Final Exam PCC AQ

A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be? 1 Staying physically close to the client 2 Gently asking what is bothering the client 3 Telling the client to try to relax by sitting quietly 4 Getting the client involved in a nonthreatening activity

1 . Staying physically close to the client By staying physically close, the nurse conveys the message that someone cares enough to be there and that the client is a person worthy of care. The client is incapable of telling anyone what the problem is. Sitting still will increase the tension the client is experiencing. Involving the client in a nonthreatening activity is not an initial nursing intervention.

A healthcare provider prescribes lithium carbonate for a client with bipolar disorder, depressive episode. What instructions will the nurse include when teaching the client about lithium? Select all that apply. 1 Take the medication with food. 2 Adjust the dosage if your mood improves. 3 Have a snack with milk before going to bed. 4 It may take several weeks for beneficial results to occur. 5 You do not have to restrict your intake of dietary sodium.

1, 4, 5 Lithium should be taken with food to prevent gastric irritation. It will take 1 to 3 weeks before beneficial results occur. Lithium decreases sodium resorption by the renal tubules. If sodium intake is decreased, sodium depletion may occur. In addition, lithium retention is increased when sodium intake is decreased; restricted sodium intake can lead to lithium toxicity. The dosage should not be adjusted without healthcare provider supervision. It is not necessary to have a snack with milk when the client goes to bed.

Which priority assessments should be included by the nurse when caring for a client who is experiencing depression? Select all that apply. 1 Appetite 2 Irritability 3 Restlessness 4 Activity status 5 Emotional status

1, 4, 5 The priority assessment for a client experiencing depression is to inquire about appetite, activity status, and emotional status. These helps determine the level of depression. Irritability and restlessness are secondary assessments for determining the depression level of a client.

Schizophrenia is associated with negative symptoms. In the assessment of a client with schizophrenia, which symptoms are classified as negative symptoms? Select all that apply. 1 Lack of energy 2 Poor grooming 3 Illogical speech 4 Ideas of reference 5 Agitated behavior

1,2 A lack of energy (anergy) is a negative symptom associated with schizophrenia. Inadequate grooming results from apathy and lack of energy and is a negative symptom associated with schizophrenia. Illogical speech that reflects disorganized thinking is a positive symptom of schizophrenia type 1. Ideas of reference, a thought process in which a person believes he or she is the object of environmental attention, is a positive symptom of schizophrenia. Agitated, hostile, angry, and violent behaviors are positive symptoms of schizophrenia.

The nurse is supporting cognitive ability in clients with Alzheimer disease. Which actions will the nurse take? Select all that apply. 1 Encouraging caregivers to support safe independence 2 Using calendars, clocks, and pictures to support memory 3 Providing a limited number of choices to support decision-making 4 Quizzing the client regularly to assess orientation to person, place, and time 5 Administering prescribed rivastigmine to the client with severe Alzheimer dementia

1,2,3 Strategies that assist orientation without challenging the client and that encourage safe independence and decision-making support cognitive function in Alzheimer disease, such as clocks, calendars, limited number of choices, and allowing safe independence. Interactions that quiz or challenge the client are not well tolerated and do not support cognitive functioning. Alzheimer dementia is characterized by cerebral atrophy and by the presence of neurofibrillary tangles and amyloid plaques. Rivastigmine is a cholinesterase inhibitor that provides a modest short-term cognitive benefit for some people with mild to moderate Alzheimer dementia. It works by increasing acetylcholine at cholinergic synapses. It is not approved for people with severe disease.

The nurse assesses a client with bipolar disorder. While reviewing the laboratory reports, the nurse finds the client's lithium levels are 1.3 mEq/L (1.3 mmol/L). Which nursing intervention would be appropriate in this client? 1 Continuing to administer the drug 2 Administering phenothiazine antipsychotics along with lithium 3 Notifying the primary healthcare provider of the lithium levels 4 Withdrawing the drug by consulting primary healthcare provider

1. The normal range of lithium is below 1.5 mEq/L (1.5 mmol/L). Because the serum lithium level is 1.3 mEq/L (1.3 mmol/L), the nurse should continue administering the drug. Administration of phenothiazine antipsychotics should be avoided because they may cause anticholinergic effects when used with lithium. The primary healthcare provider does not need to be consulted, and the drug should not be withdrawn.

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client? 1 A loss of atrial kick 2 No physiologic changes 3 Increased cardiac output 4 Decreased risk of pulmonary embolism

1. A loss of atrial kick Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The atrioventricular (AV) node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. This irregularity is called "irregularly irregular." The ineffectual contraction of the atria results in loss of "atrial kick." If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The client may or may not be aware of the atrial fibrillation. If the ventricular response is rapid, the client may show signs of decreased cardiac output or worsening of heart failure symptoms.

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary healthcare provider prescribes the anticholinergic medication benztropine, 2 mg daily. What will the nurse assess the client for daily when administering these medications together? 1 Constipation 2 Hypertension 3 Increased salivation 4 Excessive perspiration

1. Constipation The anticholinergic activity of each drug is magnified, and adverse effects such as paralytic ileus may occur. Hypotension, not hypertension, occurs with anticholinergic medications. Dryness of the mouth, not increased salivation, occurs with anticholinergic medications. Decreased, not increased, perspiration occurs with anticholinergic medications.

Which autoantigens are responsible for the development of Crohn's disease? 1 Crypt epithelial cells 2 Thyroid cell surface 3 Basement membranes of the lungs 4 Basement membranes of the glomeruli

1. Crypt epithelial cells

A client with a history of schizophrenia has recently begun reporting symptoms of depression and is now prescribed a selective serotonin reuptake inhibitor (SSRI). In light of the information in the client's chart, what is the nurse's priority? 1 Educating both the client and family on how to identify the early signs of extrapyramidal symptoms 2 Requesting a gastrointestinal consult to identify the cause of the client's need for frequent antacids 3 Stressing the importance of managing the client's diet while taking the prescribed antidepressant 4 Discussing the stressors that have developed since the client moved in with the sister and brother-in-law

1. Educating both the client and family on how to identify the early signs of extrapyramidal symptoms Extrapyramidal symptoms can result from antipsychotic medication therapy, and the risk is increased when the treatment plan includes an SSRI antidepressant. The cause of the frequent use of antacids should be explored, but does not take priority in this situation. A well-balanced diet is always important, but the importance of diet management would still exist if the antidepressant were a monoamine oxidase inhibitor (MAOI) and not an SSRI. Identifying and addressing stressors is important, but it does not take priority in this situation.

A client is hospitalized with an overdose of benzodiazepines and presents with a respiratory rate less than 10 breaths per minute. Which nursing intervention should be provided as the first priority? 1 Give oxygen. 2 Secure airway. 3 Administer flumazenil. 4 Assess the intravenous site.

1. Give oxygen Oxygen should be given as the first priority intervention for clients with a respiratory rate below 10 breaths per minute due to an overdose of benzodiazepines. Securing the airway is done before starting benzodiazepine antagonist therapy. Drugs such as flumazenil should be administered after providing the client with a sufficient oxygen supply. An intravenous site should be assessed because flumazenil can cause thrombophlebitis at the injection site.

The registered nurse is teaching about tricyclic antidepressant drugs to a nursing student. Which statement made by the nursing student indicates the need for further teaching? Select all that apply. 1 Nortriptyline is contraindicated in older clients. 2 Desipramine is preferred for use in elderly clients. 3 Imipramine is used as an adjunct in the treatment of childhood enuresis. 4 Tricyclic antidepressant drugs are prescribed for clients with seizure disorders. 5 Tricyclic antidepressant drugs are contraindicated in clients with a history of seizures.

1. Nortriptyline is contraindicated in older clients. 4. Tricyclic antidepressant drugs are prescribed for clients with seizure disorders. Nortriptyline is a preferred tricyclic antidepressant drug that can be safely administered in elderly clients. Antiepileptic drugs are prescribed to clients with seizures. Desipramine and nortriptyline are preferred tricyclic antidepressant drugs for use in elderly clients. Childhood enuresis necessitates the administration of imipramine. Clients with epilepsy should not be prescribed tricyclic antidepressant drugs, to avoid the risk of medical complications.

Which manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. 1. Pericarditis 2.Esophagitis 3.Fibrotic skin 4.Discoid lesions 5.Pleural effusions

1. Pericarditis 4. Discoid lesions 5. Pleural effusions SLE is a chronic, progressive inflammatory connective tissue disorder that can cause major organs and systems to fail. Pericarditis is a cardiovascular manifestation of SLE. Discoid lesion is a skin manifestation that is a key indicator of the presence of SLE. Pleural effusion, a pulmonary manifestation, is a key indicator of the presence of SLE. Esophagitis is one of the gastrointestinal manifestations of systemic sclerosis. Fibrotic skin is one of the skin manifestations of systemic sclerosis.

Which drugs are used as the first-line treatment for posttraumatic stress disorder (PTSD)? Select all that apply. 1 Sertraline 2 Paroxetine 3 Phenelzine 4 Venlafaxine 5 Amitriptyline

1. Sertraline 2. Paroxetine Sertraline and paroxetine are selective serotonin reuptake inhibitors that are approved by the Food and Drug Administration as a first-line treatment for posttraumatic stress disorder ( PTSD). If these drugs are ineffective, the use of phenelzine, venlafaxine, and amitriptyline is indicated.

Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. What is the most important intervention for a client who is given an as-needed medication and confined to involuntary seclusion? 1 Continue intensive nursing interactions. 2 Evaluate the client's progress toward self-control. 3 Determine whether any staff member has been injured. 4 Observe the client for side effects of the medication given.

2 For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.

A nurse is conducting an initial assessment of a client with the diagnosis of paranoid schizophrenia. Which assessment is the major concern for the nurse? 1 Continuous pacing 2 Suspicious feelings 3 Lack of love for parents 4 Disregard for the feelings of others

2 Suspicious feelings may interfere with the development of a trusting nurse-client relationship. Also, a person who is suspicious may protect himself or herself through the use of verbal or physical aggression. Safety is a priority, as is the development of a therapeutic nurse-client relationship. Continuous pacing is not a problem, because the nurse can accompany a pacing client. Lack of love for parents is not an initial concern. Disregard for the feelings of others is not an initial concern unless it jeopardizes the safety of others. There are no data indicating that it is a safety issue.

A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? 1 Chronic confusion 2 Disordered thinking 3 Defined personal boundaries 4 Violence directed toward others

2 The schizophrenic individual has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.

A client with a history of atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? 1 Memory impairment 2 Abrupt onset of symptoms 3 Difficulty making decisions 4 Inability to use words to communicate

2. The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Both vascular dementia and dementia of the Alzheimer type are associated with this deficit in function. Memory impairment may or may not be a symptom of vascular dementia, it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment, but the client does not have abrupt onset of symptoms. Difficulty making decisions is a major part of Alzheimer disease, but may not be manifested with vascular dementia, depending on which part of the brain is affected. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

The hospital management wants to prevent post-traumatic stress in the nursing staff. Which implemented strategies will be ineffective in pursuing this goal? 1 Providing breaks to the staff whenever needed 2 Encouraging the staff to work for more than 12 hours per day 3 Encouraging the staff to encourage and support their coworkers 4 Asking the staff and managers to talk about their feelings with each other

2. Encouraging the staff to work for more than 12 hours per day In order to prevent post-traumatic stress in the staff, management should not encourage the staff to work for more than 12 hours a day. Providing breaks whenever needed will help provide needed rest. Encouraging and supporting coworkers may be needed to relieve the stress of work. Asking the staff and managers to talk about feelings with each other will help in relieving stress.

What medication does the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines? 1 Lithium 2 Flumazenil 3 Methadone 4 Chlorpromazine

2. Flumazenil Flumazenil is the drug of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. Flumazenil medication competitively inhibits activity at benzodiazepine recognition sites on gamma-aminobutyric acid-benzodiazepine receptor complexes. Lithium is used in the treatment of mood disorders. Methadone is used for narcotic addiction withdrawal. Chlorpromazine is contraindicated in the presence of central nervous system depressants.

A client with a diagnosis of Graves disease refuses to have radioactive iodine (RAI) therapy, and a subtotal thyroidectomy is performed. What should the nurse do postoperatively to reduce the risk of thyroid storm? 1 Provide a high-calorie diet. 2 Prevent infection at the surgical site. 3 Encourage postoperative breathing exercises. 4 Demonstrate how to support the neck after surgery.

2. Prevent infection at the surgical site Conditions such as trauma and infection can precipitate thyroid storm (thyroid crisis, thyrotoxic crisis).

The registered nurse is delegating a task for unlicensed assistive personnel l (UAP). Which client's care would be suitable for delegation to the UAP? 1. Client with surgical removal of anal fistula hospitalized - monitor for discharges from fistula site 2. Severe malarial fever - monitor temp hourly 3. Underwent appendectomy and hospitalized - monitor for abdominal pain 4. Respiratory infections- monitor respiratory rate

2. Severe malarial fever- monitor temp hourly

What should a nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? 1 Express disbelief about the delusion. 2 Acknowledge the feeling tone of the delusion. 3 Determine the content of the delusions of control. 4 Institute an activity that will compete with the delusion.

3 Determining the content of delusions and hallucinations is essential for safety reasons. Expressing disbelief about the delusion denies the client's feelings rather than accepting and working with them. Responding to the verbal content of the client's delusion focuses on the delusion itself rather than the feeling causing the delusion. Attempting to divert the client denies feelings rather than accepting and working with them.

On the first day of the month a primary healthcare provider prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25 mg once a day, to be titrated in increments of 25 mg every other day to a desired dosage of 175 mg daily. On what day of the month will the client reach the desired daily dose of 175 mg? 1 Day 7 2 Day 9 3 Day 13 4 Day 15

3 The client will reach the desired dosage of 175 mg on the thirteenth day of the month; on the first day it is 25 mg, on the third day it is 50 mg, on the fifth day it is 75 mg, on the seventh day it is 100 mg, on the ninth day it is 125 mg, on the eleventh day it is 150 mg, and on the thirteenth day it is 175 mg.

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply. 1 Lability of affect 2 Specific food cravings 3 Neglect of personal hygiene 4 "I don't know" answers to questions 5 Apathetic response to the environment

3,4,5 Clients with depression are uninterested in their appearance because of low self-esteem. "I don't know" answers to questions require little thought or decision making, typical of depression. These clients' sense of futility leads to a lack of response to the environment. With depression there is little or no emotional involvement and therefore little alteration in affect. Clients with depression are uninterested in food of any kind.

A client who is diagnosed with schizophrenia was prescribed antipsychotic drugs. During a follow-up visit, the client had developed extrapyramidal symptoms. Which drugs might be responsible for these symptoms? Select all that apply. 1 Clozapine 2 Olanzapine 3 Perphenazine 4 Fluphenazine 5 Trifluoperazine

3,4,5 Perphenazine, fluphenazine, and trifluoperazine are first-generation antipsychotic drugs that have a high risk of causing extrapyramidal symptoms. Second-generation antipsychotic drugs such as clozapine and olanzapine have a lower risk of extrapyramidal symptoms.

A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis? 1 Loss of faith in God 2 Visual hallucinations 3 Decreased social interaction 4 Feelings about the future are absent

3. Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders. Depressed clients are commonly negative and pessimistic, especially regarding their future.

A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use? 1 Projection 2 Repression 3 Regression 4 Conversion

3. Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety. Projection is the attributing of unacceptable feelings or thoughts to others. It is an organized defense used by clients with paranoid, not undifferentiated, schizophrenia. Clients with undifferentiated schizophrenia have psychotic manifestations that are extreme and do not have thought processes effective enough to use projection. Repression is unintentionally putting disturbing thoughts, feelings, or desires out of the conscious mind. Clients with schizophrenia are not able to do this and therefore have a need to escape from reality. Conversion is an unconscious defense mechanism in which a person develops physical symptoms that have no organic cause. Conversion serves the purpose of reducing anxiety. Conversion is not used by clients with undifferentiated schizophrenia.

A client who has been diagnosed with a bipolar disorder has been admitted to the psychiatric unit. The nurse recognizes that providing adequate nutrition during the manic phase may be a challenge. Why would adequate nutritional intake be a challenge? 1 The client is too depressed to eat. 2 The client lacks the energy to eat. 3 The client is too busy keeping active to eat. 4 The client is on a restricted diet limiting cheese and other favorite foods.

3. The client is too busy keeping active during the manic part of a bipolar disorder. This stage is characterized by elation, activity, restlessness, and increased energy. Although the client may be using more calories than usual during this period, food is not a priority, and the client will not spend the time to eat. Finger foods and high-calorie snacks are suggested. The client is not too depressed to eat during the manic phase; rather there is a feeling of euphoria or grandeur. The client in the manic phase has too much energy rather than the lack of energy that accompanies depression. The restricted diet limiting cheese is associated with the parnate diet.

A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time? 1 "I'm going to miss you; we've become good friends." 2 "I know that you're going to be all right when you go home." 3 "Call the contact number we gave you if you have an emergency." 4 "This is my phone number; call and let me know how you're doing."

3. "Call the contact number we gave you if you have an emergency." Instructing the client to call the contact number that was provided in case of emergency demonstrates an understanding that the newly discharged client needs to have a support system. Clients need to feel that in a crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead to help the client become a functioning being again. The statement "I know you're going to be all right when you go home" provides false reassurance; the nurse does not know this. Saying "This is my phone number; call and let me know how you're doing" is unprofessional and blurs the roles of nurse and client.

A nurse is assigned to care for a client with the diagnosis of schizophrenia who is hallucinating. What is the first consideration in trying to establish a trusting relationship? 1 Family members must be included in the plan of care. 2 The client cannot be distracted from the hallucinations. 3 The client adamantly believes what is being experienced. 4 Electroconvulsive therapy should be explained in simple terms.

3. The client adamantly believes what is being experienced. Because the client believes the hallucinations, initially the nurse should validate the client's feelings, but not the experience of the hallucinations, to begin to build trust. Including family member's in the plan of care is not the priority; this may be done later with the client's permission. Distraction can help clients with schizophrenia pay less attention to hallucinations, but this is not done initially. Because electroconvulsive therapy usually is not that effective for schizophrenia, there is no reason to explain its use.

A nurse suggests a crisis intervention group to a client experiencing a developmental crisis. The nurse knows that these groups are successful because of what? 1 The client is encouraged to talk about personal problems. 2 The crisis group supplies a workable solution to the client's problems. 3 The client is assisted in investigating alternative approaches to solving the identified problem. 4 The crisis intervention worker is a psychologist who understands common patterns of behavior.

3. The client is assisted in investigating alternative approaches to solving the identified problem. A crisis intervention group helps clients re-establish psychological equilibrium by assisting them in exploring new alternatives for coping; it considers realistic situations through the use of rational and flexible problem-solving methods. Talking about personal problems is not an immediate goal of crisis intervention. Clients are never given a solution; they are helped to arrive at their own acceptable, workable solutions. It is not necessary for crisis intervention workers to be psychologists.

Naltrexone is used to treat clients with substance abuse problems. In which situation does the nurse anticipate that naltrexone will be administered? 1 To treat opioid overdose 2 To block the systemic effects of cocaine 3 To decrease the recovering alcoholic's desire to drink alcohol 4 To prevent severe withdrawal symptoms from antianxiety agents

3. To decrease the recovering alcoholic's desire to drink alcohol Naltrexone is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone, not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. Naltrexone is an opioid antagonist. It is not used for antianxiety agent withdrawal.

A client with a diagnosis of major depression refuses to participate in unit activities, claiming to be "just too tired." What is the best nursing approach? 1 Planning one rest period during each activity 2 Explaining why the staff believes that the activities are therapeutic 3 Encouraging the client to express negative feelings about the activities 4 Accepting the client's feelings about activities calmly while setting firm limits

4. Accepting the client's feelings about activities calmly while setting firm limits Fatigue and apathy are symptoms of depression and should be accepted; however, limits should be set to facilitate participation in unit activities. Planning one rest period during each activity allows the client to manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not change the client's mind about them, and this response does not show an understanding of the client's needs. Encouraging the client to express negative feelings about the activities will reinforce negative feelings about participating in them.

Which hormonal deficiency causes diabetes insipidus in a client? 1 Prolactin 2 Thyrotropin 3 Luteinizing hormone (LH) 4 Antidiuretic hormone (ADH)

4. Antidiuretic hormone (ADH) ADH deficiency causes diabetes insipidus. Decreased levels of prolactin may cause decreased amounts of milk secretion after birth. Decreased levels of thyrotropin cause hypothyroidism, weight gain, and lethargy. LH deficiency causes menstrual abnormalities, decreased libido, and breast atrophy.

A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiologic characteristic should the nurse include? 1 Periodic exacerbations 2 Aggressive acting-out behavior 3 Hypoxia of selected areas of brain tissue 4 Areas of brain destruction called senile plaques

4. Areas of brain destruction called senile plaques

In order to implement primary prevention of STIs (sexually transmitted infections) a nurse is counseling an adolescent. What would be the priority nursing action? 1. Help the adolescent recognize the risk 2. Educate the adolescent about proper preventative measures 3. Provide complete information about STIs 4. Assess the adolescent's sexual risk behaviors

4. Assess the adolescent's sexual risk behaviors

A client who is visiting the family planning clinic is prescribed an oral contraceptive. As part of teaching, the nurse plans to inform the client of the possibility of which adverse effect? 1. Cervicitis 2. Ovarian cysts 3. Fibrocystic disease 4. Breakthrough bleeding

4. Breakthrough bleeding

A nurse is discussing dietary guidelines with the parents of a school-aged child with irritable bowel disease (IBD) who is anorexic. What should the nurse instruct them to offer their child to ensure sufficient intake of calories? 1 High-fiber breakfasts 2 Seasoned, flavorful foods at each meal 3 Three meals a day plus an evening snack 4 Frequent snacks of high-protein, high-calorie foods

4. Frequent snacks of high-protein, high-calorie foods Small quantities of food are better tolerated than large meals. High-fiber foods, even taken in small amounts, may exacerbate the illness. Seasoned foods may be irritating and difficult for the child to tolerate; bland foods are advised. Three meals a day may not supply sufficient calories, unless the meals are large, and large meals may be difficult for the child to tolerate.

An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? 1 Providing psychotherapy to the client 2 Teaching strategies to overcome depression 3 Encouraging the client to walk for 30 minutes 4 Requesting that the physician change the drug

4. Requesting that the physician change the drug Tricyclic antidepressants have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence in older adults. Therefore the priority nursing care for an older client who is prescribed a tricyclic antidepressant is to request that the physician change the drug. Providing psychotherapy is an alternate treatment, which is of medium priority. Teaching strategies to overcome depression is of low priority. Encouraging the client to walk for 30 minutes overcomes the feelings of depression, but it is not the priority.

A mental health crisis occurs as a result of what stress-related factor? 1 The stress is chronic and maturational in nature. 2 The stress is perceived rather than real in nature. 3 The stress is extremely severe and situational in its origin. 4 The stress is not managed by the individual's usual methods.

4. The stress is not managed by the individual's usual methods. An individual experiences a crisis when stress, either real or imagined, cannot be controlled by the person's usual coping mechanisms. It would not be considered a crisis if it was chronic and maturational, severe and situational, or perceived rather than real.

A client is receiving imipramine, a tricyclic antidepressant, for depression. The nurse assesses the client for side effects and adverse effects. Which adverse effect requires further assessment and possible medical intervention? 1 Dry mouth 2 Weight gain 3 Blurred vision 4 Urinary hesitancy

4. Urinary hesitancy Urinary hesitancy and retention are adverse effects of imipramine that may require immediate medical intervention. Dry mouth, weight gain related to increased appetite, and blurred vision may occur as side effects of imipramine; they usually decrease over time or can be managed through nursing interventions.

On the fifth day postpartum, a woman calls her healthcare provider and reports pronounced fatigue, sadness and tearfulness. She states, "I feel so overwhelmed, I don't know what to do!" Which of the following questions is most appropriate for the healthcare provider to ask? A. "Do you ever think about harming yourself or your baby?" B. "How much sleep do you get in a twenty-four hour period?" C. "Is there a friend or relative that come and help you care for your baby?" D. "Do you blame yourself for not being able to cope with motherhood?"

A. "Do you ever think about harming yourself or your baby?" Feelings of fatigue, sadness, and tearfulness can be common symptoms experienced in the postpartum period. The healthcare provider will want to ask questions that will help distinguish postpartum blues from postpartum depression. Whereas patients who are diagnosed with postpartum depression may experience thoughts of harming themselves or the infant, this is not a finding in postpartum blues.

Processed meats such a pepperoni are high in tyramine. Combining tyramine-rich foods with a monoamine oxidase inhibitor (MAOI) can result in a hypertensive crisis. A. "Have you noticed that your mouth gets dry since you started taking this medication?" B. "Have you noticed any palpitations or irregular heartbeats?" C. "Is the regularity of your bowel movements changed since taking this medication?" D. "Have you experienced any unusual tingling feelings in your extremities?" E. "Do you ever get dizzy when you get up after you've been laying down for awhile?" F. Have you noticed any visual changes such as blurring of your vision?

A. "Have you noticed that your mouth gets dry since you started taking this medication?" B."Have you noticed any palpitations or irregular heartbeats?" C. "Is the regularity of your bowel movements changed since taking this medication?" E. "Do you ever get dizzy when you get up after you've been laying down for awhile?" F. Have you noticed any visual changes such as blurring of your vision? Amitriptyline is a tricyclic antidepressant. Amitriptyline exerts its effects by increasing synaptic concentrations of serotonin and norepinephrine in the central nervous system, but it affects other parts of the body as well. Amitriptyline also blocks muscarinic cholinergic receptors and alpha-1 adrenergic receptors in blood vessels. By blocking alpha-1 adrenergic receptors in blood vessels, amitriptyline can cause orthostatic hypotension. By blocking muscarinic cholinergic receptors, amitriptyline can cause numerous anticholinergic effects such as constipation, urinary retention, blurred vision, and decreased vagal influence on the heart.

A patient diagnosed with depression is prescribed fluoxetine (Prozac). Which of the following would the healthcare provider most likely observe if the patient experiences an adverse effect of this medication? A. Decreased libido B. Weight loss C. Bradycardia D. Urinary Retention

A. Decreased libido Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Fluoxetine increases the synaptic concentration of serotonin the central nervous system, but may have effects on other nervous system functions. Although the mechanism has not been completely elucidated, sexual dysfunction is one of the most common adverse effects of SSRIs in both men and women.

The healthcare provider is caring for a patient who has undergone electroconvulsive therapy (ECT). The patient should be carefully assessed for which of the following common adverse effects of this treatment? A. Headache and memory loss B. Aggression and violent behavior C. Palpitations and cardiac arrest D. Dizziness and blurred vision

A. Headache and memory loss ECT induces a seizure, which can cause transient increases in blood pressure, pulse, and intracranial pressure. ECT causes numerous alterations in the central nervous system. The most common adverse effects a patient may experience after ECT include headache, confusion, and memory loss.

While giving a lecture on attention-deficit/hyperactivity disorder, the nurse encourages which of the following to reduce children's stress regarding homework assignments? a. Time management skills b. Prevention of iron deficiency anemia c. Routine preventative health visits d. Speech articulation skills

A. Time management skills Time management skills are most related to homework assignment completion. Anemia prevention will improve energy levels but not stress. Routine health visits are important but do not directly affect ability to complete homework. Speech and other developmental aspects need to be developed if the child is to be successful, but skill development will not directly reduce homework-related stress.

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating "No way, I'm not crazy." The best response the nurse can give is which of the following? a. "Many times disasters can create mental health problems, so you really should participate with your family." b. "Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness." c. "Don't worry now. The psychiatrists are well trained to help." d. "Crisis intervention will help your family communicate better."

B. "Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness." Crisis intervention is a type of brief therapy that is more directive than typical psychotherapy or counseling. It focuses on problem solving and involves only the problem created by the crisis. The goal of crisis intervention is to create stability for the person involved in the crisis while promoting self-reliance. The other options do not properly reassure the patient and build trust

The healthcare provider is counseling a patient who is diagnosed with depression. Which of the following statements made by a patient should the healthcare provider recognize as a sign of transference? A. "I'm glad I lost my job because now I don't have to commute." B. "It's amazing how much you remind me of my favorite teacher." C. "I may not be good looking, but I get really good grades." D. "I drink so I can deal with the difficult situation at work."

B. "It's amazing how much you remind me of my favorite teacher." Transference is an unconscious response that may create a therapeutic impasse in the patient-healthcare provider relationship. Rationalization occurs when the patient attempts to create an acceptable explanation for unacceptable behavior. Transference occurs when a patient directs feelings and attributes from a person or situation in the past on to a person or situation in the present.

A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem? a. General adaptation syndrome b. Posttraumatic stress disorder c. Developmental crisis d. Alarm reaction

B. Posttraumatic stress disorder Posttraumatic stress disorder is characterized by vivid recollections of the traumatic event and emotional numbing and often is accompanied by nightmares. General adaptation syndrome is the expected reaction to a major stressor. Developmental crisis occurs as a person moves through life stages rather than in response to a trauma. Alarm reaction involves physiological events such as increased activation of the sympathetic nervous system that would have occurred at the time of the sexual assault.

Pediatric stressors related to self-esteem and changes in family structure reflect which maturational school age category? a. Elementary school age b. Preadolescence c. Adolescence d. Early adulthood

B. Preadolescence The preadolescent age category experiences stress related to self-esteem issues, changing family structure due to divorce or death of a parent, or hospitalization. Adolescent stressors include identity issues with peer groups and separation from parents. Elementary school age stressors include friends, family, and school relations. Adult stressors centralize around life events.

During a counseling session with a patient diagnosed with depression, the patient states, "I know my husband doesn't love me anymore." Which response by the healthcare provider demonstrates therapeutic communication? A. "You really should try not to dwell on something that probably isn't true." B. What happened to make you think your husband doesn't love you anymore?" C. "Let's talk about what you did to cause him to stop loving you." D. "Try not to think about it too much because it will make you depression worse."

B. What happened to make you think your husband doesn't love you anymore?" The goal of therapeutic communication is to preserve the self-respect of the patient and caregiver. Initially, the healthcare provider will want to communicate understanding of the situation. Therapeutic communication in this situation would consist of asking a question to explore the patient's perceptions and valuing the patient's feelings.

A patient is admitted to an inpatient psychiatric unit because of a plan to commit suicide by taking an overdose of medication. When administering medications to this patient, which of these interventions is the priority? A. Monitor the patient's vital signs before administration of mediations B. each the patient how to recognize adverse effects of the medications C. Ensure that the patient is not "cheeking" the medications D. Monitor the patient for signs of anorexia, nausea, and xerostomia

C. Ensure that the patient is not "cheeking" the medications All of these interventions may be included in the plan of care, but one of these is the priority. The priority intervention is designed to increase patient safety. A patient who has suicidal ideation, especially by overdosing on medications, should be monitored for "cheeking." Cheeking occurs when a patient hides the medication in the mouth, and hoards it so it can be used for the suicide attempt.

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following? a. Restorative care b. Strong financial resources c. Maturational and sociocultural factors d. Immaturity and intelligence factors

C. Maturational and sociocultural factors Maturational factors and sociocultural factors can affect people differently depending on their life experiences. An older individual would have more life experiences to draw from and to analyze on why he was successful, whereas a younger individual would have fewer life experiences based on chronological age to analyze for patterns of previous success. Nothing in the scenario implies that either man is in restorative care, has strong financial resources, or is immature or intelligent.

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery from the options below. a. Singing b. Back massage c. Sensory peaceful words d. Listening to music

C. Sensory peaceful words Guided imagery is used as a means to create a relaxed state through the person's imagination, often using sensory words. Imagination allows the person to create a soothing and peaceful environment. Singing, back massage, and listening to music are other types of stress management techniques.

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention? a. Primary b. Secondary c. Tertiary d. Quad level

C. Tertiary Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. Tertiary prevention focuses on the person who already has the disease and is recovering or rehabilitating. Tertiary prevention goals are to slow down the disease process, prevent further damage or pain from the disease, and prevent the current disease from creating other health problems. Primary level consists of stress prevention, promotion of wellness, and risk factor reduction before illness occurs. Secondary level occurs after symptoms appear and assists the person to develop resources to manage illness and stress. Quad level does not exist.

Based on the given table, which post-traumatic client is in need of counseling after a traumatic event? Client A - Having difficulty recalling the event Client B - Having difficulty sleeping one month after the event Client C - Reporting "feeling numb" 1 week after the event Client D - Feeling exhausted due to a heavy workload

Client B - Having difficulty sleeping one month after the event A huge traumatic event may lead to the development of post-traumatic stress disorder (PTSD) in some survivors. Survivors such as client B who have difficulty sleeping 2 weeks or more after a disaster are at risk for PTSD and require counseling to reduce the risk of PTSD. Survivors of a traumatic event often report vivid memories or flashbacks of the event; inability to remember the event is not typical of clients at risk for PTSD. Therefore, client A would not likely require counseling. Survivors with PTSD report feeling numb for 2 weeks or more. Therefore, client C who reports feeling numb 1 week after the event may not require counseling. Feeling exhausted is not a risk factor for PTSD; therefore, client D may not require counseling.

After reviewing the assessment findings of four different clients, the primary healthcare provider prescribed benzodiazepines to only one. Which client will benefit the greatest from benzodiazepines? Client A - 1. Swelling of the auditory tube and redness and painful ear canal. Client B - Inflamed middle ear with fluid in ear space and decreased hearing ability. Client C - Developed a spongy bone from labyrinth and conductive hearing loss Client D - Episodic vertigo and aural fullness

Client D - Episodic vertigo and aural fullness Client D shows symptoms of Meniere disease, an inner ear disease that presents with severe attacks of vertigo accompanied by nausea and vomiting. This can be treated with benzodiazepines. Client A shows symptoms of acute otitis media; this is due to an infection of the middle ear. Antibiotics are used to treat infections in middle ear. Client B shows symptoms of otitis media with effusion. The fluid accumulated in the middle ear space may be thin, mucoid, or purulent, and is usually resolved without treatment. Client C shows symptoms of otosclerosis, a hereditary autosomal dominant disease. Spongy bone developed from the bony labyrinth prevents the movement of footplate of the stapes in the oval window. It can be treated with combination of sodium fluoride with vitamin D.

A client is admitted to the hospital with the diagnosis of severe anxiety. What should the nurse's plan of care for a client with an anxiety disorder include? 1 Promoting the suppression of anger by the client 2 Supporting the verbalization of feelings by the client 3 Encouraging the client to limit anxiety-related behaviors 4 Restricting the involvement of the client's family during the acute phase

`2. Supporting the verbalization of feelings by the client Freedom to ventilate feelings serves as a safety valve to reduce anxiety. The suppression of anger may increase the client's anxiety. Encouraging the client to limit anxiety-related behaviors is not therapeutic; it may increase the anxiety that the client is feeling. Restricting the involvement of the client's family during the acute phase may or may not be helpful; the client's family may provide support to the client.

A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond? a. I see you are still hungry. I will get you some toast. b. You ate your breakfast 30 minutes ago. c. It appears you are confused this morning. d. Your family will be here soon. Lets get you dressed

a. I see you are still hungry. I will get you some toast. Use of validation therapy with clients who have Alzheimers disease involves acknowledgment of the clients feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the clients concerns.

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to a. Identify limits and scope of work responsibilities. b. Write for 10 minutes in a journal every day. c. Use progressive muscle relaxation. d. Delegate complex nursing tasks to licensed professional nurses.

a. Identify limits and scope of work responsibilities. An important step in preventing burnout is acknowledging one's own limitations, as well as what one's scope of work is while on the job. By doing this, the person will help to prevent emotional exhaustion and will limit the effects of chronic stress. Journaling and muscle relaxation are good stress-relieving techniques but are not directed at the cause of the workplace stress. Delegating if not applicable is an inappropriate coping mechanism.

A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. The best comment to the senior student would be a. "I'd better call 911 because your friend is suicidal." b. "Give her this list of university and community resources." c. "You must make an appointment for the student to obtain medications." d. "I'd recommend you help the student pack her bags to go home."

b. "Give her this list of university and community resources." A health care provider can help to reduce situational stress factors for individuals. Providing the student with a list of resources is one way to begin this process, as part of secondary prevention strategies. This is not a medical or psychiatric emergency, so calling 911 is not necessary. Not everyone who has sadness needs medications; some need counseling only. Not enough information is given to know whether the student would be best suited to leave college.

An assessment finding example for caregiver strain would be which of the following? a. Caregiver routinely creates a weekly menu plan. b. Caregiver has not received medical care when ill. c. Caregiver can identify respite care provider. d. Caregiver attends religious service.

b. Caregiver has not received medical care when ill. A nurse will identify a caregiver's lack of self-care as a potential example of caregiver role strain. Sacrificing their own health to care for the identified patient places caregivers at risk for becoming ill themselves. If caregivers jeopardize their own health, they may not be able to care for the actual patient. In all of the other options, the caregiver is handling caregiver stress appropriately.

A young adult's chief complaint is "seizure fits." A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young man's pseudo-seizures most likely are an example of which unconscious coping mechanism? a. Compensation b. Conversion c. Dissociation d. Denial

b. Conversion A conversion reaction is an ego defense mechanism that involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, loss of appetite, or sudden blindness without medical cause. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Dissociation involves experiencing a subjective sense of numbing and a reduced awareness of one's surroundings. Denial is seen as avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain.

A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond? a. This is a sign of fatigue. The client would benefit from a daily nap. b. Engage the client in scheduled activities throughout the day. c. It sounds like this is difficult for you. I will consult the social worker. d. The provider can prescribe a mild sedative for restlessness.

b. Engage the client in scheduled activities throughout the day. Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregivers concern.

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to a. Teach the patient about the food pyramid. b. Administer antidiarrheal medications with meals. c. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. d. Admonish the teen and her parents regarding her consistently poor diet choices.

c. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. Tertiary level interventions have the purpose of assisting the patient in readapting to life with an illness. By adjusting the diet to meet dietary guidelines and also addressing adolescent emotional needs, the nurse will help the teen to eat an appropriate diet without health complications and see herself as a "typical and normal" teenager. Teaching about the food pyramid will not address the real issue, which is that the teen is still eating what she knows will make her ill. Administering antidiarrheal medications may help but is not a tertiary level intervention. Admonishing the teen and parents is not a tertiary level intervention, and because this approach is nontherapeutic, it may cause communication problems.

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism? a. Dissociation b. Conversion c. Denial d. Compensation

c. Denial Denial consists of avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation involves creating subjective numbness and less awareness of surroundings. Conversion involves repressing anxiety and manifesting it into a physiological problem. Compensation occurs when an individual makes up for a deficit by strongly emphasizing another feature.

A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Assess religious and spiritual needs while in the hospital. b. Identify the clients ability to perform self-care activities. c. Evaluate the clients reaction to a change of environment. d. Ask the client about relationships with family members.

c. Evaluate the clients reaction to a change of environment. As Alzheimers disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the clients reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the clients reaction to environmental change.

. A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver? a. Allow the client to rest most of the day. b. Place a padded throw rug at the bedside. c. Install deadbolt locks on all outside doors. d. Provide a high-calorie and high-protein diet.

c. Install deadbolt locks on all outside doors. Clients with Alzheimers disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.

A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond? a. It will allow your mother to live independently for several more years. b. It is used to halt the advancement of Alzheimers disease but will not cure it. c. It will not improve her dementia but can help control emotional responses. d. It is used to improve short-term memory but will not improve problem solving.

c. It will not improve her dementia but can help control emotional responses. Drug therapy is not effective for treating dementia or halting the advancement of Alzheimers disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.

An adult male reports new-onset seizure like activity. An EEG and a neurology consultant's report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurse's next best action would be to a. Recommend acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program.

c. Obtain history of any recent life stressors. The purpose of an ego defense mechanism is to help regulate emotional stress. By regulating emotional stress, the individual gains some protection from anxiety and stress. A conversion reaction involves repressing an anxiety-producing conflict and transforming it into a nonorganic symptom such as difficulty sleeping, appetite loss, or sudden blindness without medical cause. The nurse must assess the patient fully before implementing any nursing interventions. Although the patient may be malingering, confrontation is nontherapeutic because the patient is using this type of defense mechanism in response to some type of stressor.q

Identify a sociocultural factor that can lead to developmental problems. a. Family relocation b. Childhood obesity c. Prolonged poverty d. Loss of stamina

c. Prolonged poverty Environmental and social stressors are believed to lead to developmental problems. Sociocultural refers to societal or cultural factors; poverty is a sociocultural factor. Stamina loss and obesity are health problems, and family relocation is a situational factor.

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0° F Pulse: 102 beats per minute Respiratory rate: 26 breaths per minute Blood pressure: 140/106 The nurse can identify that which hormones are the likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

d. Epinephrine and norepinephrine Epinephrine and norepinephrine are catecholamine hormones secreted by the adrenal medulla that rapidly elevate heart rate and blood pressure. ACTH originates from the anterior pituitary gland and stimulates cortisol release; ADH originates from the posterior pituitary and increases renal reabsorption of water. ACTH, cortisol, and ADH do not increase heart rate.

The nursing student gave a wellness lecture on the importance of accurate assessment and intervention from a personal, family, and community perspective. The other nursing students enjoyed the lecture about which nursing theory? a. Ego defense model b. Situational model c. Evidence-based practice model d. Neuman systems model

d. Neuman systems model The Neuman systems model is based on an individual's/family's/community's relationship to stress and the reaction to stress. This model promotes wellness on primary, secondary, and tertiary levels. The other items listed as models are not nursing theories. Ego defense mechanisms are unconscious coping mechanisms. Situational refers to factors such as relocation or family job changes that are stressors. Evidence-based practice consists of relying on data or other reputable information sources to guide nursing care.

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will a. Select nursing interventions to promote the patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions for achieving expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.

d. Reassess patient's stress-related symptoms and compare with expected outcomes. During the evaluation stage, the nurse compares current stress-related symptoms against established measurable outcomes to evaluate the effectiveness of the intervention. Selecting appropriate interventions and establishing goals are part of the planning process.

An older client is diagnosed with Alzheimer disease. For which clinical manifestations should the nurse assess the client? Select all that apply. 1 Loss of recent memory 2 Focused attention span 3 Perceptual disturbances 4 Willingness to accept change 5 Difficulty learning something new

1,3,5 Neurofibrillary tangles attack the hippocampus, impairing recent memory. As dementia progresses sensory-perceptual alterations occur, such as hallucinations. Alzheimer disease is associated with a global intellectual impairment that affects learning, thinking, and language. Progressive deterioration of the regions of the brain results in cognitive deficits, such as a decreased, not focused, attention span. Clients with Alzheimer disease are easily confused or disoriented. They require familiar routines that provide a sense of security.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? 1 Flight of ideas 2 Ritualistic behaviors 3 Associative looseness 4 Auditory hallucinations

1. flight of ideas

The purpose of unconscious ego defense mechanisms is to do which of the following for the individual? a. Protect against feelings of worthlessness and anxiety. b. Facilitate the use of problem-focused coping. c. Evaluate an event for its personal meaning. d. Trigger the stress control functions of the medulla oblongata.

Ego defense mechanisms offer the individual psychological protection from emotional stress. They are used unconsciously to protect against worthlessness and feelings of anxiety. Problem-focused coping is a coping strategy rather than an ego defense mechanism. Evaluation of an event for its personal meaning is primary appraisal. The medulla oblongata controls heart rate, blood pressure, and respirations and is not triggered by ego defense mechanisms.

A patient diagnosed with depression is prescribed a monoamine oxidase inhibitor (MAOI). When teaching the patient about the medication, which statement made by the patient indicates the need for additional teaching? A. "I'm glad that I can have pepperoni on my pizza." B. "I can still eat out at restaurants as long as I'm careful." C. "I will miss putting soy sauce on my noodles." D. "I'm glad I can still eat hamburgers and french fries."

A. "I'm glad that I can have pepperoni on my pizza." Patients taking MAOIs need to adhere to numerous dietary restrictions. The patient will need to avoid consuming foods which are high in tyramine. Processed meats such a pepperoni are high in tyramine. Combining tyramine-rich foods with a monoamine oxidase inhibitor (MAOI) can result in a hypertensive crisis.

When assessing a patient with severe depression, which of the following would the healthcare provider identify as a cognitive alteration? A. Low self-esteem B. Anxiety C. Powerlessness D. Somatic Delusions

D. Somatic Delusions Patients diagnosed with depression may experience cognitive, affective, behavioral, or physiological alterations. Cognition relates to processes such as judgment, evaluation, and reasoning. A somatic delusion, the false belief that the patient has some physical defect or disease (e.g. the patient might think he/she has an internal parasite), is a cognitive alteration associated with depression. The other choices are affective alterations.

A client is admitted to the emergency department with joint pain and swelling. Upon assessment the nurse suspects rheumatoid arthritis. Which findings support the nurse's conclusion?Select all that apply. A. Obesity B. Antinuclear antibodies C. Inflammatory disease pattern D. Disease in the bilateral symmetric joints E. Disease in the distal intrapharyngeal joints F. Disease in the weight-bearing joints and hands

B. Antinuclear antibodies C. Inflammatory disease pattern D. Disease in the bilateral symmetric joints

A client with schizophrenia becomes severely agitated, and the nurse is concerned for the safety of the client, other clients, and the nursing team. The primary healthcare provider prescribes 2.5 mg of haloperidol intramuscularly stat. The vial of haloperidol states that each milliliter of solution contains 5 mg. How many milliliters of solution will the nurse administer? Record your answer using one decimal place, including leading zero if applicable. _____ mL

0.5

A nurse is caring for a client with bipolar disorder, depressive episode. What should the nurse's initial objective for this client be? 1 Feeling comfortable with the nurse 2 Investigating new leisure activities 3 Participating in small group activities 4 Initiating conversations about feelings

1 Before therapy can begin, a trusting relationship must be developed. A client with major depression will not have the impetus or energy to investigate new leisure activities. Participating in small group activities is not appropriate initially; the client does not have the physical or emotional energy to interact with a small group of people. Initiating conversations about feelings will not be successful unless the client develops a trusting, comfortable relationship with the nurse.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? 1 Flight of ideas 2 Ritualistic behaviors 3 Associative looseness 4 Auditory hallucinations

1 Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

A client with a diagnosis of major depression tells a nurse, "No matter what I do, everything turns out bad." The nurse recognizes this as an example of what? 1 Using a cognitive distortion 2 Seeking sympathy from the nurse 3 Regressing to an earlier developmental level 4 Avoiding responsibility for previous behavior

1 The client is using the cognitive distortions of overgeneralization and pessimism. Negative events are magnified and become the focus, whereas contrary positive experiences are minimized and ignored. With the focus on the negative events, the depressive mood is reinforced. There are no data to support the conclusion that the client is seeking sympathy, regressing, or avoiding responsibility.

A 10-year-old child with recently diagnosed asthma is receiving information about the use of a peak expiratory flow meter (PEFM). The nurse knows that the child understands how to use the PEFM when she makes which statement? 1 "I have to blow out as fast and hard into the machine as I can." 2 "I can stand or sit to use the flow meter. I just can't lie down." 3 "I have to take three readings and record the average on the flow sheet." 4 "I'll use the meter whenever I can throughout the day—it doesn't really matter when."

1 "I have to blow out as fast and hard into the machine as I can." A PEFM is used to measure the amount of air being exhaled. To adequately measure this, the client must blow out fast and hard. The client should use the PEFM while in a standing position to permit better expansion of the lungs. The highest of three readings, not the average, is recorded. The readings should be obtained close to the same time each day to ensure consistency.

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. 1 Cool skin 2 Photophobia 3 Constipation 4 Periorbital edema 5 Decreased appetite

1 Cool skin 3 Constipation 4 Periorbital edema 5 Decreased appetite Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edema are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? 1 Cardiac problems 2 Joint inflammation 3 Kidney dysfunction 4 Peripheral neuropathy

1 Cardiac problems

The laboratory values shown here are returned on a male client being treated for bipolar disorder, type 2 diabetes, and peripheral vascular disease who is currently reporting chest pain. What is the priority nursing intervention? INR - 2.6 CK: 120 units/L Lithium: 2.5 mEq/L A1c: 8.2% 1 Implementing seizure precautions immediately 2 Moving the crash cart outside the client's room 3 Assessing the client's respiratory and circulatory status 4 Performing a stat fingerstick to check the blood sugar level

1. The normal range of therapeutic lithium levels is 0.6 to 1.4 mEq/L (0.6 to 1.4 mmol/L). A lithium level of 2.0 (2.0 mmol/L) or greater indicates intoxication and may present with symptoms including seizure activity. The normal hemoglobin A1c range for adults is 4% to 6%, with a level greater than 8% indicating poor diabetic control. This value is in the abnormal range, but another lab value takes priority. The creatine kinase level in men ranges from 55 to 170 units/L. There is no indication that the client has experienced or is about to experience a heart attack. A normal international normalized ratio (INR) is between 0.7 and 1.8; in an individual undergoing warfarin therapy it ranges between 2.0 and 3.0. This value is within the therapeutic range for a client being treated for peripheral vascular disease.

A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? 1 "Exercise increases the need for carbohydrates and decreases the need for insulin." 2 "Exercise increases the need for insulin and increases the need for carbohydrates." 3 "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." 4 "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin."

1. "Exercise increases the need for carbohydrates and decreases the need for insulin."

A client has chronic asthma. Which complication should the nurse monitor in this client? 1 Atelectasis 2 Pneumothorax 3 Pulmonary edema 4 Respiratory alkalosis

1. Atelectasis As a result of narrowed airways, adequate ventilation of lung tissue is compromised and alveoli may collapse.

The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? 1 Being physically immobile 2 Sobbing for no apparent reason 3 Reporting great difficulties falling asleep 4 Startling easily to loud noises and being touched

1. Being physically immobile Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. 1. Hips 2. Knees 3. Ankles 4. Shoulders 5. Metacarpals

1. Hips 2. Knees Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage. Although the ankles are weight-bearing joints and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus, there is less degeneration. Shoulder joints are not the most likely to be involved first because these are not weight-bearing joints. Although the distal interphalangeal joints are affected frequently, the remaining interphalangeal joints and metacarpals are not.

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1 Increases the cardiac workload 2 Interferes with usual respirations 3 Produces an elevation in temperature 4 Decreases the amount of oxygen used

1. Increases the cardiac workload Irritability and restlessness associated with anxiety increase the metabolic rate, heart rate, and blood pressure; these complicate heart failure. Anxiety does not directly interfere with respirations; an increase in cardiac workload will increase respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen used and leads to an increased respiratory rate.

An older client has been prescribed an atypical antipsychotic medication. Which nursing interventions demonstrate that the nurse has determined the client's risk for injury? Select all that apply. 1 Monitoring the pulse for an irregular rhythm 2 Sitting with the client during meals to encourage eating 3 Offering a favorite beverage between meals to maintain hydration 4 Assessing the temperature to determine the possibility of an infection 5 Teaching the client about the importance of taking an anticholinergic medication

1. Monitoring the pulse for an irregular rhythm 4. Assessing the temperature to determine the possibility of an infection Older clients prescribed atypical antipsychotic medications are at increased risk for death as a result of cardiovascular dysfunction and infection and should be monitored closely for such situations. This client is at risk for death related to complications of atypical antipsychotic medication therapy, but the risk is not related to poor nutrition, dehydration, or any condition that could be managed with anticholinergic therapy.

A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, "Get out of here!" What is the nurse's best approach? 1 Say, "I'll be back in 15 minutes, and then we can talk." 2 Get assistance and give the medication by way of injection. 3 Explain why it is necessary to comply with the healthcare provider's order. 4 Tell the client, "You have to take the medicine that's been prescribed for you."

1. Say, "I'll be back in 15 minutes, and then we can talk." Saying, "I'll be back in 15 minutes, and then we can talk," allows the agitated, angry client time to regain self-control; telling the client that the nurse will return will decrease possible guilt feelings and implies to the client that the nurse cares enough to come back. Getting assistance and giving the medication by way of injection does not respect the client's feelings; it may decrease trust and increase feelings of anger, helplessness, and hopelessness. An agitated, angry client will not be able to accept a logical explanation. Continued insistence may provoke increased anger and further loss of control.

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on? 1 Disturbed self-esteem 2 Potential for self-harm 3 Dysfunctional verbal communication 4 Impaired perception of environmental stimuli

2 Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury. Although promoting self-esteem is important, this is not a priority at this time. There are no data to support the need to focus on the client's ability to verbally communicate. Verbal hallucinations occur within the individual; they are not precipitated by an environmental stimulus.

A client with schizophrenia is receiving intramuscular injections of fluphenazine decanoate. After therapy is initiated, dystonia develops. What clinical manifestations does the nurse document during the assessment? Select all that apply. 1 Akathisia 2 Torticollis 3 Shuffling gait 4 Masklike facies 5 Oculogyric crisis

2, 5 Impaired or distorted muscle tone (dystonia) is a side effect of fluphenazine decanoate; spasms of the neck that pull the head to the side (torticollis) are typical of dystonia. Deviation and fixation of the eyes (oculogyric crisis) are typical of dystonia. The feeling of restlessness and an urgent need for movement (akathisia) is not related to dystonia. Shuffling gait is a symptom of pseudoparkinsonism. A masklike facies is also found in pseudoparkinsonism.

An extremely anxious client enters a crisis center and asks a nurse for help. Which initial response best reflects the nurse's role in crisis intervention? 1 "Tell me what you've done to help yourself." 2 "I'll be here for you to help you figure things out." 3 "I understand that in the past you've had problems." 4 "Tell me about the things that are bothering you the most."

2. "I'll be here for you to help you figure things out." Clients in crisis need assistance with coping; the nurse must be involved with problem solving. Clients in crisis initially need to trust the nurse. Telling the client that they are there to help develops trust. Asking what the client has done to help himself, stating the patient has had problems in the past, and asking the patient to discuss what is most bothering them all do not focus on the nurse's involvement with problem solving.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? 1 Interview the client for a health history. 2 Assess the client's heart and lung sounds. 3 Monitor the client's pulse and temperature. 4 Obtain the client's blood specimen for electrolytes.

2. Assess the client's heart and lung sounds

A client's antidepressant medication therapy has recently been modified to substitute a tricyclic antidepressant for the monoamine oxidase inhibitor (MAOI) prescribed 2 years ago. In light of this assessment data collected during the follow-up appointment, what will the nurse do first? 1 Retake the individual's blood pressure. 2 Determine exactly when the client began taking the amitriptyline (Elavil). 3 Ask how the client is managing the stress related to the new job and pregnancy. 4 Identify what measures the client has implemented to help manage the recurrent headaches.

2. Determine exactly when the client began taking the amitriptyline (Elavil). Improper weaning from an MAOI can result in the development of hypertensive crisis. The client's increased blood pressure and chronic headache are possible early warning signs of this serious side effect. Determining exactly when the client began taking the newly prescribed tricyclic medication will help the nurse determine whether the MAOI had sufficient time to be excreted from the body. Reassessing the client's blood pressure, though not inappropriate, does not have the same priority as does gathering new information that could help identify the root of the hypertension and headaches. Stress can be a factor in increased blood pressure and headaches, but in this situation a more serious potential complication must be explored. Identifying the self-treatment the client has implemented for the reported headaches, though appropriate, does not take priority over determining the possible cause of the increased blood pressure and headaches.

A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? 1 Sweating 2 Hyperpnea 3 Bradycardia 4 Hypertension

2. Hyperpnea Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? 1. Encourage bed rest. 2. Space activities throughout the day. 3. Teach the limitations imposed by the disease. 4. Have one of the client's relatives stay at the bedside.

2. Space activities throughout the day.

A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, what would the nurse expect to observe? 1 Melena 2 Steatorrhea 3 Hard, dry stool 4 Ribbon-shaped stool

2. Steatorrhea

A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? 1 Crying 2 Self-mutilation 3 Immobile posturing 4 Repetitive activities

3 Clients with catatonia exhibit rigidity and posturing behaviors. Most clients with catatonic schizophrenia are unable to express feelings. Self-mutilation is associated with depression. Repetitive activities are associated with obsessive-compulsive disorders.

An older client is admitted to the hospital with the diagnosis of dementia of the Alzheimer type and depression. Which signs of depression does the nurse identify? Select all that apply. 1 Loss of memory 2 Increased appetite 3 Neglect of personal hygiene 4 "I don't know" answers to questions 5 "I can't remember" answers to questions

3, 4, 5 Neglect of personal hygiene is associated with depression because of low self-esteem. People who are depressed do not have physical or emotional energy; "I don't know" and "I can't remember" answers require little thought or decision-making. Depression does not cause memory deficits. A typical symptom of depression is loss of interest in food.

What are the neurologic manifestations of hyperthyroidism? Select all that apply. 1 Fatigue 2 Diaphoresis 3 Blurred vision 4 Exophthalmos 5 Shallow respirations

3. Blurred vision 4. Exophthalmos

A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? 1 Client has decreased plasma colloid osmotic pressure. 2 Client has increased tissue colloid osmotic pressure. 3 Client has increased plasma hydrostatic pressure. 4 Client has decreased tissue hydrostatic pressure.

3. Client has increased plasma hydrostatic pressure

A nurse is volunteering on the community crisis hotline. What is the final objective of the counseling process? 1 Reducing anxiety 2 Exploring feelings 3 Developing constructive coping skills 4 Accomplishing the debriefing process

3. Developing constructive coping skills Past coping behaviors have been inadequate in resolving the current crisis; new coping skills are needed to manage anxiety-producing conflicts. Reduction of anxiety is an early objective. Exploration of feelings is an immediate objective. Accomplishment of the debriefing process is an early objective.

An 80-year-old client with depression requires the prescription of antidepressant drugs. Which tricyclic antidepressant drug is appropriate? 1 Doxepin 2 Amoxapine 3 Nortriptyline 4 Trimipramine

3. Nortriptyline Nortriptyline and desipramine are preferred for use in the elderly as these antidepressant drugs have less anticholinergic activity. Doxepin, amoxapine, and trimipramine have more cholinergic activity than nortriptyline and are not the preferred drugs for elderly clients.

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1. Urinary retention 2. Gastric hyperacidity 3. Rebound tenderness 4. Increased lower bowel motility

3. Rebound tenderness

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis? 1 Making huge efforts to avoid "any kind of bug or spider" 2 Experiencing flashbacks to an event that involved a sexual attack 3 Spending hours each day worrying about something "bad happening" 4 Becoming suddenly tachycardic and diaphoretic for no apparent reason

3. Spending hours each day worrying about something "bad happening"

A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect does a nurse monitor the client? 1 Torticollis 2 Oculogyric crisis 3 Tardive dyskinesia 4 Pseudoparkinsonism

3. Tardive dyskinesia Tardive dyskinesia occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It is most often manifested by abnormal movements of the lips, tongue, and mouth. Torticollis, oculogyric crisis, and pseudoparkinsonism are reversible with administration of an anticholinergic (e.g., benztropine) or an antihistamine (e.g., diphenhydramine) or cessation of the medication.

A client with generalized anxiety disorder says to the nurse, "What can I do to keep myself from overreacting to stress?" What is the best response by the nurse? 1 "Work on problem-solving skills." 2 "Improve your time-management skills." 3 "Ignore situations that you cannot change." 4 "Work on identifying and developing coping strategies."

4 "Work on identifying and developing coping strategies." Developing a wide variety of coping strategies increases the individual's ability to cope with stress; different defenses can be used in various situations. The client has already identified the problem. Improved time-management skills may or may not be helpful. People should not ignore situations that affect them.

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1 Passivity 2 Dysphoria 3 Anhedonia 4 Grandiosity 5 Distractibility 6 Talkativeness

4,5,6 Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Dysphoria, a depressed, sad mood, is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1 Passivity 2 Dysphoria 3 Anhedonia 4 Grandiosity 5 Talkativeness 6 Distractibility

4,5,6 Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Dysphoria, a depressed, sad mood, is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.

An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? 1 Probate judge 2 Client's family 3 Client's psychiatrist 4 Law enforcement officer

4. Legally it is the responsibility of the staff to notify law enforcement officers so the client can be apprehended. A judge may be involved later in a nonemergency situation. Although the family and psychiatrist will be notified eventually, neither is the priority.

A nurse is teaching a client about gastroesophageal reflux disease (GERD). Which statement made by the client indicates correct understanding of GERD management? 1 "Three meals per day is the best regimen to avoid GERD symptoms." 2 "I can reduce my GERD symptoms through a high-carbohydrate, low-fat diet." 3 "A snack at bedtime will help reduce the acidity of my stomach during the night." 4 "I will place a 6-inch (15 cm) block under the head of my bed to help with digestion."

4. "I will place a 6-inch (15 cm) block under the head of my bed to help with digestion."

How should a nurse expect a client's anxiety to be manifested physiologically? 1 Constricted pupils 2 Narrowed bronchioles 3 Decreased blood pressure 4 Increased blood glucose level

4. Increased blood glucose level The fight-or-flight response of the sympathetic nervous system is stimulated, causing an increase in blood glucose through glycogenolysis and gluconeogenesis. The pupils dilate, not constrict, to facilitate the entry of visual stimuli. The bronchioles dilate, not constrict, to facilitate gas exchange. The blood pressure increases, not decreases, to shunt blood to vital centers.

A nurse administers an antipsychotic medication to a client. The nurse will assess the client for which common manageable side effect? 1 Jaundice 2 Melanocytosis 3 Drooping eyelids 4 Unintentional tremor

4. Unintentional tremor Unintentional tremor is one of the extrapyramidal side effects of antipsychotic medications; it is considered common and manageable. Jaundice is a severe but not a common occurrence; periodic liver function tests should be performed. An excessive number of melanocytes is not a side effect of antipsychotics. Drooping of the eyelids is not a common side effect.

A patient diagnosed with bipolar disorder is experiencing the manic phase of the disorder. Which neurotransmitter alterations will the healthcare provider identify as contributing to mania? A. Decreased acetylcholine B. Decreased gamma-aminobutyric acid (GABA) C. Decreased dopamine D. Increased serotonin E. Increased norepinephrine F. Increased glutamate

B. Decreased gamma-aminobutyric acid (GABA) E. Increased norepinephrine F. Increased glutamate

A patient diagnosed with bipolar disorder is prescribed lithium carbonate (Lithobid). When teaching the patient about the medication, which of these statements is a priority for the healthcare provider include? A. "You should avoid consuming dairy products when you are taking this medication." B. "You should follow this low calorie, low sodium diet to prevent weight gain." C. "Drink lots of fluids, especially if you are active during hot weather." D. "Call our office immediately if you experience any unusual bruising or bleeding."

C. "Drink lots of fluids, especially if you are active during hot weather." Lithium is an inorganic ion similar to other ions such as potassium and sodium. If sodium levels are low, the kidneys will retain lithium, which could result in toxicity. Lithium increases urine output and antagonizes the effects of antidiuretic hormone. In order to avoid dehydration, patients should be instructed to drink 10 - 12 glasses of water each day. Additional fluids will be needed during strenuous activity, in hot weather, or if the patient experiences fluid loss through vomiting or diarrhea.

A patient diagnosed with major depressive disorder is admitted for inpatient care. Which of the following is the primary goal during the admission assessment? A. Establishing desired outcomes for the patient B. Administering antidepressant medications C. Collecting and organizing patient data D. Reviewing the policies for patient conduct

C. Collecting and organizing patient data. The healthcare provider is in the initial stage of planning care for the patient. Goals and outcomes are based on patient problems that have been identified. The primary goal during the admission assessment is to collect and organize objective and subjective data so patient problems and needs can be identified.

A trauma survivor is requesting sleep medication because of "bad dreams." Concerned about posttraumatic stress disorder, the nurse asks a. "Are you reliving your trauma?" b. "Are you having chest pain?" c. "Can you describe your phobias?" d. "Can you tell me when you wake up?"

a. "Are you reliving your trauma?" People who have PTSD often have flashbacks, reexperiencing the trauma. The other answers involve assessment of problems not specific to PTSD.

A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. If she is confused, play along and pretend that everything is okay. b. Remove the clock from her room so that she doesnt get confused. c. Reorient the client to the day, time, and environment with each contact. d. Use validation therapy to recognize and acknowledge the clients concerns.

c. Reorient the client to the day, time, and environment with each contact. Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.