mental health quizzes exam 3
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. substance abuse.
An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a.Amitriptyline b.Fluoxetine c. Desipramine d. Tranylcypromine sulfate
Fluoxetine
An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate
Fluoxetine
A patient diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."
"An individual is supported by peers while striving for abstinence one day at a time."
A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you became depressed."
"Are you having thoughts of suicide?"
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."
"Let's consider which problems are very important and which are less important."
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."
"My fingers are tingly."
MH5 When doing discharge teaching with your client who is taking chlorpromazine, which of the following instructions is appropriate? a. "Monitor blood pressure weekly as hypertension may occur." b. "Discontinue the medication if you are drowsy or dizzy." c. "Wear protective clothes and hat when in the sun." "d. A diet low in fiber with a good fluid intake will help you maintain normal bowel habits."
"Wear protective clothes and hat when in the sun."
Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate
A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate
A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a.Barbiturates b. Amphetamines c. PCP d. Heroin
Amphetamines
Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.
As depression lifts, physical energy becomes available to carry out suicide.
A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? a) Call the mental health crisis team and notify them that a client who attempted suicide is being admitted. b) Take the client's vital signs, including pulse oximetry reading. c) Assess the client's respiratory status and for the presence of neck injuries. d) Perform a focused assessment, applying particular attention to the client's neurological status.
Assess the client's respiratory status and for the presence of neck injuries.
Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy
Attending a self-help group for survivors
When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support
Availability of means and lethality of method
A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:0200: 118/78 mm Hg and 72 beats/minute0400: 126/80 mm Hg and 76 beats/minute0600: 128/82 mm Hg and 72 beats/minute0800: 132/88 mm Hg and 80 beats/minute1000: 148/94 mm Hg and 96 beats/minuteWhat is the nurse's priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint
Begin the detox protocol.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. Which action should the nurse take at this time? a) Call the nursing supervisor. b) Call security to block the exits to the nursing unit. c) Restrain the client, and call the primary health care provider. d) Tell the client that readmission is not possible after leaving against medical advice.
Call the nursing supervisor.
What is the priority nursing action when admitting a client who has just attempted suicide? a) Remove all potentially dangerous articles from among the client's belongings. b) Conduct a thorough mental health assessment of the client. c) Ensure constant observation of the client at all times. d) Determine whether the client has ever attempted suicide previously.
Ensure constant observation of the client at all times.
Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech
Drowsiness, constricted pupils, slurred speech
Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational
Empathetic, supportive
A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room
Giving away sweaters
Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient
Helping school children learn to manage stress and be resilient
What is neuroleptic malignant syndrome (NMS)?
Its a rare life threatening side effect of antipsychotic meds. Signs of NMS are extreme rigidity and catatonia, sometimes mistaken for worsening of psychotic disorder
What is the appropriate nursing intervention in dealing with a suicidal client? a) Provide authority, action, and participation. b) Display an attitude of detachment, confrontation, and efficiency. c) Demonstrate confidence in the client's ability to deal with stressors. d) Promote hope and reassurance that the problems will resolve themselves.
Provide authority, action, and participation.
A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority? a.Cardiovascular b. Respiratory c. Neurological d. Hepatic
Respiratory
A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping
Risk for suicide
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a. Sweating, nausea, and diarrhea b. Headache, watery eyes, and runny nose c. Sedation and muscle stiffness d. Mild fever, sore throat, and skin rash
Sedation and muscle stiffness
A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.
Self-assess personal attitude, values, and beliefs about this health problem.
The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms? a) Withdrawal has likely already started. b) Signs may appear at any time. c) The next hour could be critical. d) The danger time has passed.
Signs may appear at any time.
Which features should be present in a therapeutic milieu for a patient experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging
Simple and safe
When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.
Tolerance has developed.
In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. Select the priority outcome. a. the patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.
Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute.
A 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. "You want to go home to prepare your husband's dinner?"
A patient admitted to an alcohol rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? a.Denial b.Projection c.Introjection d. Rationalization
denial
A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to a. assess lethality of suicide plan. b. encourage expression of anger. c. establish trust with the patient. d. determine risk factors for suicide.
establish trust with the patient.
A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.
exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.
What does rumination mean?
getting stuck on particular thoughts
A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." The parents' reaction reflects a. guilt. b. denial. c. shame d.rescue feelings.
guilt
Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. γ-aminobutyric acid deficiency
serotonin deficiency
A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c."Bringing up these feelings is a very positive action on your part." d."We need to talk about the good things you have to live for."
"Bringing up these feelings is a very positive action on your part."
Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"
"Do you have access to medications?"
A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."
"For the next 24 hours, I will not in any way attempt to harm or kill myself."
After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."
"Genetics are associated with suicide risk. Monitoring and support are important."
A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."
"I have a plan that will fix everything."
Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."
"I have no one to turn to for help or support."
During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."
"While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."
Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability.
Achieve physiological stability.
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to a. current stress level. b. mood disturbance. c. suicide potential d.level of anxiety.
suicide potential.
A patient previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event? a. Request the information technology manager to verify the patient's medical record is secure in the hospital information system. b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments. c. Consult the hospital's legal department regarding potential consequences of the event. d.Document a report of a sentinel event in the patient's medical record.
Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments.
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? a) Hypotension, coarse hand tremors, lethargy b) Hypotension, ataxia, hunger c) Hypertension, changes in level of conscious, hallucinations d) Stupor, lethargy, muscular rigidity
Hypertension, changes in level of conscious, hallucinations
Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night
Jumping from a railroad bridge located in a deserted area late at night
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a.Bromocriptine b. Methadone c. Disulfiram d. Naltrexone
Naltrexone
A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine (IOM)-National Research Council c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine
Substance Abuse and Mental Health Services Administration (SAMHSA)
It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.
Supervise the patient 24 hours a day.
Which central nervous system structures are most associated with anger and aggression? (Select all that apply.) a) Amygdala b) Basal ganglia c) Cerebellum d) Temporal lobe e) Prefrontal cortex
a) Amygdala d) Temporal lobe e) Prefrontal cortex
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)Offering to provide the patient with medication to help b) Asking the patient, "Do you want to go into seclusion?" c) Speaking in a firm but calm voice. d) Stating the expectation that the patient will stay in control. e) Telling the patient, "You are behaving inappropriately."
a)Offering to provide the patient with medication to help c) Speaking in a firm but calm voice. d) Stating the expectation that the patient will stay in control.
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 antianxiety medication.
a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.
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. Practice and teamwork
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. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.
A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should 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. make sure there is adequate physical space between the nurse and patient.
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. a) Initiate confinement measures. b) Acknowledge the client's behavior. c) Assist the client to an area that is quiet. d) Maintain a safe distance from the client. e) Allow the client to take control of the situation.
b) Acknowledge the client's behavior. c) Assist the client to an area that is quiet. d) Maintain a safe distance from the client.
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) Quickly approach the patient and take the closest extremity. b) Select the person who will communicate with the patient. c) Move behind the patient when the patient is not looking. d) Remove jewelry, glasses, and harmful items. e) Appoint a person to clear a path and open, close, or lock doors
b) Select the person who will communicate with the patient. d) Remove jewelry, glasses, and harmful items. e) Appoint a person to clear a path and open, close, or lock doors
An acutely violent patient diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. b. Administer diphenhydramine 50 mg IM from the prn medication administration record. c. Administer atropine sulfate 2 mg subcut from the prn medication administration record. d. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time.
b. Administer diphenhydramine 50 mg IM from the prn medication administration record.
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. Help the patient identify incidents that trigger impulsive anger.
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. History of spousal abuse
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. Notify the health care provider to obtain a seclusion order.
A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, "I'm in pain all the time but you don't give me medicine until YOU think it's time." 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. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.
Olanzapine, an atypical antipsychotic medication is ordered for a client with schizophrenia. The nurse teaching the client about this medications would include which of the following information? a. Take this medication on an empty stomach for best results. b. Teach the client to change position slowly to avoid hypotension and dizziness. c. Insomnia is common, so avoid drinks/ foods high in caffeine. d. Weight Loss is a common side effect, so an increase in caloric intake is necessary.
b. Teach the client to change position slowly to avoid hypotension and dizziness.
An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room 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 three 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. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control."
The nurse is preparing to administer the benzodiazepine alprazolam to a client who has generalized anxiety disorder. Which intervention should the nurse implement prior to administering the medication? a)Assess the client's blood pressure b) Assess the client's serum potassium c) Assess the client's anxiety level d) Assess the client's apical pulse.
c) Assess the client's anxiety level
A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a) Neuroleptic malignant syndrome b) Hepatocellular effects c) Pseudoparkinsonism d) Akathisia
c) Pseudoparkinsonism
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. "I'd like to talk with you about how you're feeling right now."
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. A wish for revenge
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 b. Trazodone c. Olanzapine d. Valproic acid
c. Olanzapine
Which clinical scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder 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. Paranoid delusions of being followed by alien monsters
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. Periodically provide an update and progress report on the patient.
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. a personality style that externalizes problems.
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. saying to the patient, "This is a safe place."
At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as a. codependence. b. assertiveness. c. role reversal. d. homeostasis.
codependence.
A patient with severe burn 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 action by the nurse will best help to diffuse the patient's anger? a. Stop the dressing change and say, "I will leave the supplies so that you can change your own dressing." b. Continue the dressing change and say, "This dressing change is necessary because you were careless with fire." c. Discontinue the dressing change, tell the patient, "I will return when you gain control of yourself," and leave the room. d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"
d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"
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. Risk for other-directed violence
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. The patient interpreted the UAP's behavior as potentially harmful.
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. exhibiting clues to potential aggression.
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. presented a clear and present danger to others.
An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.
hallucinogen ingestion.
Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? The patient a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently.
has a high tolerance to alcohol.
A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having an acute psychosis.
has symptoms of alcohol withdrawal delirium.
The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a.hopelessness b.sadness c.elation d.anger.
hopelessness.
What does anhedonia mean?
inability to experience pleasure, It's a common symptom of depression as well as other mental health disorders.
What does malingering mean?
is a consciously motivated act of fabricating an illness or exaggerating symptoms, done for secondary gains
Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.
monitor vital signs
Symptoms of withdrawal from opioids for which the nurse should assess include a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.
nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
.A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.
sedative, such as lorazepam or chlordiazepoxide.
A patient asks for information about AA. Select the nurse's best response. "AA is a a. group that learns about drinking from a group leader." b. form of group therapy led by a psychiatrist." c. network that advocates strong punishment for drunk drivers." d. self-help group for which the goal is sobriety."
self-help group for which the goal is sobriety."
Select the priority outcome for a patient completing the fourth alcohol detoxification program in the past year. Prior to discharge, the patient will a. state, "I know I need long-term treatment." b. use denial and rationalization in healthy ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.
state, "I know I need long-term treatment."
A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes a. cross-tolerance. b. substance abuse. c. substance addiction. d. substance intoxication.
substance addiction.
