Psych Hesi Practice Questions

C. Enmeshment Enmeshment is a fusion or over involvement among family members whereby the expectation exists that all members think and act alike. The child who always acts to please her parents is an example of how enmeshment affects development in many cases, a child who develops anorexia nervosa exerts control only in the area of eating behavior. Enmeshed families are families in which the individual is expected to give up their own needs and desires. In enmeshed families, there is a total lack of boundaries, which usually leads to codependent relationships and a dysfunctional family.

A 16-year-old girl has returned home following hospitalization for treatment of anorexia nervosa. The parents tell the family nurse performing a home visit that their child has always done everything to please them and they cannot understand her current stubbornness about eating. The nurse analyzes the family situation and determines it is characteristic of which relationship style? A. Differentiation B. Disengagement C. Enmeshment D. Scapegoating

D. Fills in memory gaps with fantasy Confabulation is a communication device used by patients with dementia to compensate for memory gaps. Confabulation is a type of memory error in which gaps in a person's memory are unconsciously filled with fabricated, misinterpreted, or distorted information. When someone confabulates, they are confusing things they have imagined with real memories.

A 75-year-old client has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: A. Denies confusion by being jovial B. Pretends to be someone else C. Rationalizes various behaviors D. Fills in memory gaps with fantasy

B. Diphenhydramine (Benadryl) Over-the-counter medications used for allergies and cold symptoms are contraindicated because they will increase the sympathomimetic effects of MAOIs, possibly causing a hypertensive crisis.

A client taking the MAOI phenelzine (Nardil) tells the nurse that he routinely takes all of the medications listed below. Which medication would cause the nurse to express concern and therefore initiate further teaching? A. Acetaminophen (Tylenol) B. Diphenhydramine (Benadryl) C. Furosemide (Lasix) D. Isosorbide dinitrate (Isordil)

A. Aged cheese and red wine Aged cheese and red wines contain the substance tyramine which, when taken with an MAOI, can precipitate a hypertensive crisis.

A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages? A. Aged cheese and red wine B. Milk and green, leafy vegetables C. Carbonated beverages and tomato products D. Lean red meats and fruit juices

Remain with the client Reduce external stimuli Encourage low, deep breathing Encourage physical activity Teach coping measures

A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority. Reduce external stimuli Remain with the client Encourage low, deep breathing Teach coping measures Encourage physical activity

B. Development of autonomy within the family. Differentiation is the process of becoming an individual developing autonomy while staying in contact with the family system. "The ability to be in emotional contact with others yet still autonomous in one's own emotional functioning is the essence of the concept of differentiation."

According to the family systems theory, which of the following best describes the process of differentiation? A. Cooperative action among members of the family. B. Development of autonomy within the family. C. Incongruent messages wherein the recipient is a victim. D. Maintenance of system continuity or equilibrium.

D. It promotes emotional support or attention for the client. Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention. Secondary gain refers to the external benefits that may be derived as a result of having symptoms

Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statements refers to a secondary gain? A. It brings some stability to the family. B. It decreases the preoccupation with the physical illness. C. It enables the client to avoid some unpleasant activity. D. It promotes emotional support or attention for the client.

B. Hypochondriasis Complaints of vague physical symptoms that have no apparent medical causes are characteristic of clients with hypochondriasis. In many cases, the GI system is affected. Hypochondriasis, which is now known as illness anxiety disorder, and the other somatic symptom disorders (e.g., factitious disorder, conversion disorder) are among the most difficult and most complex psychiatric disorders to treat in the general medical setting

An 83-year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders? A. Conversion disorder B. Hypochondriasis C. Severe anxiety D. Sublimation

C. Remain calm and talk quietly to the client. Maintaining a calm approach when intervening with an agitated client is extremely important. Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed. Eliminate or minimize sources of hazards in the environment.

An elderly client with Alzheimer's disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A. Tell the client family that it is time to get dressed. B. Obtain assistance to restrain the client for safety. C. Remain calm and talk quietly to the client. D. Call the doctor and request an order for sedation.

C. Hypochondriasis Hypochondriasis, in this case, is shown by the client's belief that she has a serious illness, although pathologic causes have been eliminated. The disturbance usually lasts at least 6 with identifiable life stressor such as, in this case, course examinations. Hypochondriasis, which is now known as illness anxiety disorder, and the other somatic symptom disorders (e.g., factitious disorder, conversion disorder) are among the most difficult and most complex psychiatric disorders to treat in the general medical setting

Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders? A. Conversion disorder B. Depersonalization C. Hypochondriasis D. Somatization disorder

A. "I went to the mall with my friends last Saturday" Clients with panic disorder tend to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors. Panic disorder and panic attacks are two of the most common problems seen in the world of psychiatry.

David is diagnosed with panic disorder with agoraphobia and is talking with the nurse in-charge about the progress made in treatment. Which of the following statements indicates a positive client response? A. "I went to the mall with my friends last Saturday" B. "I'm hyperventilating only when I have a panic attack" C. "Today I decided that I can stop taking my medication" D. "Last night I decided to eat more than a bowl of cereal"

C. Blurred vision At lithium levels of 2 to 2.5 mEq/L the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. Intoxication degree is of utmost importance for understanding lithium toxicity diagnosis and management.

Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms? A. Weakness B. Diarrhea C. Blurred vision D. Fecal incontinence ADVERTISEMENTS

D. Loose association Loose associations are conversations that constantly shift in topic. Loose associations don't necessarily start in a cogently, then become loose.

During a conversation with Nurse John with a client, he observes that the client shifts from one topic to the next on a regular basis. Which of the following terms describes this disorder? A. Flight of ideas B. Concrete thinking C. Ideas of reference D. Loose association

C. Paranoid Because of their suspiciousness, paranoid personalities ascribe malevolent activities to others and tend to be defensive, becoming quarrelsome and argumentative. Paranoid personality disorder (PPD) is one of a group of conditions called "Cluster A" personality disorders which involve odd or eccentric ways of thinking. People with PPD also suffer from paranoia, an unrelenting mistrust and suspicion of others, even when there is no reason to be suspicious.

Francis tells the nurse that her coworkers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorders? A. Antisocial B. Histrionic C. Paranoid D. Schizotypal

C. Sundowning Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The term "sundowning" refers to a state of confusion occurring in the late afternoon and spanning into the night.

In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called: A. Aphasia B. Agnosia C. Sundowning D. Confabulation

B. Transference Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the client's past to another person. Transference occurs when a person redirects some of their feelings or desires for another person to an entirely different person.

Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to Freudian theory, the nurse should suspect that the client is experiencing which of the following phenomena? A. Intellectualization B. Transference C. Triangulation D. Splitting

B. Echopraxia Echopraxia is the copying of another's behaviors and is the result of the loss of ego boundaries. The involuntary imitation of the movements of another person. Echopraxia is a feature of schizophrenia (especially the catatonic form), Tourette syndrome, and some other neurologic diseases. From echo + the Greek praxia meaning action.

Ivy, who is in the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, "I thought the nurse was my mirror. I felt connected only when I saw my nurse." This behavior is known by which of the following terms? A. Modeling B. Echopraxia C. Ego-syntonicity D. Ritualism

B. Behavioral difficulties Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood. A failure to follow the expected trajectory of social-emotional development can lead to undetected mental and emotional health problems

Jennifer, an adolescent who is depressed and reported by her parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect? A. Anxiety disorder B. Behavioral difficulties C. Cognitive impairment D. Labile moods

C. Hallucination Hallucinations are sensory experiences that are misrepresentations of reality or have no basis in reality. Hallucinations are sensations that appear to be real but are created within the mind

Jun approaches the nurse and tells that he hears a voice telling him that he's evil and deserves to die. Which of the following terms describes the client's perception? A. Delusion B. Disorganized speech C. Hallucination D. Idea of reference

C. Drug intoxication This client was taking several medications that have a propensity for producing delirium; digoxin (a digitalis glycoside), furosemide (a thiazide diuretic), and diazepam (a benzodiazepine).

Loretta, a newly admitted client was diagnosed with delirium and has a history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client's impairment may be related to which of the following conditions? A. Infection B. Metabolic acidosis C. Drug intoxication D. Hepatic encephalopathy

D. Stopping the drug can cause withdrawal symptoms. Stopping anti-anxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms. Lorazepam, like other benzodiazepine medications, is a highly addictive medication. Great care is necessary when prescribing lorazepam at high doses or prolonged durations, particularly in patients with a history of substance use disorder or concurrent opioid prescriptions.

Mark, with a diagnosis of generalized anxiety disorder, wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication? A. Stopping the drug may cause depression. B. Stopping the drug increases cognitive abilities. C. Stopping the drug decreases sleeping difficulties. D. Stopping the drug can cause withdrawal symptoms.

C. Regression Regression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia. Adapting one's behavior to earlier levels of psychosocial development.

Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by Mike? A. Projection B. Rationalization C. Regression D. Repression

A. Regression An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. Adapting one's behavior to earlier levels of psychosocial development. For example, a stressful event may cause an individual to regress to bed-wetting after they have already outgrown this behavior.

Mr. Garcia, an attorney who throws books and furniture around the office after losing a case, is referred to the psychiatric nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents the use of which defense mechanism? A. Regression B. Projection C. Reaction-formation D. Intellectualization

C. Assess for possible physical problems such as rash. Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. They need to have an in-depth assessment of physical complaints that may spill over into their delusional symptoms.

Norma, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the following interventions should be done first? A. Talk about his hallucinations and fears. B. Refer him for anticholinergic adverse reactions. C. Assess for possible physical problems such as rash. D. Call his physician to get his medication increased to control his psychosis.

A. Lack of honesty Clients with antisocial personality disorder tend to engage in acts of dishonesty, shown by lying. Antisocial personality disorder (ASPD) is a deeply ingrained and rigid dysfunctional thought process that focuses on social irresponsibility with exploitive, delinquent, and criminal behavior with no remorse. Disregard for and the violation of others' rights are common manifestations of this personality disorder, which displays symptoms that include failure to conform to the law, inability to sustain consistent employment, deception, manipulation for personal gain, and incapacity to form stable relationships.

Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers? A. Lack of honesty B. Belief in superstition C. Show of temper tantrums D. Constant need for attention

A. triazolam (Halcion) Triazolam is one of a group of sedative-hypnotic medications that can be used for a limited time because of the risk of dependence. Triazolam is used on a short-term basis to treat insomnia (difficulty falling asleep or staying asleep). Triazolam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow sleep. Triazolam comes as a tablet to take by mouth. It is usually taken as needed at bedtime but not with or shortly after a meal. Triazolam may not work well if it is taken with food.

Nurse Daisy is aware that the following pharmacologic agents are sedative-hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is: A. triazolam (Halcion) B. paroxetine (Paxil) C. fluoxetine (Prozac) D. risperidone (Risperdal)

C. Major depression The DSM-IV-TR classifies major depression as an Axis I disorder. Axis I disorders tend to be the most commonly found in the public. They include anxiety disorders, such as panic disorder, social anxiety disorder, and post-traumatic stress disorder. Other examples of Axis I disorders are as follows: Dissociative disorders. Eating disorders (anorexia nervosa, bulimia nervosa, etc.) Mood disorders (major depression, bipolar disorder, etc.)

Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) is: A. Obesity B. Borderline personality disorder C. Major depression D. Hypertension

C. diabetes mellitus Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. Girls and young women with type 1 diabetes have about twice the risk of developing eating disorders as their peers without diabetes. This may be because of the weight changes that can occur with insulin therapy and good metabolic control and the extra attention people with diabetes must pay to what they eat.

Nurse Penny is aware that the following medical conditions are commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A

D. The client is experiencing visual hallucination. The presence of a sensory stimulus correlates with the definition of a hallucination, which is a false sensory perception. Visual hallucinations involve seeing things that aren't there. The hallucinations may be of objects, visual patterns, people, or lights.

Nurse Ron enters a client's room, the client says, "They're crawling on my sheets! Get them off my bed!" Which of the following assessments is the most accurate? A. The client is experiencing aphasia. B. The client is experiencing dysarthria. C. The client is experiencing a flight of ideas. D. The client is experiencing visual hallucination.

C. Take the client's blood pressure Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client's blood pressure (lying, sitting, and standing) before administering this drug. When administered as intramuscular or intravenous injections, it may cause hypotension and headache.

Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should: A. Assess skin color and sclera B. Assess the radial pulse C. Take the client's blood pressure D. Ask the client to void

D. It's a mood disorder similar to major depression but of mild to moderate severity. Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity. Persistent depressive disorder is a newly coined term in the DSM-5 to capture what was originally known as dysthymia and chronic major depression.

Ricardo, an outpatient in a psychiatric facility is diagnosed with dysthymic disorder. Which of the following statements about dysthymic disorder is true? A. It involves a mood range from moderate depression to hypomania. B. It involves a single manic depression. C. It's a form of depression that occurs in the fall and winter. D. It's a mood disorder similar to major depression but of mild to moderate severity.

A. Should report feelings of restlessness or agitation at once. Agitation and restlessness are adverse effects of haloperidol and can be treated with anticholinergic drugs. Due to the blockade of the dopamine pathway in the brain, typical antipsychotic medications such as haloperidol have correlations with extrapyramidal side effects.

Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol? A. Should report feelings of restlessness or agitation at once. B. Use sunscreen outdoors on a year-round basis. C. Be aware you'll feel increased energy taking this drug. D. Avoid eating sugar-free sweets.

C. 0.5

The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by drawing up how many milliliters in the syringe? A. 0.3 B. 0.4 C. 0.5 D. 0.6

A. "I'm sleeping better and don't have nightmares". MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individuals with posttraumatic stress disorder. An examination of the available literature supports the efficacy of monoamine oxidase inhibitors (MAOIs) in treating posttraumatic stress disorder (PTSD). This effect may or may not be independent of the response of symptoms of major depression; there is suggestive but inconclusive evidence supporting both.

The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in clients with posttraumatic stress disorder can be demonstrated by which of the following client self-reports? A. "I'm sleeping better and don't have nightmares". B. "I'm not losing my temper as much". C. "I've lost my craving for alcohol". D. "I've lost my phobia for water".

A. Boundaries Family boundaries are parameters that define who is inside and outside the system. The best method of obtaining this information is asking the family directly who they consider to be members. Every system has ways of including and excluding elements so that the line between those within the system and those outside of the system is clear to all. I

The nurse collecting family assessment data asks. "Who is in your family and where do they live?" Which of the following is the nurse attempting to identify? A. Boundaries B. Ethnicity C. Relationships D. Triangles

B. Coffee Coffee contains caffeine, which has a stimulating effect on the central nervous system that will counteract the effect of the antianxiety medication oxazepam. None of the remaining foods is contraindicated. These drugs may act as depressants to the CNS, specifically inhibiting respiratory drive. Therefore, careful monitoring of all vitals, especially blood pressure and respiratory rate, should be performed after the administration of benzodiazepines.

The nurse correctly teaches a client taking the Benzodiazepine Oxazepam (Serax) to avoid excessive intake of: A. Cheese B. Coffee C. Sugar D. Shellfish

C. Orientation The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person).

The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is: what the date, month, and year are; and where the client is. The nurse is attempting to assess: A. Confabulation B. Delirium C. Orientation D. Perseveration

C. Report incomplete bladder emptying. Urinary retention is a common anticholinergic side effect of psychotic medications, and the client with benign prostatic hypertrophy would have increased risk for this problem.

The nurse is administering a psychotropic drug to an elderly client who has a history of benign prostatic hypertrophy. It is most important for the nurse to teach this client to: A. Add fiber to his diet. B. Exercise on a regular basis. C. Report incomplete bladder emptying. D. Take the prescribed dose at bedtime.

A. Vascular dementia has a more abrupt onset. Vascular dementia differs from Alzheimer's disease in that it has a more abrupt onset and runs a highly variable course. VD is distinguished from other forms of dementia in that it results from brain ischemia, although the temporal relationship to the ischemic event may be subtle or go unnoticed.

The nurse is aware that the following ways in vascular dementia different from Alzheimer's disease is: A. Vascular dementia has a more abrupt onset. B. The duration of vascular dementia is usually brief. C. Personality change is common in vascular dementia. D. The inability to perform motor activities occurs in vascular dementia.

D. The nurse should remain objective and encourage mutual negotiation of issues. The nurse who wishes to be helpful to the entire family must remain neutral. Taking sides in a conflict situation in a family will not encourage negotiation, which is important for problem resolution. Nurses who choose collaboration as their conflict resolution strategy incorporate others' ideas into their own; while the result may not be as half-and-half as with the compromising method, the solution still has aspects of everyone's opinions and input, increasing group buy-in and general satisfaction with the final decision.

The nurse is interacting with a family consisting of a mother, a father, and a hospitalized adolescent who has a diagnosis of alcohol abuse. The nurse analyzes the situation and agrees with the adolescent's view about family rules. Which intervention is most appropriate? A. The nurse should align with the adolescent, who is the family scapegoat. B. The nurse should encourage the parents to adopt more realistic rules. C. The nurse should encourage the adolescent to comply with parental rules. D. The nurse should remain objective and encourage mutual negotiation of issues.

C. Diuretics The use of diuretics would cause sodium and water excretion, which would increase the risk of lithium toxicity. Clients taking lithium carbonate should be taught to increase their fluid intake and to maintain normal intake of sodium. Treatment for lithium toxicity is primarily hydration and to stop the drug. Give hydration with normal saline, which will also enhance lithium excretion. Avoid all diuretics

The nurse is teaching a group of clients about the mood-stabilizing medications lithium carbonate. Which medications should she instruct the clients to avoid because of the increased risk of lithium toxicity? A. Antacids B. Antibiotics C. Diuretics D. Hypoglycemic agents

B. Help members maintain sobriety. The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety. Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem.

The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to: A. Encourage the use of a 12-step program. B. Help members maintain sobriety. C. Provide fellowship among members. D. Teach positive coping mechanisms.

B. Depression Electroconvulsive therapy (ECT) can provide relief for patients with severe depression who have not been able to feel better with other treatments. In some severe cases where rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention

The nurse understands that electroconvulsive therapy is primarily used in psychiatric care for the treatment of: A. Anxiety disorders B. Depression C. Mania D. Schizophrenia

B. Explain the biological nature of schizophrenia. The parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biological basis of schizophrenia

The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son's problems. How can the nurse best educate the family? A. Acknowledge the parent's responsibility. B. Explain the biological nature of schizophrenia. C. Refer the family to a support group. D. Teach the parents various ways they must change.

C. The family's perception of the current problem The family's perception of the problem is essential because change in any one part of a family system affects all other parts and the system as a whole. Each member of the family has been affected by the current problems related to the school system and the nurse would be interested in the data.

The school guidance counselor refers a family with an 8-year-old child to the mental health clinic because of the child's frequent fighting in school and truancy. Which of the following data would be a priority to the nurse doing the initial family assessment? A. The child's performance in school B. Family education and work history C. The family's perception of the current problem D. The teacher's attempt to solve the problem

A. "I'm not going to look just at the negative things about myself". As the clients make progress on improving self-esteem, self-blame and negative self-evaluation will decrease

Tommy, with a dependent personality disorder, is working to increase his self-esteem. Which of the following statements by Tommy shows teaching was successful? A. "I'm not going to look just at the negative things about myself". B. "I'm most concerned about my level of competence and progress". C. "I'm not as envious of the things other people have as I used to be". D. "I find I can't stop myself from taking over things others should be doing".

D. Parental disagreement In a functional family, parents typically do not agree on all issues and problems. Open discussion of thoughts and feelings is healthy, and parental disagreement should not cause system stress.

When providing family therapy, the nurse analyzes the functioning of healthy family systems. Which situations would not increase stress on a healthy family system? A. An adolescent's going away to college B. The birth of a child C. The death of a grandparent D. Parental disagreement

C. The client demonstrates self-reliance and social adaptation. A therapeutic community is designed to help individuals assume responsibility for themselves, to learn how to respect and communicate with others, and to interact in a positive manner. The therapeutic community (TC) is an intensive and comprehensive treatment model developed for use with adults that has been modified successfully to treat adolescents with substance use disorders.

Which client outcome is most appropriately achieved in a community approach setting in psychiatric nursing? A. The client performs activities of daily living and learns about crafts. B. The client is able to prevent aggressive behavior and monitors his use of medications. C. The client demonstrates self-reliance and social adaptation. D. The client experiences anxiety relief and learns about his symptoms.

D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. Minor memory problems are distinguished from dementia by their minor severity and their lack of significant interference with the client's social or occupational lifestyle. The psychological concept of illusion is defined as a process involving an interaction of logical and empirical considerations. Common usage suggests that an illusion is a discrepancy between one's awareness and some stimulus.

Which of the following descriptions of a client's experience and behavior can be assessed as an illusion? A. The client tries to hit the nurse when vital signs must be taken. B. The client says, "I keep hearing a voice telling me to run away". C. The client becomes anxious whenever the nurse leaves the bedside. D. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall.

C. Explain that the drug is less effective if the client smokes. Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Olanzapine is a second-generation (atypical) antipsychotic medication. Olanzapine also has approval for use with fluoxetine, a selective serotonin reuptake inhibitor (SSRI), in patients with episodes of depression associated with bipolar disorder type 1 and treatment-resistant depression.

Which of the following interventions is important for a Cely experiencing a paranoid personality disorder taking olanzapine (Zyprexa)? A. Explain effects of serotonin syndrome. B. Teach the client to watch for extrapyramidal adverse reactions. C. Explain that the drug is less effective if the client smokes. D. Discuss the need to report paradoxical effects such as euphoria.

D. The client will follow an establishing schedule for activities of daily living. Following established activity schedules is a realistic expectation for clients with dementia. Frequently orient the client to reality and surroundings. Allow the client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation.

Which of the following outcome criteria is appropriate for the client with dementia? A. The client will return to an adequate level of self-functioning. B. The client will learn new coping mechanisms to handle anxiety. C. The client will seek out resources in the community for support. D. The client will follow an establishing schedule for activities of daily living.

D. Short words and simple sentences Short words and simple sentences minimize client confusion and enhance communication. Frequently orient the client to reality and surroundings.

Which of the following will the nurse use when communicating with a client who has a cognitive impairment? A. Complete explanations with multiple details B. Picture or gestures instead of words C. Stimulating words and phrases to capture the client's attention D. Short words and simple sentences

D. Risk for other-directed violence A client with these symptoms would have poor impulse control and would therefore be prone to acting-out behavior that may be harmful to either himself or others. All of the remaining nursing diagnoses may apply to the client with mania; however, the priority diagnosis would be risk for violence

A client with bipolar disorder, manic type, exhibits extreme excitement, delusional thinking, and command hallucinations. Which of the following is the priority nursing diagnosis? A. Anxiety B. Impaired social interaction C. Disturbed sensory-perceptual alteration (auditory) D. Risk for other-directed violence

A. Accepting the client's obsessive-compulsive behaviors. A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the client's attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable.

A client with obsessive-compulsive disorder is hospitalized in an inpatient unit. Which nursing response is most therapeutic? A. Accepting the client's obsessive-compulsive behaviors. B. Challenging the client's obsessive-compulsive behaviors. C. Preventing the client's obsessive-compulsive behaviors. D. Rejecting the client's obsessive-compulsive behaviors.

C. Providing a quiet environment and administering medication as needed and prescribed. Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Encourage the patient to rest by controlling minimal interpersonal contact with the patient. Decrease environmental stimuli with controlled lighting, and provide a calm, quiet private room

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time? A. Keeping the client restrained in bed. B. Checking the client's blood pressure every 15 minutes and offering juices. C. Providing a quiet environment and administering medication as needed and prescribed. D. Restraining the client and measuring blood pressure every 30 minutes.

B. Adventitious Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. An adventitious crisis can be triggered by a major natural disaster, a man-made disaster, or a crime of violence. Therefore, a tsunami or earthquake can result in an adventitious crisis.

Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis: A. Situational B. Adventitious C. Developmental D. Internal

C. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. The best indicator that the behavior is controlled if the client exhibits no signs of aggression after partial release of restraints. When the patient is no longer a danger to themselves or others, the restraints should be removed immediately.

Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when: A. The client verbalizes the reasons for the violent behavior. B. The client apologizes and tells the nurse that it will never happen again. C. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. D. The administered medication has taken effect.

B. Exploring the nurse's own feelings about suicide. The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client.

Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital. B. Exploring the nurse's own feelings about suicide. C. Discussing the future with the client. D. Referring the client to a clergyperson to discuss the moral implications of suicide.

D. Ensure an unbroken chain of evidence Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. Explain the forensic specimens you plan to collect; inform the client that they can be used for identification and prosecution of the rapist, for example blood, combing pubic hairs, semen samples, skin from underneath nails.

The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important? A. Determine the assailant's identity B. Preserve the client's privacy C. Identify the extent of an injury D. Ensure an unbroken chain of evidence

D. Returns to his previous level of functioning. Crisis intervention is based on the idea that a crisis is a disturbance in homeostasis (steady state). The goal is to help the client return to a previous level of equilibrium in functioning

The nurse considers a client's response to crisis intervention successful if the client: A. Changes coping skills and behavioral patterns. B. Develops insight into reasons why the crisis occurred. C. Learns to relate better to others. D. Returns to his previous level of functioning.

D. Psychoanalytic theory Psychoanalytic is based on Freud's beliefs regarding the importance of unconscious motivation for behavior and the role of the id and superego in opposition to each other.

The nurse explains to a mental health care technician that a client's obsessive-compulsive behaviors are related to an unconscious conflict between id impulses and the superego (or conscience). On which of the following theories does the nurse base this statement? A. Behavioral theory B. Cognitive theory C. Interpersonal theory D. Psychoanalytic theory

D. Rearrange the environment to activate the child. The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. Autism spectrum disorders (ASD) are a group of rapidly growing disabilities. They are characterized by repetitive patterns of behavior, interests, or activities, problems in social interactions. These children become distressed when their surrounding environment is changed because their adaptive capabilities are minimal.

The therapeutic approach in the care of Armand an autistic child includes the following EXCEPT: A. Engage in diversionary activities when acting-out. B. Provide an atmosphere of acceptance. C. Provide safety measures. D. Rearrange the environment to activate the child.

B. Initiation phase Increased anxiety and uncertainty characterize the initiation phase in group therapy. Group members are more self-reliant during the working and termination phases. During the beginning phase of group therapy, issues arise around topics such as orientation, beginners' anxiety, and the role of the leader.

Two nurses are co-leading group therapy for seven clients in the psychiatric unit. The leaders observe that the group members are anxious and look to the leaders for answers. Which phase of development is this group in? A. Conflict resolution phase B. Initiation phase C. Working phase D. Termination phase

A. The injury isn't consistent with the history or the child's age. When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring.

When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age. B. The mother and father tell different stories regarding what happened. C. The family is poor. D. The parents are argumentative and demanding with emergency department personnel.

D. Nifedipine and Esmolol This client requires a vasodilator, such as Nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as Esmolol, to reduce the heart rate.

When monitoring a female client recently admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. Norepinephrine (Levophed) and Lidocaine (Xylocaine) B. Nifedipine (Procardia) and Lidocaine. C. Nitroglycerin (Nitro-Bid IV) and Esmolol (Brevibloc) D. Nifedipine and Esmolol

C. Question the client directly about suicidal thoughts. Directly questioning a client about suicide is important to determine suicide risk. A host of thoughts and behaviors are associated with self-destructive acts. Although many assume that people who talk about suicide will not follow through with it, the opposite is true; a threat of suicide can lead to the completed act, and suicidal ideation is highly correlated with suicidal behaviors. A clear and complete evaluation and clinical interview provide the information upon which to base a suicide intervention.

Which method would a nurse use to determine a client's potential risk for suicide? A. Wait for the client to bring up the subject of suicide. B. Observe the client's behavior for cues of suicide ideation. C. Question the client directly about suicidal thoughts. D. Question the client about future plans.

A. Acetylcholine A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer's disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer's disease.

Which neurotransmitter has been implicated in the development of Alzheimer's disease? A. Acetylcholine B. Dopamine C. Epinephrine D. Serotonin

A. Check the client frequently at irregular intervals throughout the night. Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times

A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should: A. Check the client frequently at irregular intervals throughout the night. B. Assure the client that the nurse will hold in confidence anything the client says. C. Repeatedly discuss previous suicide attempts with the client. D. Disregard decreased communication by the client because this is common with suicidal clients.

B. Total abstinence Total abstinence is the only effective treatment for alcoholism. For people who have severe alcohol use disorder, this is a key step. The goal is to stop drinking and give the body time to get the alcohol out of the system.

A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy

A. Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives

During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you had sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

B. Impaired communication. Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses.

Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for: A. Occasional irritable outbursts. B. Impaired communication. C. Lack of spontaneity. D. Inability to perform self-care activities.

A. Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Benzodiazepine reversal has correlations with seizures

Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain

A. The client will establish adequate daily nutritional intake. According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need.

For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority? A. The client will establish adequate daily nutritional intake. B. The client will make a contract with the nurse that sets a target weight. C. The client will identify self-perceptions about body size as unrealistic. D. The client will verbalize the possible physiological consequences of self-starvation.

A. They tend to overprotect their children. Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives.

For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotect their children. B. They usually have a history of substance abuse. C. They maintain emotional distance from their children. D. They alternate between loving and rejecting their children.

B. Calling a security guard and another staff member for assistance. The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member.

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm. B. Calling a security guard and another staff member for assistance. C. Telling the client's husband that he must leave at once. D. Determining why the husband feels so angry.

A. Heart rate of 120 to 140 beats/minute Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages.

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg

B. Readiness to leave the perpetrator and knowledge of resources. Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready.

Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation). B. Readiness to leave the perpetrator and knowledge of resources. C. Use of drugs or alcohol. D. History of previous victimization.

A. Accept responsibility for own behaviors. Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child.

The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. Accept responsibility for own behaviors. B. Be able to verbalize own needs and assert rights. C. Set firm and consistent limits with the client. D. Allow the child to establish his own limits and boundaries.

B. Heroin dependence Babies born to heroin-dependent women are also heroin-dependent and need to go through withdrawal. Heroin use during pregnancy can result in neonatal abstinence syndrome (NAS). NAS occurs when heroin passes through the placenta to the fetus during pregnancy, causing the baby to become dependent, along with the mother.

The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for: A. Mental retardation B. Heroin dependence C. Addiction in adulthood D. Psychological disturbances

A. Balancing a checkbook In the early stage of Alzheimer's disease, complex tasks (such as balancing a checkbook) would be the first cognitive deficit to occur.

The nurse would expect a client with early Alzheimer's disease to have problems with: A. Balancing a checkbook B. Self-care measures C. Relating to family members D. Remembering his own name

B. Client's safety needs The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. Phencyclidine (PCP) is a dissociative anesthetic that is a commonly used recreational drug

When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Client's psychosocial needs D. Client's medical needs

D. The family's socioeconomic status. Socioeconomic status is not a reliable predictor of abuse in the home so that it would be the least important consideration in deciding issues of safety for the victim of family violence.

Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home? A. The availability of appropriate community shelters. B. The non-abusing caretaker's ability to intervene on the client's behalf. C. The client's possible response to relocation. D. The family's socioeconomic status.

D. Use the services of an interpreter An interpreter will enable the nurse to better assess the client's problems and concerns. Language barriers pose challenges in terms of achieving high levels of satisfaction among medical professionals and patients, providing high- quality healthcare and maintaining patient safety.

Which nursing intervention is best for facilitating communication with a psychiatric client who speaks a foreign language? A. Rely on nonverbal communication B. Select symbolic pictures as aids C. Speak in universal phrases D. Use the services of an interpreter

C. Reduce environmental stimuli to redirect the client's attention. The client with Alzheimer's disease can have frequent episodes of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client's attention. Maintain a nice quiet neighborhood. Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.

Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes of emotional lability? A. Attempt humor to alter the client's mood. B. Explore reasons for the client's altered mood. C. Reduce environmental stimuli to redirect the client's attention. D. Use logic to point out reality aspects.

D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy. A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Respond (confront) with reality when a patient makes unrealistic statements

A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age. B. Assigning the client to group therapy in which participants provide realistic feedback about her weight. C. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift. D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy.

D. Chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Chlordiazepoxide is a long-acting benzodiazepine and is an FDA approved medication for adults with mild-moderate to severe anxiety disorder, preoperative apprehension and anxiety, and withdrawal symptoms of acute alcohol use disorder.

A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal? A. Naloxone (Narcan) B. Haloperidol (Haldol) C. Magnesium sulfate D. Chlordiazepoxide (Librium)

D. This medication may initially cause tiredness, which should become less bothersome over time. Sedation is a common early adverse effect of imipramine, a tricyclic antidepressant, and usually decreases as tolerance develops. Since imipramine acts on various receptors in the body, it presents with adverse effects on some organs and systems. In the central and autonomic nervous system, the antihistaminic effects of imipramine can lead to dizziness, sedation, confusion, delirium, seizures, increased appetite, and weight gain.

Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that: A. This medication may be habit-forming and will be discontinued as soon as the client feels better. B. This medication has no serious adverse effects. C. The client should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking the medication. D. This medication may initially cause tiredness, which should become less bothersome over time.

C. Moderate The child with moderate mental retardation has an I.Q. of 35- 50. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnosis of intellectual disability requires deficits in intellectual function, deficits in adaptive function, and onset before the age of 18.

Kitty, a 9-year-old child has a very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: A. Profound B. Mild C. Moderate D. Severe

C. Haloperidol (Haldol) Haloperidol is the drug of choice for treating Tourette syndrome. Antipsychotic medications have been the most extensively studied. Haloperidol and pimozide are the first-generation antipsychotics with the most data showing efficacy in reducing tic severity.

Nurse Fey is aware that the drug of choice for treating Tourette syndrome? A. Fluoxetine (Prozac) B. Fluvoxamine (Luvox) C. Haloperidol (Haldol) D. Paroxetine (Paxil)

C. Monitor vital signs, serum electrolyte levels, and acid-base balance. An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid-base balance is crucial.

A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to: A. Severely restrict the client's physical activities. B. Weigh the client daily, after the evening meal. C. Monitor vital signs, serum electrolyte levels, and acid-base balance. D. Instruct the client to keep an accurate record of food and fluid intake.

B. Insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. The pathophysiology of dementia is not understood completely.

Nurse Pauline is aware that Dementia unlike delirium is characterized by: A. Slurred speech B. Insidious onset C. Clouding of consciousness D. Sensory perceptual change

C. Identify anxiety-causing situations. Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food. B. Control eating impulses. C. Identify anxiety-causing situations. D. Eat only three meals per day.

C. Lorazepam (Ativan) The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast (1 to 3 minute) onset of action when administered intravenously

A male client who reportedly consumes one (1) qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith)

B. Cocaine The manifestations indicate intoxication with cocaine, a CNS stimulant. CNS reactions may be excitatory then depressant. In its mild form, the patient may display anxiety, restlessness, and excitement. Full-body tonic-clonic seizures may result from moderate to severe CNS stimulation. These seizures are often followed by CNS depression, with death resulting from respiratory failure and/or asphyxiation if concomitant emesis is present.

Jeremy is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum. A. Heroin B. Cocaine C. LSD D. Marijuana

D. Provide objective data and feedback regarding the client's weight and attractiveness. By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem.

A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings. B. Focus discussions on food and weight. C. Avoid discussing unrealistic cultural standards regarding weight. D. Provide objective data and feedback regarding the client's weight and attractiveness.

B. The client will work with the nurse to remain safe. The priority goal in alcohol withdrawal is maintaining the client's safety. Alcohol withdrawal can range from very mild symptoms to the severe form, which is named delirium tremens.

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle. B. The client will work with the nurse to remain safe. C. The client will drink plenty of fluids daily. D. The client will make a personal inventory of strength.

A. Education and work history Education and work history would have the least significance in relation to the client's sexual problem. Depression, performance anxiety, and other sexual disorders can be strong contributing factors even when organic causes also exist. While having a sexual dysfunction can feel isolating, it's actually fairly common.

A 45-year-old woman with a history of depression tells a nurse in her doctor's office that she has difficulty with sexual arousal and is fearful that her husband will have an affair. Which of the following factors would the nurse identify as least significant in contributing to the client's sexual difficulty? A. Education and work history B. Medication used C. Physical health status D. Quality of spousal relationship

C. Risk for self-directed violence The nurse should take any nurse statements indicating suicidal thoughts seriously and further assess for other risk factors. The early identification and appropriate treatment of mental disorders is an important prevention strategy - especially given the relevant contribution of depression and other psychiatric problems to suicidal behavior.

A client tells a nurse. "Everyone would be better off if I wasn't alive." Which nursing diagnosis would be made based on this statement? A. Disturbed thought processes B. Ineffective coping C. Risk for self-directed violence D. Impaired social interaction

C. Rationalization Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors.

A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using? A. Displacement B. Projection C. Rationalization D. Sublimation

B. Gain control of one part of her life. By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control.

A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: A. Manipulate her husband. B. Gain control of one part of her life. C. Commit suicide. D. Live up to her mother's expectations.

C. The client speaks in coherent sentences. A client exhibiting flight of ideas typically has a continuous speech flow and jumps from one topic to another. Speaking in coherent sentences is an indicator that the client's concentration has improved and his thoughts are no longer racing.

A client with a bipolar disorder exhibits manic behavior. The nursing diagnosis is Disturbed thought processes related to difficulty concentrating, secondary to flight of ideas. Which of the following outcome criteria would indicate improvement in the client? A. The client verbalizes feelings directly during treatment. B. The client verbalizes a positive "self" statement. C. The client speaks in coherent sentences. D. The client reports feelings calmer.

C. Risk for violence: Self-directed related to impulsive mutilating acts. The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options

A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt. B. Situational low self-esteem related to feelings of loss of control. C. Risk for violence: Self-directed related to impulsive mutilating acts. D. Risk for violence: Directed toward others related to verbal threats.

D. Diaphoresis, tremors, and nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.

A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Confronting the client with the consequences of substance abuse helps to break through denial. Present reality by spending time with the client to facilitate reality orientation because your physical presence is the reality

A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"

A. A rigid posture, restlessness, and glaring Behavioral clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints.

A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hypervigilance and talk of past violent acts

C. Begin anytime within the next one (1) to two (2) days. Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later.

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to: A. Begin after seven (7) days. B. Not occur at all because the time period for their occurrence has passed. C. Begin anytime within the next one (1) to two (2) days. D. Begin within two (2) to seven (7) days.

D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." ccording to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving.)

A male client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."

D. Approach him slowly while speaking in a calm voice, calling his name, and telling him that the nurse is here to help him. Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner

A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, he sits staring blankly at his bleeding wrists while staff members call for an ambulance. How should Nurse Anuktakanuk approach her initially? A. Enter the room quietly and move beside him to assess his injuries. B. Call for staff back-up before entering the room and restraining him. C. Move as much glass away from him as possible and sit next to him quietly. D. Approach him slowly while speaking in a calm voice, calling his name, and telling him that the nurse is here to help him.

B. Thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake.

A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from: A. Acetate accumulation B. Thiamine deficiency C. Triglyceride buildup. D. A below-normal serum potassium level

A. Coronary artery spasm Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites

A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias C. Neurobehavioral deficits D. Panic disorder

C. Nitroglycerin (Nitro-Bid IV). The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain

A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation of the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, nurse Greg expects the physician to prescribe: A. Lidocaine (Xylocaine). B. Procainamide (Pronestyl). C. Nitroglycerin (Nitro-Bid IV). D. Epinephrine.

A. The parents reinforce increased decision making by the client. One of the core issues concerning the family of a client with anorexia is control. The family's acceptance of the client's ability to make independent decisions is key to successful family intervention. Reinforce the importance of parents as a couple who have rights of their own

A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful? A. The parents reinforce increased decision making by the client. B. The parents clearly verbalize their expectations for the client. C. The client verbalizes that family meals are now enjoyable. D. The client tells her parents about feelings of low self-esteem.

C. The child doesn't cry when the shoulder is examined. A characteristic behavior of abused children is the lack of crying when they undergo a painful procedure or are examined by a healthcare professional. Therefore, the nurse should suspect child abuse.

A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination. B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined. D. The child doesn't make eye contact with the nurse.

B. Alcohol withdrawal The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake after long-term dependence

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect: A. A postoperative infection B. Alcohol withdrawal C. Acute sepsis. D. Pneumonia.

A. Decide to continue As the group progresses into the working phase, group members assume more responsibility for the group. The leader becomes more of a facilitator. Comments about behavior in a group are indicators that the group is active and involved. In this phase, the LPN and client evaluate the client's response to treatment and explore the meaning of the relationship and what goals have been achieved. Discussing the achievements, how the client and LPN feel about concluding the relationship, and plans for the future are an important part of the termination phase.

Group members have worked very hard, and the nurse reminds them that termination is approaching. Termination is considered successful if group members: A. Decide to continue B. Elevate group progress C. Focus on positive experience D. Stop attending prior to termination

B. The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor. The basic goal for a client in any substance abuse treatment setting is to reduce the risk of harm from continued use of substances.

Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use. B. The student accepts a referral to a substance abuse counselor. C. The student agrees to inform his parents of the problem. D. The student reports increased comfort with making choices.

A. Antisocial personality disorder The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others.

Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. Antisocial personality disorder B. Borderline personality disorder C. Obsessive-compulsive personality disorder D. Narcissistic personality disorder

C. Has learned violence as an acceptable behavior. Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Unfortunately, each form of family violence begets interrelated forms of violence, and the "cycle of abuse" is often continued from exposed children into their adult relationships, and finally to the care of the elderly.

Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband: A. Has only moderate impulse control. B. Denies feelings of jealousy or possessiveness. C. Has learned violence as an acceptable behavior. D. Feels secure in his relationship with his wife.

D. Dysthymic disorder. Dysthymic disorder is marked by feelings of depression lasting at least 2 years, accompanied by at least two of the following symptoms: sleep disturbance, appetite disturbance, low energy or fatigue, low self-esteem, poor concentration, difficulty making decisions, and hopelessness. These symptoms may be relatively continuous or separated by intervening periods of normal mood that last a few days to a few weeks.

Mr. Cruz visits the physician's office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse Tiffany suspects: A. Cyclothymic disorder. B. Atypical affective disorder. C. Major depression. D. Dysthymic disorder.

B. Aftershave lotion Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions.

Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

B. One who plans a violent death and has the means readily available. The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage).

Nurse Amy is aware that the client is at highest risk for suicide? A. One who appears depressed frequently thinks of dying and gives away all personal possessions. B. One who plans a violent death and has the means readily available. C. One who tells others that he or she might do something if life doesn't get better soon. D. One who talks about wanting to die.

A. Abnormal movements and involuntary movements of the mouth, tongue, and face. Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (flycatcher tongue), and face

Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe: A. Abnormal movements and involuntary movements of the mouth, tongue, and face. B. Abnormal breathing through the nostrils accompanied by a "thrill." C. Severe headache, flushing, tremors, and ataxia. D. Severe hypertension, migraine headache.

C. Set up a strict eating plan for the client. Establishing a consistent eating plan and monitoring the client's weight is important for this disorder. Establish a minimum weight goal and daily nutritional requirements.

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat. B. Provide privacy during meals. C. Set up a strict eating plan for the client. D. Encourage the client to exercise, which will reduce her anxiety.

A. Providing one-on-one supervision during meals and for one (1) hour afterward. Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward.

Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for one (1) hour afterward. B. Letting the client eat with other clients to create a normal mealtime atmosphere. C. Trying to persuade the client to eat and thus restore nutritional balance. D. Giving the client as much time to eat as desired.

A. Increased attention span and concentration. The medication has a paradoxical effect that decreases hyperactivity and impulsivity among children with ADHD. Methylphenidate is FDA-approved for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adults and as a second-line treatment for narcolepsy in adults.

Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse: A. Increased attention span and concentration. B. Increase in appetite. C. Sleepiness and lethargy. D. Bradycardia and diarrhea.

D. It's characterized by an acute onset and lasts hours to a number of days. Delirium has an acute onset and typically can last from several hours to several days. Delirium, also known as the acute confusional state, is a clinical syndrome that usually develops in the elderly. It is characterized by an alteration of consciousness and cognition with reduced ability to focus, sustain, or shift attention.

Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? A. It's characterized by an acute onset and lasts about 1 month. B. It's characterized by a slowly evolving onset and lasts about 1 week. C. It's characterized by a slowly evolving onset and lasts about 1 month. D. It's characterized by an acute onset and lasts hours to a number of days.

C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal. Allowing the client to select her own food from the menu will help her feel some sense of control. Assisting patients to remain strong and adhere to treatment requires nurses to develop a relationship that is caring, empathetic and trusting, and in line with the person-centered approach to care.

Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray. B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal. C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal. D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count.

A. Revealing personal information to the client. Counter-transference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. Countertransference is defined as redirection of a psychotherapist's feelings toward a client - or, more generally, as a therapist's emotional entanglement with a client.

Nurse Myrna develops a counter-transference reaction. This is evidenced by: A. Revealing personal information to the client. B. Focusing on the feelings of the client. C. Confronting the client about discrepancies in verbal or nonverbal behavior. D. The client feels angry towards the nurse who resembles his mother.

C. A living, learning or working environment. A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms; limit setting, balance, and unit modification. A therapeutic milieu is a structured environment that creates a safe, secure place for people who are in therapy. It is the therapeutic environment that supports the individual in their process toward recovery and wellness. This milieu involves not just the provision of safe physical surroundings, but also of supportive therapists and staff.

Nurse Sarah ensures a therapeutic environment for all the clients. Which of the following best describes a therapeutic milieu? A. A therapy that rewards adaptive behavior. B. A cognitive approach to change behavior. C. A living, learning or working environment. D. A permissive and congenial environment.

D. The client will express anxiety verbally rather than through physical symptoms. The client with a somatoform disorder displaces anxiety into physical symptoms. The ability to express anxiety verbally indicates a positive change toward improved health.

The nurse is working with a client with a somatoform disorder. Which client outcome goal would the nurse most likely establish in this situation? A. The client will recognize signs and symptoms of physical illness. B. The client will cope with physical illness. C. The client will take prescribed medications. D. The client will express anxiety verbally rather than through physical symptoms.

D. "I notice that you're pacing. How are you feeling?" By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety. Recognition acknowledges a patient's behavior and highlights it without giving an overt compliment.

The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety? A. "I guess you're worried about something, aren't you? B. "Can I get you some medication to help calm you?" C. "Have you been pacing for a long time?" D. "I notice that you're pacing. How are you feeling?"

D. Hold the next dose and obtain an order for a stat serum lithium level. Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and a test is done to validate the observation. Monitoring of therapeutic levels includes trough plasma levels drawn 8 to 12 hours after the last dose. The therapeutic range is 1.0 to 1.5 mEq/L for acute treatment and 0.6 to 1.2 mEq/L for chronic therapy. Monitoring should be done every 1 to 2 weeks until reaching the desired therapeutic levels. Then, check lithium levels every 2 to 3 months for six months. It is also important to monitor patients for dehydration and lower the dose when there are signs of infection, excessive sweating, or diarrhea. Toxic levels are when the drug level is more than 2 mEq/L.

Tristan is on Lithium and has suffered from diarrhea and vomiting. What should the nurse in-charge do first: A. Recognize this as a drug interaction. B. Give the client Cogentin. C. Reassure the client that these are common side effects of lithium therapy. D. Hold the next dose and obtain an order for a stat serum lithium level.

C. The client's perception of the triggering event and availability of situational supports. The most important factors to determine in these situations are the client's perception of the crisis event and the availability of support (including family and friends) to provide basic needs. Crisis intervention is a short-term management technique designed to reduce potential permanent damage to an individual affected by a crisis

Which factors are the most essential for the nurse to assess when providing crisis intervention for a client? A. The client's communication and coping skills. B. The client's anxiety level and ability to express feelings. C. The client's perception of the triggering event and availability of situational supports. D. The client's use of reality testing and level of depression.

D. The distressing symptoms of this disorder can respond to treatment with medications. This statement provides accurate information and an element of hope for the family of a schizophrenic client. For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotic (SGA) such as aripiprazole, olanzapine, risperidone, quetiapine, asenapine, lurasidone, sertindole, ziprasidone, brexpiprazole, molindone, iloperidone, etc.

Which information is the most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia? A. Symptoms of this disease imbalance in the brain. B. Genetic history is an important factor related to the development of schizophrenia. C. Schizophrenia is a serious disease affecting every aspect of a person's functioning. D. The distressing symptoms of this disorder can respond to treatment with medications.

B. Advising the client to sit up for 1 minute before getting out of bed. To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for 1 minute before getting out of bed. Amitriptyline is FDA approved medication to treat depression in adults.

Which nursing intervention would be most appropriate if a male client develops orthostatic hypotension while taking amitriptyline (Elavil)? A. Consulting with the physician about substituting a different type of antidepressant. B. Advising the client to sit up for 1 minute before getting out of bed. C. Instructing the client to double the dosage until the problem resolves. D. Informing the client that this adverse reaction should disappear within 1 week.

D. Acetylcysteine (Mucomyst) The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites.

Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. Deferoxamine mesylate (Desferal) B. Succimer (Chemet) C. Flumazenil (Romazicon) D. Acetylcysteine (Mucomyst)

C. St. John's wort St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. St. John's Wort (Hypericum perforatum) is commonly used to treat mild-to-moderate depression.

What herbal medication for depression, widely used in Europe, is now being prescribed in the United States? A. Ginkgo biloba B. Echinacea C. St. John's wort D. Ephedra

C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem.

A 14-year-old client was brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. "I like the way I look. I just need to keep my weight down because I'm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."

C. Claustrophobia Claustrophobia is fear of closed space.

A 35-year-old female has intense fear of riding an elevator. She claims " As if I will die inside." The client is suffering from: A. Agoraphobia B. Social phobia C. Claustrophobia D. Xenophobia

B. "Tell me how you feel about the accident." An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings.

A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."

A. The client will demonstrate realistic interpretation of daily events in the unit. A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish? A. The client will demonstrate realistic interpretation of daily events in the unit. B. The client will perform daily hygiene and grooming without assistance. C. The client will take prescribed medications without difficulty. D. The client will participate in unit activities.

C. 30 g mixed in 250 ml of water The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested, or a minimum dose of 30 g, mixed in 250 ml of water. Doses less than this will be ineffective; doses greater than this can increase the risk of adverse reactions, although toxicity doesn't occur with activated charcoal, even at the maximum dose

After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal? A. 5 g mixed in 250 ml of water B. 15 g mixed in 500 ml of water C. 30 g mixed in 250 ml of water D. 60 g mixed in 500 ml of water

B. Physical aggressiveness, low-stress tolerance, disregard for the rights of others. Physical aggressiveness, low-stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders. Conduct disorder (CD) is classified in the spectrum of disruptive behavior disorders which also includes the diagnosis of oppositional defiant disorder (ODD). Exhibits a pattern of behavior that violates the rights of others and disregards social norms.

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess? A. Restlessness, short attention span, hyperactivity. B. Physical aggressiveness, low-stress tolerance, disregard for the rights of others. C. Deterioration in social functioning, excessive anxiety, and worry, bizarre behavior. D. Sadness, poor appetite and sleeplessness, loss of interest in activities.

B. Transference Transference is a positive or negative feeling associated with a significant person in the client's past that are unconsciously assigned to another. Transference occurs when a person redirects some of their feelings or desires for another person to an entirely different person.

Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting: A. Splitting B. Transference C. Countertransference D. Resistance

D. Opioid withdrawal The symptoms listed are specific to opioid withdrawal.

Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? A. Alcohol withdrawal B. Cannabis withdrawal C. Cocaine withdrawal D. Opioid withdrawal

B. Sodium Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day.

Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? A. Calcium B. Sodium C. Chloride D. Potassium

C. Opiate withdrawal Clonidine is used as adjunctive therapy in opiate withdrawal. Symptomatic treatment in opioid withdrawal includes loperamide for diarrhea, promethazine for nausea/vomiting, and ibuprofen for myalgia. Clonidine can be given to reduce blood pressure.

Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal

C. Help establish a plan using privileges and restrictions based on compliance with refeeding. Inpatient treatment of a client with anorexia usually focuses initially on establishing a plan for refeeding to combat the effects of self-induced starvation. Refeeding is accomplished through behavioral therapy, which uses a system of rewards and reinforcements to assist in establishing weight restoration.

Which nursing intervention is most appropriate for a client with anorexia nervosa during initial hospitalization on a behavioral therapy unit? A. Emphasize the importance of good nutrition to establish normal weight. B. Ignore the client's mealtime behavior and focus instead on issues of dependence and independence. C. Help establish a plan using privileges and restrictions based on compliance with refeeding. D. Teach the client information about the long-term physical consequence of anorexia.