Chapter 15: Schizophrenia Spectrum and Other Psychotic Disorders, Chapter 15: Schizophrenia and Other Psychotic Disorders NCLEX, Chapter 15: Schizophrenia and Schizophrenia Spectrum Disorders, Chapter 25. Depressive Disorders, Chapter 16, Chapter 15:...

A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

1 (Provide client with high-calorie finger foods throughout the day.) (Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lb by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals.)

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1 (Risk for suicide R/T hopelessness) (Rationale: The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt.)

Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 5. Genetic predisposition is not a reliable diagnostic determinant.

1, 2 (Rationale: It is difficult to diagnose a child or adolescent with bipolar disorder, because bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.)

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Restrict sodium content. 5. Restrict fluids to 1,500 mL per day.

1, 2, 3 (Rationale: The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high because of the narrow margin between therapeutic doses and toxic levels. Fluid or sodium restriction can impact lithium levels.)

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Risky Activity" tool 2. "FIND" tool 3. "Consensus Committee" tool 4. "Monotherapy" tool

2 ("FIND" tool) (Rationale: The nurse should use the "FIND" tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.)

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2 (Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss) Rationale: The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health.

A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.

2 (Discontinue the fluoxetine and rethink the client's diagnosis.) (Rationale: A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis.)

Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

2 (Empowerment of the consumer) (Rationale: The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.)

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2 (Valproic acid (Depakote)) Rationale: The nurse should anticipate that the physician may prescribe valproic acid in order to increase this client's medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss.

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

3 ("Weight gain is a common, but troubling, side effect.") (Rationale: The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.)

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? Client Outcomes: 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours a night 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

3 (3, 1, 4, 2) (Rationale: The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's safety and physical health as most important.)

A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

3 (During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.) (Rationale: Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic.)

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."

4 ( "Treatment is compromised when clients choose not to take their medications.") (Rationale: The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped.)

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

4 ("Agitated and pacing. Exhibiting grandiosity. Mood labile.") (Rationale: The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one's abilities are better than everyone else's.)

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

4 ("Zyprexa calms hyperactivity until the Eskalith takes effect.") (Rationale: The nurse should explain to the client's spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder.)

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

4 (Symptoms indicate lithium carbonate toxicity.) (Rationale: The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly with maintenance therapy to ensure proper dosage.)

A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1. Symptoms lasting for a minimum of two years 2. Numerous periods with manic symptoms 3. Possible comorbid diagnosis of a delusional disorder 4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode

4, 5 (Rationale: The following are selected criteria for the diagnosis of cyclothymic disorder. For at least one year in children and adolescents there have been numerous periods with hypomanic, not manic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.)

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

A (The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considering as a treatment option. Clozapine can have a serious side effect of agranulocytosis in which a potentially fatal drop in white blood cells can occur.)

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

A (The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.)

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

A (The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.)

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

A (The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.)

The physician orders lithium carbonate 600 mg tid for a client newly diagnosed with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. What is the therapeutic range for acute mania? A) 1.0 to 1.5 mEq/L B) 10 to 15 mEq/L C) 0.5 to 1.0 mEq/L D) 5 to 10 mEq/L

A (1.0 to 1.5 mEq/L)

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions

A, B, C (The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.)

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

A, C, E (The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.)

21. ______________ are false sensory perceptions not associated with real external stimuli and may involve any of the five senses.

ANS: Hallucinations Page: 352 Feedback: Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Types of hallucinations include auditory, visual, tactile, gustatory, and olfactory.

20. _____________________ disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania).

ANS: Schizoaffective Page: 349 Feedback: Schizoaffective disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania). The decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations or delusions that occur for at least 2 weeks in the absence of a major mood episode.

19. Order the spectrum of schizophrenic and other psychotic disorders as described by the DSM-5 on a gradient of psychopathology from least to most severe. ________ Delusional disorder ________ Schizotypal personality disorder ________ Schizophrenia ________ Brief psychotic disorder ________ Psychotic disorder associated with another medical condition ________ Catatonic disorder associated with another medical condition ________ Schizoaffective disorder ________ Schizophreniform disorder ________ Substance-induced psychotic disorder

ANS: The correct order is 2, 1, 9, 3, 5, 6, 8, 7, 4 Page: 347-348 Feedback: A spectrum of schizophrenic and other psychotic disorders has been identified in the DSM-5. These include (on a gradient of psychopathology from least to most severe): schizotypal personality disorder, delusional disorder, brief psychotic disorder, substance-induced psychotic disorder, psychotic disorder associated with another medical condition, catatonic disorder associated with another medical condition, schizophreniform disorder, schizoaffective disorder, and schizophrenia. 1. Schizotypal personality disorder 2. Delusional disorder 3. Brief psychotic disorder 4. Substance-induced psychotic disorder 5. Psychotic disorder associated with another medical condition 6. Catatonic disorder associated with another medical condition 7. Schizophreniform disorder 8. Schizoaffective disorder 9. Schizophrenia

18. The DSM-5 diagnosis of functional neurological symptom disorder can also be identified as _______disorder.

ANS: conversion Page: 507 Feedback: The DSM-5 diagnosis of functional neurological symptom disorder can also be identified as conversion disorder. Conversion disorder is a loss of or change in body function that cannot be explained by any known medical disorder or pathophysiological mechanism. There is most likely a psychological component involved in the initiation, exacerbation, or perpetuation of the symptom, although it may or may not be obvious or identifiable.

3. A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response? 1. "Your child has a chemical imbalance of the brain, which leads to altered perceptions." 2. "Your child's hallucinations are caused by medication interactions." 3. "Your child has too little serotonin in the brain, causing delusions and hallucinations." 4. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

ANS: 1 Page: 342-343 Feedback 1 The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. 2 The client hearing voices is experiencing an auditory hallucination, which is not caused by medication. 3 Serotonin excess is thought to cause hallucinations. 4 Abnormal hormonal changes have not precipitated auditory hallucinations.

14. A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention

ANS: 1 Page: 348 Feedback 1 The nurse should intervene immediately if the client experiences signs of an infectious process—such as a sore throat, fever, and malaise—when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection. 2 Akathisia and hypersalivation does not indicate the client's risk for infection. 3 Akinesia and insomnia does not indicate the client's risk for infection. 4 Dry mouth and urinary retention does not indicate the client's risk for infection.

2. A nurse is working with a client diagnosed with SSD. What criteria would differentiate this diagnosis from illness anxiety disorder (IAD)? 1. The client diagnosed with SSD experiences physical symptoms in various body systems, and the client diagnosed with IAD does not. 2. The client diagnosed with SSD experiences a change in the quality of self-awareness, and the client diagnosed with IAD does not. 3. The client diagnosed with SSD disorder has a perceived disturbance in body image or appearance, and the client diagnosed with IAD does not. 4. The client diagnosed with SSD only experiences anxiety about the possibility of illness, and the client diagnosed with IAD does not.

ANS: 1 Page: 505 Feedback 1 Individuals experiencing somatic symptoms without corroborating pathology are considered to have SSD, and those with minimal or no somatic symptoms would be diagnosed with IAD, a diagnosis new to the DSM-5. 2 Clients with IAD experience a change in self-awareness 3 Clients with IAD experience a change in body image. 4 Clients with SSD experience corroborating pathology.

11. Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which nursing care should be included for this client? 1. Deal with physical symptoms in a detached manner. 2. Challenge the validity of physical symptoms. 3. Meet dependency needs until the physical limitations subside. 4. Encourage a discussion of feelings about the lower-extremity problem.

ANS: 1 Page: 518-520 Feedback 1 The nurse should assist the client in dealing with physical symptoms in a detached manner. This client should be diagnosed with a conversion disorder in which symptoms affect voluntary motor or sensory functioning with or without apparent impairment of consciousness. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations. 2 The nurse should not challenge the validity of the symptoms. 3 The nurse should encourage the client to be as independent as possible. 4 The nurse should deal with the physical symptoms in a detached manner.

12. Which combination of diagnoses and appropriate pharmacological treatments are correctly matched? 1. SSD: predominantly pain; treated with venlafaxine (Effexor) 2. IAD; treated with cefadroxil (Duricef) 3. Conversion disorder; treated with cyclobenzaprine (Flexeril) 4. Depersonalization-derealization disorder; treated with mometasone (Elocom)

ANS: 1 Page: 524 Feedback 1 The nurse should anticipate that the diagnosis of SSD: predominantly pain can be effectively treated with venlafaxine. Antidepressants are often used with somatic symptom disorder when the predominant symptom is pain. They have been shown to be effective in relieving pain, independent of influences on mood. 2 Treatment with cefadroxil (Duricef) is not appropriate for this client. 3 Treatment with cyclobenzaprine (Flexeril) is not appropriate for this client. 4 Treatment with mometasone (Elocom) is not appropriate.

18. The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.) 1. Hyperthyroidism 2. Hypothyroidism 3. Hyperadrenalism 4. Hypoadrenalism 5. Hyperaphia

ANS: 1, 2, 3, 4 Page: 348-349 Feedback 1. The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders such as hyperthyroidism. 2. The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders, such as hypothyroidism. 3. The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders, such as hyperadrenalism. 4. The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders, such as hypoadrenalism. 5. Hyperaphia is an excessive sensitivity to touch.

17. Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

ANS: 1, 2, 4, 5 Page: 365-368 Feedback 1. The nurse should recognize that group therapy plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. 2. The nurse should recognize that medication management plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. 3. Deterrent therapy is not a part of rehabilitative programs. 4. The nurse should recognize that supportive family therapy plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. 5. The nurse should recognize that social skills training plays an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder.

16. A client is diagnosed with functional neurological symptom disorder (FNSD). Which of the following symptoms is the client most likely to exhibit? (Select all that apply.) 1. Anosmia 2. Anhedonia 3. Akinesia 4. Aphonia 5. Amnesia

ANS: 1, 3, 4 Page: 507 Feedback 1. FNSD can also be termed conversion disorder. Conversion symptoms affect voluntary motor or sensory functioning suggestive of neurological disease. The client would likely exhibit anosmia. 2. The client would not likely exhibit anhedonia. 3. FNSD can also be termed conversion disorder. Conversion symptoms affect voluntary motor or sensory functioning suggestive of neurological disease. The client would likely exhibit akinesia. 4. FNSD can also be termed conversion disorder. Conversion symptoms affect voluntary motor or sensory functioning suggestive of neurological disease. The client would likely exhibit aphonia. 5. The client would not likely exhibit amnesia.

15. A client is diagnosed with IAD. Which of the following symptoms is the client most likely to exhibit? (Select all that apply.) 1. Obsessive-compulsive behaviors 2. Pseudocyesis 3. Anxiety 4. Flat affect 5. Depression

ANS: 1, 3, 5 Page: 506-507 Feedback 1. The nurse should expect that a client diagnosed with IAD would exhibit obsessive-compulsive behaviors. 2. The client would not likely exhibit pseudocyesis. 3. The nurse should expect that a client diagnosed with IAD would exhibit anxiety. 4. The client would not likely exhibit a flat affect. 5. The nurse should expect that a client diagnosed with IAD would exhibit depression.

17. A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? (Select all that apply.) 1. "Have you taken any new medications recently?" 2. "Have you recently traveled away from home?" 3. "Have you recently experienced any traumatic event?" 4. "Have you ever felt detached from your environment?" 5. "Have you had any history of memory problems?"

ANS: 1, 3, 5 Page: 518-520 Feedback 1. The nurse should assess the client for possible causes of amnesia, which may include side effects of new medications. 2. This question would not help confirm the diagnosis. 3. The nurse should assess the client for possible causes of amnesia, which may include experiencing a traumatic event. 4. This question would not be beneficial in helping the nurse confirm the diagnosis. 5. The nurse should assess the client for possible causes of amnesia, which may include having a history of memory problems.

15. A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis? 1. The client has experienced impaired reality testing for a 24-hour period. 2. The client has experienced auditory hallucinations for the past 3 hours. 3. The client has experienced bizarre behavior for 1 day. 4. The client has experienced confusion for 3 weeks.

ANS: 2 Page: 348 Feedback 1 Impaired reality testing for a 24-hour period is typical of brief psychotic disorder and would not cause the nurse to question this diagnosis. 2 This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month. 3 Bizarre behavior for 1 day is typical of brief psychotic disorder and would not cause the nurse to question this diagnosis. 4 Confusion for 3 weeks is typical of brief psychotic disorder and would not cause the nurse to question this diagnosis.

1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? 1. Assess for medication nonadherence. 2. Note escalating behaviors and intervene immediately. 3. Interpret attempts at communication. 4. Assess triggers for bizarre, inappropriate behaviors.

ANS: 2 Page: 350-351 Feedback 1 Assessing for medication nonadherence does not indicate that the client's safety may be at risk. 2 The nurse should note escalating behaviors and intervene immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe. 3 Interpreting attempts at communication does not indicate that the client's safety may be at risk. 4 Assessing triggers for bizarre, inappropriate behaviors does not indicate that the client's safety may be at risk.

12. A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. 4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: 2 Page: 351 Feedback 1 Anhedonia and anergia are negative symptoms of schizophrenia. 2 The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia. 3 Echolalia and paranoid delusions are positive symptoms. 4 Paranoid delusions are a positive symptom.

9. Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1. Establishing personal contact with family members 2. Being reliable, honest, and consistent during interactions 3. Sharing limited personal information 4. Sitting close to the client to establish rapport

ANS: 2 Page: 355-360 Feedback 1 Establishing personal contact with family is important, but the nurse must first establish a relationship with the client. 2 The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior. 3 Sharing limited personal information can occur after a relationship has been established with the client. 4 Sitting close to the client is important, but it does not establish rapport.

13. A nurse is reviewing progress notes on a newly admitted client. One progress note reveals that the client purposefully inserted a contaminated catheter into the urethra, leading to a urinary tract infection. The nurse recognizes this behavior as characteristic of which mental disorder? 1. Illness anxiety disorder 2. Factitious disorder 3. Functional neurological symptom disorder 4. Depersonalization-derealization disorder

ANS: 2 Page: 508-509 Feedback 1 Illness anxiety disorder is the fear of having an illness or disease. 2 Factitious disorders involve conscious, intentional feigning of physical or psychological symptoms. Individuals with factitious disorder pretend to be ill in order to receive emotional care and support commonly associated with the role of "patient." Individuals become very inventive in their quest to produce symptoms. Examples include self-inflicted wounds, injection or insertion of contaminated substances, manipulating a thermometer to feign a fever, urinary tract manipulation, and surreptitious use of medications. 3 Functional neurological symptom disorder, or conversion disorder, is the loss of body function with no known medical cause. 4 Depersonalization-derealization disorder occurs when an individual switches between different personalities.

10. Which situation is an example of selective amnesia? 1. A client cannot relate any lifetime memories. 2. A client can describe driving to Ohio but cannot remember the car accident that occurred. 3. A client often wanders aimlessly after sunset. 4. A client cannot provide personal demographic information during admission assessment.

ANS: 2 Page: 510 Feedback 1 In the generalized type, the individual has amnesia for his or her identity and total life history. 2 In selective amnesia, the individual can recall only certain incidents associated with a stressful event for a specific period after the event. 3 Wandering aimlessly is not an example of selective amnesia. 4 This is not an example of selective amnesia.

3. Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with SSD? 1. The client will admit to fabricating physical symptoms to gain benefits by day three. 2. The client will list three potential adaptive coping strategies to deal with stress by day two. 3. The client will comply with medical treatments for physical symptoms by day three. 4. The client will openly discuss physical symptoms with staff by day four.

ANS: 2 Page: 515-518 Feedback 1 The client is experiencing real symptoms and is not likely to admit to fabricating symptoms. 2 The nurse should determine that an appropriate outcome for a client diagnosed with SSD would be for the client to list three potential adaptive coping strategies to deal with stress by day two. 3 The outcome may not be realistic for this client, and may require more time. 4 This outcome may not be realistic for the client.

7. A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client? 1. Disturbed sensory perception 2. Altered thought processes 3. Risk for violence: directed toward others 4. Risk for injury

ANS: 3 Page: 342-343 Feedback 1 Disturbed sensory perception does not accurately capture the client's risk based on the client's current statements. 2 Altered thought processes do not accurately capture the client's risk based on the client's current statements. 3 The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions. 4 Risk for injury does not accurately capture the client's risk based on the client's current statements.

6. A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? 1. "Did you take your medicine this morning?" 2. "You are not going to hell. You are a good person." 3. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." 4. "The devil only talks to people who are receptive to his influence."

ANS: 3 Page: 342-343 Feedback 1 Questioning the client about medications does not validate the client's feelings. 2 This statement does not validate the client's feelings or redirect the client back to reality. 3 The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that "the voices" are a part of the illness is a way to help the client accept that the hallucinations are not real. It is also important for the nurse to connect with the client's fears and inner feelings. 4 This statement does not validate the client's feelings.

10. A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? 1. Magical thinking; administer an antipsychotic medication. 2. Persecutory delusions; orient the client to reality. 3. Command hallucinations; warn the psychiatrist. 4. Altered thought processes; call an emergency treatment team meeting.

ANS: 3 Page: 342-343 Feedback 1 The nurse is not legally responsible for reporting magical thinking. 2 The nurse is not legally responsible for reporting persecutory delusions. 3 The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. Clients demonstrating a risk for violence could potentially be physically, emotionally, and/or sexually harmful to others or to self. 4 Altered thought process is not a legally reportable assessment finding.

4. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response? 1. "Tell him to stop discussing the voices." 2. "Ignore what he is saying, while attempting to discover the underlying cause." 3. "Focus on the feelings generated by the hallucinations and present reality." 4. "Present objective evidence that the voices are not real."

ANS: 3 Page: 342-343 Feedback 1 This option could cause the client to shut down. 2 The client should not be ignored, but should be encouraged to discuss what is occurring. 3 The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception. 4 This option would not be appropriate in the care of the schizophrenic client.

16. A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client's symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)? 1. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not. 2. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not. 3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features. 4. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.

ANS: 3 Page: 348 Feedback 1 Hallucinations and delusions are associated with SIPD and BPD. 2 Hallucinations and delusions are associated with BPD and SIPD. 3 Catatonic features may be associated with SIPD, whereas BPD has no catatonic features. 4 Catatonic features may be associated with SIPD.

2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? 1. The side effects of medications 2. Deep breathing techniques to decrease stress 3. How to make eye contact when communicating 4. How to be a leader

ANS: 3 Page: 365 Feedback 1 Teaching the side effects of medication does not help the client obtain better social skills. 2 Teaching deep breathing exercises does not help the client obtain better social skills. 3 The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships. 4 Teaching leadership skills do not help the client obtain better social skills.

13. An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

ANS: 3 Page: 368-369 Feedback 1 Slow, deep breaths do not reduce the client's risk of a syncopal episode. 2 Watching diet and physical activity does not reduce the client's risk of a syncopal episode. 3 The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension. 4 Wearing sunscreen does not reduce the client's risk of a syncopal episode.

11. A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? 1. Tactile hallucinations 2. Tardive dyskinesia 3. Restlessness and muscle rigidity 4. Reports of hearing disturbing voices

ANS: 3 Page: 370 Feedback 1 The symptom of tactile hallucinations would be addressed by an antipsychotic medication, such as haloperidol. 2 Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. 3 An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity. 4 Reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol.

1. A client diagnosed with somatic symptom disorder (SSD) is most likely to exhibit which personality disorder characteristics? 1. Experiences intense and chaotic relationships with fluctuating attitudes toward others 2. Socially irresponsible, exploitative, guiltless, and disregards rights of others 3. Self-dramatizing, attention seeking, overly gregarious, and seductive 4. Uncomfortable in social situations, perceived as timid, withdrawn, cold, and strange

ANS: 3 Page: 506 Feedback 1 The client is not likely to experience intense and chaotic relationships. 2 The client is not likely to be socially irresponsible or exploitive. 3 The nurse should anticipate that a client diagnosed with SSD would be self-dramatizing, attention seeking, and overly gregarious. It has been suggested that, in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These symptoms include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself. 4 The client is not likely to be perceived as timid or withdrawn.

9. According to the DSM-5 diagnostic criteria for dissociative amnesia (DA), what symptom would be essential to meet the criteria for the subcategory of dissociative fugue? 1. An inability to recall important autobiographical information 2. Clinically significant distress in social and occupational functioning 3. Sudden unexpected travel or bewildered wandering 4. "Blackouts" related to alcohol toxicity

ANS: 3 Page: 510-511 Feedback 1 An inability to recall important autobiographical information is a basic criterion for the diagnosis of DA. 2 Clinically significant distress in social and occupational functioning is a basic criterion for the diagnosis of DA. 3 Dissociative fugue is characterized by a sudden, unexpected travel away from customary place of daily activities, or by bewildered wandering, with the inability to recall some or all of one's past. 4 The DSM-5 also states that symptoms cannot be attributable to the direct physiological effects of a substance (e.g., alcohol, a drug of abuse, a medication).

7. A client diagnosed with DID switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? 1. It is a means to attain secondary gain. 2. It is a means to explore feelings of excessive and inappropriate guilt. 3. It serves to isolate painful events so that the primary self is protected. 4. It serves to establish personality boundaries and limit inappropriate impulses.

ANS: 3 Page: 511-512 Feedback 1 The switch is not to attain secondary gain. 2 The switch is not to explore feelings of excessive and inappropriate guilt. 3 The nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress. 4 The switch is not to establish personality boundaries and limit inappropriate impulses.

6. An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority? 1. Encourage exploration of sexual abuse. 2. Encourage guided imagery. 3. Establish trust and rapport. 4. Administer antianxiety medications.

ANS: 3 Page: 518-520 Feedback 1 Encouraging exploration of sexual abuse can occur after establishing rapport. 2 Encouraging guided imagery can occur after establishing rapport. 3 The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with DID. DID was formerly called multiple personality disorder. Trust is the basis of every therapeutic relationship. Each personality views itself as a separate entity and must be treated as such to establish rapport. 4 Administering antianxiety medications can occur after establishing rapport.

5. A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1. Thought insertion 2. Paranoid delusions 3. Magical thinking 4. Delusions of reference

ANS: 4 Page: 350-351 Feedback 1 Thought insertion is not a potential symptom of schizophrenia. 2 The client with paranoid delusions is very suspicious of others and their intentions. 3 The client with magical thinking believes that thoughts have power over others. 4 The nurse is assessing for the potential symptom of delusions of reference. A client that believes he or she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward himself or herself. Clients with delusions of reference believe that others are trying to send them messages in various ways, or they must break a code to receive a message.

8. Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder? 1. Provide neon lights and soft music. 2. Maintain continual eye contact throughout the interview. 3. Use therapeutic touch to increase trust and rapport. 4. Provide personal space to respect the client's boundaries.

ANS: 4 Page: 355 Feedback 1 Changing lighting and providing music does not reduce the client's risk for violence. 2 Maintaining eye contact does not reduce the client's risk for violence. 3 Therapeutic touch does not reduce the client's risk for violence. 4 The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence. The nurse should observe the patient while carrying out routine tasks.

4. Which are examples of primary and secondary gains that clients diagnosed with SSD: predominately pain, may experience? 1. Primary: chooses to seek a new doctor; Secondary: euphoric feeling from new medications 2. Primary: euphoric feeling from new medications; Secondary: chooses to seek a new doctor 3. Primary: receives get-well cards; Secondary: pain prevents attending stressful family reunion 4. Primary: pain prevents attending stressful family reunion; Secondary: receives get-well cards

ANS: 4 Page: 506 Feedback 1 Choosing a new doctor and euphoric feelings do not accurately describe primary and secondary gains for this client. 2 These feelings listed do not accurately describe primary and secondary gains for this client. 3 The primary and secondary gains listed do not accurately describe primary and secondary gains for this client. 4 The nurse should identify that primary gains are those that allow the client to avoid an unpleasant activity (stressful family reunion) and that secondary gains are those in which the client receives emotional support or attention (get-well cards).

5. A nursing instructor is teaching about the etiology of IAD from a psychodynamic perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? 1. "They tend to have a familial predisposition to this disorder." 2. "When the sick role relieves them from stressful situations, their physical symptoms are reinforced." 3. "They misinterpret and cognitively distort their physical symptoms." 4. "They express personal worthlessness through physical symptoms, because physical problems are more acceptable than psychological problems."

ANS: 4 Page: 506-507 Feedback 1 These clients do not tend to have familial disposition for the disorder. 2 Physical symptoms are not reinforced when the sick role relieves them from stressful situations. 3 They do not misinterpret or cognitively distort their physical symptoms. 4 The nurse should understand that from a psychoanalytical perspective, IAD occurs because physical problems are more acceptable than psychological problems.

14. A nursing instructor is teaching about the DSM-5 diagnosis of depersonalization-derealization disorder (D-DD). Which student statement indicates a need for further instruction? 1. "Clients with this disorder can experience emotional and/or physical numbing and a distorted sense of time." 2. "Clients with this disorder can experience unreality or detachment with respect to their surroundings." 3. "During the course of this disorder, individuals or objects are experienced as dreamlike, foggy, lifeless, or visually distorted." 4. "During the course of this disorder, the client is out of touch with reality and is impaired in social, occupational, or other areas of functioning."

ANS: 4 Page: 512 Feedback 1 This statement is correct, indicating that further education is not necessary. 2 This statement does not indicate a need for further education. 3 This statement indicates that teaching has been effective. 4 D-DD is characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. Depersonalization (a disturbance in the perception of oneself) is differentiated from derealization, which describes an alteration in the perception of the external environment. The DSM-5 states that during the depersonalization and/or derealization experiences, reality testing remains intact. This student statement indicates a need for further instruction.

8. A client is diagnosed with DID. What is the primary goal of therapy for this client? 1. To recover memories and improve thinking patterns 2. To prevent social isolation 3. To decrease anxiety and need for secondary gain 4. To collaborate among sub-personalities to improve functioning

ANS: 4 Page: 518-520 Feedback 1 To recover memories and improve thinking patterns is not the primary goal of therapy. 2 To prevent social isolation is not the primary goal of therapy. 3 To decrease anxiety and need for secondary gain is not the primary goal of therapy. 4 The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among sub-personalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the client's functioning and potential.

24. A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills

ANS: A A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this clients plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

29. A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a. a neologism. c. thought insertion. b. concrete thinking. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment

33. A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

ANS: A Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. I am sad most of the time and Ive felt this way for the last several years. B. I find myself preoccupied with death. C. Sometimes I hear voices telling me to kill myself. D. Im afraid to leave the house.

ANS: A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

38. A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad c. Anhedonia b. Neologism d. Echolalia

ANS: A Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

13. Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

ANS: A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

18. A nurse counseling a patient with a dissociative identity disorder should understand that the assessment of highest priority is: a. Risk for self-harm b. Cognitive functioning c. Identification of drug abuse d. Readiness to reestablish identity or memory

ANS: A Assessments that relate to patient safety take priority. Patients with dissociative identity disorders may be at risk for suicide or self-mutilation; therefore the nurse must be alert for hints of hopelessness, helplessness and worthlessness, low self-esteem, and impulses to self-mutilate. The distracters are important assessments but rank beneath safety.

19. A patient says, "I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study." Which term should the nurse use to document this complaint? a. Depersonalization b. Hypochondriasis c. Dissociation d. Malingering

ANS: A Depersonalization involves a persistent or recurrent experience of feeling detached from and outside one's mental processes or body. Although reality testing is intact, the detached experience causes significant impairment in social or occupational functioning and distress to the individual. Malingering involves a conscious process of intentionally producing symptoms for an obvious benefit; dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety. Hypochondriasis involves the interpretation of body sensations as symptomatic of a serious illness.

20. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

13. A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

ANS: A Patients with functional neurologic (conversion) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed "la belle indifférence." In addition, a specific cause for the development of the symptoms is identifiable; in this instance, the death of a parent precipitates the stress.

22. The causes of somatic system disorders may be related to: a. faulty perceptions of body sensations. b. traumatic childhood events. c. culture-bound phenomena. d. depressive equivalents.

ANS: A Structural or functional abnormalities of the brain have been suggested to lead to the somatic system disorders, resulting in disturbed processes of perception and interpretation of bodily sensations. Furthermore, cognitive theorists believe patients misinterpret the meaning of certain bodily sensations and then become excessively alarmed by them. Traumatic childhood events are related to the dissociative disorders. Culture-bound phenomena may explain the prevalence of some symptoms but cannot explain the cause. Somatic system disorders are not another facet of depression; however, depression may coexist with a somatic system disorder.

12. The family of a client diagnosed with conversion disorder asks the nurse, "Will his paralysis ever go away?" Which of these responses by the nurse is evidence-based? A. "Most symptoms of conversion disorder resolve within a few weeks." B. "Typically people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives." C. "The only people who recover are those that develop conversion disorder symptoms without a precipitating stressful event." D. "Technically, he could walk now since he is intentionally feigning paralysis."

ANS: A The evidence supports that most conversion disorder symptoms resolve within a few weeks, and about 20% will have a relapse within 1 year.

15. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you began feeling depressed."

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.

11. Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which nursing care should be included for this client? A. Deal with physical symptoms in a detached manner. B. Challenge the validity of physical symptoms. C. Meet dependency needs until the physical limitations subside. D. Encourage a discussion of feelings about the lower-extremity problem.

ANS: A The nurse should assist the client in dealing with physical symptoms in a detached manner to avoid reinforcing the symptoms by providing secondary gains. This is an example of a conversion disorder in which symptoms affect voluntary motor or sensory functioning. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations.

5. A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? A. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness." B. "When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. C. "People with dissociative disorders typically have strong egos." D. "There is clear and convincing evidence of a familial predisposition to this disorder."

ANS: A The nurse should understand that from a psychoanalytical perspective, dissociation occurs because of repression of painful information or experiences.

6. A college student who attempts suicide by overdose is hospitalized. When the parents are contacted they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

ANS: A The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distracters are not clearly described in the scenario.

11. Which assessment finding best supports dissociative fugue? The patient states: a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

ANS: A The patient in a fugue state frequently relocates and assumes a new identity while not recalling his or her previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

8. An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for 5 days. The patient is now more talkative and shows increased energy on the unit. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient must be supervised 24 hours per day; the patient is still a suicide risk.

2. A nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should a nurse expect to assess? A. Disproportionate and persistent thoughts about the seriousness of one's symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms

ANS: A The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues.

21. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

28. The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which reply by the nurse would be most helpful? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications.

27. A new nurse says to a peer, "My newest patient has schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful? a. "Let's reconsider your plan. Suicide risk is high in patients with schizophrenia." b. "Suicide is a risk for any patient with schizophrenia who uses alcohol or drugs." c. "Patients with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients with schizophrenia."

ANS: A Up to 10% of patients with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients with schizophrenia. Patients with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia.

2. A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.

2. A nurse assesses a patient suspected to have complex somatic system disorder. Which findings support the diagnosis? Select all that apply. a. Patient is a woman. b. Patient reports frequent syncope. c. Patient complains of heavy menstrual bleeding. d. Patient was first diagnosed with psoriasis at 12 years of age. e. Patient reports back pain, painful urination, frequent diarrhea, and hemorrhoids.

ANS: A, B, C, E No chronic disease explains the symptoms for patients with complex somatic system disorder. Patients report multiple symptoms; and gastrointestinal, sexual, and pseudoneurological symptoms are common. This disorder is more common is women than in men.

3. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injury

ANS: A, B, E Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury.

14. A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? Select all that apply. A. "Can you tell me your name and where you live?" B. "Have you ever traveled suddenly or unexpectedly away from home?" C. "Have you recently experienced any traumatic event?" D. "Have you ever felt detached from your environment?" E. "Have you had any history of memory problems?"

ANS: A, C, E An individual who has generalized amnesia has amnesia for his or her identity and total life history. The first question assesses orientation to identity. Items C and D assess for awareness of current issues and historical issues, respectively. Affirmative descriptions of either of these issues would rule out generalized amnesia.

13. A client is diagnosed with illness anxiety disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply. A. Obsessive-compulsive traits B. Pseudocyesis C. Disabling fear of having a serious illness D. Multiple pronounced physical symptoms E. Depression

ANS: A, C, E Illness anxiety disorder involves a preoccupation with and fear of having or acquiring a serious disease. Somatic symptoms are either absent or mild in intensity.

15. Which of the following somatic symptom and dissociative disorders are identified with known effective pharmacological treatments for that disorder? Select all that apply. A. Antidepressants have been used effectively in treating pain associated with somatic symptom disorder. B. Lithium has been effective in treating illness anxiety disorder. C. Muscle relaxants have been effective in resolving conversion disorder symptoms. D. The antidepressant clomipramine (Anafranil) has shown promise in treating depersonalization-derealization disorder.

ANS: A, D The nurse should recognize that psychological therapies are central treatment modalities for these disorders, although evidence exists that for specific issues (as those identified in items A and C), psychopharmacological agents have demonstrated effectiveness.

1. A patient with predominant pain disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

ANS: A, E The patient's verbalization is consistent with spiritual distress. Moreover, the patient's description of being unable to provide for and burdening the family suggests ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.

14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. Well go to the day room when you are ready for group. B. Ill walk with you to the day room. Group is about to start. C. It must be difficult for you to attend group when you feel so bad. D. Let me tell you about the benefits of attending this group.

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. I cannot drink any alcohol with this medication. B. It is going to take 2 to 3 weeks in order for me to begin to feel better. C. This drug causes physical dependence, and I need to strictly follow doctors orders. D. I cant take this medication with food. It needs to be taken on an empty stomach.

ANS: B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

27. A newly admitted client diagnosed with major depressive disorder states, I have never considered suicide. Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. There is nothing to worry about. We will handle it together. B. Bringing this up is a very positive action on your part. C. We need to talk about the things you have to live for. D. I think you should consider all your options prior to taking this action.

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

15. A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

ANS: B Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

26. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

37. A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations c. Idea of reference b. Magical thinking d. Thought insertion

ANS: B Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205-206 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

6. 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.

18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, Im feeling a lot better, so you can stop watching me. I have taken up too much of your time already. Which is the best nursing reply? A. I really appreciate your concern but I have been ordered to continue to watch you. B. Because we are concerned about your safety, we will continue to observe you. C. I am glad you are feeling better. The treatment team will consider your request. D. I will forward you request to your psychiatrist because it is his decision.

ANS: B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) c. Chlorpromazine (Thorazine) b. Olanzapine (Zyprexa) d. Diphenhydramine (Benadryl)

ANS: B Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be 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 ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 209-210 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity

1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 205-206 | Page 213-215 (Box 12-4)

5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

ANS: B The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 207 | Page 212-213 TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe

35. A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

ANS: B The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 205-206 (Table 12-1) | Page 213-215 (Box 12-4)

24. A staff nurse tells another nurse "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."

ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.

14. A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? a. Anxiety b. Risk for suicide c. Disturbed body image d. Ineffective role performance

ANS: B A high risk of completed suicide exists in patients with body dysmorphic disorder. Safety is always a high priority for the nurse; in this instance, the plan of care should include an awareness of the risk for self-inflicted harm.

17. A person comes to the clinic reporting, "I wear a scarf across my lower face when I go out but because of my ugly appearance." Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? a. Dissociative identity disorder b. Body dysmorphic disorder c. Pseudocyesis d. Malingering

ANS: B Body dysmorphic disorder involves a preoccupation with an imagined defect in appearance. Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. Pseudocyesis is the false belief that one is pregnant. Malingering is intentionally producing symptoms for a personal gain.

9. Which of the following statements accurately describes dissociative fugue? A. Dissociative fugue is not precipitated by stressful events. B. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of one's past. C. Dissociative amnesia and dissociative fugue are completely different types of disorders. D. Dissociative fugue is characterized by a sense of observing oneself from outside the body.

ANS: B Dissociative fugue is characterized by unexpected travel or bewildered wandering, and amnesia for all or part of one's past. Dissociative fugue is a subtype of dissociative amnesia.

12. A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later and sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? a. Functional neurological (conversion) disorder b. Dissociative identity disorder c. Depersonalization disorder d. Body dysmorphic disorder

ANS: B Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. At least two of the subpersonalities take control of the person's behavior but leave the individual unable to remember the periods of time in which the subpersonality is in control.

25. A patient who was hospitalized for 2 weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care.

19. Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.

25. Which treatment modality should a nurse recommend to help a patient with pain disorder cope more effectively? a. Flooding b. Relaxation c. Response prevention d. Systematic desensitization

ANS: B Pain increases when the patient has muscle tension. Relaxation can diminish the patient's perceptions of the intensity of pain. The distracters are modalities useful in treating selected anxiety disorders.

20. A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results are normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Prominent health anxiety (hypochondriasis) c. Predominant (pain) disorder d. Dissociative fugue

ANS: B Patients with hypochondriasis have fears of serious medical problems such as cancer or heart disease. These fears persist, despite medical evaluations, and interfere with daily functioning. No complaints of pain are made, and no evidence of dissociation or conversion exists.

1. A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably: a. Readily seek psychiatric counseling. b. Be resistant to accepting psychiatric help. c. Attend psychotherapy sessions without encouragement. d. Be eager to discover the true reasons for physical symptoms.

ANS: B Patients with somatic system disorders go from physician to physician trying to establish a physical cause for their symptoms. When a psychologic basis is suggested and a referral for counseling is offered, these patients reject both.

2. A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is: a. suppressing accurate feelings regarding the problem. b. relieving anxiety through the physical symptom. c. meeting needs through hospitalization. d. refusing to disclose genuine fears.

ANS: B Psychoanalytic theory suggests conversion reduces anxiety through the production of a physical symptom that is symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously).

24. A patient says, "I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive restructuring? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking." b. "Let's see whether any other explanations for your vomiting are possible." c. "You seem so worried. Let's talk about how you're feeling." d. "We'll talk about something else."

ANS: B Questioning the evidence is a cognitive restructuring technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.

1. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises.

7. An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: B The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

3. Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with somatic symptom disorder? A. The client will admit to fabricating physical symptoms to gain benefits by day 3. B. The client will list three potential adaptive coping strategies to deal with stress by day 2. C. The client will comply with medical treatments for physical symptoms by day 3. D. The client will openly discuss physical symptoms with staff by day 4.

ANS: B The nurse should determine that an appropriate outcome for a client diagnosed with somatic symptom disorder would be for the client to list three potential adaptive coping strategies to deal with stress by day 2. Because the symptoms of somatic symptom disorder are associated with psychosocial distress, increasing coping skills may help the client reduce symptoms.

3. A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed him- or herself after explaining the arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self unassisted. d. address the needs of other patients in the dining room, and then feed this patient.

ANS: B The patient is expected to maintain some level of independence by feeding him- or herself, whereas the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.

4. A patient with blindness related to a functional neurological (conversion) disorder says, "All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital don't find me interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

ANS: B The patient mentions that the symptoms make people more interested, which indicates that the patient believes he or she is uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of Chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in this scenario.

9. A patient with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. Assume roles and functions of the other family members. b. Demonstrate a resumption of former roles and tasks. c. Focus energy on problems occurring in the family. d. Rely on family members to meet his or her personal needs.

ANS: B The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and the resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes.

29. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the clients symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

36. Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility c. Poverty of thought b. Bizarre behavior d. Auditory hallucinations

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 207-208 (Table 12-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The clients understanding of the need for regular bloodwork B. The clients mood and affect score, according to the facilitys mood scale C. The clients cognitive ability to understand information about the medication D. The clients access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out senile dementia D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out senile dementia. The elderly are often misdiagnosed with senile dementia when depression is their actual diagnosis. Memory loss, confused thinking, or apathy symptomatic of dementia actually may be the result of depression.

10. Which should the nurse recognize as an example of localized amnesia? A. A client cannot relate any lifetime memories, including personal identity. B. A client can relate family memories but has no recollection of a particular brother. C. A client cannot remember events surrounding a fatal car accident. D. A client whose home was destroyed by a tornado only remembers waking up in the hospital.

ANS: C An individual with localized amnesia is unable to recall all incidents associated with a stressful event.

10. A woman is 5'7" tall, weighs 160 pounds, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." The patient tries to buy shoes to make her feet look smaller, and in social settings conceals both feet under a table or chair. Which health problem is likely? a. Dissociative fugue b. Prominent pain disorder c. Body dysmorphic disorder d. Depersonalization disorder

ANS: C Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient's feet are proportional to the rest of her body. Dissociative fugue is characterized by sudden, unexpected travel away from the customary locale and the inability to recall one's identity and information about some or all of the past. Prominent pain disorder involves the presence of pain not associated with a medical disorder. Depersonalization disorder involves an alteration in the perception of self, such as feeling mechanical or unreal.

27. A patient with predominant pain disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. unsuccessful. b. minimally successful. c. partially successful. d. totally achieved.

ANS: C Decreased preoccupation with symptoms and an increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.

10. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

ANS: C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.

2. A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the patient has nowhere else to go.

17. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.

1. A client diagnosed with somatic symptom disorder is most likely to exhibit which personality disorder characteristics? A. Uses "splitting" and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange

ANS: C It has been suggested that in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These features include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself. Somatic symptom disorder is characterized by the expression of multiple somatic complaints associated with psychosocial distress and without medical basis.

4. Carly has been diagnosed with somatic symptom disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? A. The family agrees that Carly began having physical symptoms after she lost her job. B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. C. Carly's mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. D. Carly states she noticed feeling hotter than usual the last time she had a headache.

ANS: C It is important for the nurse to identify gains that the symptoms might be providing for the client, since these can reinforce illness behavior. Having family attend to the patient when she is symptomatic could reinforce increased dependency and attention needs.

21. A patient with predominant pain disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. Mood b. Cognitive style c. Secondary gains d. Identity and memory

ANS: C Secondary gains should be assessed. The patient's dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient's diagnosis has been established.

5. To assist a patient with a somatic system disorder, a nursing intervention of high priority is to: a. imply that somatic symptoms are not real. b. help the patient suppress feelings of anger. c. shift the focus from somatic symptoms to feelings. d. investigate each physical symptom as it is offered.

ANS: C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys an interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome is that the patient expresses feelings, including anger, if it is present. Once physical symptoms have been investigated, they do not need to be reinvestigated each time the patient reports them.

12. Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Completing a psychologic postmortem assessment c. Attending a self-help group for survivors d. Contracting for two sessions of group therapy

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychologic postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide.

3. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.

9. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, "I am not going to harm myself, I am going to kill myself," or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

7. A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? A. It is a means to attain secondary gain. B. It is a means to explore feelings of excessive and inappropriate guilt. C. It serves to isolate painful events so that the primary self is protected. D. It serves to establish personality boundaries and limit inappropriate impulses.

ANS: C The nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress.

6. An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority? A. Encourage exploration of sexual abuse B. Encourage guided imagery C. Establish trust and rapport D. Administer antianxiety medications

ANS: C The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with dissociative identity disorder. DID was formerly called multiple personality disorder. Each personality views itself as a separate entity and must be treated as such to establish rapport. Trust is the basis of every therapeutic relationship.

4. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.

14. A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.

ANS: C Zoloft is a selective serotonin reuptake inhibitor (SSRI) that has a relatively benign side effect profile as compared with other antidepressants.

3. A patient's roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. A dissociative identity disorder is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply. a. "Are you sexually promiscuous?" b. "Do you think you need an antidepressant medication?" c. "Have you ever found yourself someplace and did not know how you got there?" d. "Are your memories of childhood clear and complete, or do you have blank spots?" e. "Have you ever found new things in your belongings that you can't remember buying?"

ANS: C, D, E Asking, "Are you sexually promiscuous?" would probably produce defensiveness on the part of the patient. If a subpersonality acts out sexually, the main personality is probably not aware of the behavior. "Do you think you need an antidepressant medication?" is a premature question and not in the nurse's scope of practice. All of the other questions are pertinent.

1. A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation

ANS: C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommate's absence from the dormitory. Terminating access to one's social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness.

4. A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Posttraumatic stress disorder

ANS: C, E Traumatic brain injury and posttraumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distracters would be expected to parallel the general population.

21. Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. Its just a matter of time and I will be well. B. If I ignore these feelings, they will go away. C. I can fight these feelings and overcome this disorder. D. Nothing will help me feel better.

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.

34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 211-215 (Box 12-6) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

25. A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism c. Thought broadcasting b. Idea of reference 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 205 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a. the need for psychoeducation. c. chronic deterioration. b. medication noncompliance. d. relapse.

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 213-215 (Box 12-6) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

17. A client diagnosed with major depressive disorder states, Ive been feeling down for 3 months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients affective symptoms? A. Have you been diagnosed with any physical disorder within the last 3 months? B. Have you ever felt this way before? C. People who have mood changes often feel better when spring comes. D. Help me understand what you mean when you say, feeling down?

ANS: D The nurse is using a clarifying statement in order to gather more details related to this clients mood.

1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

8. To plan effective care for patients with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. Are generally chronic. b. Have a physiological basis. c. Can be voluntarily controlled. d. Provide relief from health anxiety.

ANS: D At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide a secondary gain, patients frequently and fiercely cling to the symptoms. The symptoms tend to be chronic; however, this does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.

22. Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland

ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

18. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.

15. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity, related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

6. A patient who fears serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The patient says, "I have tightness in my chest and my heart misses beats. I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Antisocial personality disorder c. Simple somatic symptom disorder d. Prominent health anxiety (hypochondriasis)

ANS: D Prominent health anxiety (hypochondriasis) involves a preoccupation with fears of having a serious disease, even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Simple somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others.

5. A person attempts suicide by overdose, is treated in the emergency department, and is then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

26. A patient with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." The nurse should help the patient by: a. encouraging meditation. b. administering an anxiolytic medication. c. helping the patient visualize a pleasant scene. d. helping the patient focus on the here and now.

ANS: D Talking with someone who can help the patient focus on reality allows the patient to interrupt the stimulus to dissociate. The incorrect options foster detachment.

16. For a patient with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: a. functioning independently." b. verbalizing feelings of safety." c. regularly attending diversional activities." d. describing previously forgotten experiences."

ANS: D The ability to recall previously repressed or dissociated material is an indication that the patient is integrating identity and memory. A patient may verbalize feeling safe but may be disoriented and have memory deficits. A patient may be able to function independently on a basic level without being able to remember significant information. Attending activities is possible without being able to remember antecedent events.

23. An essential difference between somatic system disorders and dissociative disorders is: a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic. b. Dissociative disorders are precipitated by psychologic factors, whereas somatic system disorders are related to stress. c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound. d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychologic stress through somatic symptoms.

ANS: D The key is the only fully accurate statement. Somatic system disorders are not under voluntary control and are not culture bound.

16. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are most important and which are less important."

ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

8. A client is diagnosed with dissociative identity disorder (DID). What is the primary goal of therapy for this client? A. To recover memories and improve thinking patterns B. To prevent social isolation C. To decrease anxiety and need for secondary gain D. To collaborate among subpersonalities to improve functioning

ANS: D The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among subpersonalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the client's ability to function appropriately and achieve optimal personal potential.

7. A nurse assessing a patient with a somatic system disorder is most likely to note that the patient: a. Readily sees a relationship between symptoms and interpersonal conflicts. b. Rarely derives personal benefit from the symptoms. c. Has little difficulty communicating emotional needs. d. Has altered comfort and activity needs.

ANS: D The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic system disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.

23. A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

11. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."

ANS: D This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem-solving strategies.

26. A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response? a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."

ANS: D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.

20. A client, who is taking transdermal selegiline (Emsam) for depressive symptoms, states, "My physician told me there was no need to worry about dietary restrictions." Which would be the most appropriate nursing response? 1. "Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended." 2. "You must have misunderstood. An MAOI like Emsam always has dietary restrictions." 3. "Only oral MAOIs require dietary restrictions." 4. "All transdermal MAOIs do not require dietary modifications."

Ans: 1

4. Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client? 1. On his or her side, to prevent aspiration 2. In high Fowler's position, to prevent increased intracranial pressure 3. In Trendelenburg's position, to promote blood flow to vital organs 4. In prone position, to prevent airway blockage

Ans: 1

9. A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis? 1. Thyroid-stimulating hormone (TSH) level of 25 U/mL 2. Potassium (K+) level of 4.2 mEq/L 3. Sodium (Na+) level of 140 mEq/L 4. Calcium (Ca2+) level of 9.5 mg/dL

Ans: 1

25. A nursing instructor is teaching about the new DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD). Which of the following information should the instructor include? (Select all that apply.) 1. Symptoms include verbal rages or physical aggression toward people or property. 2. Temper outbursts must be present in at least two settings (at home, at school, or with peers). 3. DMDD is characterized by severe recurrent temper outbursts. 4. The temper outbursts are manifested only behaviorally. 5. Symptoms of DMDD must be present for 18 or more months to meet diagnostic criteria.

Ans: 1, 2, 3

24. A client is prescribed phenelzine (Nardil). Which of the following statements by the client should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) 1. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." 2. "I guess I will have to give up my glass of red wine with dinner." 3. "I'll have to be very careful about reading food and medication labels." 4. "I'm going to miss my caffeinated coffee in the morning." 5. "I'll be sure not to stop this medication abruptly."

Ans: 1, 2, 3, 5

22. A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) 1. Sad mood on most days 2. Mood rating of 2 out of 10 for the past 6 months 3. Labile mood 4. Sad mood for the past 3 years after spouse's death 5. Pressured speech when communicating

Ans: 1, 4

11. What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode? 1. The attention during the assessment is beneficial in decreasing social isolation. 2. Depression can generate somatic symptoms that can mask actual physical disorders. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed clients avoid addressing physical health and ignore medical problems.

Ans: 2

14. 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? 1. Provide a 6-month supply of Elavil to ensure long-term compliance. 2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments. 3. Provide pill dispenser as a memory aid. 4. Provide education regarding the avoidance of foods containing tyramine.

Ans: 2

16. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response? 1. "This combination of drugs can lead to delirium tremens." 2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." 3. "That's a good idea. There have been good results with the combination of these two drugs." 4. "The only disadvantage would be the exorbitant cost of the MAOI."

Ans: 2

17. A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client? 1. Zung Depression Scale 2. Hamilton Depression Rating Scale 3. Beck Depression Inventory 4. AIMS Depression Rating Scale

Ans: 2

18. The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms? 1. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions) 2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 3. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia) 4. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)

Ans: 2

21. After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem? 1. "Are you consuming foods high in tyramine?" 2. "How many packs of cigarettes do you smoke daily?" 3. "Do you drink any alcohol?" 4. "Are you taking St. John's wort?"

Ans: 2

5. A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? 1. Altered communication R/T feelings of worthlessness AEB anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered thought processes R/T hopelessness AEB persecutory delusions 4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

Ans: 2

23. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) 1. Gender differences in social opportunities that occur with age 2. Drastic temperature and barometric pressure changes 3. A seasonal increase in social interactions 4. Variations in serotonergic functioning 5. Inaccessibility of resources for dealing with life stressors

Ans: 2, 3, 4

1. A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why? 1. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure. 2. Establish room restrictions, because the client's threat is an attempt to manipulate the staff. 3. Place client on one-to-one suicide precautions, because specific plans likely lead to attempts. 4. Call an emergency treatment team meeting, because the client's threat must be addressed.

Ans: 3

10. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? 1. According to psychoanalytic theory, depression is a result of negative perceptions. 2. According to object-loss theory, depression is a result of overprotection. 3. According to learning theory, depression is a result of repeated failures. 4. According to cognitive theory, depression is a result of anger turned inward.

Ans: 3

13. A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam? 1. To rule out bipolar disorder 2. To rule out schizophrenia 3. To rule out neurocognitive disorder 4. To rule out personality disorder

Ans: 3

3. A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? 1. To prevent increased intracranial pressure resulting from anoxia. 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation. 3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles. 4. To prevent blocked airway, resulting from seizure activity.

Ans: 3

6. A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal. 2. Conducting 15-minute checks to ensure safety. 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations. 4. Encouraging client to express feelings related to suicide.

Ans: 3

8. A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse's priority at this time? 1. Give the client off-unit privileges as positive reinforcement. 2. Encourage the client to share mood improvement in group. 3. Increase the level of this client's suicide precautions. 4. Request that the psychiatrist reevaluate the current medication protocol.

Ans: 3

26. Order the depressive disorders and their predominant affective symptoms according to level of severity. ________ Dysthymic disorder (pessimistic outlook, low self-esteem) ________ Grief (feelings of anger, anxiety, guilt, helplessness) ________ Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia) ________ Transient depression (sadness, dejection, feeling downhearted, having "the blues")

Ans: 3, 2, 4, 1

12. A nurse is planning care for a 13 -year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Escitalopram (Lexipro)

Ans: 4

15. An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why? 1. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) 2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) 3. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI 4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

Ans: 4

19. A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives? 1. "It's all my fault for trusting him." 2. "I don't play games. I never win." 3. "She never visits because she thinks I don't care." 4. "I don't have a green thumb. Any old fool can grow a rose."

Ans: 4

2. In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? 1. The client will not physically harm self. 2. The client will express hope for the future by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will remain safe during hospital stay.

Ans: 4

7. A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis? 1. The client is disheveled and malodorous. 2. The client refuses to interact with others and isolates self in room. 3. The client is unable to feel any pleasure. 4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

Ans: 4

27. ___________________________ is a pervasive and sustained emotion that may have a major influence on a person's perception of the world.

Ans: Mood

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

B (The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.)

A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoid delusion." D. "The client is verbalizing a word salad."

B (The nurse should describe the client's statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.)

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

B (The nurse should focus on the client's feelings rather than attempt to change the client's delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.)

A college student has quit attending classes, isolates self due to hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

B (The nursing diagnosis that must be prioritized in this situation should be risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicates a potential for violence, and this potential safety issue should be prioritized.)

Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. Margaret is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. What is the priority nursing diagnosis for Margaret? 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 (Risk for injury related to hyperactivity)

A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client 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 (Tinnitus, severe diarrhea, ataxia)

A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

C (Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.)

A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.

C (It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.)

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 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. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."

C (The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.)

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

C (The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).)

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

C (The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.)

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

C (When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.)

Margaret, age 68, is diagnosed with Bipolar I Disorder, current episode manic. She is extremely hyperactive and has lost weight. What is one way to promote adequate nutritional intake for Margaret? A) Sit with her during meals to ensure that she eats everything on her tray. B) Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. C) Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." D) Tell Margaret that she will be on room restriction until she starts gaining weight.

C (Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run.")

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 (Quietly walk with her back to her room and help her change into something more appropriate.)

A child with bipolar disorder also has attention deficit/hyperactivity disorder (ADHD). How would these comorbid conditions most likely be treated? A) No medication would be given for either condition. B) Medication would be given for both conditions simultaneously. C) The bipolar condition would be stabilized first before medication for the ADHD would be given. D) The ADHD would be treated before consideration of the bipolar disorder.

C (The bipolar condition would be stabilized first before medication for the ADHD would be given.)

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

D (The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.)

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

D (The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.)

Which of the following 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 (Attention deficit/hyperactivity disorder)