Mental Health Midterm Study Guide
A 16-year-old wants to drive, but the parents will not allow it. A 14-year-old sibling was invited to several sleepovers, but the parents found reasons to deny permission. Both teens are annoyed because the parents buy clothes for them that are more suitable for younger children. The parents say, "We don't want our kids to grow up too fast." Which term best describes this family's boundaries? a. Rigid b. Clear c. Enmeshed d. Differentiated Rationale: Rigid boundaries are those that do not change or flex with changing circumstances, as indicated here by parents who are reluctant to revise their roles and expectations about their children as the children mature. Enmeshed boundaries are those that have failed to differentiate or develop individually; the family shares roles and thoughts to an excessive degree, without a healthy degree of individuality.
A
A student nurse leaves the psychiatric unit and does not make sure the exit door is closed and locked. What term is used to define this type of action? A. Negligence B. Cause in fact C. False imprisonment D. Malpractice Rationale: Negligence is failure to use the standard of care when you have the duty to do so.
A
Psychiatric disorders can be affected by manipulating neurotrans that alter sleep/wakefulness; dopamine leads to mania; GABA increases relaxation; serotonin promotes wakefulness; circadium rhythm in secretions of neurotransmitters so will affect sleep patterns. What assessment question will provide the nurse with information regarding the effects of a woman's circadian rhythms on her quality of life? a. "How much sleep do you usually get each night?" b. "Does your heart ever seem to skip a beat?" c. "When was the last time you had a fever?" d. "Do you have problems urinating?"
A
Select the priority outcome for a patient completing the fourth alcohol detoxification program in the past year. Prior to discharge, the patient will a. state, "I know I need long-term treatment." b. use denial and rationalization in healthy ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member. Rationale: The correct response recognizes the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.
A
The family of a client with acute symptoms of schizophrenia does not understand the disorder and how to help the client. What should the nurse recommend to the family? a. attending a psychoeducational support group b. attending family therapy c. attending transactional support therapy d. attending psychoanalytic support therapy
A
The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3. Select the nurse's best action. a. Report the results to the health care provider immediately. b. Administer the next dose as prescribed. c. Give aspirin and force fluids. d. Repeat the laboratory test. Rationale: These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider, and the drug should be withheld. The health care provider may repeat the test, but in the meantime, the drug should be withheld. (Note: This question requires students to apply previous learning regarding normal and abnormal values of white blood cell counts.)
A
The nurse administers medications to a culturally diverse group of patients on a psychiatric unit. What expectation should the nurse have about pharmacokinetics? a. Patients of different cultural groups may metabolize medications at different rates. b. Metabolism of psychotropic medication is consistent among various cultural groups. c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications. d. It is important to provide patients with oral and written literature about their psychotropic medications. Rationale: Cytochrome enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic
A
The nurse administers medications to a culturally diverse group of patients on a psychiatric unit. What expectation should the nurse have about pharmacokinetics? a. Patients of different cultural groups may metabolize medications at different rates. b. Metabolism of psychotropic medication is consistent among various cultural groups. c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications. d. It is important to provide patients with oral and written literature about their psychotropic medications. Rationale: Cytochrome enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic medication; hepatic function influences metabolism rates. Information about medication is important but does not apply to pharmacokinetics.
A
The nurse is caring for a child diagnosed with Oppositional Defiant Disorder (ODD). What behavior is consistent with DSM-V criteria for ODD? A. Argumentative with adults B. Lack of remorse C. Violation of other's rights D. Intermittent explosive behavior Rationale: ODD is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. This child is defiant and argues with adults and other figures of authority.
A
The nurse is caring for a client who has been taking Haloperidol for schizophrenia notes the presence of extrapyramidal symptoms. When providing SBAR to the physician, what medication would the nurse recommend? a. olanzapine b. clozapine c. fluoxetine d. chlorpromazine
A
The nurse is caring for a patient diagnosed with Bipolar Disorder who is experiencing rapid cycling. What additional drug will the healthcare provider prescribe to help with stabilization of the patient's mood? A. Carbamazepine (Tegretol) B. Lorazepam C. Clozapine D. Haloperidol decanoate Rationale: Anticonvulsants are commonly used to treat acute mania and bipolar maintenance. They are very useful in treating those patients who are rapid cyclers.
A
The nurse is caring for a patient displaying akathisia. What is the priority assessment tool the nurse will utilize to analyze the patient's symptoms? A. AIMS B. SADS C. Mini-Mental Exam D. CAGE Rationale: The Abnormal Involuntary Movement Scale is used to determine presence of and severity of signs and symptoms of tardive dyskinesia. Akathisia is one type of extrapyramidal side effect.
A
The nurse receives a laboratory report indicating a patient's Lithium serum level is 1mEq/L. How will the nurse interpret these laboratory values? A. Within therapeutic limits. B. Below therapeutic limits. C. Slightly above therapeutic limits. D. A toxic level. Rationale: A Lithium level of 1 mEg/L is within therapeutic limits. Lithium levels should not exceed 1.5 mEq/L to avoid serious toxicity.
A
The physician prescribes chlorpromazine 150mg orally 3 times a day and lithium 300mg twice daily for a bipolar client. What priority care will the nurse implement to decrease side effects associated with these medications? a. Providing fluids to decrease symptoms of dehydration b. providing frequent meals c. placing the client on 1 to 1 observation until stabilized d. Frequently reorienting the client
A
What nursing intervention best applies the ethical principle of autonomy? A. Exploring alternative solutions with a patient, who then makes a choice. B. Suggesting that two patients who were fighting be restricted to the unit. C. Intervening when a self-mutilating patient attempts to harm self. D. Staying with a patient demonstrating a high level of anxiety. Rationale: Autonomy is the right to self-determination, that is, to make one's own decisions. By exploring alternatives with the patient, the patient is better equipped to make an informed, autonomous decision.
A
When a 10 year old starts mowing lawns, to help support the family, how is this parent/child role enactment defined? A. Diffuse boundary B. Clear boundary C. Family management D. Rigid boundary Rationale: When parent/child role enactment becomes problematic, such as a child helping to support a family, the distinction between and among family members becomes diffuse.
A
When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? A. Monitor closely for harm to self or others. B. Assist in completing an application for admission. C. Supply the client with written information about his or her mental illness. D. Provide an opportunity for the family to discuss why they felt the admission was needed.
A
When the nurse views the lab results, of an Asian patient's blood lithium level, it is noted the lithium level is not within therapeutic range. How can the results of the lab work be explained? A. Patients of different cultural groups may metabolize medications at different rates. B. The physician ordered the wrong dose. C. Asians require smaller doses of psychotropic medications. D. Asians' kidneys do not excrete psychotropic medications effectively. Rationale: Genetic variations in culturally diverse patients can affect the pharmacokinetics (metabolism) of drugs, regardless of ethnicity.
A
Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia? a. Always afraid another student will steal her belongings. b. An unusual interest in numbers and specific topics. c. Demonstrates no interest in athletics or organized sports. d. Appears more comfortable among males.
A
Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech." Rationale: The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.
A
Which is an appropriate initial nursing intervention for a client with chronic low self-esteem? A. Assessing the content of negative self-talk B. Administering anxiolytic medications C. Using reassurance and physical touch D. Using distraction techniques Rationale: Self-negating verbalizations and internal self-talk undermine self-esteem. Assessing and then intervening to limit or eliminate these negative communications will help improve self-esteem.
A
Which physical assessment data would alert the nurse to a possible mild toxic reaction in a client receiving lithium? a. Vomiting and diarrhea b. Hypotension c. Seizures d. Increased appetite Rationale: Vomiting and diarrhea are signs of mild to moderate lithium toxicity. Hypotension and seizures occur with moderate to severe toxic reactions. Anorexia occurs with mild toxic reactions. Other side effects: diaphoresis (sweating), confusion, weakness, blurred vision, tinnitus, slurred speech, coma, convulsions, thirst, polyuria, tremors, weight gain
A
The nurse caring for a patient taking a monoamine oxidase inhibitor (MAOI), is aware of potentially dangerous side effects. What will the nurse teach the patient about this drug? (Select All That Apply) A. Monitor blood pressure. B. Avoid foods high in tyramine. C. Do not take decongestants. D. Get blood levels checked monthly. E. Report symptoms of mania. Rationale: MAOIs are drugs used to block the action of MAO. The liver uses these enzymes to break down monoamine substances that enter the body from food. If the liver cannot break down tyramine, vasoconstriction results in elevated blood pressure. Teach patients to monitor blood pressure, avoid foods high in tyramine, and do not take over-the-counter decongestants.
A, B, C
What assessment data indicates emotional abuse? A. Low self-esteem B. Feelings of inadequacy C. Learning difficulties D. Hypersomnia E. Inadequate nutrition Rationale: Emotional abuse includes low self-esteem, reported feelings of inadequacy, anxiety and withdrawal, learning difficulties, and poor impulse control. Inadequate nutrition is a sign of neglect.
A, B, C
Select all the CAGE questions A. Have you felt you needed to cut down on your drinking? B. Are people annoyed by your drinking? C. Have you felt guilty about your drinking? D. Have you ever had a drink in the morning (eye-opener)?
A, B, C, D
Select the positive symptoms of Schizophrenia associated with alterations in the patient's speech patterns. (Select All That Apply) A. Associative looseness B. Word salad C. Clang associations D. Ecoholalia E. Echopraxia Rationale: Echopraxia, although a positive symptom of Schizophrenia, is not a symptom of an alteration in speech. Echopraxia is mimicking the movements of others.
A, B, C, D
Which nursing actions demonstrate cultural competence? Select all that apply. a. Planning mealtime around the patient's prayer schedule b. Helping a patient to visit with the hospital chaplain c. Researching foods that a lacto-ovo-vegetarian patient will eat d. Providing time for a patient's spiritual healer to visit e. Ordering standard meal trays to be delivered three times daily
A, B, C, D
What is the criteria for the diagnosis of alcohol use disorder? (Select All That Apply) A. Identifiable withdrawal signs and symptoms B. Increasing tolerance C. Altered family relationships D. Blackouts or amnesia pertinent to drinking episodes E. Altered occupational productivity Rationale: All options are criteria for alcohol use disorder according the DSM-V.
A, B, C, D, E
The nurse is caring for a patient admitted for anger and aggression. What signs and symptoms indicate the risk of escalating anger? (Select All That Apply) A. Slowed, pointed and quiet speech B. Self-induced isolation C. Tense facial expression D. Bizarre somatic delusions E. Stone silence Rationale: Anger can be seen in a patient's behavior. Hyperactivity, increased volume and rate of speech or slowed pointed and quiet speech, stone silence, uncharacteristic self-isolation from others. Any change in behavior from what is typical for the patient should be addressed.
A, B, C, E
What are the patient's rights under mental health law? (Select All That Apply) A. Right to Refuse Treatment B. Right to Informed Consent C. Right to Confidentiality D. Right to Freedom from Stigma E. Right to Treatment Rationale: All choices, except the right to freedom of stigma, are included in the written list of rights given to patients upon admission to a psychiatric facility.
A, B, C, E
Based on Maslow's hierarchy of needs, physiological needs for a restrained patient include: (Select all that apply.) a. Private toileting, oral hydration b. Checking the tightness of the restraints c. Therapeutic communication d. Maintaining a patent airway
A, B, D
What statements about aggression are accurate? (Select All That Apply) A. Brain injury or brain disorders contribute to violence. B. Some people are biologically predisposed to become irritated or angry more easily. C. Aggressive behavior is a causative factor of mental illness. D. Mentally healthy persons, with adaptive coping behaviors, would not behave aggressively. E. The absence of GABA can increase impulsivity and aggression. Rationale: Some individuals are biologically more predisposed than others to respond to life events with irritability, easy frustration and anger. Aggressive behavior is not a causative factor of mental illness; however, it may be a symptom of mental illness. Mature individuals, under a warranted situation, can exhibit aggressive behavior. For example, some individuals might behave aggressively if they felt their lives were being threatened. Decreased GABA, the main inhibitory neurotransmitter, can increase impulsivity and aggressive responses.
A, B, E
Select the statements that define the effects of mental illnesses on the normal sleep cycle. (Select All That Apply) A. Sleep pattern disturbances occur in virtually every psychiatric disorder. B. The quality of sleep does not improve, even when the patient's psychiatric disorder improves. C. Drugs used to treat psychiatric problems may also interfere with normal sleep. D. There is evidence that the circadian rhythm of neurotransmitter secretion is altered in psychiatric disorders. E. Sleep disorders increase the risk for medical conditions. Rationale: Virtually all patients with mental disorders will report sleep disturbances. Dopamine, norepinephrine, serotonin, acetylcholine, histamine, glutamate and hypocretin can cause wakefulness. Sleep disorders can induce medical co-morbidities such as diabetes, cardiovascular disease, and hypertension. Drugs used to treat psychiatric disorders can interfere with the normal regulation of sleep and wakefulness: such as drugs with a sedative-hypnotic effect.
A, C, D, E
A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.) a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items. Rationale: Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.
A, C, E
A drug blocks the attachment of norepinephrine to α1 receptors. The patient may experience a. hypertensive crisis. b. orthostatic hypotension. c. severe appetite disturbance. d. an increase in psychotic symptoms. Rationale: Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of α1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Teach patients ways of minimizing this phenomenon.
B
A fearful patient has an increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter? a. GABA b. Norepinephrine c. Acetylcholine d. Histamine Rationale: Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight." GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.
B
A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should a. question the fluid restriction. b. question the order for restraint. c. transcribe the prescriptions as written. d. assess the resident's bowel elimination. Rationale: Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.
B
A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine. Rationale: Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.
B
A male patient calls to tell the nurse that his monthly lithium level is 17 mEq/L. Which nursing intervention will the nurse implement initially? a. Reinforce that the level is considered therapeutic. b. Instruct the patient to hold the next dose of medication and contact the prescriber. c. Have the patient go to the hospital emergency room immediately. d. Alert the patient to the possibility of seizures and appropriate precautions.
B
A nurse caring for a patient taking a SSRI will develop outcome criteria related to a. coherent thought processes. b. improvement in depression. c. reduced levels of motor activity. d. decreased extrapyramidal symptoms. Rationale: SSRIs affect mood, relieving depression in many cases. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.
B
A nurse inspects an inpatient psychiatric unit and finds that exits are free of obstructions, no one is smoking, and the janitor's closet is locked. These observations relate to a. coordinating care of patients. b. management of milieu safety. c. management of the interpersonal climate. d. use of therapeutic intervention strategies. Rationale: Nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse's concerns, are unrelated to the observations cited.
B
A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. 0200: 118/78 mm Hg and 72 beats/minute 0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse's priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint. Rationale: Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.
B
A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects Rationale: Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first generation antipsychotics like (chlorpromazine, haloperidol, loxapine) brain than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.
B
A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, the nurse's first intervention is to a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force. Rationale: The patient's behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. Threatening the patient or assembling a show of force is likely to exacerbate the tension.
B
A patient has disorganized thinking associated with schizophrenia. Neuroimaging would likely show dysfunction in which part of the brain? a. Hippocampus b. Frontal lobe c. Cerebellum d. Brainstem Rationale: The frontal lobe is responsible for intellectual functioning. The hippocampus is involved in emotions and learning. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.
B
A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Poor judgment and hyperactivity c. Vegetative signs and poor grooming d. Cognitive deficits and paranoia Rationale: Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.
B
A wife believes her husband is having an affair. Lately, he has been disinterested in romance and working late. The husband has an important, demanding project at work. The mother asks her teen, "What have you noticed about your father?" The teen later mentions this to the father, who says, "Tell your mother that I can't deal with her insecurities right now." Which family dynamic is evident? a. Multigenerational dysfunction b. Triangulation c. Enmeshment d. Blaming Rationale: Triangulation is a family dynamic wherein a pair relationship (usually the parents) is under stress and copes by drawing in a third person (usually a child) to align with one or the other members of the pair relationship. Multigenerational dysfunction is any dysfunction that exists within or across multiple generations of a family, such as child abuse or alcoholism. Blaming is distracting attention from one's own dysfunction or reducing one's own anxiety by blaming another person. Enmeshment refers to blurred family boundaries or blending of the thoughts, feelings
B
An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate Rationale: Selective Serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that the medication be as safe as possible in the event of another overdose of prescribed medication.
B
An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention? a. "I hate all of you" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "The other patient started the fight." Rationale: The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.
B
An adult patient assaulted another patient and was then restrained. What assessment data would require an immediate nursing intervention? A. Blood pressure 138/78 B. Capillary refill >4 seconds C. Heart rate 89 D. Brisk, elastic skin turgor Rationale: Guidelines for mechanical restraints include constant observation, with vital sign monitoring, assessment of range of motion, blood flow to hands or feet and a finger width between the restraint and the patient's skin. Of the assessment data given, a capillary refill of greater than 3-4 seconds can indicate constriction of the extremity and the restraint loosened at once.
B
An older adult diagnosed with Alzheimer's disease lives with family in a rural area. During the week, this adult attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this adult most vulnerable to abuse? a. Multiple caregivers b. Alzheimer's disease c. Living in a rural area d. Being part of a busy family Rationale: Older adults are at high risk for violence, particularly when there is significant dependency such as would be expected with dementia or other cognitive impairments. The incorrect responses are not identified as placing an individual at high risk.
B
Symptoms of withdrawal from opioids for which the nurse should assess include a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache. Rationale: The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.
B
Tatiana has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizziness
B
The nurse is gathering data, from a patient, to identify a sleep-wake disorder. What question should the nurse ask when screening for hypersomnia? A. "Do you feel rested in the morning?" B. "Have you ever been told that you snore when sleeping?" C. "What is your sleep schedule?" D. "Have you noticed any problems with your concentration?" Rationale: Pertinent questions are needed to screen for the predominant symptoms of insomnia, hypersomnia, arousal disorders and circadian rhythm disorders. Asking a patient about the presence of snoring suggests obstructive sleep apnea which is associated with hypersomnia.
B
The parent of a child diagnosed with schizophrenia tearfully asks the nurse, "What could I have done differently to prevent this illness?" Select the nurse's best response. a. "Although schizophrenia results from impaired family relationships, try not to feel guilty. No one can predict how a child will respond to parental guidance." b. "Schizophrenia is a biological illness resulting from changes in how the brain and nervous system function. You are not to blame for your child's illness." c. "There is still hope. Changing your parenting style can help your child learn to cope effectively with the environment." d. "Most mental illnesses result from genetic inheritance. Your genes are more at fault than your parenting." Rationale: The parent's comment suggests feelings of guilt or inadequacy. The nurse's response should address these feelings as well as provide information. Patients and families need reassurance that the major mental disorders are biological in origin and are not the "fault" of parents. One distracter places the burden of having faulty genes on the shoulders of the parents. The other distracters are neither wholly accurate nor reassuring.
B
What is the tertiary prevention therapy, the nurse would recommend, for a distressed family and friends of someone who has committed suicide? A. Psychological postmortem assessment B. Attending a self-help group for survivors C. Participating in reminiscence therapy D. Contracting for two sessions of dynamic group therapy Rationale: Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. This option represent tertiary prevention which is focused on assisting the individual.
B
When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial priority nursing intervention? A. Allow the patient to act out feelings. B. Set limits on patient behavior, as necessary. C. Provide verbal instructions to the patient to remain calm. D. Restrain the patient to reduce hyperactivity and aggression. Rationale: Setting limits on the patient's behavior provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.
B
When considering culturally competent care for a Muslim patient diagnosed with cardiac problems, which intervention is particularly important to implement initially when a low fat diet is prescribed? a. Requesting a dietary consult b. Identifying dietary considerations c. Explaining the importance of a low fat diet d. Including the family in conversation about food preparation Rationale: Interpreting the thinking of individual patients does not ensure culturally
B
Which intervention best demonstrates that a nurse correctly understands the cultural needs of a hospitalized Asian American patient diagnosed with a mental illness? a. Encouraging the family to attend community support groups b. Involving the patient's family to assist with activities of daily living c. Providing educational pamphlets to explain the patient's mental illness d. Restricting homemade herbal remedies the family brings to the hospital Rationale: The Asian community values the family in caring for each other. The Asian community uses traditional medicines and healers, including herbs for mental symptoms. The Asian community describes illness in somatic terms. The Asian community attaches a stigma to mental illness, so interfacing with the community would not be appealing.
B
Which factors are essential for development of a therapeutic nurse-patient relationship? (Select All That Apply) A. Sympathy B. Genuineness C. Empathy D. Values clarification E. Positive regard Rationale: Vital components for establishing a therapeutic relationship is genuineness, empathy and positive regard.
B, C, E
Nurses have the opportunity to develop a therapeutic relationship with a patient, when the focus of the interactions are based on which concepts? (select all that apply) A. Patient's support system B. Patient concerns C. Patient's psychiatric diagnosis D. Patient experiences E. Patient feelings Rationale: The basis of the therapeutic relationship is when the nurse's interaction address the patients needs, concerns, experiences and feelings.
B, D, E
A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema Rationale: Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.
C
A nurse can anticipate anticholinergic side effects are likely when a patient takes a. lithium. b. buspirone. c. imipramine (Tofranil) d. risperidone. Rationale: Imipramine (Tofranil) is a tricyclic antidepressant with strong anticholinergic properties, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid-balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.
C
A nurse instructs a patient taking a drug that inhibits MAO to avoid certain foods and drugs because of the risk of a. cardiac dysrhythmia. b. hypotensive shock. c. hypertensive crisis. d. hypoglycemia. Rationale: Patients taking MAO-inhibiting drugs must be on a low tyramine diet to prevent hypertensive crisis. In the presence of MAO inhibitors, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.
C
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety. Rationale: The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.
C
A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having an acute psychosis. Rationale: Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.
C
A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination. Rationale: Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary
C
A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement. Rationale: Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.
C
A patient is hospitalized for severe major depressive disorder. Of the medications listed below, the nurse can expect to provide the patient with teaching about a. chlordiazepoxide. b. clozapine. c. sertraline. d. tacrine. Rationale: Sertraline (Zoloft) is an selective serotonin reuptake inhibitor (SSRI). This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimer's disease.
C
An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual Rationale: Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.
C
The nurse has received SBAR report on a child newly diagnosed Oppositional Defiant Disorder. What typical age would the nurse expect the patient to be? A. 3 years of age B. 5 years of age C. 8 years of age D. 12 years of age Rationale: ODD is typically diagnosed around 8 years of age, but children as young as 3 can exhibit symptoms.
C
The nurse is caring for a client admitted with hyperthermia, tachycardia, diaphoresis and chills. These symptoms correlate with use of what type of medication? A. Opioid B. Benzodiazepine C. Stimulant D. Dissociative drug Rationale: Stimulant drugs such as methamphetamine can cause diaphoresis, tachycardia, hyperthermia and chills.
C
The nurse is caring for a patient experiencing an opioid overdose. What opioid antagonist will the nurse administer? A. diazepam (Valium) B. clonidine (Catapres) C. naloxone (Narcan) D. bupropion (Zyban) Rationale: Opioid overdose is a medical emergency. Patients may need ventilation support, with suctioning of secretions, and intubation. Naloxone is the opioid antagonist given to reverse the effects of the opioids; however it is a short-term solution; effective medical management to maintain respiratory and cardiac function will be necessary
C
The nurse is caring for a patient taking Clozapine. What is the priority laboratory result the nurse should monitor? A. Hemoglobin B. Plateletsepi C. Neutrophils D. Hgb A1C Rationale: Clozapine has the potential to suppress bone marrow and induce agranulocytosis. Any deficiency in white blood cells renders a person prone to serious infection. Therefore regular measurement of absolute neutrophil count is necessary.
C
The nurse is caring for several children, in the emergency department, for treatment of various illnesses and injuries. What assessment finding would cause the nurse to suspect child abuse? A. Complaints of abdominal pain B. Repeated middle ear infections C. Bruises on extremities D. Crying Rationale: Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence
C
Which characteristic is indicative of a healthy and functional family? A. Diffuse boundaries B. Rigid boundaries C. Mutual support D. Equal distribution of power Rationale: When family members emotional needs are met, they feel support from those around them and are free to grow and explore new roles and facets of their personalities.
C
The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration. Rationale: People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.
C, D
A client taking Lithium citrate 600mg PO 3 times a day. The client calls the metal health nurse complaining of nausea. What will the client nurse teach the client? a. Take it with antacid b. Take it with an antiemetic c. Take it with a large glass of orange juice d. Take it with meals
D
A client with acute mania has been verbally abusive to staff since admission 3 hours ago. The client tells the nurse, "You would make a better call girl than a nurse and you can't work with me you should be fired." What response by the nurse would be the most therapeutic? a. Tell the client this type of behavior is unacceptable and request an apology b. Tell the client inappropriate statements and behavior will be documented in the chart c. Calmly tell the client a degree in nursing is required to work in this hospital d. Tell the client, "I will return in a few minutes to continue the assessment interview."
D
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior? A. Providing thickened liquids to minimize the risk of aspiration B. Documenting intake and output each shift to monitor hydration C. Reinforcing appropriate social boundaries through staff role modeling D. Performing passive range-of-motion exercises three times a day for effective joint health
D
A patient diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program Rationale: Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, become self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.
D
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention Rationale: All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.
D
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat. Rationale: Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency.
D
A patient tells the nurse, "My doctor prescribed paroxetine for my depression. I assume I'll have side effects like I had when I was taking imipramine." The nurse's reply should be based on the knowledge that paroxetine is a(n) a. selective norepinephrine reuptake inhibitor. b. tricyclic antidepressant. c. monoamine oxidase (MAO) inhibitor. d. SSRI. Rationale: Paroxetine is an SSRI and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.
D
A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision. Rationale: A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.
D
An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries Rationale: The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.
D
Culturally competent care means that nurses adjust their practices to meet their patient's cultural beliefs, practices, needs and preferences. Cultural competence consists of five constructs: cultural awareness, cultural knowledge, cultural encounters, cultural skill, and cultural desire. To provide culturally competent care, the nurse should a. accurately interpret the thinking of individual patients. b. predict how a patient may perceive treatment interventions. c. formulate interventions to reduce the patient's ethnocentrism. d. identify strategies that fit within the cultural context of the patient. Rationale: The correct answer is the most global response. Cultural competence requires ongoing effort. Culture is dynamic, diversified, and changing. The nurse must be prepared to gain cultural knowledge and determine nursing care measures that patients find acceptable and helpful.
D
In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice Rationale: The nurse is concerned about justice, that is, fair distribution of care, which includes treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.
D
Tardive dyskinesia is a condition involving the involuntary movement of the face, trunk, and limbs that occurs more frequently with first generation antipsychotics. A patient begins therapy with a phenothiazine medication. What teaching should the nurse provide related to the drug's strong dopaminergic effect? a. Chew sugarless gum. b. Increase dietary fiber. c. Arise slowly from bed. d. Report changes in muscle movement. Rationale: Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Movement disorders and motor abnormalities (extrapyramidal side effects), such as parkinsonism, akinesia, akathisia, dyskinesia, and tardive dyskinesia, are likely to occur early in the course of treatment. They are often heralded by sensations of muscle stiffness. Early intervention with antiparkinsonism medication can increase the patient's comfort and prevent dystonic reactions. The distracters are related to anticholinergic effects.
D
The nurse caring for a patient with schizophrenia who is experiencing depersonalization. What therapeutic intervention will the nurse use at this time? a. place a hand on the clients are and exert light pressure b. sit close to patient on the bed c. place an arm protectively around clients shoulder d. acknowledge the clients experience and feelings
D
The nurse is caring for a patient who engages in self-mutilation. What nursing intervention should be a high priority? A. Identification of triggers for the behavior. B. Restrain the patient. C. Place the patient in seclusion. D. Caring for the patient's wounds. Rationale: Basic interventions for patients with non-suicidal self-injury include caring for the patient's wounds and injuries, establishing a therapeutic alliance and teaching adaptive coping skills. Identification of triggers is an assessment. The other options are not appropriate.
D
The nurse is teaching a group of culturally diverse patients about pharmacogenetics. What enzyme is most responsible for differences in drug tolerability and responses in individuals and ethnic groups? A. HLA-B 1502 B. CYP 2D6 C. CYP 2C19 D. CYP 450 Rationale: Pharmacogenetics explains how genetic variation leads to differences in drug tolerability and responses in individuals and ethnic groups. Cytochrome P450 (CYP) is the enzyme responsible for metabolizing most psychotropic medications.
D
The nurse knows alcohol contributes to sleep disturbances. How does alcohol affect sleep? a. Increases quality of sleep b. Increases sleep latency c. Increases REM sleep d. Induces middle-of-the-night awakenings
D
What behavior is a predictor of violence? a. A patient who is rocking back and forth in his room and cannot sit still. b. A patient yelling, while running back and forth to his room. "You cant make me go to group." c. A patient whose speech is slurred and states, "I am not going to take this drug anymore" d. A patient whose jaw and fist are clenched, while muttering, "I am going to get even with you"
D
What factor will decrease the risk of suicide? A. Male gender B. Professional occupation C. Increasing age D. Being married Rationale: Factors that decrease the risk of suicide include being married.
D
What is the central emotional factor underlying suicide intent? A. Powerlessness B. Egocentricism C. Depersonalization D. Hopelessness Rationale: Psychological factors include the central emotional factor of hopelessness. Cognitive styles contributing to higher risk includes rigid all-or-nothing thinking, the inability to see other options and perfectionism.
D
Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability. The individual must have completed withdrawal and achieved physiological stability before he or she is able to address any of the other treatment goals.
D
Which neurotransmitter is most responsible for difficulty with sleep and drowsiness? A. Dopamine B. Norepinephrine C. Adenosine D. Serotonin Rationale: Neurotransmitters are involved in sleep and wakefulness. Many psychotropic medications manipulate neurotransmitters thus altering sleep. SSRI antidepressants are most reported by patients as causing difficulty with sleep and drowsiness.
D
Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who a. is noncompliant with the treatment regimen. b. fraudulently files for bankruptcy. c. sold and distributed illegal drugs. d. threatens to harm self and others. Rationale: Involuntary hospitalization protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.
D
Which scenario best demonstrates a healthy family? a. One parent takes care of children. The other parent earns income and maintains the home. b. A family has strict boundaries that require members to address problems within the family. c. A couple requires their adolescent children to attend church services three times a week. d. A couple renews their marital relationship after their children become adults.
D
