Unit 1 Review Schizophrenia / Psychosis

A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, what are delusions? 1. A defense against anxiety 2. The result of magical thinking 3. Precipitated by external stimuli 4. Subconscious expressions of anger

ANS - 1 - Defense against anxiety. Delusions are a way the unconscious defends the individual from real or imagined threats. Magical thinking is the belief that one's thoughts and behaviors can control situations and other people. For example, having bad thoughts about someone can cause that person to die. This type of thinking is found in young children but is pathological in adults. Illusions are false interpretations of actual external stimuli. Delusions are precipitated by feelings of anxiety, not anger. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."

An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. What does the nurse identify as the cause of these problems? Correct 1 Receptive aphasia Incorrect 2 Impaired judgment 3 Decreased attention span 4 Clouding of consciousness

ANS - 1 Receptive Aphasia. interferes with interpreting and defining words in addition to following directions and selecting clothes. Following directions does not require skill in judgment or decision making. The selection of clothes does not require an intact attention span. Dementia does not cause a clouding of consciousness; delirium does. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

The primary healthcare provider prescribes thioridazine and assigns the nurse to assess the client for orthostatic hypotension. Which interventions would the nurse perform? Select all that apply. 1. Measuring the blood pressure before dosing 2. Reducing the dose if the blood pressure is low 3. Measuring the blood pressure one hour after dosing 4. Measuring the blood pressure one or two minutes after the client sits or stands 5. Avoiding the measurement of blood pressure when the client is lying down.

ANS - 1, 3, 4 - Measuring the blood pressure before dosing. Measure the blood pressure one hour after dosing. 4. Measuring the blood pressure one or two minutes after the client sits or stands. Antipsychotic drugs such as thioridazine may cause orthostatic hypotension as a side effect. Before delivering a dose, the nurse should measure the client's blood pressure. The blood pressure should be measured one hour after dosing to check the drug's effects on the client's blood pressure. Orthostatic hypotension may occur when the client sits or stands suddenly; therefore, the nurse should measure the client's blood pressure one or two minutes after the client sits or stands. If the client's blood pressure is low, the nurse should stop the administration and contact the primary healthcare provider. The client's blood pressure should be measured even while the client is lying down. This action helps the nurse understand the blood pressure variations in the client while lying down, standing, and sitting. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

After reviewing the data of a client with depression, the primary healthcare provider decided not to prescribe bupropion. Which statements made by the client would support the decision? Select all that apply. 1. "I have a history of epilepsy." 2. "I have not used phenelzine for two months." 3. "I have recently been diagnosed with glaucoma." 4. "I have a history of congestive heart failure." 5. "I have recently been diagnosed with anorexia nervosa."

ANS - 1, 4, 5 Bupropion is contraindicated in clients with a history of seizures because this drug lowers the seizure threshold. Cardiac diseases such as congestive heart failure, and eating disorders, such as anorexia nervosa, are contraindications for bupropion. Bupropion is contraindicated with concurrent use or 14 days previous use of phenelzine. Duloxetine is contraindicated for clients with uncontrolled angle-closure glaucoma.

A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent? Rest 2 Playing sports 3 Watching television 4 Interacting with others

ANS - 1. REST - Hallucinations occur most often when sensory stimulation is diminished because there is less competition for attention. Sports, television-watching, and interacting with others compete for sensory attention, thereby diminishing hallucinations. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

What must the nurse understand about breaks with reality such as those experienced by clients with schizophrenia? 1. Extended institutional care is necessary. 2. Clients believe that what they feel that they are experiencing is real. 3. Electroconvulsive therapy produces remission in most clients with schizophrenia. 4. The clients' families must cooperate in the maintenance of the psychotherapeutic plan.

ANS - 2 Failure to accept the client and the client's fears is a barrier to effective communication. Today mental health therapy is directed toward returning the client to the community as rapidly as possible. Electroconvulsive therapy is not the treatment of choice for clients with schizophrenia. Family cooperation is helpful but not an absolute necessity.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. 1. The client will become capable of part-time employment 2. The client will effectively express emotional and physical needs. 3. The client will demonstrate wellness reflective of physical potential. 4.. The client will demonstrate an understanding of the mental health disorder. 5. The client will recognize the issues most important to managing this disorder.

ANS - 2, 4, 5 Therapeutic communication facilitates the exchange of information between the nurse and the client that focuses on the client attaining health and wellness. This information can be directed toward the client's health needs, such as the effective expression of the client's physical and emotional needs, the understanding of the cause and prognosis of the current mental health problem, and the recognition of issues important to the management of the client's health issues. The client's ability to maintain part-time employment and the client's physical health potential are minimally affected by therapeutic communication.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. 1 The client will become capable of part-time employment. Correct 2 The client will effectively express emotional and physical needs. 3 The client will demonstrate wellness reflective of physical potential. Correct 4 The client will demonstrate an understanding of the mental health disorder. Correct 5 The client will recognize the issues most important to managing this disorder.

ANS - 2, 4, 5 - Therapeutic communication facilitates the exchange of information between the nurse and the client that focuses on the client attaining health and wellness. This information can be directed toward the client's health needs, such as the effective expression of the client's physical and emotional needs, the understanding of the cause and prognosis of the current mental health problem, and the recognition of issues important to the management of the client's health issues. The client's ability to maintain part-time employment and the client's physical health potential are minimally affected by therapeutic communication.

A client with the diagnosis of paranoid schizophrenia refuses to eat at mealtime. What nursing action is most beneficial? 1. Sitting with the client at mealtime 2. Giving the client food in unopened packages 3. Reminding the client repeatedly to eat the food 4. Explaining to the client the importance of eating

ANS - 2. Giving the client food in unopened packages. Clients with paranoia often have delusions that the food is poisoned. Providing packaged foods may make them feel less suspicious and more likely to eat. Just sitting with the client will not ensure that the client eats. The client needs to feel a sense of control over the food to be eaten. The client will be unable or unwilling to follow directions because of the nature of the illness, and an explanation will be of little value to this client for the same reason. Test-Taking Tip: Make educated guesses when necessary.

A client tells the nurse, "I used to believe that I was God, but now I know that that's not true." What is the best response by the nurse? 1 "You really believed that?" 2 "Many people have this delusion." Correct 3 "This is a sign you are getting better." Incorrect 4 "What caused you to think you were God?"

ANS - 3 - this is a sign you are getting better

For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected? 1 Responds to any stimulus 2 Responds to physical contact Correct 3 Unresponsiveness to the environment 4 Interacts with children rather than adults

ANS - 3 unresponsiveness to the environment Poor interpersonal relationships, inappropriate behavior, and learning disabilities prevent autistic children from emotionally adapting or responding to the environment even when the intelligence level is high. It is the lack of response to stimuli that is the clue that the child may have autism. Children with autism have an aversion to physical contact; they also have impaired interpersonal relationships regardless of the age of the other person

When planning activities for a child with autism, what does the nurse remember that autistic children respond best to? 1. Loud, cheerful music 2. Large-group activities 3. Individuals in small groups 4. Their own self-stimulating acts

ANS - 4 - Their own self-stimuating acts, Autistic behavior turns inward. Autistic children do not respond to the environment; instead, they attempt to maintain emotional equilibrium by rubbing and manipulating themselves, and they display a compulsive need for behavioral repetition. Autistic children do seem to respond to music, but not necessarily loud, cheerful music. Large-group (or small-group) activities have little effect on the autistic child's response. Part of the autistic pattern is the inability to interact with others in the environment, regardless of the size of the group.

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks? 1. Lithium 2. Diazepam 3. Fluvoxamine 4. Fluphenazine

ANS - 4 Fluphenazine - Fluphenazine can be given intramuscularly every 2 to 3 weeks to clients who are unreliable about taking oral medications; it allows them to live in the community while keeping the disorder under control. Lithium is a mood-stabilizing medication that is given to clients with bipolar disorder. This drug is not given for schizophrenia. Diazepam is an antianxiety/anticonvulsant/skeletal muscle relaxant that is not given for schizophrenia. Fluvoxamine is a selective serotonin reuptake inhibitor; it is administered for depression, not schizophrenia. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group. Topics

After 2 days on the unit a client with the diagnosis of schizophrenia refuses to take a shower. What is the most appropriate intervention by the nurse? 1. Having the staff give the client a shower 2. Simply stating that the client must shower now 3. Gently pointing out that the client's appearance is upsetting the other clients 4. Gently asking whether the client would wash the hands and face if given a basin of water

ANS - 4 Gentle asking whether the client would wash the hands and face if given a basin of water. The client needs to feel comfortable in the environment before establishing enough trust to undress for showering; the nurse's statement allows the client to make the decision. Stating that the client must shower now or having the staff give the client a shower may add to the client's anxiety and feelings of loss of control; it may also worsen any delusional thoughts the client is having. Gently pointing out that the client's appearance is upsetting the other clients will not help the client's self-image, and it does not matter what other clients think.

The nurse is caring for a client who is using paranoid ideation. When planning care, what should the nurse remember the importance of? 1. Not placing demands on the client 2. Removing stress so the client can relax 3. Giving the client difficult tasks to provide stimulation 4. Providing the client with activities that are structured and predictable

ANS - 4 Providing the client with activities that are structured and predictable. Providing the client with activities that are structured and predictable will help the client develop trust and reduce the use of paranoid ideation. Because people must function in a social environment, it is almost impossible to avoid placing some demands on others. It is impossible to remove all stress in the environment. Giving the client difficult tasks to provide stimulation will succeed in supporting the client's ideas of persecution and may lower the client's self-esteem.

The nurse cares for a client with bipolar disorder who is receiving drug therapy. The laboratory report reveals that the client's serum sodium level is 132 mEq/L (132 mmol/L). Which drug might have led to this condition? 1. Lithium 2. Bupropion 3. Fluoxetine 4. Nortriptyline

ANS = 3 Fluoxetine A serum sodium level of 132mEq/L (132 mmol/L) indicates hyponatremia. Fluoxetine is a serotonin reuptake inhibitor that may lead to hyponatremia. Lithium is a mood stabilizer used to treat bipolar disorder; it does not lead to hyponatremia. Bupropion is an atypical antidepressant that does not cause hyponatremia. Nortriptyline is a tricyclic antidepressant used to treat bipolar disorder that does not lead to hyponatremia. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.3

A delusional client is actively hallucinating and worried about being stalked by a terrorist group. What defense mechanism does the nurse identify as the most prominent in this situation? 1. Splitting 2. Undoing 3. Projection 4. Sublimation

ANS = Projection is the common defense mechanism found in delusions. Projection is attributing to others one's own unacceptable feelings, impulses, or thoughts. Splitting is when the individual fails to integrate the positive and negative qualities of the self or others into cohesive images and compartmentalizes opposite affective states. Undoing is symbolically canceling out an experience. Sublimation is the channeling of unacceptable impulses into constructive activities. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

1. A nurse wishes to teach alternative coping strategies to a patient who is experiencing severe anxiety. The nurse will first need to: a. Lower the patient's current anxiety level. b. Verify the patient's learning style. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.

ANS: A - a patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Using defense mechanisms does not apply.

18. A patient with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back; opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies that require immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis; it appears after prolonged treatment. Waxy flexibility is a symptom observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting.

17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Sublimation c. Suppression d. Passive aggression

ANS: A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurse's reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others.

35. A patient has a fear of public speaking. The nurse should be aware that social phobias are often treated with which type of medication? a. (beta)-blockers. b. Antipsychotic medications. c. Tricyclic antidepressant agents. d. Monoamine oxidase inhibitors

ANS: A Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required.

2. Which intervention is appropriate for a patient with an antisocial personality disorder who frequently manipulates others? a. Refer the patient's requests and questions related to care to the case manager. b. Encourage the patient to discuss his or her feelings of fear and inferiority. c. Provide negative reinforcement for actingout behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

5. A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic preparation b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Prolonged hospitalization; this patient is not ready for discharge

ANS: A Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for noncompliance. The other options do not address the patient's dislike of taking pills.

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, and never comes out for breaks or lunch. Which term best describes this behavior? a. Avoidant b. Dependent c. Histrionic d. Paranoid

ANS: A Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame.

21. What is the priority intervention for a nurse beginning to work with a patient with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing.

ANS: A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression

ANS: A Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

19. A person who is speaking about a rival for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. Reaction formation b. Repression c. Projection d. Denial

ANS: A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxietyproducing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

26. Which comment by a person who is experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving the car accident."

ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, "My legs feel weak most of the time," is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.

7. A patient with borderline personality disorder has a history of selfmutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic

ANS: A SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Lowdose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

4. A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.

ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for selfinjury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient's personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.

14. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

4. When a patient with paranoid schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

23. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, which are the symptoms present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

30. A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss handwashing routines. d. Focus on the patient's symptoms rather than on the patient.

ANS: B Because patients with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patient's coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom.

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

ANS: B Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone

2. A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia b. idea of reference c. delusion of infidelity d. auditory hallucination

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

16. A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as an as-needed (prn) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)

ANS: B Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

8. A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include a tremulous voice, respirations at 28 breaths per minute, and a pulse rate at 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: B Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

10. A patient with catatonic schizophrenia is semistuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patient's ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition.

9. A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security

ANS: B Physiologic needs must be met to preserve life. A patient who is semistuporous must be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiologic integrity. Safety needs rank second to physical needs. Higher level needs are of lesser concern.

24. A nurse set limits for a patient with a borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're terrible." This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.

ANS: B Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver.

19. A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline

ANS: B The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

2. A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used? a. Distracting technique to lower anxiety b. Bringing up an irrelevant topic c. Responding to physical needs d. Addressing false cognitions

ANS: B The nurse has closed off patient-centered communication. The introduction of an irrelevant topic makes the nurse feel better. The nurse is uncomfortable dealing with the patient's severe anxiety.

11. A nurse observes a patient who is in a catatonic state and standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking

10. When a patient with a personality disorder uses manipulation to get his or her needs met, the staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

3. A patient who is experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."

ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.

5. Consider these comments to three different nurses by a patient with an antisocial personality disorder: "You're a better nurse than the day shift nurse said you were"; "Another nurse said you don't do your job right"; "You think you're perfect, but I've seen you make three mistakes." Collectively, these interactions can be assessed as: a. Seductive b. Detached c. Manipulative d. Guilt producing

ANS: C Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments.

14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

ANS: C Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

17. A patient with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling propulsive gait, a masklike face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

13. A person has minor physical injuries after an automobile accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in a panic level of anxiety demonstrates significantly disturbed behavior and may lose touch with reality.

3. Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again

ANS: C, D, E The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia.

6. A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates: a. acting out. b. projection. c. rationalization. d. passive aggression.

ANS: D A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks

17. When preparing to interview a patient with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D According to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR), the characteristics of grandiosity, self-importance, and a sense of entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

7. A health care provider considers which antipsychotic medication to prescribe for a patient with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)

ANS: D Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

18. A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. Repression b. Devaluation c. Identification d. Compensation

ANS: D Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.

7. A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial

ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another

12. Which patient with schizophrenia would be expected to have the lowest score in global assessment of functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; diagnosed as catatonic at age 24 years; stable for 3 years c. 19 years old; diagnosed with undifferentiated schizophrenia at age 17 d. 40 years old; disorganized schizophrenia since age 18; frequent relapses

ANS: D Disorganized schizophrenia represents the most regressed and socially impaired of all the schizophrenias. The 40-year-old patient who has had disorganized schizophrenia since 18 years of age could logically be expected to have the lowest global assessment of functioning. In addition, the patient has been ill for a number of years and has had frequent relapses

26. A patient diagnosed with disorganized schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

1. A physical therapist recently convicted of multiple counts of Medicare fraud says to a nurse, "Sure I overbilled. Why not? Everyone takes advantage of the government. They have so many rules; no one can follow them." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident.

8. A patient with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.

Person has a fear of Dogs, volunteers at animal shelter playing with dogs. Or example - Takes care of sick dog and has medication to help get it better, dog dies and the person gives the medication to someone else that their dog has the same issue (parvo? or distemper, etc.)

Alturism

Women does not want to go out with bosses brother - calls and says her back went out of her.

Somatization

The inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Example - "I like the way my night shift nurse Mat did my bath or gave me a message."

Splitting

Reacts against news of death of a love one. "I don't believe you, the doctor said he was fine". or Example - "I don't have cancer, I am just fine". or Example - someone is explaining how to do insulin injections and the client keeps interrupting the nurse, because she doesn't believe she has diabetes.

Denial

I didn't get a raise because my boss doesn't like me. Or example - I didn't do well on a test because teacher doesn't like me. Or example - "If I had Lynn's brains, I'd get good grades too". Everybody cheats, so why shouldn't I".

Rationalization

Over compensation - Unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion - example - a person who harbors hostility towards children becomes a boy scout leader.

Reaction Formation

Tore up papers after getting turned down for a promotion and says "I'm no good".

Acting Out

Co-worker saw those awards don't mean anything, what did she have to do to get that.

Devaluation

a patient criticizes a nurse after his family fails to visit

Displacement

Saw son hit by a car, told police doesn't remember anything when being asked. Or got in car accident and can't remember how it happened

Dissociation

Uses humor to deal with stressors

Humor

Working on speech promises it done. Is sick the day of the speech

Passive Aggression

Horse didn't win competition - blames Judge or Man attracted to another women, teases wife about flirting.

Projection

Man forgets his wife's birthday after a fight. or example - Women doesn't enjoy sex due to childhood rape. Or example - forgetting the name of a former boyfriend/girlfriend or forgetting an appointment to discuss poor grades. Def. Exclusion of unpleasant or unwanted experience. Childhood rape, etc.

Repression

Man can't have sex because of recital disfunction, puts his energy into gardening instead. or example - Guy can't play on football team because he is too short - becomes a assistance coach instead. Or example - Guy can't be on baseball team because of grades - puts efforts into Art instead.

Sublimation

Student prepares for test - partner wants a divorce, deals with test although upset puts the divorce aside until test is done

Suppression

Give a gift to undo an agrument

Undoing