MH Exam 3

30. A patient diagnosed with schizophrenia begins to talks about "cracklomers" in the local shopping mall. The term "cracklomers" should be documented as: a. neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the patient. "Cracklomers" is not a known word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others that are implanted in one's mind. An idea of reference is a type of delusion in which trivial events are given personal significance. REF: Page: 312

28. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation. REF: Pages: 324-325

9. A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. "It is a self-help group with the goal of sobriety." b. "It is a form of group therapy led by a psychiatrist." c. "It is a group that learns about drinking from a group leader." d. "It is a network that advocates strong punishment for drunk drivers."

ANS: A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed. REF: Pages: 385-387 | Page: 391

18. A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back; opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies that require immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis; it appears after prolonged treatment. Waxy flexibility is a symptom observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting. REF: Page: 331

18. Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.

ANS: A Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped. REF: Page: 363

19. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately; therefore, the intramuscular route is best. In this case, the best option given is diphenhydramine. REF: Page: 331

14. The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

ANS: A Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective. REF: Page: 390

23. A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

ANS: A Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate. REF: Pages: 369-371

20. In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

ANS: A Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care. REF: Pages: 375-376 | Pages: 385-386

39. A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance

ANS: A Low self-esteem is present when a patient sees himself or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options. REF: Pages: 385-386 | Pages: 387-391

2. Which intervention is appropriate for a patient diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer the patient's requests and questions to the case manager. b. Explore the patient's feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority. REF: Page: 215 | Page: 225

5. A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

ANS: A Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for nonadherence. The incorrect options do not address the patient's dislike of taking pills. REF: Page: 326

21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use. REF: Pages: 375-376 | Pages: 385-386

21. What is the priority intervention for a nurse beginning a therapeutic relationship with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing.

ANS: A Patients diagnosed with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients diagnosed with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse. REF: Page: 216 | Page: 224

33. In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

ANS: A Patients who have ingested LSD respond well to being "talked down" by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs. REF: Pages: 379-381 | Pages: 385-386

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day and never comes out for breaks or lunch. Which term best describes this behavior? a. Avoidant b. Dependent c. Histrionic d. Paranoid

ANS: A Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame. REF: Page: 220

15. A patient diagnosed with borderline personality disorder is hospitalized several times after self-inflicted lacerations. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? a. Risk for self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient diagnosed with borderline personality disorder. REF: Pages: 217-218 | Page: 224 | Page: 228

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic

ANS: A SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive. REF: Page: 228

14. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient. REF: Pages: 318-319 | Pages: 323-325

15. When working with a patient beginning treatment for alcohol abuse, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses. REF: Pages: 384-385 | Pages: 388-389

40. Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."

ANS: A The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse. REF: Pages: 387-391

3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.

ANS: A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping. REF: Page: 373

14. A patient tells a nurse, "I sometimes get into trouble because I make quick decisions and act on them." A therapeutic response would be: a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I'll bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

ANS: A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental. REF: Pages: 224-225

13. A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines b. Allow the patient to telephone a local restaurant to deliver meals c. Offer to taste each portion on the tray for the patient d. Begin tube feedings or total parenteral nutrition

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are considered aggressive and usually promote violence. Patients often perceive foods in sealed containers, packages, or natural shells as being safe. REF: Pages: 318-321

17. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change. REF: Page: 370

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient. REF: Page: 326 | Page: 330

23. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, which are the symptoms present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that are more likely to be apparent during the acute stage of the illness. REF: Page: 308

3. A patient diagnosed with schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to assault me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of Disturbed thought processes. Risk for other-directed violence is substantiated by the patient's paranoia and feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses. REF: Pages: 316-317

2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Dependent d. Schizotypal e. Narcissistic

ANS: A, B, D Some personality disorders have evidence of genetic links; therefore the family history would show other family members with similar traits. Heredity plays a role in schizotypal and antisocial problems, as well as obsessive-compulsive personality disorder. REF: Page: 215

2. A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of relapse prevention? Select all that apply. a. Rehearsing techniques to handle anticipated stressful situations b. Advising the patient to accept residential treatment if relapse occurs c. Assisting the patient to identify life skills needed for effective coping d. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances

ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations. The nurse can participate in role playing and help the patient evaluate the usefulness of new strategies. The nurse can also provide valuable information about the physiologic changes that can be expected and the ways in which to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety. REF: Page: 385 | Pages: 387-391

1. The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply. a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress

ANS: A, D Compelling evidence exists that schizophrenia is a neurologic disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Stress and family disruption may contribute but are not considered etiologic factors. Environmental factors are not recognized as causative variables in schizophrenia. REF: Pages: 306-307

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. encourage the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.

ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The incorrect options provide positive reinforcement of the behavior. REF: Pages: 217-218 | Pages: 226-227

10. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs.

ANS: B A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs. REF: Pages: 371-372

1. A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium. REF: Pages: 372-373

25. Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

ANS: B Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both. REF: Page: 386

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

ANS: B Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone. REF: Page: 312 | Page: 320

13. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully."

ANS: B During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information. REF: Pages: 370-371 | Pages: 390-391

2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario. REF: Page: 315

38. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"

ANS: B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority. REF: Pages: 381-385

34. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5?2'6?3? tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B Lurasidone HCl (Latuda) is an atypical antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management is especially important. The incidence of tardive dyskinesia is low with atypical antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness. REF: Pages: 328-329

28. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug

ANS: B Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug. REF: Pages: 363-364 | Page: 366

27. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. chlorpromazine (Thorazine) d. diphenhydramine (Benadryl)

ANS: B Olanzapine is an atypical antipsychotic medication that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotic agents that target only positive symptoms. Diphenhydramine is an antihistamine. REF: Pages: 325-326

10. A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patient's ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition. REF: Page: 314 | Page: 316

22. Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior

ANS: B Patients with disorganization demonstrate the most regressed and socially impaired behaviors. Communication is often incoherent, with silly giggling and loose associations predominating. Highly suspicious, delusional behavior relates more to paranoia. Extremes of motor activity, from excitement to stupor, relate to catatonia. Severe anxiety and ritualistic behaviors relate to obsessive-compulsive disorder. REF: Page: 315

9. A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security

ANS: B Physiologic needs must be met to preserve life. A patient who is catatonic may need to be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiologic integrity. The assessment findings do not suggest safety concerns. Higher level needs (psychosocial and self-actualization) are of lesser concern. REF: Page: 314 | Page: 317

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

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument. REF: Pages: 320-323

26. Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.

ANS: B Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress. REF: Pages: 214-215

24. A nurse set limits for a patient diagnosed with a borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're terrible." This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.

ANS: B Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver. REF: Pages: 217-218 | Pages: 226-227

20. A patient has taken trifluoperazine (Stelazine) 30 mg/day orally 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 syndrome d. Anticholinergic effects

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are observed. 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 syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes. REF: Page: 332

37. Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

ANS: B The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety. REF: Pages: 384-385 | Pages: 387-392

19. A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline

ANS: B The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting. REF: Pages: 220-221

22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility. REF: Pages: 369-370

9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Disturbed sensory perception-auditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping

ANS: B Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority. REF: Page: 217 | Pages: 223-224

11. A nurse observes a patient who is diagnosed with schizophrenia. The patient is standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking. REF: Page: 313

1. A nurse plans the care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D Individuals diagnosed with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals diagnosed with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals diagnosed with antisocial personality disorders are more likely to be impulsive than to be perfectionists. REF: Page: 217

2. A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taking your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking

ANS: B, E Stabilization is maximized by the adherence to the antipsychotic medication regimen. Because so many patients with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiologic well-being. The other topics are also important but are not priority topics. REF: Page: 305 | Pages: 317-325

1. A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, E The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol. REF: Pages: 373-374

10. A patient diagnosed with a personality disorder has used manipulation to get his or her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately. REF: Pages: 224-225

4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. Ideally, the patient will use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control. REF: Page: 225

35. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.

ANS: C Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other. REF: Pages: 330-371

30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression.

ANS: C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use. REF: Pages: 371-372

25. Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. REF: Page: 214 | Page: 224

6. A nurse reports to the interdisciplinary team that a patient diagnosed with an antisocial personality disorder lies to other patients, verbally abuses a patient diagnosed with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters. REF: Page: 217 | Pages: 223-224

12. The most challenging nursing intervention for patients diagnosed with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy.

ANS: C Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques. REF: Page: 224

35. A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia. REF: Pages: 313-314

5. Consider these comments made to three different nurses by a patient diagnosed with an antisocial personality disorder: "You're a better nurse than the day shift nurse said you were"; "Another nurse said you don't do your job right"; "You think you're perfect, but I've seen you make three mistakes." Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt producing.

ANS: C Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments. REF: Page: 217 | Page: 225

17. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness. REF: Page: 326

16. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I will stay with you. Focus on what we are talking about, not the voices." d. "Forget the voices. Ask some other patients to sit and talk with you."

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Asking other patients to talk incorrectly shifts responsibility for intervention from the nurse to other patients. REF: Page: 320

4. A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the 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 a recurrence of an acute psychosis.

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis. REF: Pages: 372-373

3. As a nurse prepares to administer a medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I will come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, as well as to prevent splitting other staff members. "Why" questions are not therapeutic. REF: Pages: 217-218 | Page: 225

11. A patient diagnosed with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy (DBT) on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, "I'm feeling empty and want to cut myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level.

ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patient's ability to weigh alternatives to mutilating behavior. REF: Pages: 217-218 | Page: 224 | Page: 228

3. A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to overdose me." How does this patient perceive the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarre

ANS: C The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options. REF: Page: 315 | Page: 317

19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

ANS: C The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome. REF: Pages: 375-376

27. Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

ANS: C The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible. REF: Page: 372 | Pages: 375-376

7. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

ANS: C This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority. REF: Pages: 372-373 | Page: 385

6. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine

ANS: C This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patient's symptoms. REF: Page: 373

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionism. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisiveness, submissiveness. d. grandiosity, attention seeking, and arrogance.

ANS: D According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the characteristics of grandiosity, attention seeking, and arrogance are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients diagnosed with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals diagnosed with obsessive-compulsive personality disorder. Patients diagnosed with dependent personality disorder often express difficulty being alone and are indecisive and submissive. REF: Page: 219

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)

ANS: D Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain. REF: Pages: 325-329

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: a. inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

ANS: D Fear of abandonment is a central theme for most patients diagnosed with borderline personality disorder. This fear is often exacerbated when patients diagnosed with borderline personality disorder experience success or growth. The incorrect options are not associated with self-mutilation. REF: Pages: 217-218 | Pages: 226-227

2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.

ANS: D Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors. REF: Page: 369

34. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.

ANS: D Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug. REF: Pages: 378-379

29. Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse. REF: Page: 367 | Pages: 371-372

41. Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia

ANS: D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid abuse. REF: Pages: 381-382

32. A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Do the messages from the voice frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the patient to do is important; the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command. REF: Page: 317 | Page: 320

26. A patient diagnosed with schizophrenia says, "High heat. Last time here. Did you get a coat?" What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts. REF: Page: 311

11. A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial

ANS: D Minimizing one's drinking is a form of denial of alcoholism. The patient's own description indicates that "social drinking" is not an accurate name for the behavior. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one's own system. REF: Pages: 384-385 | Pages: 388-389

36. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)

ANS: D Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving. REF: Pages: 373-375 | Pages: 380-381

16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you've been drinking."

ANS: D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary. REF: Pages: 385-391

25. A patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, "You are mean and nasty. No one trusts you or wants to be around you." Select the most likely analysis. The patient: a. is trying to manipulate the nurse by using negative comments. b. is likely to experience disorganization and catatonia in the near future. c. is jealous of the nurse's position of power in the relationship. d. may be identifying another person's shortcomings in order to preserve his or her own self-esteem.

ANS: D Patients with paranoid ideation often use disparaging comments to preserve one's own self-esteem. There is no evidence the patient is trying to manipulate the nurse or is jealous. This behavior is not predictive of catatonia or disorganization. REF: Page: 315 | Page: 320

31. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "pentobarbital sodium." What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

ANS: D Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration. REF: Pages: 371-372 | Page: 385

1. A therapist recently convicted of multiple counts of Medicare fraud says, "Sure I overbilled. Why not? Everyone takes advantage of the government, so I did too." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident. REF: Page: 217

26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.

ANS: D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice. REF: Pages: 376-377 | Pages: 385-387

24. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

ANS: D Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies. REF: Page: 391

16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I hate my doctor for not giving me what I ask for." d. "I felt empty and wanted to cut myself, so I called you."

ANS: D Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking. REF: Pages: 217-218 | Page: 228

29. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is regularly taking his or her medication. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation. REF: Pages: 316-318

33. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. 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, low fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

ANS: D 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. The symptoms given in this scenario are not consistent with the medical problems listed in the incorrect options. REF: Pages: 331-332

12. Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

ANS: D The 40-year-old patient who has been diagnosed with schizophrenia since 18 years of age could logically be expected to have the lowest overall level of functioning secondary to deterioration associated with frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have a higher level because schizophrenia of short duration may be less impairing than other types. The patient who has had episodes of catatonia since the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient diagnosed with schizophreniform disorder has been ill for only 6 months, and disability is likely to be minimal. REF: Page: 308

12. A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"

ANS: D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment. REF: Pages: 385-389

18. For which behavior would limit setting be most essential? The patient: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D The correct option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance. REF: Page: 222

13. The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action.

ANS: D The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity. REF: Pages: 224-225

8. A patient with a history of daily alcohol abuse says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

ANS: D The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient. REF: Pages: 385-386 | Pages: 388-389 TOP: Nursing Process: Implementation

31. A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D The patient is describing phenomena that indicate personal boundary difficulties. The nurse should maintain an appropriate social distance and not touch the patient, because the patient is anxious about the inability to maintain ego boundaries and merging with or being swallowed by the environment. Physical closeness or touch could precipitate panic. REF: Page: 313 | Pages: 318-321

21. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You are laughing. Tell me what's happening."

ANS: D The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on the hallucinatory clue (i.e., the patient's laughter) and then eliciting the patient's observation is best. The incorrect options are less useful in eliciting a response; no joke may be involved, "Why" questions are difficult to answer, and the patient is probably not focusing on what the nurse has said in the first place. REF: Page: 320 | Pages: 322-323

32. An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.

ANS: D The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements. REF: Pages: 379-380

8. A person's spouse filed charges of battery. The person has a long history of acting-out behaviors and several arrests. Which statement by the person suggests an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I'm tired of being nagged. My spouse deserved the beating."

ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common. REF: Page: 217

24. A patient diagnosed with schizophrenia says, "Everyone has skin lice that jump on you and contaminate your blood." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of contamination indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information. REF: Page: 315

8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. REF: Pages: 318-323

15. Patients diagnosed with schizophrenia who are suspicious and withdrawn: a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior. REF: Page: 309

5. A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

ANS: D clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses. REF: Pages: 372-373 | Page: 386

3. While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever

ANS: D, E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation. REF: Pages: 376-377 | Pages: 385-386