Exam 2 Practice Questions- PSYCH

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply) a. Hypotension b. Paralytic ileus c. Memory loss d. Polyuria e. Confusion

c. Memory loss e. Confusion

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

c. Projection

Rene, a restaurant manager, is hospitalized after working 15-hour days for several weeks. Her anxiety level is severe upon admission. She has not slept well during the past 2 weeks. Her psychiatrist has ordered amitriptyline (Elavil) 25 mg, to be administered orally, three times daily. Rene asks you, her nurse, why she is so drowsy. What is your best response? A. "Drowsiness is a side effect of this medication." B. "Don't worry about being drowsy at this time." C. "Aren't you glad you will finally get to sleep?" D. "I will tell the doctor. I don't want you to fall."

A. "Drowsiness is a side effect of this medication." Amitriptyline is a TCA drug. Side effect is sedation/ drowsiness.

Choose Normal, Acute, or Chronic Anxiety for the following patient: Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name.

Acute anxiety

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and co-morbid anxiety disorder. Which of the following actions is the nurse's priority? a. placing the client on 1-to-1 observations b. assisting the client to perform ADLs c. encouraging the client to participate in counseling d. teaching the client about medication adverse effects

a. placing the client on 1-to-1 observations *priority in this situation is to prevent client from self-harm

A person who is speaking about a contender for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial.

a. reaction formation. Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise.

Statistically speaking, which TWO patients do you predict are at greatest risk for suicide? A. Ms. R, a 22-year-old grad student who is engaged B. Mr. M, a 34-year-old male with multiple sclerosis C. Mr. A, a 68-year-old Vietnam veteran with TBI D. Ms. G, a 25-year-old single Navajo mother who struggles with alcohol

C. Mr. A, a 68-year-old Vietnam veteran with TBI D. Ms. G, a 25-year-old single Navajo mother who struggles with alcohol *Although every patient who presents with possible suicidal ideation should be assessed equally, there may be additional risks for (a) veterans, especially with TBI (special risks); (b) older men (4 times as likely); (c) young American Indian adults (2.5 times more likely than their peers); and (d) those with mood disorders, (50%) and those who abuse alcohol (25%).

Choose Normal, Acute, or Chronic Anxiety for the following patient: Mr. Jones has not left his house for 3 months. He tells his family, "I know this is not normal, but I just can't go outside." His wife died 3 years earlier.

Chronic Anxiety

A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

b. hypertensive crisis.

A patient has committed suicide while under team care in your facility. A coworker says, "Why are we being called to a 'postmortem' meeting? We didn't do anything wrong." Which is your best explanation? A. There is almost always litigation after an inhouse suicide, and it only makes sense that someone must be held responsible. B. Staff are at high-risk for hurting themselves after a suicide. C. It's important that the entire team collaborate to make documentation say the right things. D. A postmortem assessment can help the team determine any changes that might be made in agency protocol to improve safety.

D. A postmortem assessment can help the team determine any changes that might be made in agency protocol to improve safety.

Choose Normal, Acute, or Chronic Anxiety for the following patient: Alex has a chemistry test this morning. She "crammed" for the test the previous night but did not study before. She has an upset stomach and headache.

Normal anxiety

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply) a. amenorrhea b. hypokalemia c. yellowing of the skin d. slightly elevated body weight e. presence of lanugo on the face

b. hypokalemia d. slightly elevated body weight

A new nurse says to a peer, "My newest patient is diagnosed with 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 diagnosed with schizophrenia." b. "Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs." c. "Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia."

a. "Let's reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia." Up to 10% of patients diagnosed 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 diagnosed with schizophrenia. Patients diagnosed 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.

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following statements as an overt comment about suicide? (Select all that apply) a. "My family will be better off if I'm dead" b. "The stress is my life is too much to handle" c. "I wish my life was over" d. "I don't feel like I can ever be happy again" e. "If I kill myself then my problems will go away"

a. "My family will be better off if I'm dead" c. "I wish my life was over" e. "If I kill myself then my problems will go away" *overt = talking direct about suicide

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? a. "stop screaming and walk with me outside" b. "why are you so angry and screaming at everyone?" c. "you will not get your way by screaming" d. "what was going through your mind when you started screaming?"

a. "stop screaming and walk with me outside" *set limits & use physical activity to de-escalate anger

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply) a. "what is your relationship like with your family?" b. "why do you want to lose weight?" c. "would you describe your current eating habits?" d. "at what weight do you believe you will look better?" e. "can you discuss your feelings about your appearance?"

a. "what is your relationship like with your family?" c. "would you describe your current eating habits?" e. "can you discuss your feelings about your appearance?"

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

a. 82-year-old white man b. 17-year-old white female adolescent e. 22-year-old man with traumatic brain injury 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.

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? a. AST/ALT and LDH b. creatinine and BUN c. WBC and granulocyte counts d. blood sodium and potassium

a. AST/ALT and LDH *Valproic Acid = potential to have hepatotoxicity

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.

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.

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

a. Altruism Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others.

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.

a. As depression lifts, physical energy becomes available to carry out suicide. 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.

Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Explore patient needs for health teaching. d. Assess for signs of impulsive eating.

a. Assist the patient to identify triggers to binge eating. For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? a. Cachexia b. Leukocytosis c. Hyperthermia d. Hypertension

a. Cachexia *means muscle/ body wasting leukocytosis =. increase in WBC, would be more likely to have leukopenia = decrease in WBC would be more likely to have hypothermia, hypotension

An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

a. Dementia Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse. a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

a. Distraction: "Let's go to the dining room for a snack." The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger.

A nurse is assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse expect? (Select all that apply) a. Excessive worry for 6 months b. Impulsive decision making c. Delated reflexes d. Restlessness e. Sleep disturbances

a. Excessive worry for 6 months d. Restlessness e. Sleep disturbances

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

a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lbs. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? a. Life isn't worth living if I gain weight b. Don't pretend like you don't know how fat I am c. If I could be skinny, I know I'd be popular d. When I look in the mirror, I see myself as obese

a. Life isn't worth living if I gain weight *client's perception of their appearance/situation is much worse than their current condition.

A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

a. Mashed potatoes, ground beef patty, corn, green beans, apple pie *Tyramine-free diet indicated when taking MAOIs *Tyramine foods: cheese, chocolate, caffeine, etc.

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

a. Rationalization Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

a. Risk of intimate partner violence

An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques

a. Social skills training

A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? (Select all that apply) a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

a. State the expectation that the patient will stay in control. d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. 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.

a. Supervise the patient 24 hours a day. The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Monitoring pupillary responses d. Assisting the patient to identify and test negative thoughts

a. Supporting physiologic stability During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability.

A nurse working in the ED is caring for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority? a. administer flumazenil b. identify the client's level of orientation c. infuse IV fluids d. prepare the client for gastric lavage

b. identify the client's level of orientation *assess patient first

A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.

a. Teach the person to use positive self-talk. This intervention, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient himself or herself to a pressured work schedule.

a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.

A nurse is planning care for a client following. surgical implantation of a VNS device. The nurse should plan to monitor for which of the following signs and symptoms? (Select all that apply) a. Voice changes b. Seizure activity c. Disorientation d. Cough e. Neck pain

a. Voice changes d. Cough e. Neck pain

An outpatient diagnosed with anorexia nervosa has begun re-feeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

a. assess lung sounds and extremities. Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure.

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply) a. conducting a suicide risk screening on all new clients b. creating a support group for family members of clients who completed suicide c. educating high school teens about suicide prevention d. initiating one-on-one observation for a client who has current suicidal ideation e. teaching middle-school educators about warning indicators of suicide

a. conducting a suicide risk screening on all new clients c. educating high school teens about suicide prevention e. teaching middle-school educators about warning indicators of suicide *primary interventions - any intervention aimed to PREVENT suicide

A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should: a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. teach the patient how to use pursed-lip breathing.

a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salt and fluids in the diet. Sodium depletion and dehydration increase the chance for developing lithium toxicity.

A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.

a. make sure adequate physical space exists between the nurse and the patient. Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened.

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

a. meals.

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."

b. "A score over 8 requires immediate hospitalization."

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient: a. "Restrict oral fluids for 24 hours and stay in bed." b. "Have someone bring you to the clinic immediately." c. "Drink a large glass of water with 1 teaspoon of salt added." d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."

b. "Have someone bring you to the clinic immediately." The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person.

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 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."

b. "I have no one for help or support." Lack of social support and social isolation increase the suicide risk

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider has not already stopped your medication."

b. "Taking the medication every day helps prevent relapses and recurrences."

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. "You look nice this morning." b. "You are wearing a new shirt." c. "I like the shirt you're wearing." d. "You must be feeling better today."

b. "You are wearing a new shirt." Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as an observation avoid negative interpretations. Saying "You look nice" or "I like your shirt" gives approval (nontherapeutic techniques). Saying "You must be feeling better today" is an assumption, which is nontherapeutic.

Which scenario presents the highest risk for a pregnancy resulting in an offspring with an intellectual developmental disability (IDD)? a. 18-year-old mother who received no prenatal care b. 32-year-old woman diagnosed with anorexia nervosa c. 26-year-old father with a history of episodic alcohol abuse d. 38-year-old father diagnosed with generalized anxiety disorder

b. 32-year-old woman diagnosed with anorexia nervosa *IDD most at risk w/ early embryonic development in pregnancy, which anorexia would put at a higher risk for due to malnutrition/ other potential medial issues Other risk factors for IDD are hereditary factors, trauma

An adult with paranoia becomes agitated and threatens to assault a staff person. Select the best initial nursing intervention. a. Tell the patient, "If you do not calm down, seclusion will be needed." b. Address the patient with simple directions and a calming voice. c. Help the patient focus by rubbing the patient's shoulders. d. Offer the patient a dose of antipsychotic medication. e. Reorient the patient to the time and place.

b. Address the patient with simple directions and a calming voice.

During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent

b. Affect flat; mood depressed *Mood is a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.

A patient says to the nurse, "My life does not have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint? a. Vegetative symptom b. Anhedonia c. Euphoria d. Anergia

b. Anhedonia

Mrs. H, 87, is anxious. She tells you she must go home immediately, saying: "My twins need me. They're barely a year old!" Select the best response. a. Help reorient her by explaining patiently that she is too old now to still have babies. b. Ask her questions to describe her need to go home and sympathize with how hard it can be to be away from home. c. Implement withdrawal and promise to return in 10 minutes when she is calmer and more rational. d. Reward her with attention when she focuses on reality.

b. Ask her questions to describe her need to go home and sympathize with how hard it can be to be away from home. *NOTE: It is cruel to try to reorient a patient who is not able to perceive their current life situation.

A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

b. Concerns stated aloud become less overwhelming and help problem solving to begin.

A nurse is caring for a client who smokes and has lung cancer. The client reports "I'm coughing because I have that cold that everyone has been getting". The client is using which of the following defense mechanisms? a. Reaction formation b. Denial c. Displacement d. Sublimination

b. Denial (pretending the truth is not reality to manage the anxiety of acknowledging what is real)

A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner, using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.

b. Describe the procedure again in a calm manner, using simple language.

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

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

A nurse is providing pre-op teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous". The client is experiencing which of the following levels of anxiety? a. Mild b. Moderate c. Severe d. Panic

b. Moderate (moderate anxiety decreases problem-solving and may hamper client's ability to understand information. Vital signs may increase somewhat, and client is visibly anxious)

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

b. Moderate Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level.

Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike next week. The adult replies, "I can't go because I don't have any hiking shoes." In actuality, this adult ears difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident? a. Displacement b. Rationalization c. Passive aggression d. Reaction formation

b. Rationalization *justifying an action to satisfy self/ others (self-deception)

A nurse is caring for a client who is prescribed lithium therapy. The client tells of the plan to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? a. That is a good choice, ibuprofen does not interact with lithium b. Regular aspirin would be a better choice than ibuprofen c. Lithium decreases the effectiveness of lithium d. The ibuprofen will make your lithium level too low

b. Regular aspirin would be a better choice than ibuprofen *Ibuprofen increases risk of lithium toxicity

After treatment for a detached retina, a victim of intimate partner violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

b. Risk for injury, related to partner's physical abuse when intoxicated Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent.

A patient diagnosed with major depressive disorder repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b. Risk for suicide A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

An older adult diagnosed with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care.

A nurse plans to lead a group in a residential facility for kindergarten-aged, abused children. Which strategy should the nurse incor- porate? a. Building a house using blocks b. Telling a story about a child who felt sad c. Drawing pictures of fun activities at a park d. Reading and discussing a book about abused children

b. Telling a story about a child who felt sad *storytelling is helpful in therapy/ understanding for children

A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

b. bring hyperactivity under rapid control. Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium is used for long-term control.

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassualtive stage of violence? (Select all that apply) a. lethargy b. defensive responses to questions c. disorientation d. facial grimacing e. agitation

b. defensive responses to questions d. facial grimacing e. agitation

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply) a. use caffeine in moderation to prevent relapse b. difficulty sleeping can indicate a relapse c. begin taking your medications as soon as relapse begins d. participating in psychotherapy can help prevent a release e. anhedonia is a clinical manifestation of a depressive relapse

b. difficulty sleeping can indicate a relapse d. participating in psychotherapy can help prevent a release e. anhedonia is a clinical manifestation of a depressive relapse

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply) a. hypothermia b. hallucinations c. muscular flaccidity d. diaphoresis e. agitation

b. hallucinations d. diaphoresis e. agitation

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Select all that apply) a. male sex b. history of chronic bronchitis c. recent death in client's family d. family history of depression e. personal history of panic disorder

b. history of chronic bronchitis c. recent death in client's family d. family history of depression e. personal history of panic disorder

A nurse is planning care for a client who has bipolar. disorder and is experiencing. a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) a. provide flexible client behavior expectations b. offer concise explanations c. establish consistent limits d. disregard client concerns e. use a firm approach with communication

b. offer concise explanations c. establish consistent limits e. use a firm approach with communication

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply) a. constipation b. polyuria c. rash d. muscle weakness e. tinnitus

b. polyuria d. muscle weakness

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet.

b. report increased suicidal thoughts. *SSRIs have black box warning for suicidal thoughts/ behavior

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? a. insist that the client stop yelling b. request that other staff members remain close by c. move as close to the client as possible d. walk away from the client

b. request that other staff members remain close by *to assist if necessary

A nurse working in an ED is assessing a preschool-aged child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (Select all that apply) a. abrasions on knees b. round burn marks on forearm c. mismatched clothing d. abdominal rebound tenderness e. areas of ecchymosis on torso

b. round burn marks on forearm e. areas of ecchymosis on torso

A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. 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."

c. "For the next 24 hours, I will not kill or harm myself in any way." *no loopholes!

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

c. "How did this happen to you?" *Obtaining the person's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? a. "I can expect my problems with PMDD to be worst when I'm menstruating" b. "I should avoid exercising when I am feeling depressed" c. "I am aware that my PMDD causes me to have rapid mood swings" d. "I should increase my caloric intake with a nutritional supplement when my PMDD is active"

c. "I am aware that my PMDD causes me to have rapid mood swings"

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."

c. "I have a plan that will fix everything." *looking for a COVERT/ concealed message here Comment alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

A patient is pacing the hall near the nurses' station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

c. "I'd like to talk with you about how you're feeling right now." With this response, the nurse is attempting to hear the patient's feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse.

A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse should advise the patient: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider." d. "Resume taking the antidepressant for 2 more weeks, and then discontinue it again."

c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider." *Amitriptyline is a tricyclic antidepressant The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice.

If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. "I don't know why it happens." b. "I have always had poor impulse control." c. "That person should not have provoked me." d. "Inside I am a coward who is afraid of being hurt."

c. "That person should not have provoked me."

A. charge nurse is discussing. the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "Care during the continuation phase focuses on treating continued manifestations of MDD" b. "The treatment of MDD during the maintenance phase lasts for 6-12 weeks" c. "The client is at greatest risk for suicide during the first weeks of an MDD episode" d. "Medication and psychotherapy are most effective during the acute phase of MDD"

c. "The client is at greatest risk for suicide during the first weeks of an MDD episode" *acute phase

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion? a. Borderline personality disorder b. Acute withdrawal related to a substance use disorder c. Bipolar disorder with rapid cycling d. Dysphoric disorder

c. Bipolar disorder with rapid cycling (indicated for major depressive disorder, schizophrenia spectrum disorders, and acute mania episodes aka bipolar with rapid cycling).

Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, apple *finger foods The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea *early signs of lithium toxicity

A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? a. ECT is the recommended initial treatment for bipolar disorder b. ECT is contraindicated for clients who are have suicidal ideation c. ECT is effective for clients who are experiencing severe mania d. ECT is prescribed to prevent relapse of bipolar disorder

c. ECT is effective for clients who are experiencing severe mania

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

c. Severe The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present

Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. asks, "What's the matter with me?" b. stays in a room alone and paces rapidly. c. can concentrate on what the nurse is saying. d. states, "I don't want anything to eat. My stomach is upset."

c. can concentrate on what the nurse is saying. The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, "What's the matter with me?" Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.

A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

c. carbamazepine (Tegretol)

When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

c. cognitive behavioral therapy. Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. consults the pharmacist when selecting over-the-counter medications. d. can identify foods with high selenium content, which should be avoided.

c. consults the pharmacist when selecting over-the-counter medications. *Phenelzine is a MAOI Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants.

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.

c. establish a rapport with the patient. *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

A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief.

c. explain the time lag before antidepressants relieve symptoms. Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients.

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

c. lamotrigine (Lamictal) *all anticonvulsants

Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

c. olanzapine (Zyprexa) Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger.

A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for providing poor care. The most likely explanation for this behavior lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm.

c. personality style that externalizes problems. Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves.

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? a. wide fluctuations in mood b. report of a minimum of five clinical findings of depression c. presence of manifestation for at least 2 years d. inflated sense of self-esteem

c. presence of manifestation for at least 2 years

A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

c. put a blanket around the patient, and walk with the patient to a quiet room. Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach.

While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance.

c. recognizing symptoms of hypokalemia. Hypokalemia results from potassium loss associated with vomiting.

A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. acrophobia. b. agoraphobia. c. social anxiety disorder (social phobia). d. Post-traumatic stress disorder (PTSD).

c. social anxiety disorder (social phobia).

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.

c. suicide potential. 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.

A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin does not seem to solve your problems. You are thin now but still unhappy."

d. "Being thin does not seem to solve your problems. You are thin now but still unhappy." (attempts to question patient's distorted thinking)

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? a. "It is common to treat depression with ECT before trying medications" b. "I can have my depression cured if I receive a series of ECT treatments" c. "I should receive ECT once a week for 6 weeks" d. "I will receive a muscle relaxant to protect me from injury during ECT"

d. "I will receive a muscle relaxant to protect me from injury during ECT"

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? a. "TMS is indicated for clients who have schizophrenia spectrum disorder" b. "I will provide post anesthesia care following TMS" c. "TMS treatments usually last 5 to 10 minutes" d. "I will try to schedule the client for TMS treatments 3 to 5 times a week for the first several weeks"

d. "I will try to schedule the client for TMS treatments 3 to 5 times a week for the first several weeks" (TMS is commonly prescribed 3-5 times a week for the first 4-6 weeks)

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."

d. "Let's consider which problems are most important and which are less important." 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.

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

d. A 79-year-old single white man with cancer of the prostate gland 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.

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "Monitor for complications of re-feeding." Which body system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular

d. Cardiovascular Re-feeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse.

Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure

d. Congestive heart failure The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function.

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

d. Imbalanced nutrition: less than body requirements, related to self-starvation *priority is physiological need of nutrition first

Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

d. Patient expresses satisfaction with body appearance. Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

d. Psychoeducation During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation.

A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence

d. Risk for other-directed violence

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. This baby is the root of my problems." The priority nursing diagnosis is: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence

d. Risk for other-directed violence *Risk for harm diagnoses become priority in mental health/ safety situatuons. When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.

Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

d. Systolic blood pressure: 62 mm Hg

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? a. a client's verbal threat of suicide is attention-seeking behavior b. interventions are ineffective for clients who really want to commit suicide c. using the term suicide increases the client's risk for a suicide attempt d. a no-suicide contract decreases the client's risk for suicide

d. a no-suicide contract decreases the client's risk for suicide

A patient experiencing severe anxiety suddenly begins running and shouting, "I'm going to explode!" The nurse should: a. say, "I'm not sure what you mean. Give me an example." b. chase after the patient, and give instructions to stop running. c. capture the patient in a basket-hold to increase feelings of control. d. assemble several staff members and state, "We will help you regain control."

d. assemble several staff members and state, "We will help you regain control."

A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.

d. cognitive restructuring.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is the priority to report to the provider? a. current medical conditions include diabetes that is controlled by diet b. recent medications include a course of prednisone for acute bronchitis c. current vaccinations include a flu vaccine last month d. current medications include furosemide for congestive heart failure

d. current medications include furosemide for congestive heart failure *lithium contraindicated in severe renal or cardiac disease

A nurse is caring for a client on suicide precautions. Which of the following interventions should the nurse include in the plan of care? a. assign the client to a private room b. document the client's behavior every hour c. allow the client to keep perfume in her room d. ensure that the client swallows medication

d. ensure that the client swallows medication *important because this prevents hoarding of medications/ attempt to exceed prescribed dose

A person attempts suicide by overdose, is treated in the emergency department, and 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.

d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence.

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.

d. experiencing hopelessness.

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing intervention? a. set consistent limits for expected client behavior b. administer prescribed medications as scheduled c. provide the client with step-by-step instructions during hygiene activities d. monitor the client for escalating behavior

d. monitor the client for escalating behavior *safety is priority here

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

d. passive aggression. A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others.

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. focusing on weight control mechanisms and food preparation. d. processing the heightened anxiety associated with eating.

d. processing the heightened anxiety associated with eating. Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals.

Information from a patient's record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. substance abuse.

d. substance abuse. The nurse should suspect marginal coping skills in a patient with substance abuse. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.