detailed fantasy to maintain self esteem; seen in conditions such as Korsakoff's psychosis

Looseness of association

Illogical and confused thinking, and interrupted connections in thought; seen mostly in schizophrenic disorders.

Neologism

Making words with own meaning

Verbigeration

Purposeless repetition of words or phrases

Echolalia

Repetition of words or phrases heard from another person

Persecution

Thought that one is being singled out to be harmed by others.

Schizophrenia

group of mental disorders characterized by hallucinations and delusions, disordered thought process and disrupted interpersonal relationships