Chapters 4 & 6

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which potentially fatal side effect will the nurse teach the client about? 1. Agranulocytosis 2. Akathisia 3. Dystonia 4. Akinesia

ANS: 1 Agranulocytosis is a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels, placing the client at great risk for infections.

In the treatment of anxiety disorders, benzodiazepines (such as Ativan and Xanax) are indicated for_________ use and have__________ abuse potential. 1. short-term; high 2. long-term; high 3. short-term; low 4. long-term; low

ANS: 1 Because tolerance to these medications occurs, there is high risk for abuse. Therefore, they should be used as a short-term intervention for anxiety.

A psychiatrist prescribes a MAOI for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid? 1. Pepperoni pizza and red wine 2. Bagels with cream cheese and tea 3. Apple pie and coffee 4. Potato chips and Diet Coke

ANS: 1 Both these foods are high in tyramine.

A client with depression and substance abuse has an interrupted sleep pattern. She demands that her psychiatrist prescribe her a sedative. What teaching would the nurse provide about the rationale for the use of non-pharmacological interventions instead? 1. "Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as one builds up tolerance to them." 2. "Sedative-hypnotics work best in combination with other techniques." 3. "Sedative-hypnotics are not permitted for use in patients with substance abuse disorders." 4. "Sedative-hypnotics are not as effective as the antidepressant medications for treating sleep disturbances."

ANS: 1 Sedative-hypnotics are potentially addictive and should be used with caution by clients with a history of substance abuse. Tolerance can easily develop.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." 1. Restatement 2. Offering general leads 3. Focusing 4. Accepting

ANS: 1 The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. It allows the client to know whether the statement has been understood and provides an opportunity to continue.

Which client action should a nurse expect during the working phase of the nurse-client relationship? 1. The client gains insight and incorporates alternative behaviors. 2. The client establishes rapport with the nurse and mutually develops treatment goals. 3. The client explores feelings related to reentering the community. 4. The client explores personal strengths and weaknesses that impact behavioral choices.

ANS: 1 The nurse should expect that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship.

Joey, age 8 years, takes methylphenidate (Ritalin) for attention deficit/hyperactivity disorder. His mother complains to the nurse that Joey has a very poor appetite, and she struggles to help him gain weight. What teaching will the nurse provide? 1. Administer Joey's medication immediately after meals. 2. Administer Joey's medication at bedtime. 3. Skip a dose of the medication when Joey does not eat anything. 4. Assure Joey's mother that Joey will eat when he is hungry.

ANS: 1 To reduce the anorexia associated with methylphenidate (Ritalin), the medication should be given after meals.

Which information suggests that caution is necessary in prescribing a benzodiazepine to an anxious client? 1. The client has a history of alcohol dependence. 2. The client has a history of diabetes mellitus. 3. The client has a history of schizophrenia. 4. The client has a history of hypertension.

ANS: 1 Tolerance and psychological dependence are common problems with the long-term use of benzodiazepines. They should be used cautiously with clients who have a history of substance abuse.

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? 1. Clarify personal attitudes, values, and beliefs. 2. Obtain thorough assessment data. 3. Determine the client's length of stay. 4. Establish personal goals for the interaction.

ANS: 1 The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding one's own attitudes, values, and beliefs is called self-awareness.

Which of the following individuals are communicating a message? (Select all that apply.) 1. A mother spanking her son for playing with matches 2. A teenage boy isolating himself and playing loud music 3. A biker sporting an eagle tattoo on his biceps 4. A teenage girl writing, "No one understands me" 5. A father checking for new email on a regular basis

ANS: 1, 2, 3, 4

The nurse is preparing to assess a client before the physician prescribes a regimen of psychopharmacological therapy. Which components will the nurse assess? (Select all that apply.) 1. Medical history 2. Physical examination findings 3. Ethnocultural characteristics 4. Current medication

ANS: 1, 2, 3, 4 1. The nurse should assess medical history. 2. The nurse should assess physical examination findings. 3. The nurse should assess ethnocultural characteristics. 4. The nurse should assess current medications.

When used in combination with anxiolytic medication, alcohol leads to _____________ effects, and caffeine leads to _______________ effects. 1. increased; increased 2. increased; decreased 3. decreased; decreased 4. decreased; increased

ANS: 2 Anxiolytic medications work through depression of certain central nervous system (CNS) functions.

A client was recently admitted to the inpatient unit after a suicide attempt and has not responded to SSRIs or tricyclic antidepressants. The client asks the nurse, "I heard about monoamine oxidase inhibitors (MAOIs). Why can't they be added to what I am on now? Wouldn't adding one help?" Which is the appropriate nursing response? 1. "Electroconvulsive therapy is your best option at this point." 2. "Combined use can lead to a life-threatening condition called hypertensive crisis." 3. "There is no reason why an MAOI couldn't be added to your therapy." 4. "They can't be used together because their mechanisms of action are very different."

ANS: 2 If MAOIs are taken with other antidepressants, a hypertensive crisis could result.

Which statement about the tricyclic group of antidepressant medications is accurate? 1. Strong or aged cheese should not be eaten while taking them. 2. Their full therapeutic potential may not be reached until 4 weeks. 3. They may cause hypomania or recent memory impairment. 4. They should not be given with antianxiety agents.

ANS: 2 It may take several weeks for tricyclic medications to reach their full therapeutic effect.

A mother rescues two of her four children from a house fire. In an emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? 1. "The smoke was too thick. You couldn't have gone back in." 2. "You're experiencing feelings of guilt, because you weren't able to save your children." 3. "Focus on the fact that you could have lost all four of your children." 4. "It's best if you try not to think about what happened. Try to move on."

ANS: 2 The best response by the nurse is, "You're experiencing feelings of guilt, because you weren't able to save your children." This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

A nurse maintains an uncrossed arm and leg posture when communicating with a client. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? 1. S 2. O 3. L 4. E 5. R

ANS: 2 The nurse should identify that maintaining an uncrossed arm and leg posture is nonverbal behavior that reflects the O in the active-listening acronym SOLER.

A client diagnosed with post traumatic stress disorder related to a rape is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique might a nurse use that is an example of "broad openings"? 1. "What occurred prior to the rape, and when did you go to the emergency department?" 2. "What would you like to talk about?" 3. "I notice you seem uncomfortable discussing this." 4. "How can we help you feel safe during your stay here?"

ANS: 2 The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of a broad opening. Using broad openings allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship? 1. Acknowledge the client's actions, and generate alternative behaviors. 2. Establish rapport and develop treatment goals. 3. Attempt to find alternative placement. 4. Explore how thoughts and feelings about this client may adversely impact nursing care.

ANS: 2 The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client, based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the client about? 1. Blurring vision and muscular weakness 2. Sore throat, fever, and malaise 3. Tremor, shuffling gait, and rigidity 4. Fine tremor, tinnitus, and nausea

ANS: 2 These are symptoms of agranulocytosis, which is a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels. This places the client at great risk for infections.

A client was recently admitted to the inpatient unit after a suicide attempt. He has been placed on a tricyclic antidepressant. In terms of medication, what steps should be taken to maintain the client's safety when he is discharged? 1. Provide a 6-month supply to ensure long-term compliance. 2. Provide a 1-week supply of medication, with refills authorized only after he visits his provider. 3. Encourage him to increase fluid intake to counteract the common side effect of diarrhea. 4. Educate him not to eat foods that contain tyramine.

ANS: 2 To prevent suicide through overdose on antidepressant medication, a limited supply should be given at discharge. Clients with a history of depression who have a lifting of mood may have an increased risk for suicide. Giving the client a larger supply of antidepressant medication increases the chances of overdose.

A physician prescribes an additional medication for a client taking an antipsychotic agent. The medication is to be administered "prn for EPS." When will the nurse plan to give this medication? 1. When the client's white blood cell count falls below 3,000/mm3 2. When the client exhibits tremors and a shuffling gait 3. When the client complains of dry mouth 4. When the client experiences a seizure

ANS: 2 Tremors and a shuffling gait are examples of extrapyramidal side effects (EPS). The other options are not examples of extrapyramidal side effects.

When an individual is "two-faced," which characteristic—essential to the development of a therapeutic relationship—should a nurse identify as missing? 1. Respect 2. Genuineness 3. Sympathy 4. Rapport

ANS: 2 When an individual is "two-faced," which means double-dealing or deceitful, the nurse should identify that genuineness is missing in the relationship. Genuineness refers to the nurse's ability to be open and honest and maintain congruence between what is felt and what is communicated. When a nurse fails to bring genuineness to the relationship, trust cannot be established.

Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.) 1. Meeting the psychological needs of the nurse and the client 2. Ensuring therapeutic termination 3. Promoting client insight into problematic behavior 4. Collaborating to set appropriate goals 5. Meeting both the physical and psychological needs of the client

ANS: 2, 3, 4, 5

The nurse is assessing a client who has a diagnosis of schizophrenia and takes an antipsychotic agent daily. Which finding requires further nursing assessment? 1. Respirations of 22 beats/minute 2. Weight gain of 8 lbs. in 2 months 3. Temperature of 101 degrees F 4. Excess salivation

ANS: 3 A fever could be one of the first signs of an infection caused by reduced immunity from agranulocytosis secondary to antipsychotic medication.

Which medication is most likely to be prescribed for the extrapyramidal side effects of antipsychotic medications? 1. Diazepam (Valium) 2. Amitriptyline (Elavil) 3. Benztropine (Cogentin) 4. Methylphenidate (Ritalin)

ANS: 3 Benztropine (Cogentin) is one of the most commonly used medications for extrapyramidal side effects.

A client is diagnosed with anxiety disorder. Which medication is prescribed for anxiety? 1. Chlorpromazine (Thorazine) 2. Clozapine (Clozaril) 3. Diazepam (Valium) 4. Methylphenidate (Ritalin)

ANS: 3 Diazepam (Valium) is an antianxiety agent.

An aging client with chronic schizophrenia takes a beta-adrenergic blocking agent (propranolol) for hypertension and an antipsychotic. Given the combined side effects of these drugs, what teaching should the nurse provide? 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 The antipsychotic medication can cause orthostatic hypotension that could be magnified by the propranolol.

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? 1. "Why did you use the client's name on your clinical worksheet?" 2. "You were very careless to refer to your client by name on your clinical worksheet." 3. "Surely you didn't do this deliberately, but you breeched confidentiality by using names." 4. "It is disappointing that after being told you're still using client names on your worksheet."

ANS: 3 The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using names," is an example of effective feedback. Feedback is method of communication for helping others consider a modification of behavior.

A client exhibiting dependent behaviors says, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate? 1. "It would be best to do that in order to increase independence." 2. "Why would you want to leave a secure home?" 3. "Let's discuss and explore all of your options." 4. "I'm afraid you would feel very guilty leaving your parents."

ANS: 3 The most appropriate response by the nurse is, "Let's discuss and explore all of your options." In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

Which therapeutic communication technique is being used in the following nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" 1. Reflecting 2. Making observations 3. Formulating a plan of action 4. Giving recognition

ANS: 3 The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking. The use of this technique may serve to prevent anger or anxiety from escalating.

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship? 1. "I can't bear the thought of leaving here and failing." 2. "I might have a hard time working with you, because you remind me of my mother." 3. "I really don't want to talk any more about my childhood abuse." 4. "I'm not sure that I can count on you to protect my confidentiality."

ANS: 3 The nurse should identify that the client statement, "I really don't want to talk any more about my childhood abuse," reflects that the client is in the working phase of the nurse-client relationship. The working phase includes overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

The nurse is interviewing a newly admitted psychiatric client. Which of the following nursing statements is an example of offering a "general lead"? 1. "Do you know why you are here?" 2. "Are you feeling depressed or anxious?" 3. "Yes, I see. Go on." 4. "Can you order the specific events that led to your admission?"

ANS: 3 The nurse's statement, "Yes, I see. Go on," is an example of a general lead. Offering general leads encourages the client to continue sharing information.

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 lbs. since then. Which is the appropriate nursing response? 1. "I'm surprised you have gained; weight loss is the typical pattern when taking lithium." 2. "Your weight gain is more likely related to food intake than medication." 3. "Weight gain is a common, but troubling side effect. Let's talk about some strategies for safely improving your nutrition and exercise habits." 4. "There's not much you can do about the weight gain. It's better than being emotionally unstable, though."

ANS: 3 Weight gain is a common side effect of lithium therapy. To ensure compliance the nurse should help the client develop strategies to prevent excessive weight gain.

Which medication does not require periodic blood-level monitoring? 1. Eskalith (lithium carbonate) 2. Depakote (valproic acid) 3. Clozaril (clozapine) 4. Paxil (paroxetine)

ANS: 4 Blood level monitoring is usually not done for Paxil (paroxetine).

A client takes a maintenance dosage of lithium carbonate for a bipolar disorder. She has come to the community health clinic, stating that she "has had the flu for over a week." She describes her symptoms as coughing, runny nose, chest congestion, fever, and gastrointestinal upset. Her temperature is 100.9°F. What situation does the nurse anticipate? 1. She has consumed some foods high in tyramine. 2. She has stopped taking her lithium carbonate. 3. She has probably developed a tolerance to the lithium carbonate. 4. The lithium carbonate may be producing symptoms of toxicity.

ANS: 4 Blurred vision, gastrointestinal upset, and tinnitus are symptoms of lithium toxicity.

As part of discharge teaching, which guideline regarding lithium therapy will the nurse plan to include? 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000mL of fluid per day. 4. All of the above

ANS: 4 Caffeine, a stimulant, should be limited in clients with mania. Adequate sodium and fluid intake is necessary to prevent lithium toxicity.

A client was recently admitted to the inpatient unit after a suicide attempt and is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse teaches the client about serotonin syndrome. Which of the following is a symptom of serotonin syndrome? 1. Change in mental status 2. Myoclonus 3. Blood pressure lability 4. Priapism

ANS: 4 Impotence may be a side effect of an SSRI antidepressant.

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? 1. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." 2. "It is important for you to discontinue these ritualistic behaviors." 3. "Why are you asking for help, if you won't participate in unit therapy?" 4. "Let's figure out a way for you to attend unit activities and still wash your hands."

ANS: 4 The most appropriate statement by the nurse is, "Let's figure out a way for you to attend unit activities and still wash your hands." This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

On which task should a nurse place priority during the working phase of relationship development? 1. Establishing a contract for intervention 2. Examining feelings about working with a particular client 3. Establishing a plan for continuing aftercare 4. Promoting the client's insight and perception of reality

ANS: 4 The nurse should place priority on promoting the client's insight and perception of reality during the working phase of relationship development.

A mother who is notified that her child was killed in a tragic car accident states, "I can't bear to go on with my life." Which nursing statement conveys empathy? 1. "This situation is very sad, but time is a great healer." 2. "You are sad, but you must be strong for your other children." 3. "Once you cry it all out, things will seem so much better." 4. "It must be horrible to lose a child, and I'll stay with you until your husband arrives."

ANS: 4 The nurse's response, "It must be horrible to lose a child, and I'll stay with you until your husband arrives," conveys empathy to the client. Empathy is the ability to see the situation from the client's point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

A nurse says to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? 1. The therapeutic technique of giving advice 2. The therapeutic technique of defending 3. The nontherapeutic technique of presenting reality 4. The nontherapeutic technique of giving reassurance

ANS: 4 The nurse's statement, "Things will look better tomorrow after a good night's sleep," is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.

What is a nurse's purpose for providing appropriate feedback? 1. To give the client good advice 2. To advise the client on appropriate behaviors 3. To evaluate the client's behavior 4. To give the client critical information

ANS: 4 The purpose of providing appropriate feedback is to give the client critical information.

A client is experiencing a psychotic episode. He is in good physical health but has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Which antipsychotic medication would be contraindicated for the client? 1. Haloperidol, because it is used only in elderly patients 2. Clozapine, because it is incompatible with desipramine 3. Risperidone, because it exacerbates symptoms of depression 4. Thioridazine, because of cross-sensitivity among phenothiazines

ANS: 4 There may be cross-sensitivity among phenothiazines. Both prochlorperazine (Compazine) and thioridazine (Mellaril) are phenothiazines. Since the client has a known allergy to one phenothiazine, he should not be given another phenothiazine.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which blood cell counts would reveal a potentially fatal side effect of this medication? 1. WBCs, >3,000/mm3; granulocytes, >2,000/mm3 2. WBCs, <3,000/mm3; granulocytes, >2,000/mm3 3. WBCs, >3,000/mm3; granulocytes, <2,000/mm3 4. WBCs, <3,000/mm3; granulocytes, <2,000/mm3

ANS: 4 These blood test results are indicative of agranulocytosis, a potentially fatal disorder in which the client's white blood cell count drops to extremely low levels.

A client was admitted with major depression that was a single episode and moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg orally every day. The nurse's discharge teaching should include all of the following except: 1. Continue taking Prozac as prescribed. You will continue to see improvement over the next few weeks. 2. Make sure that you follow up with outpatient psychotherapy as you and the social worker have arranged. 3. You may be able to discontinue the medication within 6 months to 1 year, but only under a doctor's supervision. However, there is a chance of recurring episodes. 4. You should avoid foods with tyramine, including beer, beans, processed meats, and red wine.

ANS: 4 This is true regarding MAOIs, not an SSRI antidepressant, such as fluoxetine.

A client has been diagnosed with major depression and is prescribed imipramine (Tofranil). What information specifically related to this class of antidepressants will the nurse plan to include in client and family education? 1. The medication may cause dry mouth. 2. The medication may cause nausea. 3. The medication should not be discontinued abruptly. 4. The medication may cause photosensitivity.

ANS: 4 Tricyclic antidepressants cause photo sensitivity.

If a client demonstrates transference toward a nurse, how should the nurse respond? 1. Promote safety and immediately terminate the relationship with the client. 2. Encourage the client to ignore these thoughts and feelings. 3. Immediately reassign the client to another staff member. 4. Help the client to clarify the meaning of the relationship, based on the present situation.

ANS: 4 The nurse should respond to a client's transference by clarifying the meaning of the nurse-client relationship based on the present situation. Transference occurs when the client unconsciously displaces feelings about a person from the past toward the nurse

___________________ refers to a nurse's behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse's past.

countertransference

The term ________________________ implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.

rapport