Mental Health

Which of the following statements about dissociative disorders is true? A. Dissociative symptoms are under the person's conscious control. B. Dissociative symptoms are not under the person's conscious control. C. Dissociative symptoms are usually a cry for attention. D. Dissociative symptoms are always negative.

B. Dissociative symptoms are not under the person's conscious control. Dissociation is involuntary and results in failure of the normal control over a person's mental processes and normal integration of conscious awareness. The other responses are untrue.

A 4 years old is referred to the outpatient mental health clinic after being in a severe car accident during which the child mother died. The father states that the child is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. The child states, "It's my fault because I'm bad." What trauma induced disorder does this data support? A. Adjustment disorder B. Dissociative identity disorder C. Posttraumatic stress disorder (PTSD) D. Acute stress disorder (ASD)

C. Posttraumatic stress disorder (PTSD) PTSD in preschool children may manifest as repetitive play that includes aspects of the traumatic event, social withdrawal, and negative emotions such as fear, guilt, anger, horror, sadness, shame, or confusion. Children may blame themselves for the traumatic event and manifest persistent negative thoughts about themselves. Unlike PTSD, adjustment disorder may be diagnosed immediately or within 3 months of exposure. Responses to the stressful event may include combinations of depression, anxiety, and conduct disturbances. Dissociative identity disorder includes the presence of "alters" or other personalities that take over in times of stress. As compared with PTSD that occurs a month after the trauma, ASD occurs from 3 days and up to 1 month after exposure to a highly traumatic event. Individuals with ASD experience three or more dissociative symptoms either during or after the traumatic event, including the following: a sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization (a sense of unreality related to the environment); depersonalization (experience of a sense of unreality or self-estrangement); or dissociative amnesia (loss of memory).

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client 2.ensure that the client knows that he or she is not in charge of the nursing unit 3.assist the client in developing means of setting limits on personal behavior 4.follow through about the consequences of behavior in a nonpunitive manner 5.enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6.be clear with the client regarding the consequences of exceeding limits set regarding behavior

1.Communicate expected behaviors to the client 3.assist the client in developing means of setting limits on personal behavior 4.follow through about the consequences of behavior in a non-punitive manner 6.be clear with the client regarding the consequences of exceeding limits set regarding behavior

a client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to: 1.move the client next to the nurse's station 2.use a night light and turn off the television 3.keep up the television and a soft light on during the night. 4.play soft music during the night and maintain a well-lit room

2. Use a night light and turn off the television

Key interventions for clients with substance-related problems include: 1. Focusing on the client's past problems 2. Implementing problem-solving measures for the client 3. Informing the client of punishment measures should he or she break rules in the treatment setting 4. Assisting the client's family by encouraging them to become involved in the treatment process and in group counseling

4. Assisting the client's family by encouraging them to become involved in the treatment process and in group counseling This will give support to the client and family and will help ensure that all parties are working toward the same goal. The focus should be on the client's strengths and on the present and future. The nurse should be assisting the client in learning to problem-solve, not problem-solving for him or her; and interventions should be non-punitive. REF: Page 333

A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty. What is your best nursing response? A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves. B. Does anyone in your family have schizophrenia, as this disease is known to be genetic? C. You may feel bad now, but there are so many other bad things out there, such as cancer and paralysis. D. Let me share with you some websites to help you deal with your guilt.

A. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves. Reason: Schizophrenia has a multifocal origin and its cause may include a genetic component. Support is needed for both patients and caregivers.

Which statement concerning syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered true? A. Dissociative disorders such as dissociative identify disorders B. Physical disorders, not mental disorders C. Culture-bound syndromes that are not dissociative disorders D. Myths, or rumors, because they have not been sufficiently studied to be classified as real.

C. Culture-bound syndromes that are not dissociative disorders Certain culture-bound disorders exist in which there is a high level of activity, a trancelike state, and running or fleeing, followed by exhaustion, sleep, and amnesia regarding the episode. These syndromes, if observed in individuals native to the corresponding geographical areas, should be differentiated from dissociative disorders. The other responses are incorrect.

You are caring for a patient and pour out his evening risperidone (Risperdal) 2 mg tablet. The pill falls on the countertop. What is your next intervention? A. Pick the pill up from the counter and place it in a cup. B. Wash the pill off with alcohol and place it in a cup. C. Discard the pill and repour the medication. D. Call the patient up to the pill line to receive his medication.

C. Discard the pill and repour the medication. Reason: The pill is contaminated once dropped, so for infection control purposes you discard it and repour the medication.

Which of the following best describes an allopathic method of treatment for a client with a diagnosis of generalized anxiety disorder?

Antianxiety medications to decrease anxiety levels.

The first step in treatment for substance abuse requires that the person recognize: 1. The need for help 2. That he or she is in denial of the problem 3. How ill the substance is making him or her 4. The need for continued use of the substance

1. The need for help The first step in treatment is to recognize the need for help; otherwise treatment will not be successful. REF: Page 332

The nurse is caring for a client who is taking a medication daily because she is a nonpracticing (dry) alcoholic. What is the medication known as? 1. Anatox 2. Antabuse 3. Retox 4. Hibotox

2. Antabuse

A client has developed a high tolerance for cocaine. The need for the substance encompasses every waking hour, and without it, life is miserable. The client is in what stage of addiction? 1. Early stage 2. Middle stage 3. Chronic stage 4. Latent stage

3. Chronic stage During the chronic stage, tolerance for the substance usually is high and all energy is focused on obtaining and using the substance. In the early stage, a frequent pattern of substance use develops. In the middle stage, tolerance develops to the substance. The latent stage is not a stage of addiction. REF: Page 330

Which of the following individuals would most likely benefit from joining a self-help group?

32-year-old female rape victim.

a nurse is caring for a client with a diagnosis of depression. the nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by: 1.poor dietary choices 2.lack of exercise and poor diet 3.inadequate dietary intake and dehydration 4.psychomotor retardation and side effects of medication

4.psychomotor retardation and side effects of medication

Your patient is preoccupied with perfection and control, has difficulty relaxing, exhibits rule-conscious behavior, and cannot discard anything. What type of personality disorder does this behavior reflect? A. Antisocial personality. B. Obsessive-compulsive personality. C. Manic behavior. D. Anxiety disorder.

B. Obsessive-compulsive personality. Reason: Obsessive-compulsive disorder is a personality disorder that includes perfection, control, procrastination, excessive devotion to work, difficulty relaxing, rule-conscious behavior, and inability to discard anything.

One of the major disadvantages of benzodiazepines prescribed for anxiety is that these medications:

Cause dependency with long-term use.

A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive motor activity with repetitive sit-ups. What is this behavior called? A. Delusional. B. Hallucinogenic. C. Paranoid. D. Catatonic.

D. Catatonic. Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive motor activity.

A female client is taking an antipsychotic medication for her schizophrenia. The nurse monitors this client for the peripheral nervous system side effects of:

Dry mouth, photophobia, and hypotension.

A client becomes antagonistic and emotional after consuming a large amount of alcohol. This client is __________ .

Intoxicated Intoxication is defined as a state of maladaptive behavioral or psychological changes that results from exposure to certain chemicals. REF: Page 330

The nurse is planning the discharge of a client who has been prescribed an antipsychotic medication for paranoid schizophrenia. The nurse knows that the client is most at risk for:

Noncompliance.

A female client has been taking an antipsychotic medication for several years. It is of vital importance for the nurse to observe the client for tardive dyskinesia. Signs and symptoms of tardive dyskinesia include:

Repetitious, involuntary muscle movements in the face and extremities.

A person has drunk a large amount of alcohol over a short time. Which of the following can result from ingesting a large amount of alcohol? 1. Cardiac dysrhythmias 2. Hypotension 3. Bradycardia 4. Increased body temperature

1. Cardiac dysrhythmias Large doses of alcohol can affect the pumping action of the heart, resulting in cardiac dysrhythmias. Increased amounts of alcohol can cause a rise in blood pressure and pulse. Increased amounts of alcohol can cause a rise in blood pressure. Increased amounts of alcohol can cause a reduction in body temperature. REF: Page 325

a nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1.Provide safety for the client and other clients on the unit 2.Provide the clients on the unit with a sense of comfort and safety 3. Assist the staff in caring for the client in a controlled environment 4.offer the client a less-stimulating area to calm down and gain control

1.Provide safety for the client and other clients on the unit

a client is unwilling to go out of the house for fear of "doing something crazy in public". Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has: 1.agoraphobia 2.hematophobia 3.claustrophobia 4.hypochondriasis

1.agoraphobia

a nurse is collecting data from a client and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). which disorder would the nurse suspect that this client may have based on the use of this medication? 1.dementia 2.schizophrenia 3.seizure disorder 4.obsessive-compulsive disorder

1.dementia

The client drinks at least 12 colas every day. Today he is unable to obtain his cola and is becoming more irritated and physically uncomfortable with each hour. The client is experiencing signs of: 1. Relapse 2. Addiction 3. Crankiness 4. Intoxication

2. Addiction In this situation, the client is exhibiting signs and symptoms of addiction to caffeine. An addiction is defined as a physical dependence on a substance. REF: Page 323

The client has been taking an especially potent form of heroin. What is the drug called? 1. Mushrooms 2. Black tar 3. Cannabis 4. Phencyclidine

2. Black tar

Every chemical ingested by a pregnant woman poses a potential danger to her unborn child. This is especially true during the: 1. Labor and delivery 2. First trimester of pregnancy 3. Third trimester of pregnancy 4. Second trimester of pregnancy

2. First trimester of pregnancy The fetus is most vulnerable during the first trimester of pregnancy. REF: Page 323

The nurse should suspect which of the following if a child has fetal alcohol syndrome (FAS)? 1. Lethargy 2. Intellectual impairment 3. Larger at birth 4. Large head

2. Intellectual impairment Central nervous system effects of FAS include mental retardation and irritability. Also, intellectual impairment and poor judgment are common to children of alcoholic mothers. Hyperactivity and irritability are characteristics of children with FAS. Children with FAS are smaller at birth. Children with FAS have small heads. REF: Page 323

a nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client? 1.a puzzle 2.drawing 3.checkers 4.paint by number

2.drawing

the police arrive at the emergency room with a client who has seriously lacerated both wrists. the initial nursing action is to: 1.administer an anti anxiety agent 2.examine and treat the wound sites 3.secure and record a detailed history 4.encourage and assist the client to vent feelings

2.examine and treat the wound sites

The nurse is working in a substance abuse center. She realizes that substance abuse is common. Substance abuse occurs most commonly between what ages? 1. 16 and 25 years of age 2. 25 and 45 years of age 3. 18 and 35 years of age 4. 21 and 40 years of age

3. 18 and 35 years of age

Which of the following is associated with heroin use? 1. Clammy skin 2. Sweating 3. Constricted pupils 4. Panic

3. Constricted pupils Constricted pupils are associated with heroin use. Clammy skin is associated with heroin overdose. Sweating is associated with heroin withdrawal. Panic is associated with heroin withdrawal. REF: Page 327

The nurse is taking care of a client with a serious mental illness and an addiction to drugs. The client's two conditions are known as: 1. Habituation 2. Substance dependency 3. Dual diagnosis 4. Mental illness dependency

3. Dual diagnosis

a nurse is caring for a hospitalized client who has been taking clozapine (clozaril) for the treatment of schizophrenic disorder. which laboratory study prescribed for the client will the nurse specifically review to monitor for an adverse effect associated with the use of this medication? 1.platelet count 2.cholesterol level 3.WBC 4.Blood urea nitrogen level

3.WBC

a client receiving a tricyclic antidepressent arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? 1.reports not going to work for this past week 2.complains of not being able to "do anything" anymore 3.arrives at the clinic neat and appropriate in appearance 4.reports sleeping 12 hours per night and 3 to 4 hours during the day

3.arrives at the clinic neat and appropriate in appearance

a client was admitted to a medical unit with acute blindness. many tests are performed and there seems to be no organic reason why this client cannot see. the nurse latter learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. the nurse suspects that the client may be experiencing a: 1.psychosis 2.repression 3.conversion disorder 4.dissociative disorder

3.conversion disorder

a nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing 2.make the decisions for the family 3.encourage expression of feelings, concerns, and fears 4.explain everything that is happening to all family members 5.extend touch and hold the client's or family member's hand if appropriate 6.Be honest and truthful and let the client family know that you will not abandon them.

3.encourage expression of feelings, concerns, and fears 5.extend touch and hold the client's or family member's hand if appropriate 6.Be honest and truthful and let the client family know that you will not abandon them.

The use of cocaine is higher in which group of people? 1. Hispanic Americans 2. Asian Americans 3. Whites 4. African Americans

4. African Americans The use of cocaine is higher among African Americans. Hispanic Americans prefer alcohol. No preference has been documented in Asian Americans. Whites prefer alcohol. REF: Page 324

The nurse is caring for a client who regularly uses MDMA, which is commonly known as: 1. Hash 2. Ice 3. Marijuana 4. Ecstasy

4. Ecstasy

a nurse is caring for an older adult client who has recently lost her husband. The client says, "no one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1."right! why not just pack it in?" 2."that seems rather unlikely to me" 3."i don't believe that, and neither do you" 4."you must be feeling all alone at this point"

4."you must be feeling all alone at this point"

during a conversation with a depressed client on psychiatric unit, the client says to the nurse, "My family would be better off without me" the nurse should make which therapeutic response to the client? 1."have you talked to your family about this?" 2."everyone feels this way when they are depressed" 3."you will feel better once your medication begins to work" 4."you sound very upset. are you thinking of hurting yourself?"

4."you sound very upset. are you thinking of hurting yourself?"

Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. the nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? 1.a history of hyperthyroidism 2.a history of diabetes insipid us 3.when the last full meal was consumed 4.when the last alcoholic drink was consumed

4.when the last alcoholic drink was consumed

Your neighbor's husband comes to talk to you. He says his wife has not left the house in 2 weeks, has a flat mood, and has lost interest in her usual activities. You recognize these as the primary symptoms of A. Depression. B. Schizophrenia. C. Suicidal ideation. D. Bipolar manic episodes.

A. Depression. Reason: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary symptoms of major depression.

As a nurse, you wish to reinforce functional behavior in your schizophrenic patient. Which intervention will accomplish reinforcement? A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors. B. Educate the patient about the symptoms of schizophrenia. C. Facilitate learning about the importance of medication compliance using written materials for reinforcing medication use. D. Focus on the feelings of delusion to reinforce reality and decrease false beliefs by talking to the patient.

A. Praise the patient for reality-based perceptions and cessation of acting-out behaviors. Reason: Reinforcement by praise increases functional behavior.

Psychotherapeutic drug therapy works primarily by:

Altering chemical balances within the nervous system.

A 10-year-old male client with autism experiences loneliness and social anxiety as a result of his disease. Which CAM therapy will the nurse suggest to help this client most with these feelings.

Animal-assisted therapy.

Your patient is ready for discharge after a 30-day hospitalization for manic depression. About 30 minutes before his discharge, his roommate comes to you and says, 'He is talking crazy.' When you ask your patient how he is feeling, he states, 'I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.' Which type of mania-related symptoms is this patient exhibiting? A. Social. B. Cognitive. C. Behavioral. D. Perceptual.

B. Cognitive. Reason: Cognitive symptoms include inflated self-esteem and grandiosity.

Which type of therapy helps patients with personality disorders explore ways to enjoy themselves and increase their socialization skills? A. Occupational therapy. B. Recreational therapy. C. Music therapy. D. Medication therapy.

B. Recreational therapy. Reason: Recreational therapy helps patients explore ways to enjoy themselves without using alcohol or drugs and strengthens social skills.

Your patient has just shown you some fresh, self-inflicted, superficial cuts-eight of them going up and down his right arm. What is your initial intervention based on infection control principles? A. Send the patient back to his room as part of behavioral modification. B. Suture the cuts using a large-bore needle and nondissolving sutures. C. Cleanse the wounds with soap and water. D. Administer tetanus toxoid injection intramuscularly.

C. Cleanse the wounds with soap and water. Reason: Cleansing the wound with soap and water is the initial intervention.

Your patient has a diagnosis of schizophrenia and believes that his thoughts are broadcast from his head. What is the most appropriate nursing diagnosis? A. Risk for self-directed violence. B. Disturbed sensory perception. C. Impaired verbal communication. D. Disturbed thought processes.

D. Disturbed thought processes. Reason: Thought broadcasting and thought withdrawal are disturbed thought processes.

A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his words make no sense to me. I don't understand what he wants me to do.' What is an appropriate nursing diagnosis? A. Ineffective denial. B. Bipolar mood disorder. C. Hyper-religiosity. D. Grieving.

D. Grieving. Reason: Grieving may be characterized by weight loss, sleep disturbances, and messages from beyond.

Which of the following symptoms of alcohol detoxification would you be most concerned about? A. Vitamin and mineral depletion. B. Diaphoresis. C. Increased heart rate. D. Hallucinations and delusions.

D. Hallucinations and delusions. Reason: Hallucinations and delusions can result in problems with safety and possibly lead to suicide.

Patients who require close surveillance due to the potential for safety hazards give up the right of A. Continued confusion. B. Decision making. C. Social contact. D. Privacy.

D. Privacy. Reason: Privacy and autonomy are often given up for the sake of safety.

a client taking buspirone (buspar) for 1 month returns to the clinic for a follow-up visit. which of the following would indicate medication effectiveness? 1.no rapid heartbeats or anxiety 2.no paranoid thought process 3.no thought broadcasting or delusions 4.no reports of alcohol withdrawal symptoms

1.no rapid heartbeats or anxiety

a nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. which priority nursing intervention will the nurse include in the plan of care? 1.one to one suicide precautions 2.suicide precautions, with 30 minute checks 3.checking the whereabouts of the client every 15 minutes 4.asking that the client report suicidal thoughts immediately

1.one to one suicide precautions

which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1.the client gives away a prized CD and a cherished autographed picture of the performer 2.the client runs out of the therapy group swearing at the group leader and then runs to her room 3.the client gets angry with her roommate when the roommate borrows her clothes without asking 4.the client becomes angry while speaking on the telephone and slams the receiver down on the hook.

1.the client gives away a prized CD and a cherished autographed picture of the performer

Roxie had been sober for 6 months. Last week, her best friend came to visit and they celebrated with five gin and tonics. Roxie has experienced: 1. Repose 2. Relapse 3. Withdrawal 4. Detoxification

2. Relapse This is an example of relapse. Option 1 means to lie down or take a rest and does not apply to substance abuse. Option 3 refers to symptoms experienced when one is not taking a drug that one is addicted to; and option 4 is the process of withdrawing from a substance under medical supervision. REF: Page 333

A client is hospitalized for detoxification. A potentially serious complication of detoxification is which of the following? 1. Stroke 2. Seizure 3. Kidney failure 4. Liver failure

2. Seizure A potential fatal complication of detoxification is seizure activity. Stroke, kidney failure, and liver failure are not associated with detoxification. REF: Page 332

a mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive" and "hangs out with the wrong crowd". In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother: 1.restrict the daughters socializing time with her friends. 2.restrict the amount of chocolate and caffeine products in the home 3.keep her daughter out of school until she can adjust to the school environment 4.consider taking time from work to help her daughter readjust to the home environment.

2.restrict the amount of chocolate and caffeine products in the home

a nurse is reviewing the health care record of a client admitted to the psychiatric unit. the nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. the nurse would determine that this type of crisis could be caused by: 1.witnessing a murder 2.the death of a loved one 3.a fire that destroyed the client's home 4.a recent rape episode experienced by the client.

2.the death of a loved one

a client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of buprotion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which of the following? 1.insomnia 2.weight gain 3.seizure activity 4.orthostatic hypotension

3.seizure activity

a nurse is caring for a client diagnosed with catatonic stupor. the client is lying on the bed, with the body pulled into a fetal position. the appropriate nursing intervention is which of the following? 1.ask direct questions to encourage talking. 2.leave the client alone and intermittently check on him. 3.sit beside the client in silence and verbalize occasional open-ended questions. 4.take the client into the dayroom with other clients so they can help watch him

3.sit beside the client in silence and verbalize occasional open-ended questions.

Which of the following questions is appropriate to assess for disturbances in a patient's relationships? A. What are your main worries? B. Have you ever used alcohol or illegal drugs? C. How has your appetite been in the past month? D. What do you talk about with friends?

D. What do you talk about with friends? Reason: Asking what the patient talks about with family or friends and what types of activities he or she engages in can help assess relationships.

A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first nursing priority? A. Socialization. B. Contracting for eating behavior. C. Safety. D. Administering the Beck depression scale.

C. Safety. Reason: Safety is the major principle underlying psychiatric nursing.

a hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. the nurse instructs the client to avoid consuming which foods while taking this medication? Select all that apply. 1.figs 2.yogurt 3.crackers 4.aged cheese 5.tossed salad 6.oatmeal cookies

1.figs 2.yogurt 4.aged cheese

a nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (prozac) what information would be important for the nurse to gather regarding the adverse effects related to the medication? 1.cardiovascular symptoms 2.gastrointestinal dysfunctions 3.problem with mouth dryness 4.problems with excessive sweating

2.gastrointestinal dysfunctions

a client who is diagnosed with pedophilia and has been recently paroled as a sex offender says "Im in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it" which of the following is an appropriate response by the nurse? 1. "when children are hurt as you hurt them, people want you isolated" 2. "you're lucky it doesn't escalate into something pretty scary after your crime" 3."you understand that people fear for their children, but you're feeling unfairly treated?" 4."you seem angry, but you have committed serious crimes against several children, so your neighbors are frightened?"

3."you understand that people fear for their children, but you're feeling unfairly treated?"

a nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. which statement would be appropriate to make to this client? 1."you need to stop that behavior now" 2."you will need to be placed in seclusion" 3.what is causing you to become agitated" 4."you will need to be restrained if you do not change your behavior"

3.what is causing you to become agitated"

A physical indicator of possible abuse in a battered woman would be a fracture of the distal bones, such as the skull, face, or extremities. A. TRUE B. FALSE

A. TRUE Reason: Musculoskeletal fractures and sprains, especially of distal versus proximal bones, are indications of battering. Also assess for dislocated shoulders and old fractures.

A male client, home from military combat duty, is given the diagnosis of posttraumatic stress disorder (PTSD) and is unable to discuss previous painful experiences and emotions. Which mind-body-based therapy could help to decrease his stress and emotional pain?

Hypnosis.

a client taking lithium carbonate (Lithobid) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. the lithium level is checked as part of the routine follow-up and the level is 3.0 mEq/L. the nurse knows that this level is: 1.toxic 2.Normal 3.slightly above normal excessively below normal

1.toxic

a client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on: 1.weight loss 2.sleep patterns 3.medication compliance 4.onset of the crying spells

1.weight loss

Fluoxetine (Prozac) is prescribed for the client. the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication? 1."I should take the medication with my evening meal" 2."i should take the medication at noon with an antacid" 3."I should take the medication in the morning when i first arise" 4.I should take the medication right before bed time with a snack"

3."I should take the medication in the morning when i first arise"

an older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills? 1."i will be more careful to make sure that my father's needs are met" 2."now that my father is moving into my home, I will need to change my ways" 3."i feel better able to care for my father now that I know where to obtain assistance" 4."I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

3."i feel better able to care for my father now that I know where to obtain assistance"

a nurse is gathering data from a client in crisis. when determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is: 1."with whom do you live?" 2."who is available to help you?' 3."what leads you to seek help now?" 4."what do you usually do to feel better?"

3."what leads you to seek help now?"

a nurse notes documentation in a client's record that the client is experiencing delusions of persecution. THe nurse understands that these types of delusions are characteristics of which of the following? 1.the false belief that one is a very powerful person. 2.the false belief that one is very important person 3.the false belief that one is being singled out for harm by others 4.the false belief that one's partner is going out with other people

3.the false belief that one is being singled out for harm by others

a nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. THe nurse avoids which intervention in the plan of care? 1.facing the client when providing care 2.ensuring that a security officer is within the immediate area 3.keeping the door to the client's room open when with the client 4.assigning the client to a room at the end of the hall to prevent disturbing the other clients.

4.assigning the client to a room at the end of the hall to prevent disturbing the other clients.

a client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. the client's mother begins to cry and states, "my child's brain will be destroyed. How can the doctor do this?" the nurse makes which therapeutic response? 1."it sounds as though you need to speak to the psychiatrist." 2."perhaps you'd like to see the ECT room and speak to the staff" 3.your child has decided to have this treatment. you should be supportive of the decision" 4.it sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

4.it sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A hypomanic patient tells you that she has been 'picking up energy from my car engine and car CD player' while driving and has received five speeding tickets in the past 6 months. What would be one effective intervention to avoid fast driving? A. Make a contract not to drive more than 55 miles per hour and drive with the CD played turned off. B. Call the local police and alert them to the patient's car license plate number and the make and model of her car. C. Ask the patient to "hand over the keys" to you, and tell her that now she must use a cab or other public transportation until your next session. D. Share with the patient that she cannot drink and drive.

A. Make a contract not to drive more than 55 miles per hour and drive with the CD played turned off. Reason: Contracts can see a patient through period of hypomanic agitation.

Which statement, made by a client diagnosed with dissociative identity disorder, demonstrates effective understanding in response to the question, "What exactly are the 'alters'? your provider told you about?" illustrates that the education you provided has been effective? A. "So, alters are based in mysticism and religiosity, such as demons." B. "So, alters are separate personalities with their own characteristics that take over during stress." C. "So, alters are never aware of each other." D. "So, alters are just like me, but they have no memory of the trauma I went through."

B. "So, alters are separate personalities with their own characteristics that take over during stress." Dissociative identity disorder appears to be associated with at least two dissociative identity states: one is a state or personality that functions on a daily basis and blocks access and responses to traumatic memories, and another state (also referred to as an alter state) is fixated on traumatic memories. Each alter has its own memories, behavior patterns, and characteristics. Transition from one personality to another (switching) occurs during times of stress. The other responses are incorrect, because alters may be aware of the existence of each other to some degree, and alters are not just like the host—they have different behaviors and memories.

Which of the following symptoms would lead a provider to suspect that a client is experiencing PTSD? Select all that apply. A. Visiting the scene of the accident over and over B. Talking with strangers about the events of the accident C. Flashbacks of the accident D. Hypervigilance E. Irritability F. Difficulty concentrating G. Mania

C. Flashbacks of the accident D. Hypervigilance E. Irritability G. Mania All these symptoms are signs of PTSD. The other options are not associated with signs of PTSD.

You need to assess whether a patient who has a mood disorder is ready for discharge. Which statement would indicate readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always make my mother help me or tell her to do so. She better help me. C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything.

C. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts. Reason: Verbalization of a plan for help and demonstration of care are realistic discharge criteria.

What is the priority nursing intervention to help orient a patient who has Alzheimer's disease? A. Post a schedule in the dining room of daily activities. B. Use an overhead loudspeaker to announce upcoming events. C. Provide a daily routine and easy-to-read clocks. D. Have the patient live alone in a private room.

C. Provide a daily routine and easy-to-read clocks. Reason: Daily routines and large clocks help patients' functional status.

The first 12-step program, Alcoholics Anonymous, is based on which model? 1. Psychiatric model 2. Sociocultural model 3. Medical model 4. Disease model

4. Disease model The 12-step programs and residential treatment programs follow the disease model, which states that substance abuse is a disease and should be treated as such. The psychiatric model views substance abuse as an expression of an underlying emotional conflict or mental disorder. The sociocultural model states that substance abuse can be treated by changing a person's environment and teaching him or her how to develop new responses to the current environment. The medical model considers addictions from a public health and chronic and acute infectious disease perspective. REF: Page 332

a nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states: 1. "my medications won't make me anxious" 2. "i'll go to a support group and talk so that I won't hurt anyone." 3."I won't get anxious or hear things if I get enough sleep and eat well" 4."I can call my therapist when Im hallucinating so that I can talk about my feelings and plans and not hurt anyone"

4."I can call my therapist when Im hallucinating so that I can talk about my feelings and plans and not hurt anyone"

Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-way street in his underwear and a T-shirt, shouting, 'I am being held against my will. I have personal rights.' Gerald was diagnosed with bipolar disorder, manic type. Which of the following interventions will add to everyone's safety in the acute care environment? A. Have hectic surroundings. B. Have consistent unit routines. C. Minimize staff interventions. D. Medicate the patient only if he has private health insurance.

B. Have consistent unit routines. Reason: Quiet environments with consistent routines will help calm patients and add to safety.

An angry patient is in the community room. She picks up a chair and uses it to hit another patient on the head. When you come into the community room, what should your first response to the patient holding the chair be? A. Are you crazy? Hitting people can hurt them! B. Hitting others is unacceptable. Please put the chair completely down on the floor. C. How would you like it if I hit you over the head with a chair? D. You're in big trouble now. It's probably prison you are looking at!

B. Hitting others is unacceptable. Please put the chair completely down on the floor. Reason: Use words to indicate your lack of acceptance of the patient's behavior in a nonthreatening voice or tone.

patient is extremely agitated and is throwing body fluids at anyone who comes near him. What is the best way to protect yourself as you and others physically restrain the patient? A. Wash your clothes within 30 minutes of becoming soiled with body fluids. B. Wear protective eyewear and a face shield. C. Check that your tetanus and hepatitis B titers are within normal limits. D. Wear a gown over your clothes and shoe covers.

B. Wear protective eyewear and a face shield. Reason: Protective gear helps prevent infections that may gain entry through openings in the skin, the eyes, or the mouth.

Clients with attention-deficit/hyperactivity disorder have been found to respond well to therapy in which they are taught to use signals from special equipment that monitors body functions, such as respiratory and pulse rates, to control their own responses. What is this therapy called?

Biofeedback.

A teenager is noted to have a heightened awareness of reality, feelings of depersonalization, unpredictable and sometimes violent behavior, and flashbacks. The nurse suspects that the teenager is taking which of the following chemicals? 1. Heroin 2. Phencyclidine (PCP) 3. Cocaine 4. Cannabis

2. Phencyclidine (PCP) PCP is a hallucinogen that may cause profound mind-expanding experiences to "bad trips" in which dangerous reactions occur. Heroin may cause euphoria but is not associated with flashbacks. Cocaine produces feelings of well-being that last less than 1 hour. Cannabis produces a sense of well-being and relaxation. REF: Page 327

a nurse is assisting in developing a plan of care for the client in a crisis state. when developing the plan, the nurse will consider which of the following? 1.a crisis state indicates that the individual is suffering from a mental illness 2.a crisis state indicates that the individual is suffering from an emotional illness 3.Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. 4.a client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

4.a client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an appropriate evaluative response, which of the following would be your best statement? A. I could care less if you cut yourself. It doesn't hurt me. B. If you wouldn't cut yourself, you would have a much happier life. C. You are lucky someone found you in time. Now you can help us make you better. D. The behavior of cutting is not acceptable.

D. The behavior of cutting is not acceptable. Reason: Focus on the behavior, not the person. Be neutral, but not indifferent.

a manic client announces to everyone in the day room that a stripper is coming to perform that evening. when the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: 1.escort the manic client to his or her room 2.orient the client to time, person, and place 3.tell the client that the behavior is not appropriate 4.tell the client that smoking privileges are revoked for 24 hours

1.escort the manic client to his or her room

a nurse is collecting data on a client who is actively hallucinating. WHich nursing statement would be therapeutic at this time? 1."I know you feel they are out to get you, but its not true" 2."I can hear the voice and she wants you to come to dinner" 3."sometimes people hear things or voices others can't hear" 4."I talked to the voices you're hearing and they won't hurt you now"

3."sometimes people hear things or voices others can't hear"

a client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. the nurse's most important aspect of care is to maintain client safety and plans to: 1.request that a peer remain with the client at all times 2.remove the client's clothing and place the client in a hospital gown. 3.assign a staff member to the client who will remain with him or her at all times 4.admit the client to a seclusion room where all potentially dangerous articles are removed

will remain with him or her at all times

a client experiencing a severe major depressive episode is unable to address activities of daily living. the appropriate nursing intervention is to: 1.feed, bathe, and dress the client as needed until the client can perform these activities independently. 2.offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3.structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living 4.have the client's peers confront the client about how the noncompliance in addressing activities of daily living affects the milieu.

1.feed, bathe, and dress the client as needed until the client can perform these activities independently.

A nonpracticing alcoholic is taking disulfiram (Antabuse) for the treatment of substance addiction. If the medication is taken with alcohol, which of the following reactions may occur? 1. Tachycardia 2. Low blood pressure 3. High blood pressure 4. Diarrhea

2. Low blood pressure Low blood pressure may occur if disulfiram (Antabuse) is taken with alcohol. All other answer choices are not associated with the combination of disulfiram (Antabuse) and alcohol. REF: Page 333

Your patient, who is in a community psychiatric program, shows up at your home peeping through your kitchen window. You also noticed the patient yesterday when you went to the grocery story and the hairdresser. You believe he is stalking you. What should you do? A. Call the local police and report your suspicion of stalking. B. Call the patient's spouse and discuss his behavior. C. Invite the patient to have a cup of coffee with you at a local café to discuss his behavior. D. Wait until the patient's next group meeting to discuss his stalking behavior.

A. Call the local police and report your suspicion of stalking. Reason: Stalking behavior needs to be dealt with by the police for your safety.

Which of the following questions is most appropriate to ask in screening for a potential problem of high alcohol intake? A. Have you felt you should cut down on your alcohol consumption? B. Do you enjoy getting smashed? C. Have you ever thought about killing someone? D. In the last week, have you had a glass of wine?

A. Have you felt you should cut down on your alcohol consumption? Reason: Screening requires questions associated with cutting down, feelings of guilt about drinking, and having a first drink in the morning.

Once a patient is diagnosed with a major depressive episode, the primary nursing intervention should be associated with A. Safety. B. Pharmacology. C. Administration of gastric lavage. D. Hemodialysis.

A. Safety. Reason: Safety is the primary focus for an intervention, as 25% to 30% of depressed patients are at risk for suicide.

Adolescent suicide has increased over the past and is among the top five causes of death in U.S. adolescents. A. TRUE B. FALSE

A. TRUE Reason: Adolescent suicides have quadrupled since 1950 and are the third leading cause of death in U.S. adolescents.

Alcohol tolerance develops as a result of the central nervous system's adaptive mechanisms. A. TRUE B. FALSE

A. TRUE Reason: The central nervous system adapts, so more alcohol is needed to obtain the initial effects of alcohol ingestion, especially euphoria.

In an inpatient acute psychiatric unit, it is important to shut and lock the unit door behind you. A. TRUE B. FALSE

A. TRUE Reason: This behavior enhances safety.

Prolonged alcohol ingestion can cause disorders of the liver such as A. Pancreatitis. B. Hypomagnesemia. C. Cirrhosis. D. Colitis

D. Colitis Reason: Cirrhosis is a liver disorder that can result from prolonged ingestion of alcohol.

Which of the following patients is at risk for depression? A. A patient with history of diabetes mellitus. B. A patient with a depressive genetic predisposition. C. A patient who recently bought a puppy. D. A patient who had only 6 hours of sleep last night due to watching a TV movie.

B. A patient with a depressive genetic predisposition. Reason: Risk factors include genetic predisposition, a recent loss or trauma, and a feeling of sadness or hopelessness.

Your patient experienced alcohol withdrawal syndrome and now admits he 'needs help.' Which of the following is the most appropriate resource to which you should direct the patient? A. Reach to Recovery. B. Alcoholics Anonymous. C. Depression support group. D. Suicide support group.

B. Alcoholics Anonymous. Reason: Alcoholics Anonymous is the most appropriate resource for alcoholism, although depression may or may not be involved in this case.

Which of the following statements would indicate a depressed mood? A. I can't wait to go to the ballgame today; it should be fun. B. I feel sad today, just like yesterday. C. I feel like going to the gym for a workout today, then maybe to a movie. D. Since it's raining outside, how about a game of chess?

B. I feel sad today, just like yesterday. Reason: A subjective report of feeling sad or empty is a sign of depression.

A 35-year-old male patient has been brought to your hospital unit after making a suicide attempt at his workplace. Which of the following interventions can you legally implement? A. Call the patient's girlfriend and inform her of his admission and visiting hours. B. Physically search the patient for weapons and harmful materials. C. Call the patient's boss at work and report him as in need of extended medical leave. D. Place the patient in four-point restraints and begin an IV for sedation.

B. Physically search the patient for weapons and harmful materials. Reason: A suicide attempt is a serious and self-destructive behavior that demands searching for weapons and harmful materials to increase safety.

Your patient is scheduled for a one-on-one therapy session. Upon his entry into your office, you note that the patient has a cough, is sweating, is coughing up a small amount of blood, and has a fever. What is your initial intervention regarding infection control? A. Wash all of the patient's sheets and clothes. B. Place a mask on the patient and yourself. C. Take the patient's temperature. D. Place resuscitation equipment in the patient's room.

B. Place a mask on the patient and yourself. Reason: The patient might have tuberculosis, so wear a mask, especially given that the patient is coughing.

Which of the following assessments is used to confirm alcohol intake? A. Pupil dilation. B. Serum sample. C. Hair shaft analysis. D. Sputum sample.

B. Serum sample. Reason: Urine and serum samples are toxicology specimens used to assess and monitor alcohol withdrawal.

During a group session, one patient states that he will be released soon because he is superior to his therapist, who is a female. This is an example of which bias or prejudice? A. Racism. B. Sexism. C. Ageism. D. Neonatalism.

B. Sexism. Reason: Sexism is the belief that members of one sex are superior to members of the other sex.

Your patient has an admitting diagnosis of alcohol withdrawal syndrome. You receive a phone call at the nurses' station from a person who says he is the patient's minister and wants to know if the patient 'fell off the wagon again' and when visitation hours are. What is your best response? A. Yes, the patient drank too much, but he should be fine in a few days. Visiting hours are 9 A.M. to 6 P.M. B. We do not give out any information. Visitation hours in the hospital are from 9 A.M. to 6 P.M. daily. C. Please pray for the patient; he is in bad shape. You can visit him anytime between 9 A.M. and 6 P.M. daily. D. Please contact the hospital's chief executive officer, who can give you the information you are requesting.

B. We do not give out any information. Visitation hours in the hospital are from 9 A.M. to 6 P.M. daily. Reason: Patient confidentiality is required, and there is no way to verify the identity of the person calling.

Your patient sees you at a preplanned postoperative visit 4 weeks after being hospitalized for acute alcohol withdrawal. Upon questioning, she states that her husband is abusive, so she drinks to 'drown out his yelling.' The patient also complains of depression and severe pain in the epigastric region that radiates to her back and has been constant since yesterday. She has vomited twice in the past 12 hours. What is your first priority? A. Refer her immediately for treatment of depression. B. Call social services and report spousal abuse. C. Assess her for pancreatitis. D. Administer a test or scale that assesses alcohol withdrawal.

C. Assess her for pancreatitis. Reason: Approximately 65% of cases of pancreatitis are related to alcohol. This patient is exhibiting the classic symptoms of this disease.

Which of the following is a common symptom of a major depressive episode? A. Loss of hearing. B. Increased energy. C. Hopelessness. D. Recurrent thoughts of well-being.

C. Hopelessness. Reason: Hopelessness, loss of pleasure, and a profound sense of sadness are symptoms of a major depressive episode.

You have just given your patient an intramuscular injection of fluphenazine (Prolixin) with a syringe that does not have a safety lock. What is your next step? A. Recap the needle. B. Snap the needle off and place it in the needle box. C. Immediately place the syringe in a nearby impermeable container. D. Clip the needle off with a syringe needle cutter (SNC).

C. Immediately place the syringe in a nearby impermeable container. Reason: Place the syringe in a nearby container specific for needles. Do not recap, bend, clip, or manipulate the needle in any way.

Which of the following is an example of a bite/sting that can cause a poison exposure? A. Butterfly. B. Grass seed. C. Jellyfish. D. Fly.

C. Jellyfish. Reason: A jellyfish sting can cause a poison exposure.

You drive up to the house of your patient, who is known to have schizophrenia with manic episodes. This is your fifth visit. On this occasion, the patient is sitting on his front porch in a rocking chair with a shotgun in his arms. What should your next intervention be? A. Beep your car horn to get your patient's attention. B. Yell your patient's name out your car window and wave at him to say hello. C. Keep driving in a path that is going away from the patient's house. D. Stop the car in the patient's driveway and call your boss on your cell phone.

C. Keep driving in a path that is going away from the patient's house. Reason: Safety includes not placing yourself in vulnerable situations.

When documenting the behavior of a patient with a mental health diagnosis, which chart entry includes the patient's action and responses? A. The patient is less expressive today in group therapy. B. The patient appears to drift in and out of reality. C. The patient is wearing shorts and a sleeveless top even though it's January and wintertime. When asked about her clothing choices, she states, "The devil told me what to wear. To make things different, I need an exorcism." D. The patient is wearing pants and a long-sleeved shirt, is appropriately dressed for group therapy, and refrains from sleeping as she did in last group sessions.

C. The patient is wearing shorts and a sleeveless top even though it's January and wintertime. When asked about her clothing choices, she states, "The devil told me what to wear. To make things different, I need an exorcism." Reason: Action and responses include what one does and says.

A patient who is psychotic has a formed bowel movement on the floor of his room. How should you clean up this excrement? A. Use a thick diaper or pad. B. Wear gloves and use some paper towels or toilet paper. C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution. D. Wear a gown, shoe covers, mask, and chemotherapy-impervious gloves, and wash the area with an ammonia with bleach 1:1 solution.

C. Wear gloves, use toilet paper, and wash the area with a 1:10 bleach solution. Reason: Clean all body fluids with an appropriate disinfectant such as 1:10 bleach solution, using universal precautions.

A patient has been admitted to your unit with a drug overdose, and you need to assess for acidosis and hypoxemia. Which test should you perform? A. Complete blood count (CBC). B. Serum electrolytes. C. Partial thromboplastin time (PTT). D. Arterial blood gases (ABG).

D. Arterial blood gases (ABG). Reason: ABGs assess for acidosis [pH, bicarbonate, and hypoxemia (pO2)].

Your patient has been hospitalized for acute alcohol withdrawal. It is the fifth day, and he is having visual hallucinations followed by a seizure. What is the most likely source of the patient's problem? A. Autonomic dysreflexia (AD). B. A brain tumor. C. Sleep deprivation. D. Delirium tremens (DTs).

D. Delirium tremens (DTs). Reason: Delirium tremens occurs as acute alcohol withdrawal progresses. It includes symptoms such as clouding of sensorium, hallucinations, seizures, and autonomic hyperactivity.

When a patient shares with a psychiatrist that he plans to harm a specific person and includes the person's name, the health professional must notify the intended identified victim. What is this rule called? A. Seclusion and restraints rule. B. Voluntary commitment rule. C. Right to treatment rule. D. Duty to warn rule.

D. Duty to warn rule. Reason: Duty to warn is a protective privilege and ends where public peril begins, so an intended, identifiable victim needs to be notified.

Which of the following medical conditions has similar signs and symptoms as those seen in a major depressive episode? A. Pancreatitis. B. Cholecystitis. C. Tuberculosis. D. Hypothyroidism.

D. Hypothyroidism. Reason: Signs and symptoms of hypothyroidism include changes in weight, sleep disturbances, decreased energy, and difficulty in thinking—just like in depression.

Your patient in the Emergency Department has a diagnosis of acute alcohol withdrawal syndrome (AWS). He is acting euphoric, yet shy. The APN has prescribed the following care: CAGE questionnaire, serum for toxicology, IV of D5 1/2 NS and 1 amp multivitamin (MVI) at 75 mL/h, neuro check q 1 h. What is your first priority? A. Administer the CAGE questionnaire. B. Start the IV. C. Do the neuro check. D. Obtain a serum blood sample.

D. Obtain a serum blood sample. Reason: Obtain a toxicology sample, as the patient is too euphoric to answer the CAGE questionnaire. The IV and neuro checks can wait.

Your patient's auditory, visual, and tactile hallucinations are controlled with bimonthly injections of haloperidol (Haldol) that the community health nurse administers during home visits. You are the new nurse on this case; the previous nurse has retired. The previous nurse has stated in her care plan that the patient will let the nurse in the house only if the nurse carries a public health-issued blue bag and wears black pants. You are scheduled to visit this patient tomorrow. What should you do? A. Call the patient and tell her that you are a new nurse and will be wearing white pants. B. Show up as scheduled carrying only a stethoscope, vial, alcohol wipe, and medication syringe. C. Show up as scheduled with a police officer. D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants.

D. Telephone the patient, introduce yourself, and show up carrying a blue bag and wearing black pants. Reason: The patient needs her medication, and following the care plan is the optimal course of action.

Your patient has just received his sixth electroconvulsant therapy outpatient treatment. He tells you that he plans to drive himself home because his wife is working at her part-time job today. What is your best response? A. Be careful and drive slowly. B. You need to wait 30 minutes and then you will be safe to drive. C. Let me take your vital signs; if they are stable, then you can drive. D. You cannot drive. I can call you a cab, or would you prefer to call your wife or someone for a ride home?

D. You cannot drive. I can call you a cab, or would you prefer to call your wife or someone for a ride home? Reason: Patients cannot drive after ECT, as its effects can include disorientation, muscle pain, central nervous system depression, and cardiac dysrhythmias.

A 22-year-old female was admitted to the mental health unit with major depression and suicidal ideation. She has a history of cutting her wrists intermittently throughout the last 2 years. On days 1 and 2, the patient stays in her room and eats only 20% of her meals. On day 3, she eats 80% of her meals and is talking to others in group. The nurse should consider that the patient is A. Showing improvement. B. Highly suicidal. C. Exhibiting mood swings. D. In need of electroshock therapy.

A. Showing improvement. Reason: The patient improvement is based on increased socialization and increased appetite.

Which of the following statements indicates that your patient, who has schizophrenia, is ready to manage a relapse? A. I will think of a plan of action before I get these racing thoughts again. B. I will not drink alcohol and will exercise daily. This will help me stay well. C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist. D. When I feel stressed, I will sit near my bed and wait to feel better.

C. If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist. Reason: Managing a relapse includes a plan of action, involvement of a friend or family member, and, after identification of signs, notification of a therapist.