NCLEX

A clinet is taking chlorpromazine (thoranine) for the treatment of schizo. this drug blocks the transmission of which substance? A) dopamine B) epinephrine C) norpinephrine D) thyroxine

A

A nurse is assisting with morning care when a client suddenly throws off the covers starts shouting, "my body is changing and disintegrating because i'm not from this world." Which term best describes this behavior? A) depersonalization B) ideas of reference C) looseness of association D) paranoid ideation

A

A nurse is caring for a client with delirium. Which nursing intervention has the hgihest priority? A) providing safe environment B) offering recreational activities C) providing a structured environment D) instituting measure to promote sleep

A

A nurse is facilitating a group of schizo clients when one client say, I like to drive my car, bar, tar, far. This pattern of speech is known as which disorder? A) clang association B) echolalia C) echopraxia D) neologisms

A

Involuntary, parrot like repetition of words spoken by others. A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

A

This sign / symptom is typical of a drug wtihdrawal. A) hyperactivity B) hypoactivity

A

This stage of dementia is associated with forgetfulness A) stage 1 B) stage 2 C) stage 3 D) stage 4

A

Which short term goal should a nurse focus on for a client who makes statements about not deserving things? A) ID distorted thoughts B) describe self care patterns C) discuss family relationships D) explore communication skills

A

Which sign indicated tardive dyskinesia A) involuntary movements B) blurred vision C) resltessness D) sudden fever

A

Which topic should the nurse discuss with the family of a client with bipolar disorder if the family is distressed about the client's episodes of mani behavior? A) ways to protect oneself from clients behavior B) how to proceed with an involuntary commitment C) how to confront the client about the reckless behavior D) when to safely increase medication during manic periods

A

Because they work, the family of a client with stage 1 dementia of the Alzheimer's type (DAT) cannot provide care during the daytime. Which option should the nurse help them explore? A) Adult daycare center B) Short-term hospitalization C) Skilled nursing facility D) Psychiatric commitment

A Because they work, the family of a client with stage 1 dementia of the Alzheimer's type (DAT) cannot provide care during the daytime. Which option should the nurse help them explore? Adult daycare center Short-term hospitalization Skilled nursing facility Psychiatric commitment

A client diagnosed with schizophrenia has improved and is playing a card game with peers. The group begins laughing at a joke told to them. The client jumps up and shouts, "You are all making fun of me." What term should the nurse use when documenting this incident in the client's record? A) Idea of reference B) Loose association C) Hallucination D) Delusion

A Explanation: A hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; they are real to the person. Delusions are false beliefs that cannot be changed by logical reasoning or evidence. Ideas of reference or misinterpretation occurs when the client believes that an incident has a personal reference to one's self when, in fact, it is not at all related. Loose association is a vague, unfocused, illogical flow or stream of thought.

A female client is a parent with stage 2 dementia of the Alzheimer's type. At-home care is being provided by her daughter. Which statement by the caregiver indicates to the nurse that the caregiver understands personal coping strategies that are most likely to be useful? A) "I need to spend time with my mother doing something we both enjoy." B) "I need to stay with my mother 24 hours a day." C) "I need to postpone my vacation for a few more years." D) "I need to bathe my mother every day before breakfast."

A Explanation: Because safety of the client is an urgent consideration, close supervision of the client should be provided at all times. However, if one caregiver remains with the client 24 hours a day, that person is at high risk for developing caregiver role-strain with feelings of resentment, isolation, and alienation. While assistance to personal hygiene and establishing a routine are important when providing care to the person with dementia, there is no prescribed time that personal hygiene should occur. Because safety of the client is an urgent consideration, close supervision of the client should be provided at all times. However, regular periods of respite are necessary for caregivers. Spending nonstressful time with the client helps diminish feelings of resentment, isolation, and alienation in the caregiver. Since remote memories are less diminished than recent memories, there is also the possibility that it will also increase the client's self-esteem by allowing reminiscence of past pleasurable life events.

When talking with a client, which client statement should lead the nurse to conclude that the client is experiencing a hallucination? A) "I can feel something crawling inside my body." B) "The shadows in the room at night scare me. I always mistake them for someone." C) "I know that everybody is talking about me." D) "The FBI is out to get me and my family because I did such a bad

A Explanation: Believing falsely that everyone is talking about the client is an example of a delusion. The client is describing a tactile hallucination. Hallucinations are false sensory experiences that can occur in any of the special sensory functioning areas: olfactory, gustatory, tactile, visual, or auditory. There is no external stimulus to the corresponding sensory organ; but the experience is perceived as real by the individual having the hallucination. Mistaking stimuli such as shadows is an illusory experience. Illusions are increased in states of heightened anxiety. Delusions are false thoughts without a basis in reality.

The client with a diagnosis of bipolar I disorder has a new order for carbamazepine. Before beginning to administer the medication, the nurse checks to see that which laboratory results are in the client's record? A) Liver function studies B) Blood glucose C) Thyroid profile D) Bleeding and clotting time

A Explanation: Changes in blood glucose are not commonly associated with carbamazepine. Instead, there is a strong relationship to blood glucose changes and certain second generation antipsychotics, such as olanzapine. Carbamazepine frequently causes changes in liver enzymes, which can result in dangerous or fatal problems for the client. Baseline laboratory results must be available before the first drug dose is administered. Subsequent results are then compared to baseline data as the prescriber makes decisions about future doses. While it is true that bleeding problems can be associated with carbamazepine, baseline bleed/clotting times are not required before the drug is administered. If the client were being given lithium, baseline information about thyroid functioning would be required.

A client will begin electroconvulsive therapy (ECT) after being diagnosed with major depression. The nurse prepares a teaching plan keeping in mind that which attribute is characteristic of clients with major depression? A) Clients need to be treated with respect and dignity. B) Clients should have the procedure explained many times because of inability to retain information. C) Clients should not receive ECT. D) Clients need to be brought to the treatment suite on a stretcher.

A Explanation: Clients always needs to be treated with dignity and respect. There is no reason to bring the client to the treatment suite on a stretcher. The client does not need to have a procedure explained many times. Explanations are reinforced as needed, which would be done for a client with any diagnosis. The client with major depression can receive ECT if medication therapy is not effective.

The client is to begin taking olanzapine. The nurse makes it a priority to assess which item before administering the first dose? A) Body weight B) Food and fluid preferences C) History of indigestion D) Usual sleep pattern

A Explanation: Determining the client's sleep pattern is not an urgent consideration, although the nurse should recognize that daytime somnolence might be an early side effect of the olanzapine. Food and fluid preferences are important considerations when the nurse teaches the client about usual side effects, but this can be done later. Increase in body weight and body mass index (BMI) can occur very quickly when clients take olanzapine.Baseline data about these should be obtained before the client begins to take this drug. While some clients do have digestive disturbances while taking olanzapine, this is not nearly as common as the side effect of rapid weight gain.

The nurse would formulate which nursing diagnosis as the most appropriate for a client with a medical diagnosis of delirium caused by a systemic infection? A) Interrupted Thought Processes related to elevated temperature B) Disturbed Self-esteem and Independent Functioning C) Risk for Caregiver Role Strain related to lack of respite and financial resources D) Confusion related to changing family roles and financial strain

A Explanation: Disturbed self-esteem and independent functioning is more reflective of the psychosocial processes associated with dementia. Risk for caregiver role strain related to lack of respite and financial resources is more reflective of the psychosocial processes associated with dementia. Confusion related to changing family roles and financial strain is more reflective of the psychosocial processes associated with dementia. Most cognitive impairments seen in delirium are physiological in origin; therefore, the identified problem and all its effects should be reflected in a complete nursing diagnosis.

A 79-year-old client is receiving haloperidol on a regular and a prn basis. The nurse should recognize the vital importance of assessing this client frequently for which indications? A) Tardive dyskinesia B) Fecal impaction C) Sedation D) Pseudoparkinsonian side effects

A Explanation: Elderly clients have slower metabolism and elimination of drugs causing an increased susceptibility to side effects. Haloperidol is a first generation, high potency antipsychotic that frequently causes extrapyramidal side effects (EPS), either of an acute or a chronic nature. In younger clients, EPS are more likely to be acute, but elderly clients may be more at risk for tardive dyskinesia (TD), which is generally irreversible. Constipation is a common side effect of antipsychotic drugs. Unmanaged constipation can lead to fecal impactions, especially in the elderly. However, these are considered preventable or treatable problems, while tardive dyskinesia is irreversible. Pseudoparkinsonian side effects are one of the extrapyramidal side effects associated with antipsychotics, especially traditional ones like haloperidol. They are generally reversible and treatable. While not as likely as tardive dyskinesia in the older client, acute extrapyramidal side effects (EPS) can occur. One of the more potent of the first generation antipsychotics, haloperidol is not likely to cause sedation as a side effect.

The in-patient client has bipolar I mood disorder and is in a manic state. Which expected behavior by the client is most important for the nurse to consider when planning care to address the client's safety needs? A) React impulsively to self-destructive feelings during a mood shift B) Express frequent verbal hostility and harsh sarcasm while mood is elevated C) Exhibit hypersexuality and socially inappropriate behavior D) Experience increased stimulation while in the presence of others

A Explanation: Having increased stimulation in the presence of others describes a common client presentation in states of elevated affect, but is not as important for safety as is the likelihood of rapid mood swings. Expressing frequent hostility and sarcasm during elevated mood describes a common client presentation in states of elevated affect, but is not as important for safety as is the likelihood of rapid mood swings. The client's level of risk for self-harm is a major concern. While the mood is elevated, the client may injure self from restless hyperactivity or poor judgment. Additionally, the client may experience unpredictable mood swings and act on accompanying suicidal urges. Exhibiting hypersexuality and socially inappropriate behavior describes a common client presentation in states of elevated affect, but is not as important for safety as is the likelihood of rapid mood swings.

A client with dementia is being cared for at home. Family members report that during the bath, the client tried to chew on a bar of soap. How should the home health nurse document this behavior? A) Hyperorality B) Hyperphagia C) Hypermetamorphosis D) Hyperactivity

A Explanation: Hyperactivity is a behavior characterized by decreased attention span, increased impulsivity, and emotional lability. Hypermetamorphosis is the need to compulsively touch and examine every object in the environment. This question describes a symptom called hyperorality, which is common in stage 2 of Alzheimer's disease. Clients experiencing this symptom have a need to place objects in the mouth so they can taste or chew them. They cannot discriminate between hazardous and nonhazardous items. Hyperphagia occurs when the individual eats, or ingests, excessive amounts of food.

The client has schizophrenia, residual type. A nursing care plan should give priority to which nursing diagnosis? A) Social isolation B) Self-care deficit C) Impaired verbal communication D) Anxiety

A Explanation: Impaired verbal communication is less likely to be seen in a client with residual schizophrenia than is social isolation. Self-care deficit is less likely to be seen in a client with residual schizophrenia than is social isolation. Residual-type schizophrenia manifests with socially withdrawn behavior, an inappropriate affect, and an absence of prominent psychotic symptoms. The most likely and common nursing diagnosis would be Social Isolation. Anxiety is less likely to be seen in a client with residual schizophrenia than is social isolation.

While the nurse is meeting with the family of a client with schizophrenia, a family member asks the nurse to explain what causes this disorder. What is the nurse's best response? A) "The exact cause of schizophrenia is unclear at this time." B) "Research indicates that schizophrenia is caused by a genetic predisposition." C) "It is clear that early-age psychological traumas cause schizophrenia." D) "It is likely that poor parenting skills cause schizophrenia to occur."

A Explanation: Research has correlated genetic factors with schizophrenia, but more research is needed in this area. The precise cause of schizophrenia is unknown. The general consensus is that schizophrenia results from the interaction between a variety of biologic and psychosocial factors that have been correlated with schizophrenia. Poor parenting skills have not been documented as exact causes of schizophrenia. Early-age traumas have not been documented as exact causes of schizophrenia.

The nurse is establishing client outcomes for a client with stage 3 dementia of the Alzheimer's type. Which client outcome would be most appropriate? A) Maintain skin integrity despite incontinence or prolonged pressure. B) Maintain minimal anxiety level in response to difficult situations. C) Interact with others in group activities and therapeutic outings. D) Shave, shower, and dress self by 9:00 A.M. every day.

A Explanation: The client in stage 1 dementia might be able to meet this outcome with assistance. However, in stage 2, behavior deteriorates markedly and the client begins needing assistance with ADLs. When Stage 3 is reached, total care becomes necessary. In Stage 3 dementia, the client is confused and easily overwhelmed by unfamiliar situations and persons. He/she may become unable to identify even very familiar persons, such as a spouse. The client is also prone to wandering, so attending therapeutic outings would present a safety issue for the client. Clients in stage 3 of Alzheimer's disease experience severe impairments usually requiring total dependent care. The client is often incontinent and mobility is severely impaired. As the disease progresses a more realistic goal for these clients is that the client will remain clean and dry. A client in Stage 3 dementia easily becomes agitated and even violent. The client has poor impulse control and is prone to behavioral outbursts. Nurses and other staff members should make every effort to manage these situations and to keep anxiety at a manageable level, but maintenance of physiologic functioning is the priority.

The 26-year-old female hospitalized client is being treated for major depression. The client participated actively in group therapy during the hour before lunchtime. When it is time for lunch, the client tells the nurse, "I'm not going. I'm going to my room." What is the nurse's best response? A) Ask the client to sit for a few minutes to discuss this. B) Ask the client if there is a problem with the food. C) Tell the client that there is a unit schedule that must be followed by everyone. D) Ask the client if she is angry.

A Explanation: The client is demonstrating a pattern of behavior that should be investigated. The nurse should take the time to assess the client's feelings, thoughts, and actions. The client may just be tired and have a need to rest, but the nurse needs to be sure that the client is safe and not upset. The nurse should not make assumptions about the client's feelings. Before ascribing a meaning to the client's behavior, the nurse should first talk to the client to determine the client's feelings. Additionally, the nurse is using a closed-ended question that can be answered with a "yes" or "no," which is an incorrect therapeutic technique to use when interviewing a client. This statement does acknowledge the client's change in attitude but does not indicate that the nurse has any concern for the client. This response changes the focus from the client to food in addition to prematurely and inappropriately presuming to understand the meaning of the client's behavior.

The client diagnosed with schizophrenia says, "Everyone here is part of the secret police and wants to torture me," and refuses to be weighed by a member of the nursing staff. What is the most appropriate response by the nurse? A) "That must be a frightening thought. We are nurses who work at this hospital." B) "There is no need to be frightened. We will keep you safe from torture." C) "That is a strange idea. We aren't secret police persons." D) "Being suspicious isn't easy, is it? You won't be tortured here."

A Explanation: The client is experiencing a delusion and indeed believes that the nursing staff members are secret police. This statement demeans the client and fails to allow the client to know the staff's role. The client is experiencing a delusion and indeed believes that the nursing staff members are secret police. Understandably, the client will be distrusting, suspicious, and frightened of all actions of the staff. The nurse should show awareness of the feelings of the client ("That must be a frightening thought.") and present reality about the role of the nursing staff. ("We are nurses who work at this hospital."). This statement attempts to respond to the client's feeling and present reality, but it does not tell the client about the role of the staff. This statement attempts to be reassuring, but it fails to give reality-based information that might assist the client to feel more comfortable with the staff. It also could suggest to the client that torture will occur, but not at this location.

The client with dementia of the Alzheimer's type says to the nurse, "I have a date tonight for the Valentine's dance." What is the most appropriate response by the nurse? A) "Today is January 11th. Tell me about some of the other dances you've been to." B) "You're confused again. There isn't a dance tonight and this isn't Valentine's Day." C) "I think you need some more medication. I'll be right back with your shot." D) "I didn't think your spouse was still living. Who is your date with?"

A Explanation: The nurse is attempting to present reality, but in a non-therapeutic manner. The statement is made in a demeaning and belittling manner. The nurse should present reality and provide orienting stimuli in a manner that preserves the client's self esteem. The response of the nurse promotes further disorganization in thinking and orientation in this client with dementia. The client's statement indicates disorientation and disorganized thinking that is very common in persons with dementia. There is nothing to suggest that this behavior requires a prn medication (such as aggression toward others) is present. This response uses a method of reality orientation that increases self-worth and personal dignity. It also allows client reminiscence, which is useful to persons with dementia as their remote memories are more intact than recent ones.

The client has dementia of the Alzheimer's type (DAT) and is being cared for by the spouse in the home. What self-care activity will be most important for the nurse to recommend to the spouse? A) Periodic times of respite from caregiving B) Participation in reminiscence therapy C) Establishment of a predictable daily schedule D) Regular attendance at church services

A Explanation: The nurse should not assume that the spouse's spiritual belief system includes worship in a church. The nurse should assess the spouse's belief system before making any recommendation for spiritual support. It is most important for the nurse to recognize that this spouse, like others providing care to persons with DAT, is at high risk for caregiver role-strain. Having to provide constant care to a person with declining cognitive and physical capacity can exhaust and overwhelm the caregiver. Reminiscence therapy is more likely to be useful to the client in early stages of dementia. While it may be useful to the spouse as part of anticipatory grieving, it is most important to recognize the high risk for caregiver role-strain. While a predictable daily routine is generally helpful to the spouse, it is most necessary for the client.

A client diagnosed with schizophrenia tells the nurse that another client is "creating negative thoughts in me against my will." The nurse documents that the client is exhibiting which feature of schizophrenia? A) Thought insertion B) Thought broadcasting C) Thought blocking D) Thought control

A Explanation: Thought broadcasting is the belief by a client that he or she can broadcast his or her thoughts to others. Thought blocking occurs when a client's thoughts stop in midstream. Thought insertion is a thought disorder of schizophrenia defined as the client believing that others are putting thoughts in his or her mind against the client's will. Thought control is the belief that others can control one's thoughts against his or her will.

A client with schizo is exhibiting delusions, hallucinations, minimal self care and hyperactive behavior. which of these observations would the nurse document as a negative symptom of schizo? A) minimal self care B) delusions C) hallucinations D) inappropriate affect

A Rationale: B, C, D are negative symptoms

A client is experiencing continuous auditory hallucinations but is refusing to take the prescribed medications. What potential reason for the​ client's behavior should the nurse​ explore? A) Medication side effects B) Cause of the hallucinations C) Recent hospitalization D) Availability of group therapy

A Rationale: Because of the side effects of many antipsychotic​ agents, adherence to a medication regimen is often a challenge for clients with schizophrenia. The cause of the​ hallucinations, the availability of group​ therapy, and recent hospitalization do not assist in explaining the​ client's behavior.

Which nursing diagnosis is most appropriate for a client with acute schizophrenic reaction? A) social isolation related ti impaired ability to trust B) impaired mobility related to fear of hostile impulses C) risk for other directed violence related to perceptual distorions D) disturbed sleep

A Rationale: Client with schizo are mistrustful which results in social isolation and withdrawal

A client has started takine haloperidol( haldol). Which instruction is most appropriate for a client taking haloperidol? A) you should report feelings of restlessness or agitation at once B) use a sunscreen outdoors on a year round basis C) be aware youll feel increased energy taking this drug D) this drug will indirectly control essential hypertension

A Rationale: agitation and restlessness are side effects of haloperidol and can be treated by anticholinergic drugs

A nurses laces an object in the hand of a client with alzheimers and ask the client to ID the object. Which term represents the client's inability to name the object? A) agnosia B) aghasia C) apraxia D) perseveration

A Rationale: agnosia is the inability to recognize familiar objects, aphasia is inability to speak, apraxia refers to the client's inability to use objects properly. Perseveration is of a meaningless continued repetition of meaningless word or phrase that occurs in stage 2 of alzheimers.

Impaired memory, both recent and remote A) delirium B) dementia

A dementia is impaired memory recent is affected before remote

Which medication should the nurse expect to administer to the client with bipolar disorder for immediate treatment of the clinical manifestations of​ mania? A) An antipsychotic mood​ stabilizer, olanzapine B) Anticholinergic​ medication, diphenhydramine C) An antidepressant​ medication, paroxetine D) Antimanic​ medication, lithium carbonate

A ​Rationale: An antipsychotic might be used for immediate treatment of manic manifestations. Lithium carbonate takes 1 to 3 weeks for​ effectiveness, so it is not an immediate help for current symptoms. Anticholinergic medication is given to treat the symptoms that result from antipsychotic medication. Antidepressants are administered to treat depression and take 4 to 6 weeks to reach an effective level. In the client with bipolar​ disorder, antidepressants are usually combined with anticonvulsant mood stabilizers to prevent the occurrence of mania.

The nurse is providing care for a client recently diagnosed with schizophrenia. Which hallmark symptom should the nurse expect in this​ client? A) Auditory hallucinations B) Anxiety C) Manic behavior D) Melancholy

A ​Rationale: Auditory or visual hallucinations are the hallmark symptom of schizophrenia. Anxiety is more indicative of an anxiety disorder. Melancholy is associated with​ depression, and manic behavior is more likely to occur with bipolar disorder.

The nurse is planning care for a client who is diagnosed with delirium. Which nursing diagnosis is most appropriate for the nurse to​ assign? A) Communication: Verbal, Impaired B) Grieving, Complicated C) Airway​ Clearance, Ineffective D.) Coping, Ineffective

A ​Rationale: Clients who are diagnosed with delirium have problems with thought processes and speech patterns. Depending on the severity of the​ delirium, ​Communication: Verbal, Impaired might be an appropriate diagnosis. Delirium does not cause​ airway, coping, or grieving issues.​ (NANDA-I ©2014)

The nurse is discussing the care of a client with Alzheimer disease​ (AD) with the family. The family reports the client has frequent mood swings and becomes combative. Which intervention should the nurse expect the healthcare provider to​ prescribe? A) Administer selective serotonin reuptake inhibitor​ (SSRI) antidepressants. B) Increase acetylcholinesterase inhibitor dose. C) Utilize physical and chemical restraints. D) Implement behavioral interventions.

A ​Rationale: Clients with AD will experience frequent mood swings and may become combative. Research shows success in decreasing mood swings with the use of SSRI antidepressants. Increasing the acetylcholinesterase inhibitor dose will not change the​ client's mood. Behavioral interventions may be​ effective, but do not last long. Physical and chemical restraints should be a last resort.

The nurse is planning care for a client who is diagnosed with delirium. Which goal is most appropriate for the nurse to assign to this​ client? A) The client will obtain adequate sleep and rest. B) The client will express understanding of the disease process. C) The client will perform activities of daily living​ (ADLs) with assistance. D) The client will deny any suicidal thoughts.

A ​Rationale: Clients with delirium often experience a disturbed sleep pattern. As their confusion​ fades, natural, normal sleep becomes more of a reality. An appropriate goal for the client with delirium is to be able to perform ADLs without assistance. Suicidal thoughts are not normally a part of delirium. It is not expected that the client will express understanding of the disease process.

An older client with severe depression and suicide ideation is prescribed an antidepressant medication. Which home safety issue should the nurse discuss with the client and​ spouse? A) Discussing any herbal medications with the healthcare provider B) Disposing of all medications at home C) Taking antidepressant medication as needed D) Allowing client to drive the car

A ​Rationale: Herbal medications such as St.​ John's wort may be used to treat symptoms of​ depression, but can cause serotonin syndrome when used with a selective serotonin reuptake inhibitor​ (SSRI). The nurse should emphasize first discussing the use of any herbal preparation with the healthcare provider. Driving would depend upon the effects of the medication. There is no reason to dispose of all medications in the home unless the client used medications for a previous suicide attempt. Antidepressant medication should be taken as prescribed.

The parents of a child with bipolar disorder ask the nurse what treatments will help control the​ child's violent outbursts and temper tantrums. Which would be the​ nurse's best​ response? A) ​"Psychotherapy will help the child learn coping and appropriate actions to build​ relationships." B) "Punishing the child will help change​ behavior." C) "Maximum doses of prescribed medication should be administered to control​ behavior." D) ​"There is no cure for bipolar disorder and no hope for the​ child's behavior to​ improve."

A ​Rationale: The child with bipolar disorder may benefit from psychotherapy to learn how to react in social situations and build relationships. Punishing the child is not a therapeutic treatment for bipolar disorder. While there is no cure for bipolar​ disorder, medication and behavioral therapy can help to manage the disorder. The child should remain on the least amount of medication at the lowest dose possible to minimize adverse effects.

The nurse is caring for a client with stage 2 Alzheimer disease​ (AD) who is unable to remember how to get dressed. Which nursing intervention would assist the client to maintain​ independence? A) Tell the client each step and allow her to perform it. B) Play a video of a person dressing herself. C) Give the client pictures of each step to follow. D) Provide assistance with each step of dressing.

A ​Rationale: To maintain independence as much as​ possible, the nurse should tell the client each step to perform and allow the client to do the task. Playing a video or giving the client pictures may be overwhelming. Providing assistance with each step promotes dependence

Which symptom of schizophrenia is relieved by transcranial magnetic​ stimulation? A) Auditory hallucinations B) Visual hallucinations C) Tardive dyskinesia D) Impaired verbal communication

A ​Rationale: Transcranial magnetic stimulation uses a magnetic field to help decrease the frequency and duration of​ auditory, but not​ visual, hallucinations; it can also help to alleviate depression.​ Omega-3 fatty acids could help reduce the symptoms of tardive dyskinesia. Overall symptom reduction may help with impaired verbal communication.

A fourteen-year-old client is to be admitted to a psychiatric in-patient unit for treatment of bipolar disorder. When assisting staff to understand behaviors that are likely to be seen in this client, what should the nurse emphasize?Select all that apply. A) Socially aggressive B) Inattention and detractibility C) Inflated self-esteem D) Prolonged periods of extreme mood E) Poor management of spending money

A, B You answered this question correctly.× Explanation:The adolescent client with bipolar disorder is much more likely to be irritable and socially aggressive and to experience multiple mood swings in the course of the day.The adolescent client, who has a diagnosis of bipolar disorder, is much more likely to be irritable and socially aggressive.The adolescent client with bipolar disorder does have inflated self esteem, but this is not as evident as it is in the adult with bipolar disorder.The adolescent client with bipolar disorder does tend to manage money poorly, but this is not as evident as in the adult with bipolar disorder. This manifestation in an adolescent client may be overlooked as an indication of a lack of maturity.Children and adolescents with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD, which are part of the spectrum disorders of childhood.

The nurse should assess a client diagnosed with delirium for which​ symptom? (Select all that​ apply.) A) Disorganized thoughts B) Altered sleep patterns C) Limited attention span D) Ability to answer questions E) Ability to​ read, write, and understand speech

A, B, C ​Rationale: Common manifestations of delirium include reduced awareness indicated by a limited attention​ span, impaired thinking skills evidenced by disorganized​ thoughts, and changes in behavior evidenced by altered sleep patterns. Other signs include an inability to answer questions and difficulty in​ reading, writing, and understanding speech.

The nurse is caring for a client diagnosed with delirium. Which outcome should lead the nurse to determine that treatment is​ successful? (Select all that​ apply.) A) The client remains free of injury. B) The client maintains adequate nutrition. C) The client returns to an optimal level of​ functioning, if possible. D) The client verbalizes feelings of being able to cope with the disease. E) The client prepares advanced future planning for progressive disease stages.

A, B, C ​Rationale: One expected outcome for delirium is that the client will return to the level of functioning she had before the onset of the delirium. The client should remain free of injury and maintain adequate nutrition. Verbalizing feelings of being able to cope with the disease and preparing advanced future planning for progressive disease stages are expected outcomes for clients with Alzheimer​ disease, who are not expected to return to an optimal level of functioning.

A​ 21-year-old college student is brought to student health services complaining of hearing voices and being unable to study. Which possible diagnosis must be ruled out before a diagnosis of schizophrenia can be​ made? (Select all that​ apply.) A) Depression B) Brain tumor C) Bipolar disorder D) Coronary heart disease E) Medication or illicit drug reaction

A, B, C, E ​Rationale: Depression, brain​ tumor, bipolar​ disorder, and medication or illicit drug reaction must be ruled out before a diagnosis of schizophrenia can be made. Coronary heart disease does not have symptoms similar to those of schizophrenia.

Which should the nurse identify as a risk factor for the development of​ depression? (Select all that​ apply.) A) Dysfunctional family relationship B) Family member with depression C) Caucasian D) Childhood sexual abuse E) Male sex

A, B, D ​Rationale: A dysfunctional family​ relationship, having a family member with​ depression, and having been sexually abused as a child are all risk factors for the development of depression. Male sex or Caucasian is not considered a risk factor for the development of depression.

A nurse is providing information about acetylcholinesterase inhibitors for the spouse of a client diagnosed with Alzheimer disease​ (AD). Which item will the nurse include in the teaching​ session? (Select all that​ apply.) A) Observe the client for improvement in manifestations. B) Notify the healthcare provider if manifestations worsen. C) The medication must be administered 1 hour before meals. D) Do not stop the medication without consulting the healthcare provider. E) Cholinesterase inhibitors will stop the progression of Alzheimer disease.

A, B, D ​Rationale: Appropriate teaching points to include are to not stop the medication without consulting with the healthcare​ provider, to observe for​ improvement, and to notify the healthcare provider if conditions worsen. The medication does not need to be administered 1 hour before a meal. The nurse would not include the teaching point that the medication will stop the progression of AD.

The behavioral health nurse is collaborating with the dietitian to create a diet plan for a client with bipolar disorder who is living independently. Which intervention should the nurse​ include? (Select all that​ apply.) A) Planning foods that are portable B) Identifying easily prepared meals C) Planning three large meals per day D) Making a list of client food preferences E) Reviewing the use of nutritious​ meal-replacement drinks

A, B, D, E ​Rationale: The client with bipolar disorder needs​ quick, easy,​ on-the-go food to manage nutritional needs in a heightened state of activity related to mania.​ Portable, easily​ prepared, preferred foods are likely to provide nutrition for the client as well as quick access to nutritional supplement drinks. Planning three large scheduled meals per day is unlikely to be successful for the client with bipolar disorder.

The nurse is caring for an adolescent experiencing a manic period of bipolar disorder. Which technique reinforces behavior​ limits? (Select all that​ apply.) A) Speaking in a calm but​ matter-of-fact tone B) Curbing manipulative behavior C) Overstepping personal boundaries to help the adolescent D) Modeling behavior for the adolescent to follow E) Building trust with the adolescent

A, B, D, E ​Rationale: The nurse uses therapeutic interventions to set limits with the adolescent client with mania to reduce harm and control behaviors. Curbing manipulative​ behaviors, building​ trust, using a calm​ matter-of-fact tone, and modeling behavior supports setting limits. The nurse would​ self-reflect often to ensure boundaries were not overstepped.

The family of a client with Alzheimer disease​ (AD) report that they can no longer manage the care in their home and are planning​ long-term care placement. Which information should the nurse provide the family to decrease the risk of relocation​ syndrome? (Select all that​ apply.) A) Bring pictures from home. B) Retain the same structure. C) Refrain from visiting for 1-2 weeks. D) Administer medication at different times. E) Use a daily schedule to remind the client of tasks.

A, B, E ​Rationale: Ways the nurse can help minimize the effects of relocation​ syndrome, which can occur when a client with AD is moved to another care​ facility, include bringing pictures from home and retaining as close to the same structure as possible. The client should be provided a daily schedule to remind the client of what happens at what time. Family should be encouraged to visit and be a part of the​ client's routine. Medications should be administered as they have been prescribed and not varied. Next Question

The nurse notes a behavior change in a client. Which manifestation should the nurse identify that is a less obvious symptom of​ depression? (Select all that​ apply.) A) Anger B) Insomnia C) Aches and pains D) Excessive sleep E) Sadness

A, C ​Rationale: Anger and physical complaints are less obvious symptoms of depression.​ Sadness, insomnia, and excessive sleep are considered major symptoms of depression.

Which information should the nurse include when providing teaching at a community center about ways to prevent Alzheimer disease​ (AD)? (Select all that​ apply.) A) Consume a heart healthy diet. B) Refrain from consuming alcohol. C) Keep mentally active with puzzles. D) Get tested annually for Alzheimer disease. E) Take N​-methyl-D-aspartate ​(NMDA) receptor antagonists.

A, C ​Rationale: Clients who are trying to prevent the onset of Alzheimer disease​ (AD) should consume a heart healthy​ (Mediterranean) diet because the foods in this diet have antioxidants and prevent the formation of amyloid plaques. Clients should keep mentally active by doing puzzles and playing games. It is believed that alcohol can be consumed in moderation to prevent AD. An individual should not routinely take NMDA receptor antagonists to prevent​ AD, and there is not a test that can be performed to diagnose AD.

A male client is taking a second-generation antipsychotic drug. The client's spouse tells the nurse that she read that the drug is effective to treat negative symptoms of schizophrenia and asks the nurse to explain what these are. What should the nurse include in a response to the spouse?Select all that apply. A) Diminished pleasure B) Abnormal thoughts C) Blunted affect D) Difficulty making decisions E) Hallucinations

A, C, D Explanation: The presence of abnormal thoughts is a positive symptom of schizophrenia, rather than a negative symptom. Diminished pleasure represents a loss of functioning of the individual, which is the definition of negative symptoms of schizophrenia. First-generation antipsychotic drugs typically do not improve these symptoms, but second-generation antipsychotic drugs do. Blunted affect represents a loss or lack of normal functioning of the individual, which is the definition of negative symptoms of schizophrenia. First-generation antipsychotic drugs typically do not improve these symptoms, but second-generation antipsychotic drugs do. The presence of hallucinations is a positive symptom of schizophrenia, rather than a negative symptom. Difficulty making decisions represents a loss or lack of normal skills and functioning of the individual, which is the definition of negative symptoms of schizophrenia. First-generation antipsychotic drugs typically do not improve these symptoms, but second-generation antipsychotic drugs do.

Which disorder is a client with known schizophrenia at increased risk of​ developing? (Select all that​ apply.) A) Depression B) Gastric ulcers C) Mood disorders D) Substance abuse E) Complications of coronary artery disease

A, C, D Rationale: Schizophrenia is often associated with dual diagnosis for other mental health​ disorders, including​ depression, substance​ abuse, and mood disorders. This complicates treatment in that multiple psychiatric disorders are​ involved, and treatment must address all disorders. There is no increased risk of gastric ulcers or complications of coronary artery disease

The spouse of a client diagnosed with delirium tells the​ nurse, "I'm not sure what caused​ this, as my spouse has never had any mental issues​ before." Which potential cause should the nurse include in the response to the​ client's spouse?​ (Select all that​ apply.) A) Infection B) Thyroid disease C) Sleep deprivation D) Drug or alcohol use E) Irritable bowel disease

A, C, D ​Rationale: Causes of delirium include sleep​ deprivation, infection, and drug or alcohol use or withdrawal. Irritable bowel disease and thyroid disease have not been shown to cause delirium.

The nurse is completing a health history of a​ 15-year-old client to assess for possible schizophrenic indications. Which information should the nurse obtain during this​ assessment? (Select all that​ apply.) A) Paternal age B) Maternal age C) Drug and alcohol use D) Presence of symptoms E) Assessment of daily functioning

A, C, D, E ​Rationale: To consider the diagnosis of​ schizophrenia, the nurse needs to obtain the following information when completing a health​ history: assessment of daily​ functioning, drug and alcohol​ use, and presence of symptoms. Paternal age represents a risk factor for the​ condition; maternal age does not.

Which psychological factors should the nurse assess for in a client to determine the risk for development of Alzheimer disease​ (AD)? (Select all that​ apply.) A) Depression B) Schizophrenia C) Sleep disorders D) Bipolar disorder E) Elevated stress levels

A, C, E Rationale: Research shows a correlation between​ depression, sleep​ disorders, and elevated stress levels and the onset of Alzheimer disease. Schizophrenia and bipolar disorder do not lead to AD.

A client with major depression asks why he is taking mirtazapine (remeron) instead of tofraril. Which explanation is most accurate? A) new SSRI drugs are better tested drugs B) SSRI have few adverse effects C) SSRI require a low dose of antidepressant drug D) SSRI drugs are as good as other antidepressant drugs

B

A combo of manifestations of schizo and mood disorders' delusions, hallucinations, disorganized speech and behavior, communication difficulties, poor abstractions, passive social withdrawal, poor grooming,. A) dysthymic disorder B) schzoaffective disorder C) major depression D) bipolar disorder E) cyclothymic disorder F) seasonal affective disorder.

B

This state of dementia is when client presents with confusion A) stage 1 B) stage 2 C) stage 3 D) stage 4

B

Which condition or characteristic is related to the cluster of symptoms associated with disorganized schizophrenia? A) odd beliefs B) flat affect C) waxy flexibility D) systematized delusions

B

Which discharge teaching is most important for a client taking lithium? A) limit fluids to 1500 ml per day B) maintain a high fluid intake C) take advantage of the warm weather by exercising outside whenever possible D) when feeling a cold coming, its ok to take OTC remedies

B

Which mental disorder is associated with the GABA complex? A) alzheimers disease B) anxiety C) depression D) PTSD

B

Which symptom is usually responsive to traditional antipsychotic drugs? A) apathy B) delusions C) social withdrawal D) attention impairment

B

rhyming words that have no connection and make no sense A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

B

serotonin has been associated with depression because it plays which role? A) plays a role in cerebral functioning B) it has a proposed role in mood states C) its found widely in the hippocampus D) it regulates the sleep and wakefulness cycle

B

The nurse is evaluating a client diagnosed with bipolar disorder in the home environment following discharge 2 weeks ago from an inpatient unit. The nurse assesses the client for which behaviors that are expected at this time? A) Gregarious interactions with significant others B) Calm, focused exchange of self-care information with nurse C) Quiet and evasive presentation D) Euphoric and talkative presentation with nurse

B Explanation: A client in a manic state would present with euphoria and be talkative. A client in a manic state or a client who is very outgoing could have gregarious interactions with significant others. A client with depression would be more likely to have a quiet and evasive presentation. A client who demonstrates a calm, focused exchange of information and self-care information would demonstrate control of the disorder, which is expected after discharge from an inpatient setting.

A client taking antipsychotic medications for treatment of schizophrenia reports feeling nervous. The client is pacing the long hallway and is unable to remain still, even when in conversation with other clients. What term should the nurse use to document this occurrence? A) Dystonia B) Akathisia C) Tardive dyskinesia D) Akinesia

B Explanation: Akathisia is an extrapyramidal side effect of antipsychotic medications that may manifest as subjective and objective restlessness and increased motor movement. Akinesia is decreased activity or motor movement. Dystonia is also an extrapyramidal side effect, but it is not shown in this client's behavior. Dystonia presents as sudden and often painful contractions of muscles, especially of the head and neck. Tardive dyskinesia is an extrapyramidal side effect, but it is not shown in this client's behavior. Tardive dyskinesia presents as involuntary muscle movements, strange tics, and repetitive motor movements in persons who have taken antipsychotics for a long period of time. The situation gives no past history of the client.

A depressed older adult client with short-term memory loss is receiving paroxetine. A family member says, "I don't remember the reason this medicine might help." What would be the nurse's best response? A) Paroxetine increases the acetylcholine levels in the brain. B) An increase in the serotonin levels in the brain occurs with paroxetine. C) Paroxetine increases circulation to the brain. D) Oxygen levels in the brain will increase with paroxetine administration.

B Explanation: Increasing the circulation to the brain is not a function of paroxetine. Paroxetine does not increase the acetylcholine levels in the brain. Short-term memory loss is a sign of depression in the older adult that can be caused by a deficit of serotonin in the brain. Paroxetine blocks the reuptake of serotonin resulting in elevated levels of serotonin in the brain. Also, the nurse should keep the communication as simple as possible because the listeners may not know or understand human anatomy or commonly used medical expressions. The administration of paroxetine does not increase oxygen levels in the brain.

A client hospitalized with bipolar disorder is in a state of mania. The client who was admitted on a formal voluntary status demands immediate discharge from the facility. What action should the nurse take first? A) Notify the supervisor on the nursing unit. B) Offer the client a contract for safety. C) Notify the police of the client's intention. D) Inform the client's spouse of the client's request.

B Explanation: It is not appropriate to involve the police. While informing the spouse might be an appropriate later action, at this time the nurse should focus attention on the client. The manic client has poor judgment and is impulsive and at risk for injury. The nurse should attend to the safety needs of this client before taking other actions. It is possible that the client will not be able to contract for safety. (At this point the first part of the contract would be for the client to remain in the hospital.) If the client could not do this, the nurse's next action is to explain the terms of the client's admission status. Because the client is being treated on a formal voluntary basis, the nurse cannot comply with the client's demand to be discharged. It is appropriate for the nurse to report the client's request to the nursing supervisor, but the first response to the client's request should be made to the client.

Which information should the nurse include when teaching a family caregiver how to help a client with early dementia complete activities of daily living (ADLs)? A) Perform ADLs for the client B) Give the client ample time to perform the ADLs as independently as possible C) Have the client plan a schedule for ADLs D) Tell the client that the ADLs must be finished by 9:00 AM

B Explanation: It is premature to provide ADLs to the client with early dementia. This will likely be necessary at a later stage of the illness. Having the client develop a written schedule for ADLs may be overwhelming to the client and increase confusion and uncooperativeness. Clients with early dementia should be allowed to provide their own ADLs as independently as possible for as long as possible. They will need extra time to perform tasks. Giving the client an ultimatum about the time in which ADLs must be completed may be overwhelming and therefore increase confusion and/or uncooperativeness.

Which information should the nurse assess prior to administering a benzodiazepine to the client? A) Stressors and use of coping mechanisms B) Recent use of alcohol or other depressants C) Level of motivation for treatment D) Situational and social support

B Explanation: Motivation for treatment is an important factor to document during the assessment. However, the client's immediate risk for safety is the priority and must be assessed first. Other data can be compiled when the formal assessment is completed at a later time. Situational and social support is an important factor to document during the assessment. However, the client's immediate risk for safety is the priority and must be assessed first. Other data can be compiled when the formal assessment is completed at a later time. Stress and use of coping mechanisms are important factors to document during the assessment. However, the client's immediate risk for safety is the priority and must be assessed first. Other data can be compiled when the formal assessment is completed at a later time. Combined use of benzodiazepines and other central nervous system depressants can lead to death from respiratory failure. If the alcohol has been ingested shortly before admission (which is not at all uncommon for a client experiencing anxiety), giving a benzodiazepine could put the client at risk.

The nurse plans care for a client in the manic phase of bipolar disorder. Which action should the nurse take to ensure for this client's safety? A) Emphasize the need to participate in several focused activities B) Assess risk for self-harm C) Encourage unrestricted vistors D) Admit to a two-bed room for companionship

B Explanation: The client's level of risk for self-harm is a major concern and should be a priority. The client may need a private room if in a manic state, not a two-bed room. The client may need restricted visitors if in a manic state rather than unrestricted visitors. The client should not be overstimulated, making it inadvisable to recommend client participation in several focused activities.

A client hears voices telling him that he is a terrible person who would be better off dead. What would be a priority problem for the nurse to address in the client's plan of care? A) Inadequate communication B) Risk for suicide C) Impaired sensory perceptions D) Impaired social interactions

B Explanation: There is no indication that the client has inadequate communication. Client safety is a priority because the voices that the client hears could result in a client suicide attempt. While hearing voices (hallucination) is a sensory-perceptual alteration, safety is the priority. There is no information regarding the client's social interactions with others.

The client has been taking lithium carbonate 300 mg by mouth for six days. The serum lithium level is 1.1 mEq/L. In addition to noticing minor tremulousness in the client's hands, the nurse also observes the client drinking water frequently. What conclusion should the nurse reach about this client's status? A) Manifesting behaviors that suggest early return of manic symptoms B) Experiencing normal side effects while at therapeutic blood level C) Experiencing early renal impairment associated with side effects of lithium D) Showing probable signs of lithium toxicity while at non-therapeutic lithium level

B Explanation: This client is not showing signs of possible Lithium toxicity, but rather is displaying normal side effects while in the therapeutic blood level range. While renal impairment is a possible untoward effect of Lithium, nothing in the question suggests that renal problems are being experienced. The client is not manifesting early return of symptoms of elevated affect, which would include increased grandiosity, flight of ideas, and irritability. The client is experiencing normal side effects of lithium. Full control of symptoms of mania may not occur for 1-2 weeks. This client is within the therapeutic blood level for clients newly begin on Lithium (0.8 mEq/L to 1.4 mEq/L) and is displaying two of the commonly expected side effects of lithium.

The nurse is conducting an initial assessment interview with a newly admitted client whose diagnosis is paranoid schizophrenia. When the client says, "The voices are talking with me right now. They won't go away," what is the most important response from the nurse? A) "I don't hear the same sounds that you are hearing." B) "Are you receiving a message from what you are hearing?" C) "Does what you're hearing seem real to you?" D) "What you're hearing aren't really voices of people. They're thoughts in your head."

B Explanation: This response could be appropriate later, once the nurse has established the content and nature of the hallucinatory experience. At this point, the client is newly admitted, and the nurse must assess for command hallucinations. If the client feels commanded to harm self or others the nurse must implement appropriate safety measures. The client who is hallucinating perceives the experience as being real. What is important is for the nurse to assess for the possible presence of command hallucinations. When a client first mentions hallucinations, it is imperative for the nurse to assess for the possible presence of command hallucinations, or hallucinations that give the client an instruction. If command hallucinations are present, the risk of physical danger for the client or others is great. Note also that the nurse does not refer to the "voice" as a voice, because this could lead the client to believe that the "voice" is indeed an actual voice. It is inappropriate to try to educate the person at this point. More assessment data is needed so that appropriate interventions can be planned. Specifically, the nurse must assess for the presence of command hallucinations.

The client being seen in the outpatient clinic has been taking olanzapine for one month and has experienced a 12-pound weight gain during that time. When the client expresses an interest in preventing further weight gain, the nurse's first action should be to make which recommendation to the client? A) Report to the clinic for daily weights B) Keep a careful record of all food intake for one week C) Make an appointment with a nutritionist D) Enroll in a weight management program

B Explanation: Weighing daily can be discouraging, as within the course of a week, several normal fluctuations in weight might occur. Additionally, reporting to the clinic daily (if the client has not already been doing so) is unnecessary and would add to both expense and stress levels of the client. It is premature to enroll in a formal weight management program.The nurse should assist the client to establish baseline data before seeing other professionals. Keeping a careful record of all food intake for one week, will allow for collection of baseline data that can be used for developing a weight control/loss program. It is premature to see a nutritionist at this time. The nurse should assist the client to establish baseline data before seeing other professionals.

When assessing an adolescent client for depression, what is most important for the nurse to recognize regarding depression in adolescents? A) Adolescent depression is similar in presentation to depression in adult clients. B) Adolescent depression is masked by aggressive behaviors. C) Adolescent depression is situational and not as serious as depression in adults. D) Adolescent depression is an indication of family dysfunction.

B Explanation: While the DSM-IV-TR criteria for depression are the same for adults, children, and adolescents, the clinical presentation may be different in the different age groups. Depression in adolescents is often masked by aggressive and/or behavioral problems, including intense mood swings, academic difficulties, antisocial behavior, and hypersomnia. Depression in adolescents can have the same consequences as in adults and should be treated seriously. Family dysfunction may or may not be present when the adolescent client is depressed. As with adults who are depressed, there is evidence that depression in adolescence is highly associated with psychobiologic changes, especially in neuroendocrine functioning.

A​ 68-year-old client is being evaluated after reporting auditory hallucinations and feeling that his family is trying to poison him. Which should be considered in the​ client's evaluation for​ schizophrenia? A) Adult protective services should be consulted to investigate whether the family is trying to poison the client. B) Schizophrenia should be considered only after other disease processes are ruled out. C) The client has​ late-onset schizophrenia and should be referred to some group or individual therapy quickly. D) The client likely always had schizophrenia and learned to ignore the symptoms.

B Rationale: An older adult client who reports symptoms that may be associated with psychosis should have a full evaluation to rule out any​ disease-related causes of the symptoms. A brain tumor or dementia could also cause hallucinations. The client has not always had schizophrenia. In​ early-onset schizophrenia, symptoms tend to diminish over time. If the fear of family poisoning the client is associated with​ hallucinations, the likely cause is a psychiatric disorder. Group therapy is not always the best option for​ late-onset schizophrenia.

The family of a client who has recovered from a period of delirium​ states, "We are so glad that this episode is over because it was really scary to see Dad like​ that." How should the nurse​ respond? A) "Your dad is now immune to future episodes of​ delirium." B) ​"Yes, but it is important that you know that your dad is at risk for future episodes of​ delirium." C) "Giving your dad vitamins will prevent him from having any future attacks of​ delirium." D) "It is good that your dad is all better​ now."

B Rationale: Individuals who experienced one episode of delirium are at increased risk for future episodes. Teaching should emphasize the​ prevention, detection, and treatment of health issues that may precipitate other episodes of delirium. The first response does not address the future risk of developing delirium. An episode of delirium does not infer immunity. Vitamins do not protect one against delirium.

A client is being treated for a major depressive disorder. Which symptom should the nurse expect to assess in this​ client? A) Enhanced energy B) Insomnia C) Increased libido D) Euphoria

B Rationale: Insomnia is a symptom of a major depressive disorder.​ Euphoria, increased​ libido, and enhanced energy are not symptoms of a major depressive disorder.

The nurse is leading a group therapy session for clients with bipolar disorder. During the​ session, a client with bipolar I disorder becomes increasingly restless and starts constantly interrupting and criticizing other members of the group. The client ignores the​ nurse's repeated requests to stop the disruptive behavior. Which type of bipolar episode is the client likely​ experiencing? A) Cyclothymic B) Manic C) Disruptive D) Depressive

B Rationale: The client is likely experiencing a manic bipolar state. Mania is an abnormal and persistent period of​ increased, expanded, or irritable mood that is characterized by increased energy for a period of time. A depressive state is characterized by five or more symptoms in a​ 2-week period that demonstrate either a depressed mood or a decrease in pleasure or interest in daily activities. Cyclothymic disorder is characterized by at least 2 years of chronic fluctuating periods of hypomanic and depressive behaviors.

Many clients with schizophrenia simultaneously have opposing emotions. Which term describes this phenomenon? A) double blind B) ambivalence C) loose associations D) inappropriate affect

B Rationale: ambivalence, one of the symptoms associated with schizo, immobilizes the person from acting.

A depressed client is taking trazodone (desyrel), an atypical antidepressant,. On discahrge the nurse will instruct the client to take the medication when? A) morning B) bedtime C) at any time during day D) when she has an urge for a cigarette

B Rationale: trazodone makes you sleepy

PROGRESSIVELY LOSES ORIENTATION to time, place, then person, sundown syndrome A) delirium B) dementia

B delirium fluctuates throughout day, periods of lucidity, sundown syndrome that worsens at night

duration is months to years A) delirium B) dementia

B delirium is hours to days

labile affect, prone to apathy, depression, withdrawal, stubbornness in attempt to cope with surroundings and decreased abilities A) delirium B) dementia

B delirium is labile affect

Which term describes an effect of isolation? A) delusions B) hallucinations C) lack of volition D) waxy flexibility

B rationale: Prolonged isolation can produce sensory deprivation, manifested by hallucinations.

A client with bipolar disorder has only been prescribed an antidepressive medication. Which risk factor should the nurse consider to be the highest​? A) Increased anxiety B) Manic episode C) Compulsive behaviors D) No change

B ​Rationale: A client with bipolar disorder​ (BPD) who is prescribed antidepressive medication has a high risk of having a manic episode in response to the​ antidepressant; to avoid this​ possibility, most clients with BPD who need an antidepressant will also take mood stabilizers. Compulsive behaviors and increased anxiety are not directly related to antidepressive medications.

Which assessment finding in children could indicate an increased risk of developing schizophrenia later in​ life? A) Attention deficit disorder B) Manifestations of neurodevelopmental problems C) Growing up with an alcoholic family member D) Dyslexia or other learning disabilities

B ​Rationale: Children who display certain alterations in​ emotional, cognitive,​ language, and motor development are considered at increased risk of developing psychoses such as schizophrenia later in life. Attention deficit disorder is a type of behavioral disorder not related to psychosis. Dyslexia is a learning disability not associated with psychosis. Growing up in a household in which there is substance abuse increases the likelihood of abusing​ substances, but does not increase the risk of psychosis.

Which type of treatment for schizophrenia involves assigning clients to a specific interprofessional team that delivers all services when and where the client needs​ them? A) Family therapy B) Assertive community treatment C) Group therapy D) Psychiatric rehabilitation

B ​Rationale: In assertive community​ treatment, clients are assigned to a specific interprofessional team that delivers all services when and where the client needs them. Group therapy offers treatment in a group​ setting, and psychiatric rehabilitation emphasizes the development of skills and support for clients with persistent psychiatric disability. Family therapy is usually conducted in specific places at specific times and is focused on helping the family cope with their​ relative's schizophrenia.

A client with major depressive disorder​ (MDD) has not gotten out of bed for weeks and has not gone outside of the home for a month. Which should the nurse recall about this​ disorder? A) Depression will eventually resolve in this particular client. B) The course of MDD can be extremely variable in this client. C) The risk of suicide decreases as the client begins to get back into society. D) The client seems to be on the upswing of this depressive episode.

B ​Rationale: Onset of MDD generally occurs​ gradually, with symptoms progressing from anxiety and mild depression to a major depressive episode over a period of​ days, weeks, or months. The course of MDD is extremely​ variable, with some individuals experiencing remission for a period of months and others experiencing many years between episodes. Individuals who experience MDD in the context of another​ disorder, such as substance abuse or borderline personality​ disorder, often experience symptoms that are more difficult to treat.

A recently widowed client is experiencing memory​ loss, insomnia, loss of​ appetite, and irritability over the last few months. Which data should the nurse obtain when assessing this​ client? A) Medication history B) Suicidal ideations C) Alcohol use D) Anhedonia

B ​Rationale: The client is likely experiencing a major depressive disorder and is at risk for suicidal ideations or recurring thoughts of death. To ensure the​ client's safety, the nurse needs to identify if he is having any suicidal ideations. Once it has been identified that the client is​ safe, the nurse can determine whether he is experiencing anhedonia or has been drinking alcohol and can obtain his medication history.

A client reports feeling depressed most days for the last 2 years. Which health problem should the nurse associate with these​ symptoms? A) Situational disorder B) Dysthymia C) Seasonal affective disorder​ (SAD) D) Major depressive disorder​ (MDD)

B ​Rationale: The term persistent depressive disorder​, also known as dysthymia or dysthymic​ disorder, describes chronic depression for most days for at least 2 years​ (1 year for children and​ adolescents). Throughout those 2​ years, no more than 2 months can be described as symptom free. The symptoms of dysthymic disorder tend to be less severe than those in​ MDD, with fewer physiologic symptoms. But the degree of impact on individual functioning can be as great or greater than that of MDD. The​ client's symptoms are not associated with situational disorder or SAD.

Which collaborative process of initial monitoring should the nurse implement for a client who has been prescribed​ lithium? A) Arranging for blood urea nitrogen​ (BUN) and creatinine levels every 1-3 days B) Testing lithium serum levels every 1-3 days C) Testing sodium levels every 1-3 days D) Arranging for therapy sessions every 1-3 days

B ​Rationale: The window between lithium toxicity and therapy is​ short, and close monitoring is required.​ Sodium, blood urea nitrogen​ (BUN), and creatinine would not be a priority for initial monitoring of lithium.

The nurse working in a​ long-term care facility develops a plan of care for a client with stage 2 Alzheimer disease​ (AD) and a nursing diagnosis of ​Memory, Impaired. The client becomes agitated easily. Which intervention would be appropriate for the nurse to​ include? A) Avoid making eye contact. B) Ask the client one question at a time. C) Challenge the​ client's responses. D) Speak in a loud monosyllabic tone.

B ​Rationale: When communicating with the client who has impaired​ memory, it is best to ask only one question at a time and preferably yes or no questions. The nurse should make eye contact with the​ client, but never challenge the​ client's responses because this can increase agitation. The nurse should speak in a calm and reassuring tone so as to not frighten the client.​ (NANDA-I ©2014)

The nurse would conclude that a client with schizophrenia is exhibiting positive symptoms of the disorder after noting that the client does which of the following? Select all that apply. A) Has a flat affect B) States he is a king C) Repeats words the nurse says D) Withdraws from other people E) Exhibits lack of energy

B, C Explanation: Negative symptoms of schizophrenia are those that reflect the absence of what is normally seen in a person's behavior, such as energy. Positive symptoms of schizophrenia are those behaviors that a client would not usually exhibit in everyday life, including a delusion of being a king. Positive symptoms of schizophrenia are those behaviors that a client would not usually exhibit in everyday life, including echolalia (repeating words). Negative symptoms of schizophrenia are those that reflect the absence of what is normally seen in a person's behavior, such as flat affect. Negative symptoms of schizophrenia are those that reflect the absence of what is normally seen in a person's behavior, such as social withdrawal.

The client with dementia is confused and frequently wanders. To ensure the client's safety, which nursing interventions should the nurse employ?Select all that apply. A) Orient the client to the address of his or her home or nursing facility B) Post pictures of the client with arrows pointing to the client's room C) Explore the feasibility of installing sensor devices on unit doors D) Provide a map of the surrounding community to the client E) Ask the client to explain reasons for wandering behavior

B, C Explanation: Wandering behaviors usually begin in Stage 3 dementia. At that point, the client will not be able to remember information such as addresses and phone numbers. By the time dementia has progressed sufficiently to cause wandering, the client will have lost the cognitive skills for reading and understanding a map. The client may not have the ability to read posted signs or the verbal ability to ask for help. An appropriate nursing intervention is one that will directly assist with orientation thereby reducing confusion that may indirectly lead to wandering that can compromise the client's safety. Sensor devices can provide a warning if the confused client wanders through an outside door. Within a safe environment wandering can be beneficial, as it promotes exercise and stimulates oxygenation and circulation. Because of significant cognitive impairment, the client will not be able to verbalize an explanation of reasons for wandering.

The client has catatonic schizophrenia and demonstrates rigidity, waxy flexibility, and extreme psychomotor retardation. The nurse anticipates that this client is at risk for which problems? A) Memory deficit B) Nutritional deficiency C) Aggressive outbursts D) Constipation E) Panic attacks

B, C, D Explanation: Catatonic schizophrenia is characterized by two phases: nonresponsive hypoactivity and unpredictable hyperactivity and aggression that may be dangerous to self or others. The nurse must always anticipate that the aggressive stage may occur. Constipation is possible because of the psychomotor retardation and relative immobility of the client. This client will likely be receiving antipsychotic medications, most of which have anticholinergic side effects, including constipation. Panic attacks are the most severe form of anxiety, while this client has a diagnosis of schizophrenia. Unless the staff assists the client and allows extra time for meals, the likelihood of nutritional deficiency is increased because of the client's psychomotor retardation and inability to verbally report any feelings of hunger. Many clients who have had catatonic episodes are able to recall details and events occurring during a period of stupor.

The nurse is preparing a presentation about schizophrenia. Which comorbid condition of schizophrenia needs to be​ addressed? (Select all that​ apply.) A) Cancer B) Addiction C) Type 2 diabetes mellitus D) Obsessive-compulsive disorder E) Attention deficit hyperactivity disorder​ (ADHD)

B, C, D ​Rationale: Almost half of the individuals diagnosed with schizophrenia are also diagnosed with an addiction at some point. A recent study of type 2 diabetes mellitus found the disease present in more than twice as many clients with schizophrenia as in the control population. Almost​ 20% of clients with schizophrenia are diagnosed with comorbid obsessive-compulsive disorder. Comorbidity of ADHD or cancer does not seem to be a typical feature of schizophrenia.

Which nursing intervention is most appropriate for the nurse to implement for a client with​ delirium? (Select all that​ apply.) A) Restricting visiting hours B) Providing adequate pain management C) Using calendars and clocks to reorient the client D) Assigning the same nurse to care for the client each day E) Keeping lights on at all​ times, so the client can see her surroundings

B, C, D ​Rationale: Appropriate nursing interventions for the client diagnosed with delirium include using calendars and clocks to reorient the client. Providing adequate pain management addresses an underlying cause of delirium. Assigning the same nurse to care for the client each day provides consistency and safety. Lights should be kept at an appropriate level during day and night to ensure proper sleep and rest times. Loved ones should be encouraged to visit the client to provide familiarity and a feeling of safety.

The healthcare provider has prescribed lithium carbonate for a client diagnosed with bipolar disorder. Which information should the nurse include in the client​ teaching? (Select all that​ apply.) A) ​"Monitor for​ constipation, as this could indicate lithium​ toxicity." B) "This medication needs to be closely monitored by a healthcare provider if you suspect that you may be​ pregnant." C) "Monitor for nausea and​ vomiting, as this could indicate lithium​ toxicity." D) ​"Lab work will be needed to monitor the therapeutic level of this​ medication." E) "This medication may be used with an anticonvulsant used as a mood​ stabilizer."

B, C, D, E Rationale: Nausea,​ vomiting, and​ diarrhea, not​ constipation, are symptoms of lithium toxicity. Lithium carbonate needs to be closely monitored in pregnant clients. Anticonvulsants used as mood stabilizers are often used in treating bipolar disorder along with lithium or antipsychotic medications. Lab work is needed to monitor the therapeutic level of this medication. Next Question

The nurse is caring for a client with stage 2 moderate Alzheimer disease. Which collaborative colleague in healthcare should the nurse anticipate working with for optimal care of this​ client? (Select all that​ apply.) A) Hospice B) Dietitian C) Speech therapist D) Physical therapist E) Occupational therapist

B, C, D, E ​Rationale: In moderate Alzheimer​ disease, it is appropriate for the client to receive physical​ therapy, occupational​ therapy, speech​ therapy, and guidance from the dietitian. Hospice is applicable in stage 3 severe Alzheimer disease.

After interviewing a client diagnosed with recurrent depression, the nurse determines the client's potential to commit suicide which factors should the nurse consider as contributors to the client's potential for suicide? [sata] A) psychomotor retardation B) impulsive behaviors C) overwhelming feelings of guilt D) chronic debilitating illness E) decreased physical activity F) repression of anger

B, C, D, F

The hospitalized client is in a manic phase of bipolar I disorder. When developing the nursing care plan for this client, what should the nurse anticipate this client's behavior will be in social interactions?Select all that apply. A) Indecisive B) Competitive C) Demanding D) Isolative E) Unpredictable

B, C, E Explanation: Providing nursing care to clients with elevated mood (mania) can be particularly challenging for the nurse. The client will generally be excited, physically hyperactive, labile, and unpredictable. Persons experiencing manic states will resist being alone and act as if they feel compelled to interact with others at all times. Clients in manic states tend to exhibit behaviors that are controlling, competitive, irritable, aggressive, and domineering in social situations. They are often socially intrusive and inappropriate. When their demands are not met, they can easily become aggressive in ways that are dangerous to self or others. Because of this, the nurse should always consider the person in a manic state to be at risk for injury to self or others especially. Persons in a manic state have unrealistically elevated self-esteem, often feeling that they are the brightest, the wisest, or the most knowledgeable person in the world. They will therefore not hesitate to make decisions, but the decisions are made impulsively and without regard for consequences.

The nurse is developing a plan of care for a client who is diagnosed with delirium. Which nursing goal should the nurse​ include? (Select all that​ apply.) A) Treating all mental health issues B) Preventing further cognitive impairment C) Providing a​ safe, therapeutic environment D) Restoring the client to​ better-than-previous functioning E) Promoting resolution for the condition causing the delirium

B, C, E ​Rationale: Nursing interventions for the client with confusion and delirium revolve around providing a therapeutic environment for the client to feel safe​ in, preventing further cognitive​ impairment, and promoting resolution of whatever condition is causing the delirium. It is not possible to restore the client to​ better-than-previous functioning. The aim of treatment for delirium is not to treat all mental health​ issues, but to deal with the confusion and underlying condition causing the delirium.

A nurse is caring for a client with hypomania. In performing the assessment, which behavior should the nurse expect? A) hypomanic client is on the verge of experiencing depression and crisis B) hypomanic cient is indecisive and vacillating, with diminished ability to think C) hypomanic client is irritable, with an elevated mood and symptoms of mania D) hypomanic client is disorganized and tends to exhibit impaired judgment

C

A nurse teaches a class of caregivers about the postivie and negative behaviors of schizo. Positive behaviors include: A) limited spontaneous speech B) inability to initiate and persis in goal directed activities C) misinterpretation of experiences and altered sensory input D) extremely brief replies to questions

C

A schizo client who is receiving antipsychotic medication paces, fidgets, and cant seem to stay still. The nurse recognizes these behaviors as which disorder? A) tardive dyskinesia B) dystonia C) akathisia D) akinesia

C

A single 24 year old client is admitted with acute schizophrenic reaction. Which method is appropriate therapy for this type of schizo? A) counseling to produce insight into behavior B) biofeeback to reduce agitation C) drug therapy to reduce symptoms associated with AS D) ECT to treat mood component of schizo

C

In addition to disturbances in cognition and orientation, a client with alzheimer's disease may also show changes in which area? A) appetitie B) energy levels C) personality

C

Loss of interest in life and a mild to severe depressed mood that lasts at least 2 weeks; if uncontrolled, interferes with eating, sleeping, and functioning at work, home and or school; withdrawal and decreased sociability;possible delusions and or hallucinations with psychotic features if disorder progresses to severe depression A) dysthymic disorder B) schzoaffective disorder C) major depression D) bipolar disorder E) cyclothymic disorder F) seasonal affective disorder.

C

A client states that he is able to receive radio waves from aliens because they placed a computer chip in his brain. The nurse would document this behavior as which of the following in the medical record? A) An illusion B) Reality-oriented C) A delusion D) A hallucination

C Explanation: A hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; however, it is real to the client. The client is not exhibiting reality orientation. An illusion is a sensory misperception of environmental stimuli. A delusion is a false belief that cannot be changed by logical reasoning or evidence.

Which intervention would the nurse perform to support optimal memory function for a client with dementia? A) Orient the client to reality. B) Restrain the client when agitated. C) Develop stimulating and meaningful therapeutic activities. D) Remind the client of forgotten events.

C Explanation: Cognitive function is supported by participation in meaningful activities that the client enjoys. Stimulating activities also promote self-esteem and encourage the client to attain the highest level of cognitive function possible. Reminding the client of forgotten events may be helpful momentarily but could also lead to frustration. Reorienting the client to reality will not support sustained memory function and while it might be helpful momentarily, it could also lead to frustration. Restraining a client who is agitated could increase agitation rather than decrease it.

A client living in an assisted living facility is taking conventional antipsychotic medications. One evening the nurse notices that the client is experiencing muscle rigidity, confusion, delirium, and has a temperature of 40°C (104°F). The nurse interprets these as symptoms of which adverse drug effect? A) Dystonia B) Akathisia C) Neuroleptic malignant syndrome D) Tardive dyskinesia

C Explanation: Dystonia is an extrapyramidal symptom characterized by involuntary movements and prolonged muscle contraction, resulting in twisting body motions, possible tremors, and abnormal posture. Akathisia is an extrapyramidal symptom characterized by restlessness and an inability to sit still. Neuroleptic malignant syndrome is a potentially fatal extrapyramidal symptom characterized by muscle rigidity, respiratory problems, and hyperpyrexia. Tardive dyskinesia symptoms include frowning, blinking, grimacing, puckering, blowing, smacking, licking, chewing, tongue protrusion, and spastic facial distortions, which can be socially disfiguring.

A client with schizophrenia will be taking clonapine when discharged from the hospital. The nurse makes it a priority to teach the client to notify the healthcare provider immediately for which manifestation? A) Unusual reactions to exposures to the sun B) Feelings of increased energy and interest in the environment C) Indications of any sort of infection ID) Interferences with the normal sleep pattern

C Explanation: Feeling more energy and interest probably indicates a decrease in the intensity of negative symptoms of schizophrenia, and notification of the healthcare provider is not needed. Agranulocytosis is the most dangerous common side effect of clozapine and can lead to death if not detected and treated early. In addition to the requirement that weekly analysis of WBCs must be completed before clozapine can be reordered, it is important that the client, family, and nursing staff understand that changes in the WBC could occur during the time period between two laboratory testings. Therefore, reporting any observations of suspected infection is an urgent priority. Feeling more energy and interest (option 1) probably indicates a decrease in the intensity of negative symptoms of schizophrenia, and notification of the healthcare provider can be delayed. Sensitivity to ultraviolet rays (option 2) is a potential side effect of clozapine that is generally more bothersome than dangerous. Interference with a normal sleep pattern (option 3) is a problem that should be reported to the healthcare provider, but urgent reporting is not necessary. Interference with a normal sleep pattern is a problem that should be reported to the healthcare provider, but urgent reporting is not necessary. Agranulocytosis is the most dangerous common side effect of clozapine and can lead to death if not detected and treated early. In addition to the requirement that weekly analysis of WBCs must be completed before clozapine can be reordered, it is important that the client, family, and nursing staff understand that changes in the WBC could occur during the time period between two laboratory testings. Therefore, reporting any observations of suspected infection is an urgent priority.

The nurse cares for a client with a dysthymic disorder. Which is the most important nursing intervention to include in this client's plan of care? A) Include at least 3 regular meals per day and no snacks B) Include at least 2 liters of clear liquids per day C) Encourage to eat in the main dining room with other clients D) Provide at least 2 hours of quiet time every morning

C Explanation: For clients with dysthymic disorder, a type of depressive mood disorder, a major concern is social isolation. Encouraging the client to eat in the dining room with others addresses this concern. Quiet time is not necessarily helpful for a client with a form of depression. Regulating food intake to three meals and no snacks is not helpful, especially if the client has an accompanying symptom of poor appetite. Although fluids are necessary to maintain hydration, assigning clear liquids has no value for the client.

A client reports having blurred vision that began after beginning drug therapy with a traditional antipsychotic. What would be the best response by the nurse? A) "You need to schedule an appointment with your eye doctor to get a new prescription for your eyeglasses." B) "You need to stop taking your antipsychotic medication and notify your healthcare provider immediately." C) "Blurred vision is a temporary side effect of your medication that usually resolves within a few weeks." D) "Blurred vision is a permanent condition as a result of your medication."

C Explanation: It is too early to schedule an appointment, as the client can be expected to accommodate to this side effect within a matter of days. However, if the client also complains of pain in the eye, the healthcare provider should be notified immediately, as the client may be experiencing glaucoma as a result of the pupillary dilation that caused the blurred vision. Blurred vision is an anticholinergic symptom/side effect that usually resolves in a few weeks. If there is no improvement with time, then the healthcare provider should be notified. There is no indication of pain with the blurring of vision, so the nurse does not have to respond urgently. Permanent blurred vision is unusual. The client can be expected to accommodate to this side effect within a matter of days.

To which evaluation criterion should the nurse give first priority to when planning the care of a client with dementia? A) Supporting family caregivers B) Finding a suitable long-term care placement C) Preventing injury D) Preventing further deterioration

C Explanation: Preventing further deterioration is an appropriate outcome for a client with dementia but is not the first priority. Finding a suitable, skilled nursing facility placement may be needed for a client with dementia but is not the first priority. Supporting family caregivers is appropriate when working with a client with dementia but is not the first priority. The most important area of concern identified by both family and staff is the safety of clients with dementia. Because the risk for injury is always present in clients, the outcome of preventing injury has highest priority.

A client with Alzheimer disease tends to become disoriented and confused at night. What initial suggestion should the nurse provide to the family? A) Try to walk in the neighborhood with the client to promote sleep B) Lock the windows and the door to the client's bedroom C) Provide low-level indirect light in the client's bedroom at night D) Keep a television or music playing softly in the client's bedroom

C Explanation: Providing low-level indirect light helps the client recognize surroundings and may help to reorient the client who has confusion at night. Locking the windows may promote general safety but locking the client's door imprisons the client and does not aid in reorientation to environment. Constant stimuli at night, such as from television or music, does not help with orientation and might disturb sleep. Walking in the neighborhood to promote sleep does not address the underlying concern about nighttime confusion.

The client has a medical diagnosis of dementia. The nurse observes that when anyone speaks loudly or harshly to the client, the client cries out, retreats to bed, shivers, and covers the head. When documenting and giving change of shift report, what terminology should the nurse use to refer to the client's behavior? A) Sundown syndrome B) Pseudodementia C) Catastrophic reaction D) Pseudodelirium

C Explanation: Pseudodementia (a medical diagnosis) is a reversible disorder that mimics dementia. Pseudodelirium (a medical diagnosis) is characterized by symptoms of delirium without any identifiable organic cause. Catastrophic reaction is the human response of overreacting to minor stresses that often occurs in demented clients. Clients with dementia rather than delirium also often experience extreme agitation at the end of the day, probably as a result of tiredness and fewer orienting stimuli such as planned activities and contact with people. This human response of restless and agitated behavior worsens at night and is commonly referred to as sundown syndrome

A client with dementia has been admitted to a nursing home. Which nursing action will help the client maintain optimal cognitive function? A) Provide the client with a list of tasks to perform each day B) Watch the evening news on the television with the client C) Discuss pictures of children and grandchildren with the client D) Play word games and do crossword puzzles with the client

C Explanation: Recent memory loss is a common problem found in dementia; therefore, the client may be frustrated when constantly confronted with evidence of failing memory. Pictures of family members can encourage a discussion of remote memories that will help the client feel less anxious while promoting a sense of pleasure from discussing past experiences. Playing word games and doing crossword puzzles rely on recall of recent memories rather than remote memories and can cause increased anxiety and confusion for the client. Watching the evening news on the television with the client and can cause increased anxiety and confusion because the client can become confused about what is on the television and what is actually happening. Being able to perform tasks from a list requires that the client be able to rely on recall of recent memories rather than remote memories and can cause increased anxiety and confusion.

The family members of a client in an acute state of mania relate that the client has not slept for 4 nights. They further report that the client climbed up and down the stairs of a nearby sports stadium for at least 6 hours without stopping. The client now has blisters on the feet and is perspiring profusely. When planning care for this client, the nurse should give priority to which problem? A) Ineffective coping B) Impaired adjustment C) Risk for deficient fluid volume D) Impaired skin integrity

C Explanation: The nurse must first attend to safety and physiologic needs necessary to sustain life. Considering the prior level of physical activity and current profuse perspiration, the nurse should recognize that this client could easily develop fluid and/or electrolyte imbalance. This at-risk problem will take priority over actual problems that do not involve basic physical needs or safety. Ineffective coping is not a priority problem at this time. It is a psychologic problem that can be addressed after basic physiologic and safety needs are addressed. Impaired skin integrity is incorrect. The nurse should recognize that while this is an actual physical problem, it does not pose the same level of risk that the risk for injury and fluid deficit pose for this client. Like the psychological needs, this problem can be addressed after basic physiologic and safety needs are addressed. Impaired adjustment is not a priority problem at this time. It is a psychologic problem that can be addressed after basic physiologic and safety needs are addressed.

Which action should the nurse take to best improve the orientation level of a 74-year-old male client with dementia? A) speak directly into the client's ear when telling him the day of the month and time B) Keep the client's television tuned to a 24-hour news station during the daytime hours. C) Put traditional seasonal decorations within the client's view. D) Assure the client that his deceased spouse is expected home later in the day.

C Explanation: The nurse should not assume that the client with dementia has a hearing deficit; what is present is a cognitive deficit. When telling the client the day of month and time, it will be more important for the nurse to speak simply and to repeat reorienting stimuli frequently. Except in emergency situations where client safety is compromised, the nurse should avoid giving the client with dementia untruthful or nonrealistic information. Instead of reorienting the client, the news station would likely increase the client's disorientation because the client would not be able to process the events in a normal cognitive manner. Additionally, the constant stimulation would probably be overtaxing to the client. When the nurse is attempting to increase the level of orientation of the client with dementia, nonverbal stimuli may be more effective than verbal stimuli. It is important that the decorations be traditional, as the client is more likely to have intact remote memory that allows for recognition of objects from the distant past.

While talking with a client diagnosed with schizophrenia, the nurse notices the client look away from the nurse and stare at the wall while making facial grimaces. What is the most appropriate intervention by the nurse? A) Administer the prescribed prn trihexyphenidyl B) End the conversation because the client is not listening C) Ask the client if he/she sees something on the wall D) Redirect the conversation to a neutral topic

C Explanation: This client is most likely experiencing a visual hallucination. Ending the conversation would not promote trust with the client or allow the nurse to assess content of the hallucination. This client is most likely experiencing a visual hallucination. Trihexyphenidyl will not prevent hallucinations. This client is most likely experiencing a visual hallucination. First, it is important for nurses to know the content of the hallucination so they can assist the client to process the experience and prevent any aggressive behavior. After this intervention is completed, then the client should be oriented back to reality. This client is most likely experiencing a visual hallucination. The nurse should not redirect the conversation until completing an evaluation for hallucinations.

The client diagnosed with bipolar I disorder is in an inpatient locked unit. The client begins to yell loudly at another client who is also sitting in the dayroom. In order to provide a safe environment for both clients, the nurse should take which action? A) Call the healthcare provider for a prn medication prescription for the client who is escalating. B) Turn on the television in the dayroom to distract the client. C) Redirect the client in a calm, firm, non-defensive manner. D) Escort the client to the seclusion room.

C Explanation: Turning on the television is not an appropriate approach because it is not likely to distract the client. Redirecting the client in a calm, firm, non-defensive manner is the most appropriate action to begin de-escalation. This client will be distractible but irritable, so it is important that the nurse's approach is one of quiet, matter-of-fact calmness. If the client with bipolar disorder is in a locked unit, prn orders should already be in place. At this time, the client's behavior requires the nurse's personal attention and intervention, not medication. If medication is given before other less restrictive interventions are used, this is a legal issue, since medication is a form of chemical restraint. The client's behavior is not sufficiently out of control to warrant the use of seclusion. In addition, the nurse should be aware that before seclusion can be legally justified; all other less restrictive techniques should be attempted.

Which medication is used to decrease the agitation, violence, and bizarre thoughts associated with dementia? A) diazepam (vallum) B) ergoloid ( hydergine) C) haloperidol (haldol) D) tacrine (cognex)

C Haloperidol is an antipsychotic that decreases the symptoms of agitation, violence, and bizarre thoughts. Diazepam is used for anxiety and muscle relaxation. Tracrine is used for improvement of cognition

Which fact does a nurse need to include when teaching a client with bipolar disorder and his family about ehd rug carbamazepine ( tegretol) A) risk of losing hair is a problem for clients taking this drug B) clients must be closely monitored for nephrogenic diabetes insipidus C) hematologic toxicity and bone marrow depression are serious adverse effects D) to avoid toxic reactions, most other drugs shouldnt be take concurrently

C Rational: bone marrow depression is th most serious adverse effect of this drug

A client is experiencing sadness and anhedonia. Which clinical manifestation indicates that the client may be grieving and not experiencing​ depression? A) Displays low​ self-esteem and confidence B) May dwell on past failures C) Actively feels their emotional pain and emptiness D) Lacks interest in previously enjoyed activities

C Rationale: Clients who are experiencing grief tend to actively feel their emotional pain and​ emptiness, in which a client with depression will have a generalized feeling of helplessness and hopelessness. Clients experiencing grief can be persuaded to participate in​ activities, have intact​ self-esteem and​ confidence, unless a sense of failure relates directly to the loss.

Which aspect should the nurse address in the psychosocial history assessment of a client with bipolar​ disorder? A) Vital signs B) Presence of physical complaints C) Observation of client affect D) Neurologic assessment

C Rationale: During the psychosocial history​ assessment, the nurse will observe client affect. The nurse will also assess for the presence of physical​ complaints, perform a neurologic​ assessment, and obtain vital signs.​ However, these aspects are performed as part of the physical​ examination, not the psychosocial history assessment.

A client who has been depressed most of the time for the past 2 years is unable to cope with family​ responsibilities, and has frequent thoughts of suicide and death. For which disorder should the nurse plan care for this​ client? A) Seasonal affective B) Cyclothymic C) Dysthymic D) Bipolar

C Rationale: Manifestations of a dysthymic disorder include a depressed mood most of the time for 2 years​ (for adults), inability to cope with​ responsibilities, and having thoughts of suicide and death. Bipolar disorders are a group of mood disorders that include manic​ episodes, hypomanic​ episodes, and mixed episodes. Cyclothymic disorder symptoms include fluctuating mood disturbances involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. Seasonal affective disorder occurs when the individual experiences depression during the fall and winter seasons.

A client with a family history of Alzheimer disease​ (AD) asks the nurse how to decrease the risk of developing the disease. How should the nurse​ respond? A) "You should decrease intake of alcoholic beverages to decrease the​ risk." B) ​"You can take​ over-the-counter gingko biloba to improve​ memory." C) ​"You should maintain a healthy lifestyle with diet and​ exercise." D) "You cannot decrease your risk because this disease is in your​ genetics."

C Rationale: The best way to decrease this​ person's risk for acquiring AD is to maintain a healthy lifestyle. This includes diet and exercise. The nurse would not inform the client there is no way to decrease the risk of developing AD since it runs in the family because this is inaccurate.​ Over-the-counter herbal supplements such as gingko biloba and other complementary health approaches have not been proven to help slow the onset of AD. Moderate alcohol consumption is appropriate to decrease the risk.

A woman with bipolar disorder wishes to become pregnant and asks the nurse if she should stop the medications. Which would be the​ nurse's best​ response? A) "Stop your medications​ immediately." B) ​"Do not stop your medications or you will have a manic​ episode." C) "Speak with your healthcare provider about tapering and changing some of your​ medications." D) ​"Stop all of your medications except your​ lithium."

C Rationale: The woman with bipolar disorder needs to make an informed decision about how medication may impact the fetus and the risk of symptoms of bipolar disorder without medical management. Some medications may be tapered or changed under the direction of the healthcare provider. The nurse should not instruct the client to stop any medications without input from the healthcare provider.

Which medication for alzheimer's dsease, approved by the FDA, is a moderately long acting inhibitor of cholinersterase? A) baproprion (wellbutrin) B) haloperidol ( haldol) C) donepezil ( aricept) D) triazolam (halcion)

C Rationale: denopezil is used to improve cognition and functional autonomy in mild to moderate dementia. Buproprion is used for depression. Haloperidol is used for agitation, aggression, hallucinations, thought disturbances and wandering. Triazolam is used for sleep disturbances

A client is having beliefs based on faulty perceptions and inference. She believes that she is the president of the United States and she needs to broadcast instructions to her citizens on TV. Which manifestation of schizophrenia does this​ describe? A) Hallucination B) Negative symptoms C) Delusion D) Impaired communication

C ​Rationale: A delusion is a belief that is entirely based on abnormal perception and inference. Delusions may be complex and often are associated with ideation of grandeur or persecution. Hallucination is the perception of​ auditory, visual,​ olfactory, or other sensations that are not there. Negative symptoms are the diminishment of certain​ behavior, usually resulting in a withdrawn or flat affect. Impaired communication is a lack of ability to speak or understand language due to altered thought processes.

A client has been diagnosed with stage 1 Alzheimer disease​ (AD). Which activity should the nurse describe as helpful for the client when meeting with the​ spouse? A) Interacting in group activities B) Driving a car locally C) Writing reminders for appointments D) Doing a crossword puzzle each day

C ​Rationale: A person with stage 1 AD may need to use assistive devices such as calendars and written instructions to remember important events and appointments. Driving may be dangerous depending on the​ client's mental status. Group activities may be overwhelming for a client with AD and can increase confusion and combativeness. Doing a daily crossword puzzle can stimulate the​ mind, slowing the progression of AD.

The parent of a child diagnosed with delirium states to the​ nurse, "I thought only old people get confused. Why is this happening to my​ child?" How should the nurse​ respond? A) ​"Delirium in children is usually caused by mental health​ issues." B) "Your child is just being willful and​ obstinate." C) "Children are at risk for delirium because they lack the reserves to deal with certain​ stressors." D) "Delirium is very common in​ children; the prevalence in hospitalized children is close to​ 70%."

C ​Rationale: Children are at risk for delirium because they lack the functional reserves to deal with physiologic stressors.​ Often, any febrile illness can cause them to develop delirium. Manifestations of delirium in children are often confused with obstinate behavior. Physiologic issues usually cause​ children's delirium. The prevalence of delirium in hospitalized children is 10-​30%

A client living in a group home is having increasingly alarming hallucinations and is becoming very anxious and agitated. The client is tearful and yelling​ out, and shows signs of increasing violence potential. Which collaborative intervention is the most appropriate in this​ situation? A) Electroconvulsive therapy B) Placement in restraints and seclusion C) Crisis intervention D) Group therapy

C ​Rationale: Crisis intervention is indicated for clients in the community who are experiencing escalating symptoms in which they pose a risk to themselves or others. An intervention team is activated to evaluate the situation and provide emergent services as needed to maintain the safety of the client until symptoms can be effectively managed. Group therapy in this scenario is not appropriate and likely to result in an escalation of symptoms. Electroconvulsive therapy is not effective in​ schizophrenia, but can be utilized to treat severe depression or​ catatonia; it is typically administered in a hospital or clinic setting. Placement in restraints and seclusion whatever the setting is likely to escalate anxiety and​ panic, increasing violent behavior.

The nurse is caring for a client who is diagnosed with delirium. The​ client's spouse is upset and tells the​ nurse, "I​ don't know how I am going to be able to care for my​ spouse, who can no longer think​ clearly." How should the nurse​ respond? A) ​"I'm sure that you will be​ fine." B) "Delirium is usually more prevalent in​ younger, rather than​ older, clients." C) "It is important for you to know​ that, generally, delirium is​ reversible." D) ​"Your spouse's condition will continue to​ deteriorate; maybe you should look into nursing​ homes."

C ​Rationale: Delirium generally signals the presence of a reversible but potentially​ life-threatening condition. Early detection and management of delirium may mitigate the consequences of the condition. If​ treated, delirium does not​ deteriorate, and it is more prevalent in older rather than younger clients. Telling family members that they will be fine gives false reassurance and dismisses their concerns.

Which statement by a family member of a client with Alzheimer disease​ (AD) indicates an understanding of the​ disease? A) ​"Clients with AD frequently have sexually transmitted​ infections." B) Clients with AD show rapid improvement in mental status with​ medication." C) ​"Clients with AD can only be definitively diagnosed with an​ autopsy." D) "Clients with AD have remissions and exacerbations of the​ disease."

C ​Rationale: Due to the neurofibrillary​ tangles, amyloid plaques can only be noted during an autopsy.​ Therefore, AD can only be diagnosed with an autopsy. Sexually transmitted infections can be a cause of delirium and​ confusion, but they do not cause AD. AD is a progressive deterioration of mental status. The client does not experience remissions and exacerbations. Medication will slow the progression of the disease but does not produce a rapid improvement in mental status.

A​ 15-year-old client has begun having auditory hallucinations and is being evaluated for possible​ early-onset schizophrenia. The​ client's family is concerned about the​ long-term prognosis. Which aspect describes the most likely prognosis for​ early-onset schizophrenia? A) Symptoms will become more severe over time as the client ages. B) Management of symptoms is easier in​ early-onset schizophrenia​ (EOS). C) Symptoms are more​ severe, treatment is less​ effective, and prognosis is poor. D) Symptoms are less​ severe, and treatment is more effective.

C ​Rationale: Early-onset schizophrenia is associated with severe symptoms and limited effectiveness of medications. Often the prognosis is poor. Symptoms will become less severe over​ time, with​ age-related changes in the brain. Management of symptoms is more​ difficult, and the overall level of disability is greater in​ early-onset schizophrenia. Family support and education is important.

The nurse reviews the symptoms of a major depressive disorder​ (MDD) with a new colleague. Which statement should the nurse identify that indicates teaching was​ effective? A) "A person with MDD will more than likely be using​ substances." B) "A person with MDD will be​ aggressive." C) A person with MDD may sleep​ excessively." D) "A person with MDD will not have problems​ concentrating."

C ​Rationale: Major depressive disorder​ (MDD) may consist of a single episode or may exhibit as recurrent major depression at various points in life. Signs and symptoms of MDD include sleep​ disturbances, ranging from excessive sleeping to no​ sleep, feelings of​ despair, sadness,​ crying, and recurrent thoughts of suicide.​ Aggression, problems with​ concentrating, and use of substances are not typically associated with MDD.

The nurse is caring for a client with stage 3 Alzheimer disease​ (AD) who has become bedridden and requires​ 24-hour care. The family is exhausted and requests assistance. Which intervention would the nurse​ suggest? A) Acetylcholinesterase inhibitor B) Hospice services C) Respite care D) Antipsychotic medication

C ​Rationale: Respite care is important for the family of a client with AD because the care is exhausting and demanding. Respite care can provide the family a short break to refresh and take care of themselves. Hospice services are for clients with a terminal illness. Hospice may eventually be beneficial for this client and​ family, but there is no information that the client meets hospice criteria yet. An acetylcholinesterase​ (AChE) inhibitor is used to slow the disease progression. This client is in the third and final stage of AD and would likely not derive benefit from this medication. Antipsychotic medication can help calm the client but does not provide relief from the demands of​ 24-hour client care. A healthcare provider must prescribe medications.

A​ 30-year-old client with schizophrenia is following a treatment program. Which outcome indicates effectiveness of the prescribed plan of​ care? A) The client reports that his hallucinations have increased but he is able to recognize that they are not real. B) The client no longer needs medication. C) The client functions independently and has gotten a job. D) The client has stopped attending group therapy.

C ​Rationale: The desired outcome for treatment of schizophrenia is to optimize independent function. A client who is able to live independently and keep a job is meeting the goals of treatment of schizophrenia. Medication is most likely going to be indicated on an ongoing basis. Group​ therapy, if​ appropriate, should be continued even when symptoms are not present. Increased hallucinations are an indication that the plan of care is not effective.

The family of a client diagnosed with delirium asks what they can expect. Which symptom should the nurse include in the response to the​ family? (Select all that​ apply.) A) Manic behavior and flight of ideas B) Chest pain that radiates to the left arm C) Sudden loss of both​ long-term and​ short-term memory D) Might look physically​ unwell; acute onset of irrational and repetitive behaviors E) Fluctuations in the intensity and level of​ consciousness, from drowsy to near unconsciousness

C, D, E ​Rationale: Clients with delirium have fluctuations in the intensity and level of​ consciousness, from drowsiness to near unconsciousness. They might have both​ long-term and​ short-term memory​ problems, look physically​ unwell, and have acute onset of irrational and repetitive behaviors. A client experiencing angina or myocardial infarction would experience chest pain that radiates to the left arm. A client diagnosed with bipolar disorder may exhibit manic behavior with flight of ideas.

combing in a sentence words that have no connection and make no sense A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

D

Also called manic depressive disorder: alteration of depression and elation' categroized as one or more manic episodes and one or more depressive episodes or one or more hypomanic or mild manic episodes and one or more depressive episodes. A) dysthymic disorder B) schzoaffective disorder C) major depression D) bipolar disorder E) cyclothymic disorder F) seasonal affective disorder.

D Bipolar 1 and bipolar 2

The nurse writing a care plan for a client with dementia would include which goal as the overall goal of nursing care? A) Reorient the client to reality. B) Maintain adequate hydration and nutrition. C) Assist the client with tasks of daily living. D) Keep the loss of capacity for self-care to a minimum.

D Explanation: A client with dementia will gradually lose orientation to time, place, and person, making reality orientation an unrealistic goal. Dementia is a progressive disease that results in loss of ability to perform tasks that were once familiar and routine. Self-care deficits involving many functional abilities occur to varying degrees. The most effective and respectful goals are those that allow the client to carry out as much self-care as possible. The overall goal is to assist the client to remain as independent as possible, and assist with daily living activities only to the extent that is needed. Maintaining hydration and nutrition are important goals for the client, but are not global enough to represent the overall goal of nursing care.

A client in stage 2 of dementia of the Alzheimer's type often wanders and becomes lost or confused. What is the most important nursing diagnosis the nurse should select to address this behavior? A) Anxiety related to fear of cognitive deficits B) Impaired verbal communication related to anxiety C) Confusion related to impaired cognition D) Risk for injury related to impaired judgment and cognitive deficits

D Explanation: Although the nursing diagnosis addressing confusion related to impaired cognition does apply, maintaining the safety of these clients is of utmost importance. Although the nursing diagnosis addressing anxiety related to fear of cognitive deficits does apply, maintaining the safety of these clients is of utmost importance. Although the nursing diagnosis addressing Impaired Verbal Communication related to anxiety does apply, maintaining the safety of these clients is of utmost importance. Wandering behavior poses a potential risk for injury or trauma because clients experiencing dementia get lost easily and are unable to retrace their steps back home.

The in-patient client is being treated for schizophrenia. While the nurse and client are talking about the client's childhood, the client changes the topic and begins talking about volunteering at a shelter for the homeless. The client does not return to the topic of childhood. How should the nurse document the client's speech pattern? A) Circumstantiality B) Loose association C) Word salad D) Tangentiality

D Explanation: Circumstantial speech pattern includes many unnecessary and insignificant details before arriving at the main point. A word salad is an incoherent mixture of words or phrases. Loose association is a vague, unfocused, illogical flow or stream of thought. Tangential speech occurs when the topic of conversation is changed to an entirely different topic. A permanent detour follows. It is considered a disturbance in associative thinking. There may be a logical progression but causes a permanent detour from the original focus.

What would the nurse formulate as an appropriate nursing outcome for a 68-year-old female client experiencing an acute episode of delirium? A) Remain free from self-directed violence as evidenced by agreement to a no-suicide contract. B) Have intact tactile senses as evidenced by ability to recognize familiar objects placed in her hand. C) Verbalize increased feelings of self-esteem as evidenced by statements acknowledging ability to perform certain tasks independently. D) Decreased confusion as evidenced by orientation to person, place, and time.

D Explanation: Clients experiencing acute episodes of delirium will have periods of lucidity and will regain full orientation when the underlying cause of the delirium is identified and treated. Suicidal ideation may be seen with dementia but not usually associated with delirium. When the client is delirious, injury is more likely to be the result of impulsive, non-intentional acts. Low self-esteem is commonly seen with dementia but not usually associated with delirium. Tactile agnosia is commonly seen with dementia but not usually associated with delirium.

An in-patient client on the psychiatric unit is being treated for paranoid schizophrenia. As the nurse approaches the client says, "You're with the FBI; I can tell by the way you are walking." How should the nurse interpret this statement? A) Idea of reference B) Loose association C) Hallucination D) Delusion

D Explanation: Delusions are false, fixed beliefs that cannot be changed by logical reasoning or evidence. These beliefs arise from an incorrect appraisal of external reality. They are firmly maintained even in the face of clear evidence to the contrary. A hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; they are real only to the person experiencing it. An idea of reference is a cognitive distortion in which a person believes that what is in the environment is related to him or her, even when no obvious relationship existed. A loose association is a vague, unfocused, illogical flow or stream of thought.

What should be the primary nursing intervention when working with a client who has dementia? A) Ensure the client is offered dietary choices to stimulate appetite. B) Have the client meets other clients with dementia to prevent social isolation. C) Let the client discuss feelings of fear and loss to prevent low self-esteem and anxiety. D) Allow the client to remain in a safe and secure environment to prevent injury.

D Explanation: Dietary choices will not stimulate appetite; this intervention is stated illogically. Additionally, recall that clients with dementia should not be expected to make choices, as this can overwhelm them. Client safety and security are nursing priorities for clients with dementia rather than concerns related to social isolation. Client safety and security are nursing priorities for clients with dementia rather than low self-esteem or anxiety. Client safety and security are nursing priorities for clients with the disorientation, confusion, and memory deficits seen in dementia.

While engaging in a group activity, a client with schizophrenia accuses others of making fun of the client. Which characteristic of the disorder is this client demonstrating? A) Hallucinations B) Delusions C) Loose association D) Ideas of reference

D Explanation: Ideas of reference or misinterpretation occur when the client believes that an incident has a personal reference to one's self when, in fact, it is not at all related. A hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ, although they are real to the person. Delusions are false beliefs that cannot be changed by logical reasoning or evidence. Loose association is a vague, unfocused, illogical flow or stream of thought.

The nurse is assigned to the care of a client who has dysthymic disorder. What is the most important nursing intervention that the nurse should include in the client's plan of care? A) Observe the client carefully for indications of "spacing out" into another personality. B) Provide at least 2 hours of quiet time every morning for the client. C) Teach the client about the expected effects of second-generation antipsychotics. D) Encourage the client to eat in the main dining room with other clients.

D Explanation: Quiet time would encourage or perpetuate continuance of social withdrawal. The client will feel tired and may resist being more active, but increased physical activity can help to combat feelings of depression and any accompanying feelings of anxiety. For clients with dysthymia, major concerns are chronic dissatisfaction and social isolation. Additionally, they may have changes in appetite, although this is not as common as it is in persons with major depression. Dysthymia is not a psychotic condition, and antipsychotic medications are not generally given to these clients. Spacing out describes behaviors associated with dissociative identity disorder (DID), not dysthymic disorder.

The nurse is establishing outcomes for a client who is depressed. The outcomes will be entered into the nursing care plan and used by all members of the treatment team. The best stated outcome is the client will do the following: A) Increase amount of time spent with other clients B) Develop more insight into own problems C) Feel less depressed D) Decrease score on depression scale by one half

D Explanation: Statements of client outcomes should be written in specific measurable terms so that any nurse could determine outcome achievement or lack of achievement. It is difficult to measure if the client feels "less depressed." A decreased score on the depression scale by one half is a measurable outcome. Statements of client outcomes should be written in specific measurable terms so that any nurse could determine outcome achievement or lack of achievement. This option indicates that a specific numerical comparison can be made. The development of more insight into the client's problems indicates the nurse's intention to bring about a change in the client's status, but it is not measurable. A measurement of "more" without a standard of comparison is not useful. The development of more insight into the client's problems indicates the nurse's intention to bring about a change in the client's status, but it is not measurable. A measurement of "increase" without a standard of comparison is not useful.

The client has bipolar I disorder. Lithium carbonate 300 mg 4 times daily has been prescribed. After 3 days of lithium therapy, the client says, "What's wrong? My hands are shaking a little." What is the best response by the nurse? A) "There's no reason to worry about that. We won't, unless it lasts longer than a couple of weeks." B) "Just in case your blood level is too high, I am not going to give you your next dose of Lithium." C) "I wouldn't worry about it if I were you. It's a small tremor that doesn't interfere with your functioning." D) "Minor hand trembling often happens for a few days after lithium is started. It usually stops in 1-2 weeks."

D Explanation: The client is experiencing side effects that are normal at this time. That information should be conveyed to the client, as well as information about what to expect in the future. The client should continue to take the medication as prescribed. Serum lithium levels should be monitored frequently in order to determine therapeutic blood levels and prevent lithium toxicity. Minor hand tremors do not indicate lithium toxicity, but they can interfere with writing and other motor skills. Helping the client understand that the tremors can subside or disappear after 1 or 2 weeks is reassuring. This option fails to give the client important information about side effects of Lithium. It also fails to respond to the client's concern that something is wrong. Fine hand tremors are expected side effects at this time in the client's treatment, but the presence of coarse tremors, coupled with such symptoms are gait changes, would suggest possible toxicity, which would require a totally different response from the nurse. The nurse is probably trying to be reassuring but the client will likely feel demeaned. This response also deprives the client of the opportunity to receive important teaching.

The client is taking triazolam to reduce anxiety related symptoms. Which client statement indicates that the nurse should provide more teaching? A) "I should not abruptly stop taking this medication." B) "I might not be able to drive while I am taking this medication." C) "The healthcare provider wants me to take this drug at bedtime because it will help me sleep better." D) "I will probably have to take this medication for the rest of my life."

D Explanation: The client shows awareness of correct drug information; this statement does not indicate a need for additional teaching. Triazolam has both anxiolytic and sedative effects. Its primary use is as a nighttime sedative. The client shows awareness of correct drug information; this statement does not indicate a need for additional teaching. Since clients can become physically dependent on benzodiazepines in a very short period of time, abrupt discontinuation can precipitate a withdrawal response. The client shows awareness of correct drug information; this statement does not indicate a need for additional teaching. Driving or operating heavy machinery is not recommended when clients take benzodiazepines or other drugs that have sedating effects. Hypnotic and anxiolytic agents should be taken for as short a period of time as possible. Physical dependence on these drugs can develop in a very short period of time. Additionally, anxious clients should be assisted to improve their coping mechanisms without relying on medication. This statement indicates a need for additional teaching.

The client with dementia is receiving medications related to the diagnosis. The nurse should recognize that which medication may lead to recovery of some mental functioning by increasing acetylcholine in the nerve synapse? A) Haloperidol B) Trazodone C) Fluoxetine D) Donepezil

D Explanation: The medication, fluoxetine, may be prescribed for clients with dementia, but this medication is not known to directly bring about improved cognitive function. The medication, trazodone, may be prescribed for clients with dementia, but this medication is not known to directly bring about improved cognitive function. The medication, haloperidol, may be prescribed for clients with dementia, but this medication is not known to directly bring about improved cognitive function. Donepezil is a cholinesterase inhibitor that appears to slow down cognitive deterioration in individuals with mild to moderate dementia. When the activity of cholinesterase is inhibited, the amount of acetylcholine in the synapse is increased.

Which action should the nurse take to best improve the orientation level of a 74-year-old male client with dementia? D)Put traditional seasonal decorations within the client's view. A) Assure the client that his deceased spouse is expected home later in the day. B) Speak directly into the client's ear when telling him the day of the month and time. C) Keep the client's television tuned to a 24-hour news station during the daytime hours.

D Explanation: The nurse should not assume that the client with dementia has a hearing deficit; what is present is a cognitive deficit. When telling the client the day of month and time, it will be more important for the nurse to speak simply and to repeat reorienting stimuli frequently. Except in emergency situations where client safety is compromised, the nurse should avoid giving the client with dementia untruthful or nonrealistic information. Instead of reorienting the client, the news station would likely increase the client's disorientation because the client would not be able to process the events in a normal cognitive manner. Additionally, the constant stimulation would probably be overtaxing to the client. When the nurse is attempting to increase the level of orientation of the client with dementia, nonverbal stimuli may be more effective than verbal stimuli. It is important that the decorations be traditional, as the client is more likely to have intact remote memory that allows for recognition of objects from the distant past.

The hospitalized client is in the acute stage of mania. The nurse would formulate which appropriate goal for the client to work toward? A) Spend at least 30 minutes per hour watching TV in the activity room. B) Participate actively in the psychodrama group each day. C) Lead other clients in group physical exercises each morning. D) Maintain distance of 2-3 feet at all times when interacting with others.

D Explanation: The person in a manic state is unlikely to be able to conform to a schedule or to sustain attention for 30 minutes. Also, the client is likely to find the activity room more stimulating than a quieter area of the unit. Individuals experiencing manic affect tend toward overreaction and overdramatization in any situation, so participating in a such a group would likely increase the client's manic hyperactivity and dramatization. While physical exercise allows the client to sublimate some excessive energy, the client is likely to be domineering, overbearing, and highly competitive in groups. Further, the extra stimulation could increase the client's level of mania. The client in the manic state is generally intrusive and insensitive to others' needs and does not recognize boundaries, whether psychologic or physical. The client also tends to have an intense preoccupation with sexual urges and frequently touches others or positions self in socially inappropriate ways. The nurse must encourage the client to set and maintain boundaries while interacting with others.

The nurse determines that the client understands the instructions given before beginning drug therapy with tranylcypromine (Parnate) if the client says he will not eat which food while taking the medication? A) Baked chicken B) Cottage cheese C) Potatoes D) Salami

D Explanation: Tranylcypromine is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs can eat potatoes. Salami is a cured meat and must be avoided by clients taking tranylcypromine, a monoamine oxidase inhibitor (MAOI). Foods rich in tyramine or tryptophan, such as cured foods, may induce a hypertensive episode in clients taking MAOI medication. Other foods to be avoided include those that have been aged, pickled, fermented, or smoked. Tranylcypromine is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs can eat baked chicken. Tranylcypromine is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs can eat cottage cheese in limited amounts.

The client has acute delirium associated with overdose of a nonprescribed drug. Toward which client outcome should the nurse initially address care? A) Verbalization of dependence on drugs B) Demonstration of adaptive coping strategies for dealing with stress C)Exploration of reasons for addictive behaviors D) Demonstration of orientation to person, place, and time during lucid periods

D Explanation: Verbalization of dependence on drugs could be appropriate at a later time after the client has been stabilized physically. Drug overdose and delirium place the client at significant medical and physical risk, and the priority at this time is to preserve physiologic functioning and reduce risk for injury. Demonstration of adaptive coping strategies could be appropriate at a later time after the client has been stabilized physically. Drug overdose and delirium place the client at significant medical and physical risk, and the priority at this time is to preserve physiologic functioning and reduce risk for injury. Initially, the delirious client is dazed and drowsy with disturbed perceptions and difficulty sustaining attention. Further, the client is expected to experience alternating periods of disorientation, confusion, and lucidity. These symptoms place the client at risk for injury, so an absence of them indicates that the client's safety is less threatened. Exploration of the reasons for addictive behaviors could be appropriate at a later time after the client has been stabilized physically. Drug overdose and delirium place the client at significant medical and physical risk, and the priority at this time is to preserve physiologic functioning and reduce risk for injury.

The client is experiencing delirium in the postoperative period. Which nursing measure will have highest priority to the nurse? A) Offering frequent reorienting statements B) Turning and repositioning every 2 hours C) Reducing anxiety D) Maintaining adequate hydration

D Explanation:Anxiety and fear are common experiences when the client is delirious. When present, they complicate management of delirium. However, these are psychological experiences and have lesser priority than basic physiologic or safety needs, such as hydration. In every instance, physiologic and safety needs take precedence over psychological needs. Therefore, of the options given, assuring adequate hydration is the highest priority. If hydration is not maintained, the delirium will intensify, and the client will become at risk for various physiologic complications, ultimately even death. Turning and repositioning the postoperative client is very important to prevent future problems, but this physical measure is not a basic requirement for maintaining life. Maintaining adequate hydration is critical to continuation of life and therefore takes priority. The client who is delirious is generally disoriented, and the nurse should make frequent attempts to reorient the client. However, providing basic safety and maintaining basic physiologic needs are always of highest priority. Prev Next Reset Notes Answer Review Save Exam Grade Exam

While looking out the window, a client with schizo remarks, " that school across the street has creatures in it that are waiting for me". Which term best describes what the creatures represent? A) anxiety attack B) projection C) hallucination D) delusion

D Rationale: A delusion is a false fixed belief that has no basis in reality. Hallucination are perceptual disorders of the five senses and are part of most psychoses.

The family of a client who is diagnosed with delirium asks the​ nurse, "What is the best way to deal with our father when he makes delusional​ statements?" How should the nurse​ respond? A) "It is best to quickly challenge all delusions to nip them in the​ bud." B) ​"Be sure to correct all misconceptions or delusions that your father​ has." C) ​"Just allow your father to persist in his​ delusions; do not try to correct​ them." D) "When he is making delusional​ statements, try validating what exactly he​ needs."

D Rationale: Instead of ignoring or confronting a client making delusional​ statements, use validation techniques to determine if the delusional statement is reflecting some unmet need. The family can then meet that need. Challenging the delusional client has the potential to make the client anxious and might lead to agitation or aggressive behavior.

Which intervention is an important part of providing care to a client with alzheimers? A) avoid contact B) confine the client to his room C) provide high level of sensory stimulation D) monitor the client carefully

D Rationale: Safety

The nurse reviews the importance of accepting a​ client's negative feelings with a group of colleagues. Which statement should indicate to the nurse that teaching was​ effective? A) ​"I can turn all the negatives into positives for the​ client." B) ​"I should share my past failures with the​ client." C) "I will write down the positives and negatives for the​ client." D) "I should limit the amount of time spent on the​ negative."

D Rationale: The nurse should be accepting of​ clients' negative feelings but set limits on the amount of time spent discussing accounts of past failures. The nurse should also be alert for opportunities to interrupt negative conversational patterns with more neutral ones.

During a male​ client's admission to a psychiatric​ unit, he tells the nurse that Bill Gates personally delivered a tablet computer to his home and has called him every week for the past 3 months. Which information should the nurse obtain from the client to support the diagnosis of schizophrenia when completing the health​ history? A) Height and weight B) Signs of a mood disorder C) Indications of malnutrition and poor​ self-care D) Family history of schizophrenia and other psychotic disorders

D Rationale: When completing a health​ history, obtaining information regarding a family history of schizophrenia and other psychotic disorders assists in supporting the​ client's diagnosis of schizophrenia. The​ client's height and​ weight, signs of a mood​ disorder, and indications of malnutrition and poor​ self-care are data that should be obtained during the physical​ examination, not the health history.

A client with bipolar disorder who complains of headache, agitation, and indigestion is most likely experience which of the following problems? A) depression B) cyclothymia C) hypomania D) mania

D Rationale: headache, agitation and indigestion are symptoms of mania

Which intervention is a priority to include in the plan of care for the client with bipolar disorder to prevent​ suicide? A) Joining a local sports league for social interaction B) Engaging the client in conversation of current events C) Developing a daily schedule for consistency D) Access to contact information for help in times of crisis

D ​Rationale: Access to contact information for help in times of crisis like the National Suicide Hotline is a priority in the prevention of suicide in the client with bipolar disorder. A daily schedule and the discussion of current events promote​ reality-based thinking. Joining a competitive sport is not recommended for the client with bipolar disorder.

The nurse is teaching a group of unlicensed assistive personnel​ (UAPs) about caring for clients with Alzheimer disease​ (AD). Which statement by a UAP provides an accurate description of​ AD? A) ​"Alzheimer disease is an exaggerated feeling of physical and mental​ well-being." B) ​"Alzheimer disease is a temporary state of mental confusion and fluctuating​ consciousness." C) Alzheimer disease involves dyskinetic movements from disordered tonicity of​ muscles." D) ​"Alzheimer disease is a progressive deterioration of brain​ function."

D ​Rationale: Alzheimer disease is a type of dementia that causes progressive deterioration of brain function. Euphoria is an exaggerated feeling of physical and mental​ well-being. Dystonia describes dyskinetic movements caused by disordered tonicity of muscle. Delirium is a temporary state of mental confusion and fluctuating consciousness.

Which assessment finding for a client with delirium should lead the nurse to determine that treatment was​ successful? A) The client is oriented to person but not place and time. B) The client falls out of bed. C) The client requires some assistance to perform activities of daily living​ (ADLs). D) The client communicates with the nurse on a variety of topics

D ​Rationale: As delirium​ resolves, the client is able to communicate clearly and transitions logically between topics. The client should be able to perform ADLs without​ assistance, should remain free of injury​ (and not fall out of​ bed), and should be oriented to​ person, place, and time.

A client with depression is admitted to the mental health unit because of attempted suicide. Which​ short-term goal should be given the highest priority for this​ client? A) The client will establish healthy and mutually caring relationships. B) The client will learn strategies to promote relaxation and​ self-care. C) The client will identify and discuss actual and perceived losses. D) The client will seek out the nurse when feeling​ self-destructive.

D ​Rationale: By seeking out a nurse when feeling​ self-destructive, the client can feel safe and begin to discover coping skills to assist in dealing with her​ self-destructive tendencies. Identifying actual and perceived​ losses, learning strategies to promote relaxation and​ self-care, and developing healthy caring relationships are all important for the client with depression to​ achieve, but safety is the priority goal for this client at this time.

A client with known​ early-onset schizophrenia has recently been diagnosed with an affective symptom. Which describes the most likely​ manifestation? A) Anxiety B) Bipolar disorder C) Alzheimer disease D) Depression

D ​Rationale: Depression is the most common affective symptom associated with​ schizophrenia, especially common in those with​ early-onset schizophrenia. Certainly anxiety may be​ increased, but this most commonly occurs with other symptoms and is not necessarily an affective disorder. Bipolar disorder is a separate psychiatric disorder that may​ co-occur with​ schizophrenia, but not as often as depression. Alzheimer disease is an organic disease process of the brain not associated with schizophrenia.

The nurse is teaching the family of a client diagnosed with delirium how to maintain safety in the home. Which information is most important for the nurse to​ include? A) Activity restrictions B) Diet restrictions C) Lab tests necessary to monitor in the client D) Side effects of medications that might cause cognitive changes

D ​Rationale: It is important for the nurse to carefully explain to the​ client's family any side effects of medications that might cause cognitive changes and what to do if these occur. Lab​ tests, diet​ restrictions, and activity restrictions may not be ordered for the client. If they​ are, they are not as necessary to maintain safety in the home as is preparing the family for coping with confusion.

The nurse is working with a client newly diagnosed with Alzheimer disease​ (AD). The family member asks about the cause of this disease. Which statement explains the etiology of AD to the family​ member? A) ​"Alzheimer disease can be caused by​ infections, new​ medications, and cardiopulmonary​ diseases." B) ​"Most cases of AD have a genetic basis. These are considered familial and happen to older​ adults." C) "Do not worry. Your chances of acquiring the disease are minimal since the genetic mutation skips a​ generation." D) ​"Many theories exist about the cause of AD. One theory is the brain cannot process a specific​ protein."

D ​Rationale: Many theories do exist about the cause of AD. This includes the​ cholinergic, amyloid, and tau hypotheses. The amyloid hypothesis is the most accepted one at this point and is based on the brain being unable to process a certain protein called amyloid precursor protein. Familial AD occurs in​ younger, not​ older, adults.​ Infections, new​ medications, and cardiopulmonary diseases can cause delirium or temporary​ confusion, not AD. There is no evidence that AD skips a generation

A client with major depressive disorder​ (MDD) no longer wants to participate in activities that once were a source of pleasure. In which way should the nurse document this​ finding? A) Psychomotor retardation B) Hypersomnia C) Anorexia D) Anhedonia

D ​Rationale: No longer enjoying activities that previously brought pleasure is termed anhedonia. Hypersomnia is sleeping for prolonged periods during the day and night. Anorexia is a loss of the desire for food. Psychomotor retardation is slowed body movements.

The nurse is caring for a client with bipolar disorder experiencing a depressive episode. The client tells the​ nurse, "I​ don't know why I even try anymore. I always fail at everything in my life. I should just give​ up." Which aspect of the psychosocial history during the nursing exam is most​ important? A) Hallucination assessment B) Self-esteem assessment C) Interpersonal relationship assessment D) Suicide assessment

D ​Rationale: The nurse must assess the client for suicidal ideations because the client expresses thoughts of​ worthlessness, which indicate the client may be suicidal.​ Self-esteem, hallucination, and interpersonal assessments are also​ important; however, these are not the most important for this client during this depressive episode.

During the physical assessment of a mental health​ client, it is important for the nurse to thoroughly assess for any medical​ conditions, because clients who are depressed are at greater risk for comorbidities. Which rationale explains the above​ statement? A) Impaired oxygen exchange B) Impaired sensory function C) Impaired circulation D) Impaired​ self-care

D ​Rationale: Assess for the presence of medical illnesses. This is important not only to rule out the possibility of an underlying medical condition causing the​ client's symptoms of​ depression, but also to identify illnesses that may trigger depression. These include​ autoimmune, oncologic,​ metabolic, and endocrine disorders. Chronic​ illnesses, such as asthma and​ diabetes, are associated with increased risk of depression. A diagnosis of a chronic or​ life-threatening illness may also trigger a depressive episode.

The client is being admitted to the inpatient psychiatric unit with a diagnosis of major depression. During the initial nursing assessment, the nurse anticipates that the client will acknowledge which symptoms? (Select all that apply.) A) History of one depressive episode within the past 2 years B) Presence of hallucinations for at least 3 days C) Loss of appetite for approximately 3 days D) Suicidal thoughts or plans of suicide over at least the past 2 weeks E) Loss of interest in previously enjoyed activities

D, E Explanation: The nurse should understand that in order for a client to be diagnosed with major depression, DSM-IV-TR specifies that symptoms consistent with at least 5 of 9 criteria must have been present for at least 2 weeks. Suicidal ideations and plans are included in one criterion. Major depressive symptoms represent a more recent change in functioning, not a single episode within 2 years. While persons with major depression often have changes in weight and appetite, the relevant DSM- IV-TR criterion for major depression does not involve a 3-day period. It also allows for either increases or decreases in appetite to have occurred. The nurse should understand that in order for a client to be diagnosed with major depression, DSM-IV-TR specifies that symptoms consistent with at least 5 of 9 criteria must have been present for at least 2 weeks. One criterion for major depression involves markedly diminished interest or pleasure in all, or almost all, activities. Hallucinations may occur in psychotic levels of major depression, but they are not part of the diagnostic criteria in DSM-IV-TR.

The nurse is working with a client who presents with​ confusion, losing important​ items, and inappropriate behavior. Which assessment should the nurse anticipate to assist with diagnosis of Alzheimer disease​ (AD)? (Select all that​ apply.) A) Borg scale B) Braden scale C) SF-36 health survey D) Presence of dementia E) Mental status examination

D, E ​Rationale: The presence of​ dementia, a mental status​ examination, and the Alzheimer Disease Assessment Scale are used to diagnose AD. The Borg scale is used to measure perceived exertion during exercise. The​ SF-36 health​ survey, a measure of health status and quality of​ life, is not used to diagnose AD. The Braden scale is used to assess the risk for developing a pressure ulcer.

A client taking antipsychotic medications shows dystonic reactions including torticollis and oculogyric crisis. Which medication is given? A) benztropine ( cogentin) B) chlordiazepaxied (librium) C) diazepam (valium) D) fluoxetine (prozac)

A Rationale: benztropine is anticholinergic

hallucinations, delusions, illusions A) delirium B) dementia

A dementia change in personality; normal peculiarties are exaggerated

disturbed attention, learning, and thinking, poor perception A) delirium B) dementia

A dementia is disorientation, impairments in judgment, abstract thinking, and learning

A chronic disorder in which depressed mood fluctuates with normal mood; symptoms are less severe than in major depression. A) dysthymic disorder B) schzoaffective disorder C) major depression D) bipolar disorder E) cyclothymic disorder F) seasonal affective disorder.

A

A client diagnosed with schizo several years ago tells the nurse that he feels "very sad", the nurse observes that he's smiling when he says it. Which term best describes the nurse's observation? A) inappropriate affect B) extrapyramidal C) insight D) inappropriate mood

A

A client is referred to a self help group after discharge from the hospital. Which type of individuals leads these groups? A) individuals concerned about coping with mutual concerns B) social workers familiar with the problems of the mentally ill C) psychiatrists trained to help with stressors in the community D) psychiatric nurses specialists able to provide help with monitoring medication

A

Onset is usually sudden (acute) A) delirium B) dementia

A dementia is insidious and progressive (chronic)

Temporary, reversible disturbance in brain function A) delirium B) dementia

A dementia is irreversible alteration of brain

inability to carry out daily responsibilities typically occurs during the prodomal phase of schizo. Which symptom may also occur during this phase? A) increased energy and motivation B) increased social interaction C) ipaired role functioning and neglect of personal hygiene D) heightened work performance.

C

inventing new words that are meaningful only to that person; often associated with delusions A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

C

The nurse observes that the client with paranoid schizophrenia appears very preoccupied. The client is pacing back and forth in the hall, periodically looking to the side, clenching the fist, and saying, "I told you to go away." What should the nurse plan to do at this time?Select all that apply. A) Avoid touching the client during conversation. B) Reduce proximity to others C) Reassure the client of the safety of the environment. D) Offer frequent orienting stimuli E) Substitute non-verbal hand gestures for words

A, B Explanation: The described behaviors do not suggest that this client is disoriented. Instead the nurse should recognize indications that the client is experiencing hallucinations. This client is actively responding to internal stimuli and could easily react aggressively to others, especially if experiencing command hallucinations or if responding to actual or perceived intrusions of others into the client's own personal space. The client is likely to respond aggressively to moving hand gestures, which will be perceived as a physical threat. The nurse should avoid touching the client during the conversation as this woulr invade the client's personal space and may be considered threatening. A reassuring statement is not likely to reassure the client, but is likely to provoke further suspiciousness, as the client's hyperalertness and mistrust will lead to misinterpretation of environmental events.

The nurse is working with the activities director in a group home for clients with bipolar disorder. Which activity should the nurse​ include? (Select all that​ apply.) A) Dance B) Floor aerobics C) Walking D) Flag football E) Soccer

A, B, C Rationale: Dance,​ walking, and group exercise like floor aerobics are appropriate activities for the client with bipolar disorder. Competitive and aggressive activities like flag football or soccer should be avoided.

The parent of an adolescent asks the​ nurse, "I've heard that teenagers can be at risk for delirium. Can you tell me​ why?" Which cause should the nurse include in the​ response? (Select all that​ apply.) A) Tendency for​ risk-taking behaviors B) Drug and substance abuse and withdrawal C) Risk of head injury from playing contact sports D) Ability to think clearly about results of behavior E) Decreased ability to compensate for physiologic alterations that precipitate delirium

A, B, C ​Rationale: Adolescents may be at increased risk for the development of delirium because they engage in contact sports with an increased risk of head trauma. They also have a tendency to engage in​ risk-taking behaviors and often engage in drug or substance abuse. Adolescents have increased ability to compensate for physiologic alterations that precipitate delirium. They also have a tendency to engage in impulsive​ behavior, not carefully thinking about results of behavior.

The home health nurse is caring for a client with a lower extremity venous stasis ulcer. Which clinical manifestations would lead the nurse to suspect the client has Alzheimer disease​ (AD)? (Select all that​ apply.) A) Looking for misplaced car keys B) Inability to tell time with a clock C) Evening and nighttime confusion D) Reporting the use of a day planner E) Taking walks up and down the street

A, B, C ​Rationale: Clients with AD may frequently lose items such as car keys and important items. They will also eventually lose the cognitive ability to tell time and be disoriented to place and time. Evening and nighttime​ confusion, called​ sundowning, is a frequent occurrence in clients with AD. Many people use a day planner or calendar to remember important appointments and events. Taking walks up and down the street is a form of exercise. As long as the client knows where he is and how to find his way​ home, this does not indicate AD.

The nurse is caring for a client with bipolar disorder who is admitted to the hospital after an accidental overdose of sleeping medication. Which is an appropriate nursing diagnosis for this​ client? (Select all that​ apply.) A) Self-care, Readiness for Enhanced B) Violence: Self-Directed, Risk for C) Knowledge, Deficient D) Coping, Ineffective E) Relationship, Ineffective

A, B, C, D ​Rationale: Appropriate nursing diagnoses for a client with bipolar disease who is displaying mania include ​Knowledge, Deficient about the disease​ process; ​Self-care, Readiness for Enhanced​; ​Violence: Self-Directed, Risk for​; and ​Coping, Ineffective. The rate of attempted suicide in those with bipolar disorders is high. The client with mania who has overdosed on medication has a knowledge deficit about his disease and has a potential for appropriate​ self-care. The client with mania is also at risk for altered nutritional status due to the decreased need for eating. The client with mania who overdoses on medication has ineffective coping mechanisms. It is not known if the client has ineffective interpersonal relationships. This information may be obtained in a psychosocial assessment.​ (NANDA-I ©2014)

The nurse is preparing an educational seminar on depression for a community health fair. Which strategy should the nurse include to reduce depressive​ episodes? (Select all that​ apply.) A) Have regular visits with the healthcare provider. B) Obtain adequate rest. C) Be aware of family risk factors. D) Build a strong support system. E) Ingest alcohol on a daily basis.

A, B, C, D ​Rationale: Strategies to reduce the onset of depressive episodes include obtaining adequate​ rest, building a strong support​ system, being aware of family risk​ factors, and having regular appointments with the healthcare provider to detect symptoms of depression early. Alcohol intake should be limited to prevent the onset of substance abuse disorders.

The nurse is evaluating the effectiveness of the nursing interventions for a client with bipolar disorder. Which evaluation of outcomes is appropriate for this​ client? (Select all that​ apply.) A) The client remained in a safe environment and free from injury. B) The client was able to demonstrate​ reality-based thinking by making an effective decision. C) The client was able to avoid unsafe or socially inappropriate behavior in a variety of situations. D) The client did not commit violent or harmful acts against self or others. E) The client was able to sleep at least 4 hours at night.

A, B, C, D ​Rationale: The client with bipolar disorder should sleep at least 6​ hours, not​ 4, at night. All other evaluations are appropriate for this client.

The nurse is providing teaching to a client recently diagnosed with Alzheimer disease. The​ client's daughter wants to know which services the Alzheimer Association offers. Which activity should the nurse include in the​ response? (Select all that​ apply.) A) Support B) Education C) Treatment D) Legal referrals E) Caregiver respite guidance

A, B, D, E Rationale: The Alzheimer Association provides​ education, support, legal​ referrals, and caregiver respite guidance. It does not provide direct treatment.

The nurse is teaching a group at a community event on depression. Which primary prevention strategy should the nurse​ emphasize? (Select all that​ apply.) A) Socialization B) Family dynamics C) Dietary management D) Age-related issues E) Stress management

A, B, C, E Rationale: A number of approaches can be useful in preventing depression. Individuals should be encouraged to eat a healthy​ diet, engage in regular​ exercise, avoid​ smoking, and obtain adequate sleep. Other primary prevention strategies include providing teaching about stress management and healthy emotional​ functioning; encouraging clients to participate in meaningful social​ relationships; providing targeted teaching and support to individuals who have experienced traumatic or otherwise​ life-altering events; and using​ family-based cognitive-behavioral interventions to reduce the likelihood of depression among children with depressed parents.​ Age-related issues are not a strategy to prevent depression.

The nurse is providing discharge instructions for a client with bipolar disorder who presented to the hospital in a manic state. Which instruction should the nurse​ include? (Select all that​ apply.) A) Recognize the importance of adhering to therapy schedules. B) Seek help when needed. C) Learn effective​ self-administration of medications. D) Learn methods to prevent the disorder. E) Recognize medication side effects.

A, B, C, E Rationale: Home care instruction for the client with bipolar disorder includes recognizing medication side​ effects, seeking help when​ needed, learning effective​ self-administration of​ medications, and recognizing the importance of adhering to therapy schedules. Bipolar disorder cannot be​ prevented, but it may be treated.

The nurse is completing a health history on a client with seasonal affective disorder​ (SAD). Which data should the nurse obtain during this​ interview? (Select all that​ apply.) A) Sleep disturbances B) Medical history C) Anhedonia D) Sexual history E) Feelings of guilt

A, B, C, E Rationale: When completing a health history on a client with seasonal affective​ disorder, the nurse needs to obtain information regarding sleep​ disturbances, medical​ history, feelings of​ guilt, and anhedonia​ (decreased ability to experience​ pleasure). The​ client's sexual history is not pertinent when completing the health history on this client.

The family of a client who is diagnosed with delirium asks the​ nurse, "Can you give us any pointers on how we can help our father with his​ delirium?" Which statement should the nurse include in the​ response? (Select all that​ apply.) A) "Promote consistency in your​ father's schedule." B.) Make sure that your father has appropriate​ nutrition." C) "Encourage your father to partake in new activities​ daily." D) ​"Reassure your father that delirium is often​ temporary." E) ​"If your father appears to be confused as to who he​ is, do not correct his​ misconceptions."

A, B, D ​Rationale: Providing appropriate nutrition is an example of a physical​ intervention, which targets biologic factors contributing to the delirium. Promoting consistency in schedule is an environmental intervention that helps minimize the likelihood of confusion. A period of delirium is not the time to introduce new activities. A cognitive intervention is reassuring the client that the delirium is​ temporary, which will contribute to comfort. The client with delirium should be reoriented frequently.

Which expected outcome should the nurse document for a client with a depressive​ disorder? (Select all that​ apply.) A) The client does not express suicidal ideation. B) The client returns to work or school. C) The client reports no side effects from medication. D) The client sleeps 8 hours a night. E) The client describes hopefulness for the future.

A, B, D, E Rationale: Expected outcomes for clients with any of the depressive disorders include having adequate​ rest, returning to routine​ activities, not expressing suicide​ ideation, and feeling hopeful about the future. It is expected that the client who adheres to the medication regimen will report a few side​ effects; it is not expected that the client will experience no side effects at all from medication.

Which condition should the nurse expect the healthcare provider to evaluate for an older adult client who is diagnosed with delirium of unknown​ cause? (Select all that​ apply.) A) Stroke B) Dehydration C) Celiac disease D) Urinary tract infection​ (UTI) E) New prescription medications

A, B, D, E Rationale: Intracranial events​ (like stroke or​ bleeding), infections​ (respiratory or urinary​ tract), and dehydration often manifest themselves as delirium in older adult clients. Prescription medications such as​ hypnotics/sedatives, anxiolytics,​ antidepressants, anti-Parkinson​ drugs, anticonvulsants, or antispasmodics also increase the risk of delirium.​ UTIs, if not diagnosed and treated​ promptly, can lead to infection and​ sepsis, which cause delirium. Celiac disease is an autoimmune disease of gluten sensitivity and is not associated with manifestations of delirium.

What information is important to include in nutritional counseling of a family with. a member who has bipolar? A) if sufficient roughage isnt eaten while taking lithium, bowel problems will occur B) if the intake of carbs increases, lithium level increases C) if the intake of calories is reduced, the lithium level will increase D) if the intake of sodium increases, lithium level will decrease

D

The nurse should understand that cognitive-behavioral therapy focuses on which​ activity? (Select all that​ apply.) A) Mindfulness B) Cognitive modification C) Hypnosis D) Role playing E) Reflection

A, B, D, E ​Rationale: Cognitive-behavioral therapy includes​ reflection, cognitive​ modification, and mindfulness. They focus on the client recognizing negative thinking and behaviors and refocusing them. Role playing is also an important aspect of cognitive-behavioral therapy. Hypnosis is not included in cognitive-behavioral therapy.

Which factor should the nurse understand contributes to the shorter life expectancy of clients with​ schizophrenia? (Select all that​ apply.) A) Suicide B) Accidents C) Brain cancer D) Coronary heart disease E) Complications of type 2 diabetes mellitus

A, B, D, E ​Rationale: Suicide,​ accidents, coronary heart​ disease, and complications of type 2 diabetes mellitus all contribute to the​ 20% shorter life expectancy of clients with schizophrenia compared to the general population. Affective symptoms such as depression significantly increase the risk of suicide in clients with schizophrenia. The presence of these conditions adds to the overall burden of the illness and accounts for the significant reduction in lifespan for affected individuals. Contributing factors to comorbid illness include​ self-care deficits, sedentary​ lifestyles, social​ isolation, lack of access to quality​ healthcare, and poor dietary habits. Clients with schizophrenia are at no greater risk of brain cancer. OK

The client is scheduled for electroconvulsive therapy (ECT). When teaching the client about what to expect in the post-ECT period, which statements should the nurse make?Select all that apply. A) "It may hard for you to remember everything that happens during the days and weeks you receive ECT." B) "You should expect that you will be able to remember recent events more clearly than you did before you started receiving ECT." "C) Even though modifications have been made in ECT over the years, you may have some disorientation briefly upon awakening from the procedure." D) "If you notice that you are having changes in your memory, let a staff member know immediately." E) "It is common for persons who receive ECT to lose all painful memories of early life."

A, C Explanation: The client is likely to have amnesia for recent events, especially for events that occurred just before the treatment was administered, so the client will not remember that the treatment has been administered. The client receiving a series of ECTs can be expected to have "patchy" memories of events occurring during the days or weeks of the treatment period. This may or may not resolve as time passes. The memory loss that may occur as a side effect to ECT is not selective. Both positive and negative life events may be forgotten. Memory deficits are common in the client receiving ECT. When they do occur, the client and significant others generally feel alarmed. However, the nurse should recognize this as an expected and nonurgent side effect. While modifications in the ECT procedure have increased the level of safety for the client, amnesia and possibly temporary confusion still remain as side effects of the procedure.

The nurse is caring for a client with a history of schizophrenia for over 20 years. A participant in an assertive community treatment​ (ACT) program, the client frequently stops taking her medications and becomes verbally and physically assaultive. Which intervention should the nurse include when planning​ care? (Select all that​ apply.) A) Monitoring for violent ideations B) Referring the client for occupational training C) Setting limits to inappropriate client behavior D) Maintaining a safe environment for the client and staff members E) Administering medications and assessing client response to medications

A, C, D, E ationale: Administering​ medications, assessing client response to​ medications, and maintaining a safe environment are essential. Violent ideations must be monitored. When the client is not actively​ psychotic, behavioral limits must be enforced. The client is not stable enough for occupational training.

A nurse on the​ medical-surgical unit has identified safety as a priority problem for a client who is in the late stages of Alzheimer disease​ (AD). The client is awake at night and tends to wander. Which priority intervention should the nurse use in the care of this​ client? (Select all that​ apply.) A) Keep a nightlight on in the room. B) Place a vest restraint on the client. C) Place nonskid slippers on the client. D) Keep the​ client's room free of clutter. E) Take the client to the bathroom every 2 hours.

A, C, D, E ​Rationale: Appropriate nursing interventions for this client to enhance safety include placing nonskid slippers on the​ client, keeping the​ client's room free of​ clutter, placing a nightlight in the​ client's room, and taking the client to the bathroom every 2 hours. Restraints are a last resort and should not be used unless absolutely necessary.

A​ middle-aged couple was referred to community resources after their​ 19-year-old child was diagnosed with schizophrenia. Which comment from the parents would indicate that this family is utilizing resources in a useful​ manner? (Select all that​ apply.) A) ​"We think the family therapy we have started will help our​ child." B) "We have learned that surgery could really help reverse the​ disorder." C) "We have learned about the prescribed medications and specific adverse​ effects." D) "We want to know more about the new laws affecting the treatment of​ schizophrenia." E) "We have been referred to some​ state-sponsored support groups that focus on​ schizophrenia."

A, C, D, E ​Rationale: Community resources for families dealing with schizophrenia include referrals to state and local affiliates and support groups throughout the country.​ Also, education about medications and legal and advocacy groups can provide valuable support and a community for families affected by schizophrenia. Surgical intervention is not part of schizophrenia​ treatment, so any information obtained about this is incorrect.

The nurse is caring for a client with delirium in the ICU. Which finding should the nurse consider as a contributing​ factor? (Select all that​ apply.) A) Unrelieved pain B) History of cerebral atherosclerosis C) Awakened for frequent assessments and treatment D) Magnetic resonance image​ (MRI) shows atrophy of the hippocampus E) Admitted after a motor vehicle crash with a blood alcohol level of​ 0.25%

A, C, E ationale: Recognizing the cause of delirium in a client in the ICU will allow the nurse to implement interventions to alleviate or reduce delirium. Prolonged sleep deprivation and sensory overload can precipitate​ delirium, as can untreated​ pain, poor pain​ management, and withdrawal from alcohol or drugs. Cerebral atherosclerosis and atrophy of the hippocampus are associated with dementias and cannot be modified by nursing interventions.

A client is being discharged after a suicide attempt. Which action should the nurse include when designing a home safety plan with the​ client? (Select all that​ apply.) A) A list of triggers B) Memorandum from previous depressive episodes C) A list of useful coping strategies D) Medications that should be taken E) Contact information for family members

A, C, E ​Rationale: Information for a home safety plan includes a list of​ triggers, a list of coping​ strategies, and contact information for family. Medications are not a part of a home safety plan. Information about previous depressive episodes is not essential for this plan.

The nurse is admitting a client who is suspected of having delirium. The nurse should assess for which potential precipitating​ factor? (Select all that​ apply.) A) Infection B) Excessive sleep C) Fracture or trauma D) Moderate alcohol use E) History of hypoglycemia

A, C, E ​Rationale: Precipitating factors for developing delirium include​ infection, a fracture or​ trauma, and a history of hypoglycemia. Excessive sleep and moderate alcohol use are not precipitating factors for delirium.

A client with schizo is taking the atypical antipsychotic medication clozapine (clozaril). What are the adverse effects associated with this medication? [sata] A) sore throat B) pill rolling movements C) polyuria D) fever E) polydipsia F) orthostatic hypotension

A, D

The nurse is teaching a group of adults at a health fair about modifiable risk factors for the onset of Alzheimer disease​ (AD). Which risk factor should the nurse​ include? (Select all that​ apply.) A) Obesity B) Hypertension C) Type 1 diabetes D) Sedentary lifestyle E) Traumatic brain injury

A, D ​Rationale: Modifiable risk factors are those that the client can control. This would include controlling weight​ (obesity) and increasing movement​ (sedentary lifestyle). Hypertension and type 1 diabetes can be​ controlled, but not eliminated. A traumatic brain injury cannot be modified.

The family of a client with Alzheimer disease​ (AD) reports the client is losing weight and having difficulty remembering how to use utensils. Which intervention should the nurse include in the plan of care for this​ client? (Select all that​ apply.) A) Use finger foods. B) Initiate tube feedings. C) Begin total parenteral nutrition. D) Refer the client to a registered dietician. E) Provide liquid supplements such as Ensure or Boost.

A, D, E Rationale: The client with AD may eventually forget how to use utensils for eating and begin to lose weight. Appropriate interventions for the nurse to include would be to incorporate finger foods into the diet. A registered dietician would be able to develop a meal plan for the client. Liquid supplements such as Ensure or Boost would provide a concentrated source of calories and can be used without utensils.

An older client is beginning lithium therapy for newly diagnosed bipolar disorder. For which medical condition should the nurse review the chart before administering the prescribed​ medication? A) Liver failure B) Anemia C) Kidney insufficiency D) Infection

C ationale: The older adult with bipolar disorder is at risk of lithium toxicity in the setting of renal disease. The client with​ anemia, infection, or liver issues is not at increased risk for lithium toxicity.

This sign / symptom is typical of metabolic imbalance. A) hyperactivity B) hypoactivity

B

Which action should a nurse implement when caring for a client who is having delusion? A) ask the client to describe his delusion B) explain to the client aht the delusion isn't real C) act as if the delusion is real to reduce the client's anxiety D) engage the client in an organized activity

D

Which characterization is appropriate for the rapid cycling in bipolar disorder? A) no episode of depression B) one or more episode of mania in a year C) two or more episodes of depression in a year D) four or more episodes of depression or mania each year

D

Which instruction is correct for a client taking chlorpromazine ( thorazine) A) reduce dosage if you feel better B) occasional social drinking isnt harmful C) stop taking the drug immediately if adverse reactions develop D) schedule routine medication checks

D

The nurse would conclude that a client with schizophrenia is exhibiting positive symptoms of the disorder after noting that the client does which of the following? [sata] A) exhibits lack of energy B) states he is a king C) repeates words the nurse says D) has a flat affect E) withdraws from other people

B, C Positive symptoms are those behaviors that a client would not usually exhibit in everyday life, echolalia or a delusion of being kind

This stage of dementia is when client presents with ambulatory dementia A) stage 1 B) stage 2 C) stage 3 D) stage 4

C

A client is taking conventional antipsychotic medications. One evening the nurse notices that the client is experiencing muscle rigidity, confusion, delirium and has a temp of 104. The nurse interprets these as symptoms of which adverse drug effect? A) dystonia B) akathisia C) neuroleptic malignant syndrome D) tardive dyskinesia

C

A client with bipolar disorder has been receiving lithium for 2 weeks. He aslo has been taking chemo drugs that cause him to feel nauseated and anorexic, making it difficult to distinguish early signs of lithium toxicity. Which sign would indicate lithium toxicity at serum drug levels below 1.5 mEq/L? A) hyperpyrexia B) marked analgesics and lethargy C) hypotonic reflexes with muscle weakness D) oliguria

C

A depressed client taking a prescribe tricyclic antidepressant tells the nurse hes sleep all the time and doesnt feel like doing anything. Which nursing action is appropriate? A) tell the client to stop taking drug B) advise the client to continue taking the drug to see whether these effects wear off C) ask the physician whether the medication can be given in one dose at bedtime D) advise the client to get another opinion

C

A​ client, hospitalized with schizophrenia and having severe hallucinations and​ catatonia, has been prescribed clozapine​ (Clozaril) for the symptoms.​ However, the client shows no improvement. Which intervention should the nurse initiate in this​ situation? A) Changing the​ client's medication B) Increasing the​ client's therapy sessions C) Ensuring the client has swallowed his medication D) Adjusting the​ client's dosage

C ​Rationale: If the client has not responded to his​ medication, resistance to taking medication may be the reason. Assess the client after administering his oral medications to ensure the medications have not been​ "cheeked" (hidden in the mouth instead of​ swallowed). Adjusting the​ client's dosage and changing his medication are the responsibilities of the healthcare provider. Increasing the​ client's therapy sessions is not likely to have a major impact on his hallucinations or catatonia.

The nurse is caring for an older adult client who progressively develops symptoms of delirium. Which collaborative intervention should the nurse expect to implement first​? A) Applying wrist restraints B) Abdominal​ x-ray C) Urine culture and sensitivity D) Electrocardiogram​ (ECG)

C ​Rationale: In older adult​ clients, delirium often is the most common manifestation of other​ conditions, most notably of urinary tract infections. Getting a urine culture and sensitivity will help determine if that is the cause of the​ client's symptoms. Restraints are never the first option. Abdominal​ x-rays are done to visualize abdominal​ structures, and ECGs are done to examine cardiac rhythms. Neither factors into the development of delirium.

A client with schizophrenia is exhibiting delusions, hallucinations, minimal self-care, and hyperactive behavior. Which of these observations would the nurse document as a negative symptom of schizophrenia? A) Delusions B) Inappropriate affect C) Hallucinations D) Minimal self-care

D Explanation: Minimal self-care is a behavioral negative symptom of schizophrenia. A delusion is a cognitive positive symptom of schizophrenia. A hallucination is a perceptual positive symptom of schizophrenia. Inappropriate affect is an affective positive symptom of schizophrenia.

A client with chronic schizophrenia has been receiving an atypical antipsychotic for 3 months. The nurse concludes that the client is experiencing a reduction in negative symptoms of schizophrenia if a family member makes which statement?Select all that apply. A) "It's been more than a month since he said that he is a Martian prince." B) "I've noticed that his thoughts are better organized." C) "We went to a musical concert, and he smiled and applauded the musicians. D) "For the past week, he has gotten up, dressed, and taken a walk early each morning." E) "We walked together for 15 minutes, and I could see no evidence he was 'hearing voices'."

C, D Explanation: Not hearing voices for 15 minutes would be an improvement in a positive symptom of schizophrenia: auditory hallucinations. Improvement in motivation and volition indicate a reduction in negative symptoms. This statement indicates improvement in a positive symptom of schizophrenia: delusions. An ability to experience pleasure indicate a reduction in negative symptoms. Better organization of thoughts indicate improvement in a positive symptom of schizophrenia: delusions.

The nurse is teaching colleagues about cyclothymic disorder. Which statement should the nurse​ include? A) ​"It is a form of depression that occurs in the fall and​ winter." B) ​"It is a mood disorder similar to major depression but of mild to moderate​ severity." C) ​"It involves a single manic​ episode." D) ​"It involves a mood range from moderate depression to​ hypomania."

D Rationale: Cyclothymic disorder involves a mood range from moderate depression to hypomania. Bipolar I disorder is characterized by at least one manic​ episode; the manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. Seasonal affective disorder is a form of depression occurring in the fall and winter.

A client can't eat because he believes his bowels have turned against him. Which term describes this phenomenon? A) conversion hysteria B) depersonalization C) hypchondriasis D) somatic delusion

D

A client is brought to the crisis response center by his family.. During evaluation, he reports being depressed for the last month and complains about voices constantly whispering to him. which diagnosis is most likely? A) catatonic schizo B) disorganized schizo C) paranoid schizo D) schizoaffective disorder

D

A nurse if providing discahrge teaching to the client being discharged on lithium. The nurse would emphasize that the client should report which of the following? A) black tongue B) increased lacrimation C) periods of excitability D) persistent GI upset

D

In the early stages of alzheimer's disease, which symptom is expected? A) dilated pupils B) rambling speech C) elevated BP D) significant recent memory impairment

D

The nurse is evaluating a client diagnosed with bipolar disorder in the home environment following discharge 2 weeks ago from an inpatient unit. The nurse assesses the client for which behaviors that are expected at this time? A) euphoric and talkative presentation with nurse B) gregarious interactions with significant others C) quiet and evasive presentation D) calm, focused exchange of self care info with nurse

D

The teenage son of a father with schizo is worried that he might have schizo as well. Which behavior would be an indication that he should be evaluated for signs of disorder? A) moodiness B) preoccupation with his body C) spending more time away from home D) changes in sleep patterns

D

This stage of dementia is when client present with end stage qualities A) stage 1 B) stage 2 C) stage 3 D) stage 4

D

The behavioral health nurse is assessing a client with bipolar disorder. Which finding indicates that the client is in a state of​ hypomania? A) The client demonstrates flight of ideas. B) The client is experiencing hallucinations. C) The client feels powerless and is coping with the use of alcohol. D) The client expresses euphoric feelings of being on top of the world.

D ​Rationale: Hypomania is less extreme compared with mania and does not involve manifestations of psychosis such as hallucinations. The client may feel like they are​ "on top of the​ world." Flight of ideas and hallucinations align with mania. Powerlessness and coping with alcohol may be observed with depression.

A client with severe depression reports waking up almost every night and being unable to fall back asleep. Which symptom should the nurse realize this client is​ describing? A) Hypersomnia B) Narcolepsy C) REM sleep D) Middle insomnia

D ​Rationale: Middle insomnia refers to waking up during the night and having difficulty falling asleep again. The client is not described​ REM, narcolepsy, or hypersomnia.

lack of production of verbal speech A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

E

mood changes between moderate depression and hypomania; lasts for at least 2 years; usually no sign of normal range. A) dysthymic disorder B) schzoaffective disorder C) major depression D) bipolar disorder E) cyclothymic disorder F) seasonal affective disorder.

E

Depressed mood occurs during fall and winter when there are few hours of daylight. A) dysthymic disorder B) schzoaffective disorder C) major depression D) bipolar disorder E) cyclothymic disorder F) seasonal affective disorder.

F

rapid speech produced with a sense of urgency A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

F

repetition of words or phrases that serves no purpose A) Echolalia B) clang associations C) neologisms D) word salad E) mutism F) pressured speech H) verbigeration

H