Nursing Psych Care
The effectiveness of monoamine oxidase inhibitor (MAOI) drug therapy in a client with PTSD can be demonstrated by which client self-report? 1. "I am sleeping better and don't have nightmares" 2. "I'm not losing my temper as much" 3. "I've lost my craving for alcohol" 4. "I've lost my phobia of water"
Answer 1. "I am sleeping better and don't have nightmares" Rationale MAOIs are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individuals with PTSD. MAOIs aren't used to help control flashbacks or phobias or to decrease the craving for alcohol.
A nurse in instructing a 38-year-old male client undergoing treatment for anxiety and insomnia. the practitioner has prescribed lorazepam (Ativan) 1 mg by mouth 3 times per day. The nurse determines that the teaching regarding the client's medication has been effective when the client makes which statement? 1. "I'll avoid coffee." 2. "I'll avoid aged cheese." 3. "I'll avoid sunlight." 4. "I'll maintain adequate salt intake."
Answer 1. "I'll avoid coffee." Rationale Lorazepam (Ativan) is a benzodiazepine used to treat various forms of anxiety and insomnia. Caffeine is contraindicated because it's a stimulant and increases anxiety. A client on a monoamine oxidase inhibitor should avoid aged cheeses. Clients taking certain antipsychotic medications should avoid sunlight. Salt intake has no effect on lorazepam.
A client has been taking haloperidol (Haldol). What is the most important instruction for the nurse to give the client? 1. "You should report feelings of restlessness or agitation at once." 2. "Use a sunscreen outdoors on a year-round basis." 3. "Be aware you'll feel an increased energy taking this drug." 4. "This drug will indirectly control essential hypertension."
Answer 1. "You should report feelings of restlessness or agitation at once." Rationale Agitation and restlessness are adverse effects of haloperidol and can be treated with anticholinergic drugs. Haloperidol isn't likely to cause photosensitivity or control essential hypertension. Although the client may experience increased concentration and activity, these effects are due to a decrease in symptoms, not the drug itself.
The preceptor is teaching a graduate nurse about electroconvulsive therapy (ECT). The preceptor determines that further teaching is not needed when the graduate nurse makes which statement? 1. ECT is used to treat clients with major depression 2. ECT is used to treat antisocial personality disorder 3. ECT is used to treat clients diagnosed with schizophrenia 4. ECT is used to treat clients diagnosed with somatoform disorders
Answer 1. ECT is used to treat clients with major depression Rationale ECT is most commonly used for the treatment of major depression in clients who haven't responded to antidepressants or who have medical problems that contraindicate the use of antidepressants. ECT isn't commonly used for treatment of personality disorders. ECT doesn't appear to have value to individuals with chronic schizophrenia and isn't the treatment of choice for clients with somatoform disorders.
A client with a history of bipolar disorder was admitted to the psychiatric unit 2 days ago. The client stopped taking lithium (Eskalith) 2 weeks ago and is now in a manic phase. The nurse would anticipate the client's assessment to include which finding? 1. Flight of ideas 2. Echolalia 3. Clang associations 4. Neologism
Answer 1. Flight of ideas Rationale Flight of ideas is a speech pattern characterized by rapid transition from topic to topic typically without finishing one idea. It's common in mania. Echolalia (repetition of words heard), clang associations (use of rhyming), and neologism (inverted words) aren't' seen in mania states.
The nurse is teaching a student nurse about somatoform disorders. Which of the following statements by the nurse would be the most accurate in describing somatoform disorders? 1. Individuals experience physical symptoms without an organic cause 2. Individuals attend psychotherapy sessions 3. Individuals are considered to be hypochondriacs 4. Individuals are frustrated about the inability to find the source of their symptoms
Answer 1. Individuals experience physical symptoms without an organic cause Rationale A client with a somatization disorder has a history of multiple physiological complaints without associated demonstrable organic pathological causes. The etiology of the disease takes priority.
A client with a history of panic attacks tells the nurse, "I feel so trapped," right after an attack. The nurse determines that the client is most likely expressing which fear? 1. Loss of control 2. Loss of identity 3. Loss of memory 4. Loss of maturity
Answer 1. Loss of control Rationale People who fear loss of control during a panic attack commonly make statements about feeling trapped, getting hurt, or having little or no personal control over their situations. People who experience panic attacks don't tend to have loss of identity or memory impairment. People who have panic attacks also don't regress or become immature.
What is the nursing intervention of primary importance during the administration of paroxetine (Paxil) to the depressed client with a phobic disorder? 1. Monitor renal function 2. Determine electrocardiogram (ECG) changes 3. Assess for sleeping difficulties 4. Observe for extrapyramidal symptoms
Answer 1. Monitor renal function Rationale Clients with impaired renal function shouldn't take paroxetine (Paxil). ECG changes aren't adverse effects of paroxetine. Other than a transient period of drowsiness occurring when the client begins to take the drug, sleep difficulties don't tend to be a problem. Extrapyramidal symptoms aren't seen with paroxetine.
A client taking alprazolam (Xanax) reports light-headedness and nausea every day while getting out of bed. What is the most important action by the nurse? 1. Take the client's blood pressure 2. Monitor body temperature 3. Teach the Valsalva maneuver 4. Obtain a blood chemical profile
Answer 1. Take the client's blood pressure Rationale The nurse should take a blood pressure reading to validate orthostatic hypertension. A body temperature reading or chemistry profile won't yield useful information about hypotension. The Valsalva maneuver is performed to lower the heart rate and isn't an appropriate intervention.
Five days after running out of medication, a client taking clonazepam (Klonopin) says to the nurse, "I know I shouldn't have just stopped the drug like that, but I'm OK." What is the most appropriate response from the nurse? 1. "Let's monitor you for problems, in case something else happens." 2. "You could go through withdrawal symptoms for up to 2 weeks." 3. "You have handled your anxiety, and you now know how to cope with stress." 4. "If you're fine now, chances are you won't experience withdrawal symptoms."
Answer 2. "You could go through withdrawal symptoms for up to 2 weeks." Rationale Withdrawal syndrome symptoms can appear after 1 to 2 weeks because the benzodiazepine has a long half-life. Looking for another problem unrelated to withdrawal isn't the nurse's best strategy. The act of discontinuing an antianxiety medication doesn't indicate that a client has learned to cope with stress. Every client taking medication needs to be monitored for withdrawal symptoms when the medication has stopped abruptly.
A client whose wife recently died in an automobile accident is now being treated at the outpatient psychiatric clinic. The nurse anticipates that the most effective treatment would be? 1. Electroconvulsive therapy (ECT) 2. Group therapy 3. Hypnotherapy 4. Individual therapy
Answer 2. Group therapy Rationale The client history suggests he is experiencing complicated mourning. Group therapy has been shown to be effective with this condition.
The nurse is preparing discharge instructions for a client taking lithium (Eskalith). What is the most important information for the nurse to give the client? 1. Limit fluids to 1,500 ml daily 2. Maintain a high fluid intake 3. Take advantage of the warm weather by exercising outside whenever possible. 4. When feeling a cold coming, it's OK to take over-the-counter (OTC) remedies
Answer 2. Maintain a high fluid intake Rationale Clients taking lithium need to maintain a high fluid intake. Exercising outside may not be safe; photosensitivity occurs with lithium use, and activity in warm weather could increase sodium loss, predisposing the client to lithium toxicity. The client shouldn't take OTC drugs without the physician's approval.
A client is demonstrating hostility toward the nursing staff he just met. The nurse interprets the behavior as: 1. intellectualization 2. transference 3. triangulation 4. splitting
Answer 2. transference Rationale Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the client's past to another person. Intellectualization is a defense mechanism in which the client avoids dealing with emotions by focusing on facts. Triangulation refers to conflicts involving three family members. Splitting is a defense mechanism commonly seen in clients with multiple personality disorders in which the world is perceived as all good or all bad.
A depressed client who is taking a prescribed tricyclic antidepressant tells the nurse that he is sleepy all the time and does not feel like doing anything. what is the best response by the nurse? 1. Tell the client to stop taking the drug until he sees his physician 2. Advise the client to continue taking the drug to see whether these effects wear off. 3. Ask the physician whether he medication can be given in one dose at bedtime. 4. Advise the client to get another opinion.
Answer 3. Ask the physician whether he medication can be given in one dose at bedtime. Rationale Many tricyclic antidepressants can be given safely in one dose; when an antidepressant is taken at bedtime, the adverse effect of drowsiness can help the client sleep. It's inappropriate for the nurse to tell the client to stop taking the drug, to continue taking it until the undesired effects wear off, or to seek a second opinion.
A client with bipolar disorder has been receiving lithium (Eskalith) for 2 weeks. He also takes chemotherapeutic drugs that cause him to feel nauseated and anorexic. It is most important for the nurse to assess the client for which of he following? 1. Hyperpyrexia 2. Marked arthritis 3. Hypotonic reflexes with muscle weakness 4. Oliguria
Answer 3. Hypotonic reflexes with muscle weakness Rationale Lithium alters sodium transport in nerve and muscle cells, slowing the speed of impulse transmission, so look for hypotonic reflexes and muscle weakness. Lithium has no known effect on body temperature or on the transmission of pain impulses. The drug doesn't cause arthritis. Oliguria and other signs of renal failure occur late in severe lithium toxicity.
The nurse suspects a client may have posttraumatic stress disorder (PTSD). It would be most important for the nurse to assess the client for which of the following? 1. Eating disorder 2. Schizophrenia 3. Suicide 4. "Sundown" syndrome
Answer 3. Suicide Rationale Clients who experience posttraumatic stress disorder are at high risk for suicide and other forms of violent behaviors. Eating disorders are possible but aren't a common complication of PTSD. Clients with PTSD don't usually have their extreme anxiety manifest itself as schizophrenia. "Sundown" syndrome is an increase in agitation accompanied by confusion. It's commonly seen in clients with dementia, not clients with PTSD.
The nurse explains that the therapeutic action of tricyclic antidepressant (TCAs) for clients experiencing PTSD is to: 1. prevent hyperactivity and purposeless movements 2. increase the client's ability to concentrate 3. help prevent experiencing the trauma again 4. facilitate the grieving process
Answer 3. help prevent experiencing the trauma again Rationale Tricyclic antidepressant medication will decrease the frequency of reenactment of the trauma for he client. It will help memory problems and sleeping difficulties and will decrease numbing. The medication won't prevent hyperactivity and purposeless movements or increase the client's concentration. No medication will facilitate the grieving process.
A client with generalized anxiety disorder (GAD) states, "I'm afraid I'm going to die from cancer. My mother had cancer." What is the most appropriate response by the nurse? 1. "We all live in fear of dying from cancer." 2. "Did your father also have cancer?" 3. "I wouldn't worry about it just yet. You seem to be in good health." 4. "Has something happened that is causing you to worry?"
Answer 4. "Has something happened that is causing you to worry?" Rationale By asking the client about what is making him/her worry, the nurse assists the client in determining the cause of anxiety. The other responses deflect and minimize the client's concerns.
A client with generalized anxiety disorder (GAD) tells the nurse that he wants to stop taking his lorazepam (Ativan). What is the most appropriate response by the nurse? 1. "Stopping the drug may cause depression" 2. "Stopping the drug increases cognitive abilities" 3. "Stopping the drug decreases sleeping difficulties" 4. "Stopping the drug can cause withdrawal symptoms"
Answer 4. "Stopping the drug can cause withdrawal symptoms Rationale Stopping anxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms. Stopping a benzodiazepine doesn't tend to cause depression, increase cognitive abilities, or decrease sleeping difficulties.
A client diagnosed with bipolar disorder becomes verbally aggressive during group therapy. The client states "I hate all of you." What is the MOST APPROPRIATE response by the nurse? 1. "You're behaving in an unacceptable manner." 2. "If you continue to talk like that, I will dismiss you from the group." 3. "Other people are not comfortable with your statement, please stop it." 4. "You're frightening the group; let's walk down the hall to release some energy."
Answer 4. "You're frightening the group; let's walk down the hall to release some energy." Rationale This response informs the client that, although the behavior is unacceptable, the client is still worthy of help. The other responses are nontherapeutic and blaming.
The nurse is teaching a group of students about the benefits of group psychotherapy. Which statement best describes the rationale for group psychotherapy? 1. It decreases the focus on the individual 2. It fosters the physician-client relationship 3. It confronts the individuals with their shortcomings 4. It fosters a new learning environment
Answer 4. It fosters a new learning environment Rationale In a group, the individual has the opportunity to learn that others have the same problems and needs. The group can also provide an arena where new methods of relating to others can be tried. Decreasing focus on the individual isn't a key advantage (and sometimes isn't an advantage at all). Groups don't, by themselves, foster the physician-client relationship, and they aren't always used to confront individuals.
An adolescent client verbalizes to the nurse about being fat and ugly and states, "Everybody makes fun of me." The nurse interprets this statement as: 1. anxiety of the unknown 2. anxiety related to loss of respect 3. anxiety related to separation anxiety 4. anxiety related to change in body image
Answer 4. anxiety related to change in body image Rationale Anxiety about body image and changes in physical appearance is a common fear of adolescents. Fear of the unknown is associated with toddlerhood. Fear of loss of respect, love, and emerging self-esteem is associated with school age development phase. Anxiety related to guilt is also associated with the school-age developmental phase.
A nurse who is caring for a client with panic disorder receives an order for alprazolam (Xanax) from the physician. The nurse reviews the client's chart and determines further intervention is needed when the medical history includes: 1. intermittent insomnia 2. acute-angle glaucoma 3. seizure disorder 4. tartrazine hypersensitivity
Answer: 2. acute-angle glaucoma Rationale Acute angle glaucoma is a medical problem that contraindicates the used of alprazolam (Xanax). Alprazolam causes drowsiness and sedation, so sleep shouldn't be interrupted. Seizure disorder isn't a contraindication for the use of alprazolam. Tartrazine hypersensitivity is associated with yellow dye used in some convenience foods and isn't a contraindication for the use of alprazolam.
A nurse is administering haloperidol (Haldol) to a client experiencing psychosis. What are the most appropriate nursing interventions? Select all that apply. 1. Review subcutaneous objectives 2. Closely monitor vital signs, especially temperature 3. Provide the client the opportunity to pace 4. Monitor blood glucose levels 5. Provide client with hard candy 6. Monitor for s/s of urticaria
Answers 2, 3, and 5 Rationale Neuroleptic malignant syndrome is a life-threatening adverse effect of antipsychotic medications such as haloperidol (Haldol). It's associated with a rapid increase in temperature. The most common extrapyramidal adverse effect, akathisia, is a form of psychomotor restlessness that can typically be relieved by pacing. Haloperidol and the anticholinergic medications that are provided to alleviate its extrapyramidal effects can result in dry mouth. Providing the client with hard candy to suck on can help with this problem. Haloperidol (Haldol) isn't given subcutaneously and doesn't affect blood glucose levels. Urticaria isn't usually associated with haloperidol administration.
The nurse is preparing discharge instructions for a client who will be taking lithium that has been prescribed for bipolar disorder. What is the most important information for the nurse to give the client? Select all that apply. 1. The potential for addiction 2. Signs and symptoms of drug toxicity 3. The potential for tardive dyskinesia 4. A low-tyramine diet 5. The need to consistently monitor blood levels 6. The expected time frame for noticing improvements in mood
Answers 2, 5, and 6 Rationale Client education should cover the signs and symptoms of drug toxicity as well as the need to report them to the physician. The client should be instructed to monitor his lithium levels on a regular basis to avoid toxicity. The nurse should explain that 7 to 21 days may pass before the client notes a change in his mood. Lithium doesn't have addictive properties. Tardive dyskinesia isn't associated with lithium. Tyramine is a potential concern for clients taking MonoAmine Oxidase Inhibitors (MAOI's).
A client is prescribed sertraline (Zoloft). It is most important for the nurse to provide information to the client about which adverse side effects? Select all that apply. 1. Agitation 2. Agranulocytosis 3. Sleep disturbance 4. Intermittent tachycardia 5. Dry mouth 6. Seizures
Answers: 1, 3, and 5 Rationale: Common adverse side effects of sertraline (Zoloft) include agitation, sleep disturbance, and dry mouth. Agranulocytosis, intermittent tachycardia, and seizures are adverse side effects of clozapine (Clozaril).