MH exam 3

D One cannot conduct meaningful therapy with an intoxicated patient. The nurse is setting reasonable limits. The patient should be taken or escorted home and then make another appointment.

When a patient comes to an outpatient appointment, a nurse smells alcohol. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you have been drinking." (Ch. 18)

A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

Which assessment finding is most associated with bulimia nervosa? a. Prominent parotid glands b. Peripheral edema c. Thin, brittle hair d. Amenorrhea (Ch. 16)

A The nurse intent on diverting drugs for personal use usually attempts to isolate self from peers and may manipulate others to gain access to medications. Appearance often deteriorates, and errors are blamed on others.

An attractive nurse worked at a community hospital for several months, resigned, then took a position at another hospital. In the new position, the nurse volunteered to be the medication nurse. Several serious medication errors occurred in rapid succession. Investigation uncovered that the nurse was allowed to resign from the community hospital after diverting patient narcotics for own use. The nurse manager retrospectively identified which early indicator of the nurse's drug use? The nurse: a. sought to be assigned as medication nurse. b. cooperated with the investigation. c. presented a neat appearance. d. was sociable with peers. (Ch. 18)

B Observing for complications associated with refeeding is the highest priority because of potentially adverse effects on electrolytes. Patient teaching and communication are important, but not the priorities in this situation.

Therapeutic nutrition begins for a patient with anorexia nervosa who is 70% of ideal body weight. Which nursing intervention is most important to add to the plan of care? a. Communicate empathy for the patient's feelings. b. Observe for adverse effects associated with refeeding. c. Teach patient about psychological origins of the disorder. d. Direct the patient to balance energy expenditure and caloric intake. (Ch. 16)

A Compelling evidence exists that schizophrenia is a neurological disorder probably related to neurotransmitter abnormalities, neuroanatomical disruption of brain function, and genetic vulnerability. Stress, family disruption, and developmental influences may contribute to the development or expression of the illness but are not considered to be causes of the illness.

Family members of a patient newly diagnosed with paranoid schizophrenia state that they do not understand what caused the patient's illness. The nurse's response should be predicated on the: a. neurobiological-genetic model. b. stress model. c. family theory model. d. developmental model. (Ch. 15)

D Alcohol withdrawal usually begins 6 to 8 hours after cessation or marked reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

An alcohol-dependent patient was hospitalized at 4 AM on Saturday. The patient's last drink was at 2 AM. When would the nurse expect withdrawal symptoms to peak then disappear or progress to delirium? a. Between 8 AM and 10 AM Saturday b. Between 10 AM and 4 PM Saturday c. Between 4 PM Saturday and 4 AM Sunday d. Between 2 AM Sunday and 2 AM Monday (Ch. 18)

D The correct response is the only comment that questions the patient's distorted thinking.

A psychiatric clinical nurse specialist uses cognitive therapy with a patient with anorexia nervosa. Which statement by the nurse supports this type of therapy? a. "What are your feelings about not eating foods you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve problems. You're thin now but still unhappy." (Ch. 16)

A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 96.8° F (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from: a. 150 to 102 pounds over a 4-month period. Vital signs: temperature, 96.1° F; pulse, 38 beats/min; blood pressure 64/42 mm Hg. b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 97.2° F; pulse, 50 beats/min; blood pressure 70/50 mm Hg. c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 97.6° F; pulse, 60 beats/min; blood pressure 80/66 mm Hg. d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 98.6° F; pulse, 62 beats/min; blood pressure 74/48 mm Hg. (Ch. 16)

B Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol dependence. a. Strongly confrontational b. Empathetic, supportive c. Skeptical, guarded d. Cool, distant (Ch. 18)

B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echopraxia involves the patient assuming the positions or postures he observes in others. Depersonalization is a sensation of unreality wherein some aspect of the self seems distorted or unreal. Thought withdrawal refers to a belief that thoughts are being removed from one's mind.

A catatonic patient admitted in a stuporous condition begins to demonstrate increased motor activity. During his assessment, the psychiatrist raises the patient's arm above his head and releases it. The patient maintains the position his arm was placed in, immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. What symptom is demonstrated by this assessment technique? a. Echopraxia b. Waxy flexibility c. Depersonalization d. Thought withdrawal (Ch. 15)

D The patient may perceive foods in sealed containers, packages, or natural shells that he has selected himself as being less likely to have been adulterated. Attempts to tube feed are seen as threatening and tend to increase mistrust and worsen paranoia. His mistrust would cause him to assume that any food "taster" was simply making it seem as if the food was safe (e.g., the patient could believe that the staff member tasting the food has taken an antidote to the poison before tasting.) The patient who is delusional about his food being poisoned is likely to believe restaurant food might also be poisoned during preparation or delivery.

A highly suspicious patient who has delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which of the following interventions would be most appropriate under these circumstances? a. Feed the patient via tube, involuntarily via court order if needed. b. Offer to taste each food item on the tray yourself while he watches. c. Allow the patient to contact a local restaurant to deliver his meals. d. Allow him supervised access to use food vending machines in the hospital lobby. (Ch. 15)

A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually express distorted perceptions of the self and persist in trying to lose more weight even though underweight.

A history reveals that a patient virtually stopped eating 5 months ago and lost 25% of body weight. The nurse says, "Describe what you think about your present weight and how you look." Which response would be most consistent with anorexia nervosa? a. "I'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but I cover it well." d. "I'm a few pounds overweight, but I can live with it." (Ch. 16)

B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

A hospitalized, alcohol-dependent patient believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes. b. One-on-one supervision. c. Keep the room dimly lit. d. Force fluids. (Ch. 18)

D Patients with paranoid ideation unconsciously use the defense mechanism projection to deal with unacceptable, anxiety-producing ideas and impulses, in this case homosexual urges. Although the behavior seems hostile, the root cause of the behavior is the patient's homosexual urges rather than hostility. Patients who exhibit paranoid ideation may fear rejection or abandonment, but the data here do not indicate fear of rejection, and the patient's relationships with female staff suggest he does not fear rejection. Although the patient may be uncomfortable with intimacy, the focus on sexual identity of a same-sex staff member suggests the bigger issue involves the patient's own sexuality or sexual urges.

A male patient diagnosed with paranoid schizophrenia typically relates effectively with female staff but angrily tells the male nurse, "You act like a homosexual. None of the men trust you or want to be around you." The nurse, who is heterosexual, is perplexed by the patient's statements and discusses the event with his mentor. Which explanation most likely underlies the patient's behavior? a. The patient was unleashing unconscious, hostile feelings toward the nurse. b. The patient feared the nurse would reject him, so he coped by rejecting the nurse first. c. It was the patient's way of distancing himself from potential emotional intimacy. d. The patient was coping with homosexual urges by projecting them onto the nurse. (Ch. 15)

A Ideas of reference are misinterpretations of the verbalizations or actions of others wherein the patient believes the behaviors have special meanings relative to him. For example, seeing two people talking, the individual assumes they are talking about him or her. Hallucinations are a misinterpretation of internal stimuli as being external reality, a delusion is a persistent irrational belief, and echolalia is repeating the words of others.

A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior? a. Idea of reference b. Delusion of infidelity c. Auditory hallucination d. Echolalia (Ch. 15)

C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, providing reality orientation, forestalling responses to the hallucinations that could result in injury, and general support to reduce anxiety. Asking for more information about the patient's experience allows for assessment of (and later intervention for) potential safety issues such as command hallucinations or paranoid themes. Asking about the frequency of the hallucinations is not particularly relevant at this point and does not address potential safety issues. Patients may have ways of coping with voices, but this patient's presentation suggests that his/her coping skills have been overwhelmed. Ignoring the voices and distracting oneself are not likely to be sufficient when the hallucinations are intrusive, disruptive, or frightening, as appears to be the case here.

A newly admitted patient with schizophrenia approaches the unit nurse and says, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which response by the nurse would be most appropriate? a. "Do you hear these voices very often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Tell me what you are hearing." d. "Try to ignore them and play cards with the others." (Ch. 15)

C Eating produces high anxiety for all patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. The distracters are not desirable and do not support the rationale.

A nurse conducts group therapy on the eating disorders unit. Sessions are scheduled immediately after meals. What is the rationale? a. Provide a forum for journaling about foods eaten. b. Shift the patients' focus from food to psychotherapy. c. Promote processing of anxiety associated with eating. d. Focus on weight control mechanisms and food preparation. (Ch. 16)

D Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

A nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Select the nurse's best comment. a. "It bothers me to see you exercising." b. "You and I will have to sit down and discuss this problem." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, exercising is not permitted until you have gained a specific amount of weight." (Ch. 16)

C Changes in serum electrolytes signal complications of refeeding syndrome. Rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. The other body assessment findings are not indicative of refeeding syndrome.

A nurse monitors a patient with anorexia nervosa for complications of refeeding. Which assessment is most important? a. Pupillary reaction to light b. Temperature measurements c. Reports of serum electrolytes d. Complaints of sleep disturbances (Ch. 16)

C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource.

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. Oral hygiene is poor in methamphetamine abusers. (Ch. 18)

B Elevated pulse and blood pressure may indicate impending withdrawal delirium and that additional sedation is warranted. None of the other options takes into account the possible need for sedation. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

A nurse reviews vital signs for a patient admitted last night with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings: Admission, 2 AM - 118/78 mm Hg and 72 beats/min 4 AM - 126/80 mm Hg and 76 beats/min 6 AM - 128/82 mm Hg and 72 beats/min 8 AM - 132/88 mm Hg and 80 beats/min 10 AM - 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint. (Ch. 18)

C Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The other options are therapeutic and appropriate.

A nurse with a history of narcotic abuse became unconscious in the locker room after overdosing. After stabilization, the nurse was transferred to the inpatient psychiatric unit. Which action by nursing staff may be enabling? a. Empathizing when the nurse discusses fears of disciplinary action by the state board of nursing. b. Pointing out that work problems are the result, not the cause, of substance abuse. c. Conveying understanding that pressures associated with nursing practice cause substance abuse. d. Providing health teaching about stress management. (Ch. 18)

D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of ineffective coping. This outcome is measurable. The distracters relate to other nursing diagnoses.

A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness and isolation. (Ch. 16)

C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol-withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

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/min. 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. (Ch. 18)

A Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one's own personality.

A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually a social drinker. I usually have one drink at lunch, two cocktails in the afternoon, wine with dinner, and a few drinks during the evening." Which defense mechanism is evident? a. Denial b. Projection c. Introjection d. Rationalization (Ch. 18)

D The assessment reveals cachexia, thus the diagnosis of imbalanced nutrition. No defining characteristics support the other diagnoses.

A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin." Select the best initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation (Ch. 16)

D The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The scenario does not provide data to support the other diagnoses.

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Ineffective airway clearance b. Ineffective coping c. Ineffective denial d. Risk for injury (Ch. 18)

B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: a. form of group therapy led by a psychiatrist." b. self-help group for which the goal is sobriety." c. group that learns about drinking from a group leader." d. network that advocates strong punishment for drunk drivers." (Ch. 18)

D The patient's history and lab result support this nursing diagnosis. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia, not hyperkalemia.

A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives, as evidenced by electrolyte imbalances and weight loss b. Ineffective health maintenance related to self-induced vomiting, as evidenced by swollen parotid glands and hyperkalemia c. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake, as evidenced by weight loss and hyperkalemia d. Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia (Ch. 16)

A Anticholinergic toxicity is due to excessive anticholinergic activity, typically from the use of multiple anticholinergic medications and/or sensitivity to anticholinergic medications. Symptoms include but are not limited to hyperpyrexia, elevated and unstable vital signs, a worsening of psychotic symptoms, hallucinations, delirium, hot and dry skin, erythema, and dilated pupils. Emergency cooling measures are indicated for hyperpyrexia. A simple relapse would not include the physical changes noted here. Neuroleptic malignant syndrome would include hyperpyrexia and marked motor stiffness (the patient would not be moving about her room) but would not include pupillary dilation. Agranulocytosis would present with symptoms suggesting infection, not the symptoms noted here.

A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ________ , and the nurse should ___________. a. anticholinergic toxicity...check vital signs and prepare to use a cooling blanket stat b. relapse of her psychosis...administer PRN antipsychotic drugs and notify her physician c. neuroleptic malignant syndrome...contact her physician for a transfer to intensive care d. agranulocytosis...hold her antipsychotic and draw blood for a complete blood count (Ch. 15)

A Teaching alternative stress-reduction techniques that may be substituted for overeating most directly addresses the goal of replacing binge eating with a constructive anxiety-releasing activity. The other options offer interventions that relate to other outcomes.

A patient has recently been under significant stress and worked long hours. At home, the patient watches television and eats until going to bed. The patient is too tired to exercise and has gained 25 pounds in 1 month. A desired outcome for the patient is to recognize anxiety that precedes binge eating and reduce it. Which intervention addresses the outcome? a. Teach stress-reduction techniques such as relaxation and imagery. b. Encourage the patient to design and implement an exercise program. c. Explore ways in which the patient may feel more in control of the environment. d. Encourage the patient to attend a support group such as Overeaters Anonymous. (Ch. 16)

C Olanzapine is an atypical antipsychotic that produces few extrapyramidal side effects (EPS) and is effective in treating both positive and negative symptoms of schizophrenia. Chlorpromazine often produces EPS and is not effective in treating negative symptoms. Clozapine produces fewer EPS but would not be the drug of choice because of the danger of agranulocytosis. Fluoxetine is a selective serotonin reuptake inhibitor antidepressant.

A patient has schizophrenia and is troubled by negative symptoms, muscle stiffness, and motor restlessness. His Advanced Practice Nurse (APN) is considering changing the patient's antipsychotic medication, haloperidol (Haldol, a typical or first generation antipsychotic drug). For planning purposes, which medication can the nurse assume that the APN will probably choose? a. Chlorpromazine (Thorazine) b. Clozapine (Clozaril) c. Olanzapine (Zyprexa) d. Fluoxetine (Prozac) (Ch. 15)

B Nicotine meets the criteria for a "substance," the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or recreational use of a social drug.

A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, he experiences anxiety, craving, poor concentration, and headache. This scenario describes: a. substance abuse. b. substance dependence. c. substance intoxication. d. recreational use of a social drug. (Ch. 18)

A Both codeine and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

A patient is comatose after ingesting six codeine tablets. The patient's friend says, "Often my friend drinks along with taking more of the drug than is prescribed." Use of alcohol with this drug: a. has a synergistic effect. b. diminishes the drug's effect. c. causes no effect. d. stimulates metabolism of the drug. (Ch. 18)

B Abstract thinking is the ability to think in a nonliteral way and is essential for tasks such as understanding symbolism and abstract concepts such as love or time. Concrete thinking is the absence of abstract thinking, or literal thinking, and is seen here in the patient's interpreting the expression literally and actually bending over to help himself. Impaired reality testing is an inability to figure out whether a perception or thought is based in reality. Boundary impairment is difficulty telling where one's self begins or ends or how one is distinct from others or one's surroundings.

A patient is noted to be bending over backward in the group room. A peer asks what he is doing, and he replies, "People say they are bending over backwards to help me, so I am bending over backwards to help myself." This is an example of: a. abstract thinking. b. concrete thinking. c. impaired reality testing. d. boundary impairment. (Ch. 15)

D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "I'm burning up. I need help." The patient allows a temperature to be taken (it is 104° F), 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. PCP b. Heroin c. Barbiturates d. Amphetamines (Ch. 18)

C Marked, persistent psychomotor restlessness suggests akathisia, an often distressing and intense form of psychomotor restlessness. Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Anxiety often presents as motor restlessness but the inability to remain at rest is seen as frequent changes in position or location. Tardive dyskinesia involves involuntary rhythmic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis that usually appear after extended treatment and do not respond to antiparkinsonian drugs.

A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating _________ , and the nurse should __________. a. a dystonic reaction...administer PRN IM benztropine (Cogentin) b. anxiety... teach and guide the patient to use relaxation exercises c. akathisia...administer PRN diphenhydramine (Benadryl) PO d. tardive dyskinesia...recommend a change in medication (Ch. 15)

B Tardive dyskinesia is a neurological condition induced by antipsychotic medications and involves involuntary rhythmic movements of the face, trunk, and limbs, including tongue thrusting, licking, blowing, rocking, and pill-rolling of the fingers. These symptoms usually persist even when the drug is discontinued. The scenario is not consistent with the other disorders mentioned: Agranulocytosis does not involve abnormal movements, the movements in Tourette's syndrome are intermittent (tics) rather than persistent and rhythmic, and anticholinergic effects include dry mouth, blurred vision, constipation, and dry eyes and mucous membranes (which could explain the lip smacking but not the other motor changes).

A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ________ and should __________. a. agranulocytosis...check the patient's complete blood count for changes b. tardive dyskinesia...administer the Abnormal Involuntary Movement Scale c. Tourette's syndrome...consult the patient's physician about a neuro evaluation d. anticholinergic effects...consult the physician about possible medication changes (Ch. 15)

A Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotic medications that presents with increasing muscular stiffness (leading to rigidity), hyperpyrexia, autonomic nervous system instability, diminished level of consciousness, and other symptoms. Emergency cooling measures are indicated for hyperpyrexia, and because this is a dangerous medical emergency, care in a medical unit (preferably intensive care unit) is required stat. Anticholinergic toxicity includes hyperpyrexia and elevated and unstable vital signs but includes hot, dry skin and does not include motor rigidity. A simple relapse would not include the physical changes noted here. Agranulocytosis would present with symptoms suggesting infection, not the severe symptoms noted here.

A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect _________ and should ______________. a. neuroleptic malignant syndrome...place him in a cooling blanket and transfer to ICU b. anticholinergic toxicity...check vital signs and prepare to use a cooling blanket stat c. relapse of his psychosis...administer PRN antipsychotic drugs and notify his physician d. agranulocytosis...hold his antipsychotic and draw blood for a complete blood count (Ch. 15)

C Although all the questions might be appropriate to ask, only the correct response focuses on the patient's eating patterns. The distracters focus on distortions in body image and explore the patient's feelings about weight.

A patient referred to the eating disorders clinic lost 35 pounds over 3 months. To assess eating patterns, the nurse should ask: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?" (Ch. 16)

B The patient is misinterpreting the ropes of the Buck's traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Codependence is an experience of significant others.

A patient was admitted last night with a hip fracture sustained while intoxicated. The patient points to the Buck's traction and screams, "Why did you tie me up? Please let me go." The patient is experiencing: a. a delusion. b. an illusion. c. hallucinations. d. codependence. (Ch. 18)

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

A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider? a. Disturbed thought processes and Risk for other-directed violence b. Spiritual distress and Social isolation c. Risk for loneliness and Knowledge deficit d. Disturbed personal identity and Nonadherence (Ch. 15)

B Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The other options are undesirable because they increase the risk for cardiac complications.

A patient with anorexia nervosa in outpatient treatment has begun refeeding. Between the first and second appointment, the patient gained 8 pounds. The nurse should: a. praise the weight gain. b. assess lung sounds and extremities. c. suggest implementation of an exercise program. d. establish a higher target for weight gain for the next week. (Ch. 16)

B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Consent for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures to produce a specified weekly weight gain? a. Severe anxiety concerning eating is expected, so objective and subjective data must be routinely collected. b. Patient involvement in decision making increases sense of control and promotes adherence. c. Because of risks of physical problems from refeeding, the patient's consent is essential. d. A team approach to treatment planning ensures that physical and emotional needs are met. (Ch. 16)

A The correct response is the only option that can be accomplished within 1 week when the patient is an outpatient. The focus would not be on the patient weighing self. The other answers are not desirable outcomes.

A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. gain 1 to 2 pounds. b. exercise 1 hour daily. c. take a laxative every 3 days. d. weigh self accurately using balanced scales. (Ch. 16)

D Residential programs and therapeutic communities help a patient change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

A patient with antisocial behavior was treated several times for substance dependence. Each time, the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program (Ch. 18)

A Physical needs must be met to preserve health and life. Although all of the interventions here are therapeutic, the priority is maintaining physical and physiological functioning, including maintaining conducting passive range-of-motion exercises to prevent muscular atrophy and contractions.

A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which nursing intervention should receive the highest priority? a. Conducting passive range-of-motion exercises b. Exposing the patient to auditory and visual stimuli c. Interacting with the patient as if he is responding d. Including the patient in a variety of milieu activities (Ch. 15)

B The patient presents with significant psychiatric symptoms that will require further assessment and intensive treatment of a type not often available outside of an inpatient mental health unit. He will also require a 24-hour locked setting until he responds to treatment; otherwise he could elope to obtain the gun and use it to protect himself against whomever he might believe is a threat to him (with potentially disastrous consequences). The patient has no support system to provide care at home, and both partial hospitalization and day treatment would leave the patient without structure and support for at least 12 hours daily; neither would provide the level of security needed to preserve the safety of the patient and others. A residential crisis center that is unlocked would not provide for safety needs, and most such facilities are designed for persons who have already been fully assessed and begun on medications.

A patient with many positive symptoms of schizophrenia, whose behavior is disorganized and who is highly anxious, tells the nurse in the psychiatric emergency department, "You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun." The patient, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend: a. admission to an unlocked residential crisis unit. b. inpatient hospitalization on a locked unit. c. attending a day treatment program for 4 weeks. d. admission to a partial hospital program. (Ch. 15)

A A neologism is a newly coined word having special meaning to the patient. "Volmer" is not a known word for an existing creature and given its context, most likely represents a new word created by the patient. Clanging (or clang associations) involves choosing words based on their sounds instead of their meanings, and is usually indicated by using words that somehow sound alike. Anhedonia is an inability to derive pleasure from pleasurable stimuli or activities, and alogia is a poverty or absence of speech.

A patient with schizophrenia begins to talk about creatures called "volmers" hiding in the warehouse where he works and undoing his work each night. The term "volmers" most likely represents: a. a neologism. b. clanging. c. anhedonia. d. alogia. (Ch. 15)

B A psychoeducational group for caregivers explores the causes of schizophrenia, the role of medication and other treatments, promoting treatment adherence, what the caregivers can expect to see and how best to respond, and support for the ill member and caregivers. Such a group can be of immeasurable practical assistance to the family. The other types of therapy are designed to address dysfunction in the family unit or members of the family and do not focus on improving the family's understanding of the illness and how to manage it.

A patient with schizophrenia has been stabilized in the Crisis Center and is about to be discharged. He will be living with his family, but the family knows nothing about the patient's illness, its treatment, or the role they can play in his recovery. Which activity would be most beneficial for the family to attend? a. Psychoanalytic group b. Psychoeducational group c. Individual counseling d. Family therapy (Ch. 15)

B Olanzapine is an atypical (second-generation) antipsychotic that targets both positive and negative symptoms of schizophrenia. Haldol and Thorazine are typical antipsychotics of the same class as the patient's present medication and are effective primarily on positive symptoms. Benadryl is an antihistamine and has no antipsychotic properties.

A patient with schizophrenia has received typical (first-generation) antipsychotics for a year. His hallucinations are less intrusive, but he remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might consult the prescribing health care provider to suggest a change to: a. haloperidol (Haldol). b. olanzapine (Zyprexa). c. diphenhydramine (Benadryl). d. chlorpromazine (Thorazine). (Ch. 15)

A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention, and the primary intervention is administration of an antiparkinsonian agent IM (due to impaired swallowing). Tardive dyskinesia involves involuntary rhythmic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis that usually appear after extended treatment and do not respond to antiparkinsonian drugs. Waxy flexibility is a form of catatonia wherein the patient will remain in whatever position he is placed in for extended periods. Akathisia is psychomotor restlessness, often presenting as pacing and an inability to remain at rest.

A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _________ , and the nurse should _________. a. a dystonic reaction...administer PRN IM benztropine (Cogentin) b. tardive dyskinesia...seek a change in the drug or its dosage c. waxy flexibility...continue treatment with antipsychotic drugs d. akathisia...administer PRN diphenhydramine (Benadryl) PO (Ch. 15)

C When a person with schizophrenia denies having the disorder, the most common reason for this is that the neurological changes that cause the illness also interfere with the person's ability to recognize that he is ill, a condition called anosognosia. Although a person with mental illness may experience denial, stigma, or command hallucinations, these are not the most common reasons for a lack of insight.

A patient with schizophrenia refuses to take his medication because he believes he is not ill. What phenomenon most likely underlies this presentation? a. The patient is unable to face having an illness and is in denial. b. Stigma causes the patient to refuse to admit his mental illness. c. The illness itself is preventing the patient from realizing he is ill. d. Command hallucinations are instructing him to deny the illness. (Ch. 15)

D When a patient's speech is loosely associated, confused, and disorganized, it is important to inform that patient that you have not understood what he has said. This provides the patient with an opportunity to clarify and be assured that the nurse has understood him and will respond appropriately. Stating, "You are not making sense" places all responsibility for communication on the patient and suggests that the nurse believes the patient is defective; this would likely frustrate and distress the patient and reduce his self-esteem. Pretending to understand is nontherapeutic because it gives the patient the false impression that he is communicating effectively. Asking him to organize his thoughts is asking him to do something that is very difficult for him to do; his cognitive impairment is persistent and broad, not momentary or limited.

A patient with schizophrenia tells the nurse "I don't know, it's just all the same. You never know. It comes, it goes, it blows away. Get it?" The best response for the nurse to make would be: a. "Nothing you are saying is clear; you are not making sense." b. "Yes, life can be like that sometimes, very confusing." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying." (Ch. 15)

C The patient's grandiose delusion is based on reaction formation to actual feelings of low self-esteem; in other words, the grandiose delusion compensates for the patient's poor self-esteem. The scenario does not provide sufficient data to support the other diagnoses.

A patient with schizophrenia tells the nurse, "Everyone must listen to me. I am the redeemer. I will bring peace to the world." From this the nurse can determine that an appropriate nursing diagnosis is: a. Disturbed sensory perception: auditory. b. Risk for other-directed violence. c. Chronic low self-esteem. d. Nonadherence: medication. (Ch. 15)

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

A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Which of the following responses should the nurse make next? a. "Do you recognize the voice you hear?' b. "How long has this been happening?" c. "Does what the voice tells you to do frighten you?" d. "What is the voice telling you to do?" (Ch. 15)

B Clanging, or clang associations, involves choosing words based on their sounds rather than their meanings and usually involves alliteration or rhyming. Neologisms are newly coined words. Looseness of association refers to thoughts that are poorly connected to each other, or that do not seem to present in logical order. Ideas of reference involve interpreting neutral events as somehow having specific meaning or relationship to the patient.

A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, "It's beat, it's eat. No room for doom." The nurse can correctly assess this verbalization as: a. neologisms. b. clanging. c. ideas of reference. d. associative looseness. (Ch. 15)

C The fine, downy hair is lanugo, frequently seen in patients with anorexia nervosa. None of the other conditions is supported.

A patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor (Ch. 16)

D Clues to hallucinations include eyes looking around the room as though to find the speaker, appearing preoccupied or distracted, and grimacing, mumbling, or talking aloud as though responding conversationally to someone. Mood changes, ritualistic behavior, and aloofness are not indicators of hallucinations.

A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include: a. aloofness, increased distractibility, and suspicion. b. elevated mood, hypertalkativeness, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, distracted, and mumbling to self. (Ch. 15)

C The patient is expressing paranoid delusions. By definition, a delusion is a persistent irrational belief held despite evidence to the contrary. Therefore, stating that his belief is untrue will not make sense to him and may reinforce his belief that people are set against him. Similarly, because the delusion is believed firmly regardless of the evidence, providing more evidence that the belief is wrong or guiding the patient to look at the evidence are unlikely to be helpful and may reinforce his delusion. The most therapeutic response is the one which focuses on the feeling associated with the belief rather than the belief itself. It conveys empathy and interest in the patient's concerns, helping to build trust in the staff and giving him an opportunity to work through the fear he is experiencing.

A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response? a. "No, that is not true. People here are trying to help you if you will let them." b. "Let's think about it: what reason would people have to want to destroy you?" c. "Thinking that people want to destroy you must be very frightening." d. "That doesn't make sense; staff are health care workers, not murderers." (Ch. 15)

A The patient has a significant history of losses: her mother and sister are no longer available as supports, she has terminated the relationship with her boyfriend, and she has moved from her hometown. Feelings of loss and depression are often associated with bulimia. The other options are of lesser relevance.

A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address? a. Losses b. Sleep patterns c. School activities d. Menstrual flow (Ch. 16)

B Overcontrol of eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The bulimic individual usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.

An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely? a. Eating disorder not otherwise specified b. Anorexia nervosa c. Bulimia nervosa d. Binge eating (Ch. 16)

D The patient who is high on lysergic acid diethylamide (LSD) often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

An adult in the emergency department states, "Everything I see waves. 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. opium intoxication. c. cocaine overdose. d. LSD ingestion. (Ch. 18)

D This response will help the patient see alcohol as a cause of the problems, not a solution. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

An alcohol dependent patient says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the patient conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank." (Ch. 18)

A Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

An alcohol-dependent patient admitted yesterday 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: a. benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium). b. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). c. monoamine oxidase inhibitor, such as phenelzine (Nardil). d. narcotic analgesic, such as codeine. (Ch. 18)

A One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound binging.

Appropriate teaching for a patient with bulimia nervosa who binges and purges is: a. not to skip meals or restrict food. b. to eat a small meal after purging. c. eat a large breakfast but no lunch. d. increase nutritional intake after 4 PM. (Ch. 16)

C Persons who think concretely have difficulty understanding and using abstract concepts such as the passage of time. Schizophrenia itself also interferes with one's ability to judge the passage of time. Therefore, giving the patient the needed information in the most concrete (literal, specific) manner possible is desirable, and telling him "when the hands of the clock both point straight up" is the most specific response here. Letting the patient know when it is time makes the patient dependent on the nurse and removes an opportunity to practice a needed skill. It also leaves the patient without any way to judge when the nurse might next give him the medication, which is likely to increase his anxiety.

At 11:00 AM, a patient with schizophrenia who exhibits concrete thinking asks the nurse for PRN acetaminophen (Tylenol). However, he last had it at 8:00 AM, and it is ordered only every 4 hours. Which nursing response would be most therapeutic? a. "I'm sorry, it's not quite time yet; please come back again in 1 hour." b. "I'm sorry, it's not quite time yet; please come back again at 12 noon." c. "It's not time yet; please come back when both hands of the clock point straight up." d. "It's not time yet; I will let you know when it is time. Perhaps a nap would help?" (Ch. 15)

D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to this nursing diagnosis

Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most applicable to this diagnosis? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake within required parameters of treatment plan c. Weight at established normal range for the patient d. Patient satisfaction with body appearance (Ch. 16)

B During recovery, patients identify and use alternative coping mechanisms to reduce reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program 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. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "While sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as you can. You will need to provide social protection." d. "Alcohol is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." (Ch. 18)

A This short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.

In the emergency department, a patient's vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose. Select the priority outcome. a. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. b. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. c. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields. d. The patient will demonstrate effective coping skills within 1 week of hospitalization. e. The patient will identify community resources for treatment of substance abuse. (Ch. 18)

C As a matter of sound practice, all persons with what appears to be a first episode of mental illness should have a full medical workup so that contributing and concurrent medical issues can be ruled out or treated. In this case, the patient is past the age when schizophrenia usually develops, and she has had an acute onset of symptoms, which is inconsistent with schizophrenia. Both these factors suggest a possible medical origin for her mental status changes. Therefore, further medical assessment is needed, and the most direct and professional means of achieving this is to speak assertively with the physician, reminding him of the factors which merit a more complete medical evaluation before diagnosis. Involving another physician could create conflict among those involved and would not be professional. Achieving a further evaluation by involving a psychiatrist and/or focusing on secondary rationale (speeding up the initiation of psychiatric treatment, addressing vital sign abnormalities) is disingenuous and could misdirect the focus of the evaluation, allowing medical causes of the patient's presentation to again be overlooked.

Police bring a 63-year-old woman to the emergency room, reporting that her behavior is disorganized and disruptive, that her speech makes little sense, and that she does not seem able to take care of herself. The woman has had elective surgeries at the hospital previously and was seen in the ER last week after a fall; records show no history of similar symptoms or mental illness. The ER physician speaks with the patient but does not examine her medically, diagnoses her with schizophrenia, and orders admission to the inpatient psychiatric unit. Which response by the nurse would be most appropriate? a. Ask another physician with more of an interest in psychiatry to also take a look at this patient, explaining that you just want to be as thorough as possible. b. Suggest that a psychiatric consult be requested before admitting the patient to a psychiatric unit, to validate the diagnosis and speed the initiation of medication. c. Remind the physician that schizophrenia usually develops earlier in life, that such presentations may be caused by medical problems, and suggest a medical work-up. d. Note that the patient's blood pressure and respirations were elevated when she arrived, and suggest that they be evaluated before admitting the patient to the psychiatric unit. (Ch. 15)

B A nontolerant drinker would be in coma with a blood alcohol level of 0.40 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic and has slurred speech and mild confusion. The blood alcohol level is 0.4 mg%. Considering the relationship between the behavior 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. (Ch. 18)

B According to the DSM-IV-TR, substance dependence involves lack of control over use as well as tolerance and withdrawal symptoms when intake is reduced or stopped. The distracters describe antagonistic and synergistic effects.

Select the most accurate description of substance dependence. a. Symptoms occur when two or more drugs affecting the central nervous system are used for their additive effects. b. Lack of control over use. Tolerance exists. Withdrawal symptoms occur when intake is reduced or stopped. c. Psychoactive drug use interferes with the action of competing neurotransmitters. d. Taking a combination of drugs to weaken or inhibit the effect of another drug. (Ch. 18)

A Overdose of amphetamines can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. The patient is likely to have hyperthermia.

Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Use warmers to maintain body temperature. d. Offer intellectual activities to stimulate concentration. (Ch. 18)

A The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, would not help the patient maintain sobriety.

Select the priority outcome for a patient completing the fourth alcohol-detoxification program in 1 year. Prior to discharge, the patient will: a. state, "I know I need long-term treatment." b. use denial and rationalization in healthier ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member. (Ch. 18)

C The symptoms of withdrawal from central nervous system depressants are similar to those of alcohol withdrawal.

Symptoms of withdrawal from central nervous system depressants for which the nurse should assess include: a. dilated pupils, tachycardia, elevated blood pressure, elation. b. mood lability, incoordination, fever, drowsiness. c. nausea, vomiting, diaphoresis, anxiety, tremors. d. excessive eating, constipation, headache. (Ch. 18)

D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, increased bizarre or magical thinking, and a general worsening of the patient's residual symptoms or a return of previous symptoms. The patient is more symptomatic, and medication nonadherence may be a contributing factor, but there is no information to indicate that the patient has been nonadherent (relapse can occur even when the patient is taking medication regularly). A lack of understanding of one's illness and treatment would not itself lead to the presentation described here, and psychoeducation is better delivered when the patient's symptoms are stable. In this case, the symptoms have worsened and/or new symptoms have been added; this suggests a change is occurring rather than the continued presentation of chronic symptoms.

The family of a patient with schizophrenia who has been stable for a year reports to the community mental health nurse that the patient reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about creatures called "volmers" hiding in the warehouse where he works and undoing his work each night. This information most likely suggests: a. medication nonadherence. b. a need for psychoeducation. c. the chronic nature of his illness. d. relapse of his schizophrenia. (Ch. 15)

D The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on this clue to internal stimuli and exploring the patient's experience of this stimuli (e.g., the content of the hallucination) shows an interest in the patient and provides potentially valuable assessment data, enabling the nurse to better understand the patient. The other options are less useful in eliciting a response, since no joke may be involved, and the patient is probably not focusing on what the nurse said in the first place. "Why are you laughing?" implies that the behavior is wrong or unacceptable, diminishing the patient's self-esteem and hampering the therapeutic relationship.

The nurse is sitting with a patient diagnosed as having schizophrenia, disorganized type, who starts to laugh uncontrollably, although nothing funny has occurred. The nurse should say: a. "Please share the joke with me." b. "Why are you laughing?" c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening." (Ch. 15)

C Patients with disorganized schizophrenia demonstrate the most regressed and socially impaired behaviors of the schizophrenias. Communication is often incoherent, with inappropriate giggling and loose associations predominating. Suspiciousness and delusions relate more to paranoid schizophrenia; dominant motor symptoms are suggestive of catatonic schizophrenia. Anxiety and ritualistic behavior are seen in obsessive-compulsive disorder.

The nurse is told that a patient with disorganized schizophrenia is being admitted to the unit. The nurse should expect the patient to demonstrate: a. highly suspicious, delusional behavior. b. extremes of motor activity and excitement to stupor. c. social withdrawal and ineffective communication. d. severe anxiety and ritualistic behavior. (Ch. 15)

D Aripiprazole is a new atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Haloperidol is unlikely to be effective against negative symptoms. Olanzapine fosters weight gain.

The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a patient with schizophrenia who demonstrates auditory hallucinations, apathy, anhedonia, and poor social functioning. The patient is overweight and has hypertension. Bearing these facts in mind, the drug the nurse should advocate would be: a. clozapine (Clozaril). b. haloperidol (Haldol). c. olanzapine (Zyprexa). d. aripiprazole (Abilify). (Ch. 15)

A First-generation (typical) antipsychotics are generally effective improving positive symptoms such as hallucinations and delusions, but they are much less helpful for negative symptoms such as affective flattening, alogia, attention deficits, anhedonia, and asociality. The atypical (second-generation and later) antipsychotic medications target both the negative and positive symptoms of schizophrenia.

The physician prescribes haloperidol (Haldol), a first-generation antipsychotic drug, for a patient with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should most be monitored to evaluate the expected improvement from this medication? a. Talking to himself, belief that others will harm him b. Flat affect, avoidance of social activities, poor hygiene c. Loss of interest in recreational activities, alogia d. Impaired eye contact, needs help to complete tasks (Ch. 15)

C Both diagnoses should be considered primary and receive simultaneous treatment. Co-occurring disorders require longer treatment and progress is slower, but treatment may occur in the community.

The treatment team discusses a patient diagnosed with paranoid schizophrenia and cannabis abuse who is having increased hallucinations and delusions. The patient has recently used cannabis on a daily basis. To plan effective treatment, the team should: a. provide long-term care for the patient in a residential facility. b. withdraw the patient from cannabis, then treat the schizophrenia. c. consider each diagnosis primary, and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment. (Ch. 18)

A Prodromal symptoms of schizophrenia are those that are present before the development of florid symptoms and can be subtle and nonspecific. They include social withdrawal, reduced concentration, phobic or obsessive behavior, oddities of speech or thinking, and decreased functioning in school or other roles. The other options each list the positive symptoms of schizophrenia that might be apparent during the later stage of the illness.

The wife of a patient with schizophrenia is worried about her 17-year-old daughter and asks the nurse what symptoms mark the prodromal stage of schizophrenia. The nurse should respond by listing behaviors such as: a. withdrawal, poor concentration, phobic or obsessive behavior, oddities of speech. b. auditory hallucinations, ideas of reference, thought insertion, and broadcasting. c. stereotyped behavior, echopraxia, echolalia, waxy flexibility, thought-blocking. d. looseness of associations, concrete thinking, echolalia, paranoid delusions. (Ch. 15)

D Rescue feelings stem from the nurse's wish to take over for or control a patient who is recognized by the nurse as feeling out of control. When a nurse experiences rescue feelings, the nurse tries to provide simple answers rather than use a problem-solving approach and focus on the patient's feelings of shame and low self-esteem. The other options reflect appropriate interventions that do not signal a particular need for supervision.

What behavior signals that a nurse caring for a patient with bulimia nervosa is experiencing rescue feelings? The nurse: a. makes nonjudgmental comments. b. refers the patient to a self-help group for persons with eating disorders. c. teaches the patient about signs of increased anxiety and ways to intervene. d. determines the patient has poor eating habits and provides a diet to follow. (Ch. 16)

B Most first-generation antipsychotic (FGA) medications often produce sedation and extrapyramidal side effects such as tremor, stiffness, and gait disturbance, effects the patient might describe as making him feel like a "zombie." The side effects mentioned in the other options are usually not associated with FGA therapy.

When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a "zombie." What other common side effects should the nurse determine if the patient experienced? a. Sweating, nausea, and weight gain b. Sedation, tremor, and muscle stiffness c. Headache, watery eyes, and runny nose d. Mild fever, sore throat, and skin rash (Ch. 15)

B Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.

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. The alcohol is less potent. b. Tolerance has developed. c. Hypomagnesemia has occurred. d. Antagonistic effects are evident. (Ch. 18)

D Orthostasis involves an impaired ability to adjust one's blood pressure momentarily upward to compensate for changes in position; it produces dizziness or fainting when moving from a lying or seated position to a standing position. Arising slowly reduces dizziness. Maintaining adequate hydration and preventing blood pooling in lower extremities can also reduce the degree of orthostasis experienced. The use of support hose may also be helpful to prevent pooling of blood in the lower extremities. Postural hypotension is not an extrapyramidal side effect and will not be helped by anticholinergic medication. Dry mouth would be helped by foods that stimulate salivation, but this would not help hypotension.

When a patient with paranoid schizophrenia has a recurrence of positive symptoms after stopping his antipsychotic medication because of its postural hypotension (orthostasis) side effect, he is readmitted to the mental health unit. What measure should the nurse suggest to help the patient address this side effect? a. Ask the doctor to prescribe an anticholinergic drug like trihexyphenidyl (Artane). b. Chew sugarless gum or use sugarless hard candy to moisten your mouth. c. Increase the amount of sleep you get, and try to take frequent rest breaks. d. Wear elastic support hose, drink adequate fluids, and change position slowly. (Ch. 15)

D Flunitrazepam is also known as the "date rape drug" because it produces disinhibition and relaxation of voluntary muscles as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly seen after use of this drug.

When assessing a patient who ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia. (Ch. 18)

C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

When teaching a patient with binge-purge bulimia, the nurse should give priority to information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. symptoms of hypokalemia. d. self-esteem maintenance. (Ch. 16)

D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

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 (Ch. 18)

B Severely reduced urinary output indicates dehydration, reduced kidney function, or retention caused by cardiac malfunction. Many normal people have bradycardia. Weight loss of more than 30% of ideal body weight would call for hospitalization. This potassium level is within the normal range.

Which finding for a patient with an eating disorder most clearly indicates the need for hospitalization? a. Weight 15% below ideal weight b. Urine output less than 30 mL/hr c. Serum potassium 3.4 mEq/L d. Pulse rate 54 beats/min (Ch. 16)

D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

Which medication to maintain abstinence would most likely be prescribed for patients with either alcoholism or opioid addiction? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia) (Ch. 18)

D The patient with bulimia nervosa usually maintains weight close to normal, whereas the patient with anorexia nervosa may approach starvation. The distracters may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

Which nursing diagnosis is more relevant for a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements (Ch. 16)

A For most patients with bulimia nervosa, certain situations trigger the urge to binge. Purging then follows bingeing. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge/purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

Which nursing intervention has highest priority for a patient with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide remedial consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching. (Ch. 16)

B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The distracters are rarely seen in patients with eating disorders, for which inflexibility, controlled emotions, and pessimism are more the rule.

Which personality characteristic is most likely in a patient with anorexia nervosa? a. Open displays of emotion b. Perfectionism c. Optimism d. Flexibility (Ch. 16)

C The correct answer reflects understanding of the condition. Cognitive distortions often used by patients with eating disorders include "catastrophizing," overgeneralization, all-or-none thinking, personalization, and emotional reasoning.

Which statement by a patient with an eating disorder reflects a correct understanding of the condition? a. "Gaining 1 pound is as much of a disaster as gaining 100 pounds." b. "I was happy when I was a size 4, so I must diet to that size." c. "I've been coping with my feelings by overeating." d. "Binging is the only way I can soothe myself." (Ch. 16)

A Patients with eating disorders have body image distortions and perceive themselves as overweight, even when their weight is subnormal. Poor self-image precludes making positive statements about self. Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

Which statement is most likely from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My mother is doesn't pay much attention to me." (Ch. 16)

D The theme of lack of trust in the patient by the family is frequently noted when the patient does provocative things such as going to the bathroom and remaining there after meals. The patient is unable to fathom the concern of the family about possible purging behaviors. The patient frequently shifts coalitions. The patient perceives positive messages as negative. The patient usually competes with the mother.

Which theme is most likely during family therapy with parents, siblings, and a teen patient with anorexia nervosa who engages in provocative behavior? a. Stable coalitions between family members b. Interpreting negative messages as positive c. Competition between the patient and father d. Lack of trust in the patient by family members (Ch. 16)