Quiz 2 Review
Which of the following assessments by the nurse would convey a need for prn benztropine? a. Increased level of agitation b. Complaints of a sore throat c. A yellowish cast to the skin d. Muscle spasms
D
A client on the psychiatric unit tells the nurse that the CIA is looking for him and will kill him if they find him. The client's false belief is an example of a: a. Delusion of persecution. b. Delusion of reference. c. Delusion of control or influence. d. Delusion of grandeu
A
A client on the psychiatric unit has a diagnosis of antisocial personality disorder. Which of the following characteristics is consistent with this diagnosis? a. Lack of guilt for wrongdoing b. Insight into his own behavior c. Ability to learn from past experiences d. Compliance with authority
A
A client diagnosed with borderline personality disorder manipulates the staff in an effort to fulfill her own desires. All of the following may be examples of manipulative behaviors in the borderline patient except: a. Refusal to stay in a room alone, stating, "It's so lonely." b. Asking the nurse for cigarettes after 30 minutes, knowing the assigned nurse has explained she must wait 1 hour. c. Stating to the nurse, "I really like having you for my nurse. You're the best one around here." d. Cutting arms with razor blade after discussing dismissal plans with physician.
A
A client with depression asks the nurse, "Why would they be checking my thyroid function when I clearly have depression and I'm not overweight?" Which of these is an accurate response? a. An underactive thyroid gland can manifest as depression. b. Depression has been proven to be a hormonal illness. c. Thyroid hormone replacement is a first-line treatment for most clients with depression. d. All of the above.
A
A client with schizophrenia has physician's orders for haloperidol (Haldol) 5 mg IM STAT and then 3 mg PO tid; 2 mg benztropine PO bid prn. Why is benztropine ordered? a. To treat extrapyramidal symptoms b. To prevent neuroleptic malignant syndrome c. To decrease psychotic symptoms d. To induce sleep
A
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurses priority? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects
A
The goal of cognitive behavior therapy with depressed clients is to: a. Identify and change dysfunctional patterns of thinking. b. Resolve the symptoms and initiate or restore adaptive family functioning. c. Alter the neurotransmitters that are creating the depressed mood. d. Provide feedback from peers who are having similar experiences
A
The nurse identifies the primary nursing diagnosis for a client as Risk for suicide related to feelings of hopelessness from loss of relationship. Which is the outcome criterion that would be most appropriate for this diagnosis? a. The client has experienced no self-harm. b. The client sets realistic goals. c. The client expresses some optimism and hope for the future. d. The client has reached a stage of acceptance in the loss of the relationship.
A
The physician orders lithium carbonate 600 mg tid for a newly diagnosed patient with bipolar I disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. The therapeutic range for acute mania is: a. 0.5 to 1.5 mEq/L b. 10 to 15 mEq/L c. 0.5 to 1.0 mEq/L d. 5 to 10 mEq/
A
Which of the following behavioral patterns is characteristic of individuals with narcissistic personality disorder? a. Overly self-centered and exploitative of others b. Suspicious and mistrustful of others c. Rule conscious and disapproving of change d. Anxious and socially isolated
A
Which of the following individuals is at highest risk for a suicide attempt? a. A client who reports he is in deep emotional pain, feels hopeless, and says "No one is there for me." b. A client who has been seeing a doctor for chronic, intractable pain and is taking pain medication. c. An American Indian client who just graduated from high school with honors. d. A physician who reports feeling "burnt out" and is considering retirement.
A
Recent research on the RAISE approach to the treatment of schizophrenia incorporates which of the following elements as important to improving outcomes? (Select all that apply.) a. Early intervention at the first episode of psychosis b. Support for employment or educational pursuits c. Rapid high-dose loading with antipsychotic medication d. Court-ordered sanctions for treatment e. Recovery-focused psychotherapy
A,B,C
Which of the following interventions are appropriate for a client on suicide precautions? (Select all that apply) a. Remove all sharp objects, belts, and other potentially dangerous articles from the client's environment. b. Accompany the client to off-unit activities. c. Reassess intensity of suicidal thoughts and urges on a regular basis. d. Put all of the client's possessions in storage and explain to her that she may have them back when she is off suicide precautions
A,B,C
A client expresses interest in alternative treatments for depression with seasonal variations and asks the nurse about light therapy. Which of the following are evidence-based teaching points that the nurse may share with the client? (Select all that apply.) a. Light therapy has demonstrated effectiveness that is comparable to antidepressants. b. Light therapy should be used regularly until the season changes. c. Light therapy should be used only when electroconvulsive therapy has proven to be ineffective. d. Side effects such as headache, nausea, or agitation, when they occur, are usually mild and transient. e. Light therapy causes sedation, so the best time to use it is before bedtime.
A,B,D
A client is admitted to the hospital with major depressive disorder and repeatedly makes negative statements about herself. Which of the following interventions are identified as those that will promote positive self-esteem in the client? (Select all that apply) a. Teach assertive communication skills. b. Make observations to the client when she completes a goal or task. c. Instruct the client that you will not talk with her unless she stops talking negatively about herself. d. Offer to spend time with the client using a nonjudgmental, accepting approach.
A,B,D
Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? (Select all that apply.) a. Olanzapine (Zyprexa) b. Oxycodone (OxyContin) c. Carbamazepine (Tegretol) d. Gabapentin (Neurontin) e. Tranylcypromine (Parnate)
A,C,D
The nurse is providing medication education to a cliient on lithium. Which of the following are important points to include? (Select all that apply.) a. Significant reductions in sodium intake increase the risk for lithium toxicity. b. Weight loss is a common side effect of lithium. c. Serum lithium levels will need to be checked at regular intervals throughout treatment. d. Lithium therapy should be continued even during periods when the patient feels well.
A,C,D
The nurse in the emergency department encounters a client who is expressing suicide ideation. The nurse recognizes that which of the following considerations are important to good suicide risk assessment? (Select all that apply.) a. Collaborating with the patient b. Asking specific questions about leisure activities c. Establishing trust and open communication with the patient d. Asking the patient specific questions about the strength of his intention to die e. Identifying whether the patient has thought about a plan for trying to kill himself
A,C,D,E
A client has just been admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which of the following behavioral manifestations might the nurse expect to assess? (Select all that apply) a. Slumped posture b. Hallucinations c. Feelings of despair d. Appears to have boundless energy e. Anorexia
A,C,E
A nurse is caring for a group of clients within the DSM-5 Cluster B category of personality disorders. Which factors should the nurse consider when planning client care? Select all that apply A. These clients have personality traits that are deeply ingrained and difficult to modify. B. These clients need medications to treat the underlying physiological pathology. C. These clients use manipulation, making the implementation of treatment problematic. D. These clients have poor impulse control that hinders compliance with a plan of care. E. These clients commonly have secondary diagnoses of substance abuse and depression.
ANS: A, C, D, E The nurse should consider that individuals diagnosed with cluster B-type personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.
ANS: B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.
What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.
ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.
A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.
ANS: C The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.
A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the client's threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the client's threat must be addressed
ANS: C The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? A. "Why don't you consider doing volunteer work in a homeless shelter?" B. "Let's discuss the negative aspects of your life." C. "Things will look better in the morning." D. "It sounds like you are feeling pretty hopeless."
ANS: D This statement verbalizes the client's implied feelings and allows him or her to validate and explore them.
A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)
ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents
A client admitted to the inpatient psychiatric unit with bipolar disorder tells the nurse, "I need to sit in on change-of-shift report because I have been appointed director of this unit." Which action by the nurse demonstrates the best clinical judgment at this point? a. Invite the client to sit in on the change-of-shift report, but do not share any confidential client information. b. Instruct the client that this is not permitted and redirect the client to other unit activities that are available. c. Tell the client that she is delusional but that these symptoms will go away with medication. d. Place the client in seclusion for protection of self and others.
B
A client has been diagnosed with schizophrenia. He has been socially isolated and is hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Josh is to: a. Give him an injection of haloperidol. b. Assess his safety toward himself and others. c. Place him in restraints. d. Order him a nutritious diet.
B
A client is brought to the emergency department by a family member who reports that the client stopped taking mood stabilizer medication a few months ago and is now agitated, pacing, demanding, and speaking very loudly. Her family member reports that she eats very little, is losing weight, and almost never sleeps. What is the priority nursing diagnosis? a. Imbalanced nutrition: Less than body requirements related to not eating b. Risk for injury related to hyperactivity c. Disturbed sleep pattern related to agitation d. Ineffective coping related to denial of depression
B
A client reports to the nurse that his foot is on fire and he thinks the demons are trying to burn off his flesh. The priority nursing intervention for this symptom is to: a. Administer prn haloperidol as ordered. b. Evaluate the client's foot to rule out physical causes for his complaint. c. Administer prn benztropine as ordered. d. Ask the client if he would like to speak with a chaplain.
B
A client who has been taking sertraline (Zoloft) 50 mg PO bid for depression tells the nurse, "I've been on this medication for almost a week and I don't feel a bit better." What is the most appropriate response by the nurse? a. "Cheer up. You have so much to be happy about." b. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms." c. "I'll report that to the physician. Maybe he will order something different." d. "Try not to dwell on your symptoms. Why don't you join the others down in the dayroom?"
B
A client who is experiencing a manic episode is admitted to the psychiatric unit after being brought to the emergency department by a family member. The client yells, "My family is trying to make it look like I'm insane! They just want to take all my money." This behavior is an example of: a. A delusion of grandeur b. A delusion of persecution c. A delusion of reference d. A delusion of control or influence
B
A male client with antisocial personality disorder was found in a female patient's room on her bed. When instructed to leave the room, the client states, "I'm sick of you telling me what I can or can't do. If I want to carry on a relationship with a female patient, it's my right. I'll do exactly as I please!" Which of these actions by the nurse is a priority at this point? a. Reassure the client that he will have plenty of opportunities with women after he is discharged. b. Reinforce the rules of the treatment program that all clients are expected to follow. c. Escort the client to seclusion. d. Establish a trusting relationship by telling the client that you will make an exception just this once.
B
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give you my money". Which of the following responses should the nurse take? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you" C. "I can request that your case manager discuss appropriate charity options with you" D. "You should know that giving away your money is inappropriate"
B
A nurse is educating a patient about his lithium therapy and explaining the signs and symptoms of lithium toxicity. Which of the following would she instruct the patient to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia
B
A nurse on the psychiatric unit documents that the client was attempting to use "splitting" behaviors with staff. This should be interpreted to mean that the client is: a. Trying to keep staff away from other patients. b. Characterizing staff members as either all good or all bad. c. Having brief psychotic episodes. d. Manifesting two or more distinct subpersonalities when communicating with staff.
B
An acutely depressed client isolates herself in her room and just sits and stares into space. Which of these is the best example of an active communication approach with this client? a. "Do you like exercise?" b. "Come with me. I will go with you to group therapy." c. "Would you like to go to group therapy, stay in bed, or come out to the day lounge for some activities?" d. "Why do you stay in your room all the time?"
B
In determining the degree of suicidal risk with a client, the nurse assesses the following behavioral manifestations: severely depressed, withdrawn, statements of worthlessness, difficulty accomplishing activities of daily living, no close support systems. The nurse identifies the client's risk for suicide as which of the following? a. Low risk b. High risk c. Imminent risk d. Unable to be determined
B
Success of long-term psychotherapy with a client (who attempted suicide following a break-up with her boyfriend) could be measured by which of the following behaviors? a. The client has a new boyfriend. b. The client has an increased sense of self-worth. c. The client does not take antidepressants anymore. d. The client told her old boyfriend how angry she was with him for breaking up with her.
B
Which of the following behavioral patterns is characteristic of individuals with schizotypal personality disorder? a. Belittling themselves and their abilities b. A lifelong pattern of social withdrawal c. Suspicious and mistrustful of others d. Overreacting inappropriately to minor stimuli
B
Which of the following is the primary goal in working with an actively psychotic, suspicious client? a. Promote interaction with others. b. Decrease his anxiety and increase trust. c. Improve his relationship with his parents. d. Encourage participation in therapy activities.
B
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (SATA) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client concerns E. Use a firm approach with communication
B,C,D
A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor of depression? (SATA) A. Male Sex B. Hx of chronic bronchitis C. Recent death in clients family D. Family hx of depression E. Personal hx of panic disorder
B,C,D,E
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (SATA) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse C. Begin taking your medications as soon as relapse begins D. Participating in psychotherapy can help prevent a relapse E. Anhedonia is a clinical manifestation of a depressive relapse
B,D, E
A client who has been hospitalized following a suicide attempt is placed on suicide precautions on the psychiatric unit. She admits that she is still feeling suicidal. Which of the following interventions are most appropriate in this instance? (Select all that apply.) a. Restrict access to any item that might be harmful by placing the client in a seclusion room. b. Check on the client every 15 minutes at irregular intervals, or assign a staff person to stay with her on a one-to-one basis. c. Obtain an order from the physician to give the client a sedative to calm her and reduce suicide ideas. d. Do not allow the client to participate in any unit activities while she is on suicide precautions. e. Ask the client specific questions about her thoughts, plans, and intentions related to suicide.
B,E
A client was admitted to the inpatient unit after a suicide attempt. The client was started on a tricyclic antidepressant. In terms of medication, what steps should be taken to maintain client's safety after discharge? A.Provide a 6 month supply to ensure long-term compliance B.Provide a 1-week supply of meds, with refills authorized only after visiting his provider. C.Encourage the client to increase fluid intake to counter common side effect of diarrhea. D.Educate client not to eat foods high in tyramine.
B. To prevent suicide through overdose on antidepressant medication, a limited supply should be given at discharge Clients with history of depression who have lifting of mood may have an increased risk for suicide.
A 27-year-old female client was admitted to the psychiatric unit from the medical intensive care unit where she was treated for taking a deliberate overdose of her antidepressant medication, trazodone (Desyrel). She says to the nurse, "My boyfriend broke up with me. We had been together for 6 years. I love him so much. I know I'll never get over him." Which is the best response by the nurse? a. "You'll get over him in time." b. "Forget him. There are other fish in the sea." c. "You must be feeling very sad about your loss." d. "Why do you think he broke up with you?"
C
A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phases focuses on treating continued manifestations of MDD" B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks" C. "The client is at greatest risk for suicide during the first weeks of an MDD episode" D. "Medication and psychotherapy are most effective during the acute phase of MDD."
C
A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell the client she cannot wear this outfit while she is in the hospital. b. Do nothing, and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit, she must remain in her room.
C
A client is hospitalized following a suicide attempt after breaking up with her boyfriend. She says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll choose a no-fail method." Which is the best response by the nurse? a. "You are safe here. We will make sure nothing happens to you." b. "You're just lucky your roommate came home when she did." c. "What exactly do you plan to do?" d. "I don't understand. You have so much to live for"
C
A client recently admitted to the hospital reports to the nurse, "I don't understand why I was brought here. I was simply hanging out in my apartment and the police said I had to come with them." This is an example of what symptom of schizophrenia? a. Delusions of reference b. Loose association c. Anosognosia d. Auditory hallucinations
C
A client whose husband died 6 months ago is given a diagnosis of major depressive disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a. "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response." d. "Just think about the good times that you had while he was alive."
C
A client with BPD reports to the nurse that she is having abdominal pain and is requesting pain medication. Which action by the nurse is a priority? a. Explore alternative pain management strategies. b. Confront the client about her manipulation to try to get drugs. c. Assess her pain in more detail. d. Set limits on her attempts to cling to the nurse.
C
A client, age 68, is a widow of 6 months. Over the last month she has become socially withdrawn, has lost weight, and told her sister today that she "doesn't have anything more to live for." She has been hospitalized with major depressive disorder. The priority nursing diagnosis for this client would be: a. Imbalanced nutrition: less than body requirements. b. Complicated grieving. c. Risk for suicide. d. Social isolation
C
A nurse is interviewing a client who has a diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self esteem
C
A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be the worst when i am menstruating" B. "I should avoid exercising when I am feeling depressed" C. "I am aware that my PMDD causes me to have rapid mood swings" D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active"
C
A nurse is teaching a newly licensed nurse about the electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for client who have suicidal ideation" C. "ECT is effective for clients who are experiencing severe mania" D. "ECT is prescribed to prevent relapse of bipolar disorder"
C
One way to promote adequate nutritional intake for a client in an acute manic episode who is not eating is to: a. Sit with the client during meals to reinforce the importance of eating everything on the tray. b. Have family members bring food from home so the client will have only favorite foods. c. Provide high-calorie, nutritious finger foods and snacks that can be eaten "on the run." d. Restrict the client to their room until they begin to gain weight
C
The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. Which of the following is the most appropriate follow-up assessment based on this information? a. Ask the patient if he is experiencing loose associations. b. Ask the patient if he needs more medication. c. Ask the patient if he is hearing something or someone other than the nurse's voice. d. Ask the patient if his neck is stiff.
C
When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? a. Provide large motor activities to relieve the client's pent-up tension. b. Administer a dose of prn haloperidol to keep the patient calm. c. Call for adequate help to control the situation safely. d. Convey to the client that his behavior is unacceptable and will not be permitted.
C
The nurse is assessing a client who has diagnosis of schizophrenia and takes an antipsychotic daily. Which finding requires further nursing assessment? A. Respirations of 22/minute B. Weight gain of 8lbs in 2 months C. Temperature of 101 F D. Excess salivation
C. A fever could be the first signs of infection caused by reduced immunity from agranulocytosis secondary to antipsychotic medication.
A client is hospitalized following a suicide attempt after breaking up with her boyfriend. Freudian psychoanalytic theory would explain the client's suicide attempt in which of the following ways? a. She feels hopeless about her future without her boyfriend. b. Without her boyfriend, she feels like an outsider with her peers. c. She is feeling intense guilt because her boyfriend broke up with her. d. She is angry at her boyfriend for breaking up with her and has turned the anger inward on herself.
D
A client diagnosed with a personality disorder is cold, aloof, and avoids others on the unit. The nurse recognizes that this behavior is symptomatic of which personality disorder? A.Schizoid personality disorder B.Dependent personality disorder C.Borderline personality disorder D. Antisocial personality disorder
Correct answer: A •A hallmark of the schizoid personality is a marked withdrawal from social contact. The client behaviors presented in the question are indicative of schizoid personality disorder.
A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? A. Identify with the person speaking B. Imitate the nurse's movements C. Poverty or reduction in speech (alogia) D. Lack of motivation or initiative (avolition)
Correct answer: A •Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.
A client, diagnosed with schizophrenia, states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? A. "I find that hard to believe." B. "What would make you think such a thing?" C. "I know your roommate. He would do no such thing." D. "I can see why you feel that way."
Correct answer: A •This client is experiencing a persecutory delusion. This nursing response is an example of "voicing doubt," which expresses uncertainty as to the reality of the client's perceptions. This is an appropriate therapeutic communication technique in dealing with clients who are experiencing delusional thinking.
A client has been diagnosed with major depression. The psychiatrist prescribes paroxetine (Paxil). Which of the following medication information should the nurse include in discharge teaching? A. Do not eat chocolate while taking this medication. B. The medication may cause priapism. C. The medication should not be discontinued abruptly. D. The medication may cause photosensitivity.
Correct answer: C •Antidepressants such as paroxetine must be tapered and not stopped abruptly. All classifications of antidepressants have varying potentials to cause discontinuation syndromes. Abrupt withdrawal from SSRIs, such as paroxetine, may result in dizziness, lethargy, headache, and nausea.
A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. At this time, which is the most appropriate nursing intervention for this client? A. Provide the client with a safe and structured environment. B. Isolate the client from all stressful situations that may precipitate a suicide attempt. C. Observe the client continuously to prevent self-harm. D. Assist the client to develop more effective coping mechanisms.
Correct answer: D Assisting the client to develop more effective coping mechanisms is a nursing intervention that can and should be implemented in outpatient settings as ongoing follow-up.
A client on the psychiatric unit has been diagnosed with schizophrenia. He tells the nurse that the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: a. "That's ridiculous. No one is going to hurt you." b. "The CIA isn't interested in people like you." c. "Why do you think the CIA wants to kill you?" d. "I know you believe that, but it's really hard for me to believe."
D
A client reports to the mental health clinic with complaints of feeling more depressed over the last few weeks. The patient's score on the Hamilton Depression Rating Scale is 40. What is the priority nursing action at this finding? a. Assess the client's history of treatment for depression. b. Encourage the client to keep weekly follow-up appointments at the clinic. c. Educate the client about treatment options for mild, moderate, and severe depression. d. Assess the client's current risk for suicide.
D
A client with a diagnosis of borderline personality disorder exhibits alternating clinging and distancing behaviors with the nurse who has been assigned to her care. The most appropriate nursing intervention with this type of behavior would be to: a. Encourage the client to establish trust in one staff person, with whom all therapeutic interaction should take place. b. Secure a verbal contract from the client that she will discontinue these behaviors. c. Withdraw attention if these behaviors continue. d. Rotate staff members who work with the client so that she will learn to relate to more than one person
D
A patient diagnosed with antisocial personality disorder approaches the nurse and says, "You're so cute, are you married?" Which of these is the most appropriate response by the nurse? a. "I'm married, but that's none of your business." b. "Let's talk about your love life instead." c. "Thank you so much for the compliment but I'm married." d. "Our relationship is strictly professional. It is not appropriate for us to have that kind of discussion."
D
According to researchers, which of the following is a common theme in the health history of the client with BPD? a. Autism b. Attention deficit-hyperactivity disorder c. Positive and fulfilling interpersonal relationships d. Early childhood trauma
D
An individual experienced the death of a parent two years ago. This individual has not been able to work since the death, cannot look at any of the parent's belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes this individual's problem? A. Posttrauma syndrome R/T parent's death B. Anxiety (severe) R/T parent's death C. Coping, ineffective, R/T parent's death D. Grieving, complicated, R/T parent's death
D
The nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior B. Administer prescribed medications as scheduled C. Provide the client with step-by-step instructions during hygiene activities D. Monitor the client for escalating behavior
D
The primary focus of family therapy for clients with schizophrenia and their families is: a. To discuss problem-solving and adaptive behaviors for coping with stress. b. To introduce the family to others with the same problem. c. To keep the client and family in touch with the health-care system. d. To promote family interaction and increase understanding of the illness.
D
What is the most common comorbid condition in children with bipolar disorder? a. Schizophrenia b. Substance disorders c. Oppositional defiant disorder d. Attention deficit-hyperactivity disorder
D
An aging client with chronic schizophrenia takes a beta-adrenergic blocking agent (propranolol) for hypertension and an antipsychotic. Given the combined side effects of these drugs, what teaching should the nurse provide? A. Make sure you concentrate on taking slow, deep, cleansing breaths. B. Watch your diet and try to engage in some regular physical activity. C. Wear sunscreen and try to avoid midday sun exposure. D. Rise slowly when you change position from lying to sitting or sitting to standing.
D. The antipsychotic medication can cause hypotension that could be magnified by the propranolol.
A client who has been taking chlorpromazine (Thorazine) for several months presents in the ED with extrapyramidal symptoms (EPS) of restlessness, drooling and tremors. What medication will the nurse expect the physician to order? A. Paroxetine (Paxil) B. Carbamazepine (Tegretol) C. Benztropine (Cogentin) D. Lorazepam (Ativan
•Correct answer: C •Benztropine is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for EPS. Anticholinergics are the drugs of choice to treat extrapyramidal symptoms associated with antipsychotic medications.
