Psych Exam #3

Number the following nursing interventions as they would proceed through the steps of the nursing process.

Measure a client's vital signs & review past history Recognize & document the client's problems Aim, with client collaboration, for a seven hour night's sleep Encourage deep breathing & teach relaxation techniques Determine if an antianxiety medication is decreasing a client's stress

A nurse is planning care for a client diagnosed w/bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit?

Remains free from injury Maintains nutritional status Sleeps 6-8 hours a night Interacts appropriately w/peers

A nurse prepares to assess a client using the Abnormal Involuntary Movement Scale [AIMS]. Which side effect of antipsychotic medications led to the use of this assessment tool?

Tardive Dyskinesia

A client on an inpatient unit angrily says to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response?

["I can see that you are angry. Let's discuss ways to approach Peter with your concerns."]

An adult patient assaults another patient & is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention?

["My fingers are tingly"]

A nurse is reviewing the STAT laboratory data of a client in the ED. At what minimum blood alcohol should a nurse expect intoxication to occur?

[100 mg/dL]

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors?

[A client diagnosed w/borderline personality disorder]

On the first day of a client's detoxification, which nursing intervention should take priority?

[Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol]

A client diagnosed w/functional neurological symptom disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply.

[Akinesia, Aphonia, Ansomia]

A nursing instructor is teaching about the impaired nurse & the consequences of this impairment. Which statement by a student indicates that further instruction is needed?

[All state boards of nursing have passed laws that, under any circumstances, do not allow impairs nurses to practice]

A client has recently been placed in a long term care facility because of marked confusion & inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the client's self-esteem?

[Allow client to choose between two different outfits when dressing for the day]

A client diagnosed w/schizophrenia receives fluphanazine decanoate from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate?

[Allow the client to decline the medication & document the decision]

An older client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen?

[Altered liver & kidney functioning]

The spouse of a patient w/Schizophrenia says "I don't understand why childhood experiences have anything to do with this disabling illness." Select the nurse's response that will best help the spouse understand this condition.

[Although this disorder more likely has a biological rather than psychological sign, the support & involvement of caregivers is very important."]

After one week of continuous mental confusion, an older African American client is admitted with a preliminary diagnosis of Alzheimer 's disease. What should cause the nurse to question the diagnosis?

[Alzheimer's Disease does not develop suddenly]

A patient discloses several concerns & associated feelings. If the nurse wants to seek clarification, which comment would be appropriate?

[Am I correct in understanding that...]

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing & now has amenorrhea. Her current weight is 95lbs, a loss of 35lbs. Which diagnosis is most likely?

[Anorexia nervosa]

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome?

[Antipsychotic medications]

A participant at a community education conference asks, "What is the most prevalent mental disorder in the United States?" Select the nurse's best response.

[Anxiety disorders]

After threatening to jump off a bridge, a client is brought to an ED by police. To assess for suicidal potential, which question should a nurse ask first?

[Are you currently thinking about harming yourself?]

After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed symptom would a student nurse recognize?

[Arguing with authority figures for more than six months]

A patient is hospitalized for a reaction to a psychotropic medication & then is closely monitored for 24hrs. During a pre-discharge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to:

[Arrange a temporary place for the patient to stay until new housing can be arranged]

Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium?

[Chlordiazepoxide (Librium) & Phenytoin (Dilantin)]

Which symptoms should a nurse recognize that different a client diagnosed w/obsessive-compulsive disorder (OCD) from a client diagnosed w/obsessive-compulsive personality disorder (OCPD)?

[Clients diagnosed w/OCD experience both obsessions & compulsions and clients diagnosed w/OCPD do not]

Family members of a client ask the nurse to explain the difference between schizoid & avoidant personality disorders. Which is the appropriate nursing response?

[Clients diagnosed w/avoidant personality disorder desire intimacy but fear it & client diagnosed w/schizoid personality disorder prefer to be alone]

[During the course of this disorder, individuals or objects are experienced as dreamlike, foggy, lifeless or visually distorted.]

[Clients diagnosed w/gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with tranvestic disorder are not]

A paranoid client diagnosed w/schizophrenia spectrum disorder states "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting & what is the nurse's legal responsibility related to this symptom?

[Command hallucinations: warn the psychiatrist]

A patient was abducted & raped by gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome?

[Confusion & disbelief]

Which assessment findings support a nurse's suspicion that a patient has been using inhalants?

[Confusion, mouth ulcers & ataxia]

A patient w/severe injuries is irritable, angry & belittles the nurses. As a nurse changes the dressing, the patient screams, "Don't touch me! You are stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient?

[Continue the dressing change, saying "Do you know this dressing change is needed so your wound will not get infected."]

Which clinical presentation is associated w/the most commonly diagnosed adjustment disorder (AD)?

[Depressed mood, tearfulness & hopelessness]

Purpose of rape

[Desire to humiliate & control others]

Which assessment finding will the nurse expect in an individual who has just injected heroin?

[Drowsiness, constricted pupils, slurred speech]

A nursing instructor is teaching about Bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?

[During a manic episode, clients experience psychosis and this symptom is absent in hypomania]

A nursing instructor is teaching about the DSM-5 diagnosis of depersonalization-derealization disorder (D-DD). Which student statement indicates a need for further instruction?

[During the course of this disorder, individuals or objects are experienced as dreamlike, foggy, lifeless or visually distorted.]

A nurse has been caring for a client diagnosed w/generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? Select all that apply.

[Encourage the client to employ newly learned relaxation techniques; encourage the client to cognitively reframe thoughts about situations that generate anxiety; encourage the client to recognize the signs of escalating anxiety; encourage the client to avoid caffeinated products]

Which of the following conditions have been known to precipitate delirium in some individuals? Select all that apply.

[Febrile illness, Migraine Headaches, Seizures]

A client diagnosed with PTSD is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication.

[Flashbacks of killing the enemy]

A nurse prepares a plan of care for a patient with adult attention deficit hyperactivity disorder (ADHD). Which interventions should be included?

[Give encouragement & strategies for managing and organizing]

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed w/schizophrenia spectrum disorder? Select all that apply.

[Group therapy, Medication management, Supportive family therapy, Social skills training]

During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder?

[I am getting a message from the beyond that we have been involved with each other in a previous life]

A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling the situation in a healthy manner?

[I know that it was not my fault]

Which client statement reflects an understanding of circadian rhythms in psychopathology?

[I'm a morning person. I get my best work done before noon]

A nurse is assessing a client diagnosed w/schizophrenia spectrum disorder. The nurse asks the client "Do you receive special messages from certain sources, such as a television or radio?" The nurse is assessing which potential symptom of this disorder?

[Ideas of reference]

A 10 yr. old child wins the science fair competition & is chosen as a cheerleader for the basketball team. A nurse should recognize that this child is in the process of successfully accomplishing which stage of Erikson's developmental theory?

[Industry vs. Inferiority]

A patient asks for information about alcholics anonymous (AA). Which is the nurse's best response?

[It is a self-help group w/goal of sobriety]

In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? Select all that apply.

[It often takes several attempts before a woman leaves an abusive situation; women in abusive relationships usually feel isolated & unsupported; substance abuse is a common factor in abusive relationships]

A patient is hospitalized for depression & suicidal ideation after their spouse asks for divorce. Select the nurses most caring comment.

[Let's discuss some means of coping other than suicide when you have these feelings]

A woman comes to the ED with a broken nose & multiple bruises after being beaten by her husband. She states "The beatings have been getting worse & I'm afraid next time he will kill me." Which is the appropriate nursing response?

[Let's talk about your options so that you don't have to go home]

Which client statement indicates a knowledge deficit related to a substance use disorder?

[Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."]

Select the nursing intervention necessary after administering naloxone (Narcarn) to a patient with an opiate overdose.

[Monitor the airway & vital signs every 15 minutes]

A patient's nursing diagnosis is insomnia. The desired outcome is "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps on average 4 hours nightly & takes a 2 hour afternoon nap. Which evaluation should be documented?

[Never demonstrated]

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?

[Observe for depression & suicidal ideation]

Which medications should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?

[Olanzapine]

At what point in the nurse-patient relationship should a nurse plan to first address termination?

[Orientation phase]

Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply.

[Pacing, Rigid posture & clenched jaw, Staring with narrowed eyes into the eyes of another]

A nurse caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, neologisms & echolalia. Which statement correctly differentiates the client's positive & negative symptoms of schizophrenia?

[Paranoid delusions, neologisms & echolalia are positive symptoms of schizophrenia] (hallucinations/delusions of grandeur) Negative symptoms include apathy, anhedonia, poor social functioning (ex: poor personal hygiene), and poverty of thought.

Documentation in a patient's chart shows, "Throughout a 5 minute interaction, patient fidgeted & tapped left foot, periodically covered face w/hands & looked under chair while stating "I enjoy spending time with you." Which analysis is most accurate?

[Patient's verbal & nonverbal messages are incongruent]

In the majority culture of the United States, which individual is at greatest risk to be incorrectly labeled mentally ill?

[Person who attends a charismatic church & describes hearing God's voice]

A nurse is performing a mental health assessment on an adult client. According to Maslow's, which client action would demonstrate the highest achievement in terms of mental health?

[Possessing a feeling of self-fulfillment & realizing full potential]

A patient being admitted suddenly pulls a knife from a coat pocket & threatens "I will kill anyone who tried to get near me." An emergency code is called. The patient is safely disarmed & placed in seclusion. Justification for the use of seclusion is that the patient:

[Present a clear & present danger to others]

Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patient who:

[Present a clear danger to self or others]

On which task should a nurse place priority during the working phase of the relationship development?

[Promoting the client's insight & perception of reality]

A preschool child is admitted to a psychiatric unit w/a diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care?

[Provide consistent caregivers]

Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed w/moderate ID?

[Providing simple directions & praising client's independent self-care efforts]

A fourth grade boy teases & makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism?

[Reaction Formation]

A nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which finding would be expected?

[Reduce anxiety]

A client is brought to an ED after being violently raped. Which nursing action is appropriate?

[Remain non-judgmental while actively listening to the clients description of the violent rape event.]

Children of a widowed parent confer with the nurse; their surviving parent repeatedly relates the details of finding the deceased parent not breathing, performing CPR, going to the hospital by ambulance & seeing the pronouncement of death. The family asks, "What can we do?" The nurse should counsel the family.

[Repeating the store is a helpful & a necessary part of grieving]

What is a nurse's legal responsibility if child abuse or neglect is suspected?

[Report the suspected abuse or neglect according to state regulations]

An older adult w/Alzheimer's Disease lives w/family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority?

[Risk for injury, related to poor judgement, cognitive impairment & lack of caregiver supervision.]

A client diagnosed w/Neurocognitive Disorder is disoriented, ataxic & wanders. Which is the priority nursing diagnosis?

[Risk for injury]

Which combination of diagnosis appropriate pharmacological treatments are currently matched?

[SSD: predominantly pain; treated w/venlafaxine (Effexor)]

A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness?

[Schizophrenia Spectrum Disorder]

A nurse assists a victim of spousal abuse to create a plan of escape if it becomes necessary. The plan should include which components? Select all that apply.

[Secure a supply of current medication for self & children; assemble birth certificates, social security cards & licenses; keep a cell phone fully charged; have the telephone number of nearest shelter; determine a code word to signal children that it is time to leave]

An older client has recently moved to a nursing home. The client has trouble concentrating & socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe?

[Sertraline]

Which principle should guide the nurse in determining the extend of silences to use during a patient interview session?

[Silences provide meaningful moments of reflection]

A woman says "I can't take it anymore! Last year my husband had an affair & now we don't communicate. Three months ago, I found a lump in my breast. Yesterday, my daughter said she's quitting college." Which type of crisis is this person experiencing?

[Situational]

A client is diagnosed w/major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?

[Social isolation r/t poor self-esteem AEB secluding self in room]

Which behavior best demonstrates aggression?

[Stomping away from the nurses station, going to the day room & grabbing a pool cue from a patient standing by the pool table]

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?

[Strong negative feelings interfere with assessment & judgement]

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment?

[Supporting physiologic stability]

A 60 yr. old client diagnosed w/schizophrenia spectrum disorder presents in the ED w/uncontrollable tongue movements, stiff neck and difficulty swallowing. Which medical diagnosis & treatment should a nurse anticipate when planning care for this client?

[Tardive dyskinesia treated by discontinuing antipsychotic medications & give benztropine (Cogentin)]

A geriatric client is confused wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?

[The client is monitored by an ankle bracelet]

A client's altered body image is evidence by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem?

[The client will perceive personal ideal body weight & shape as normal]

A client comes to a psychiatric clinic experiencing sudden extreme fatigue & decreased sleep & appetite. The client works 12 hours a day & rates anxiety 8/10 on a numeric scale. What long term outcome is realistic in addressing this client's crisis?

[The client will return to previous adaptive levels of functioning by week six]

A family asks why their father is attending activity groups at the long term care facility. The son states "My father worked hard all his life. He just needs some rest at this point." Which is the appropriate nursing response?

[The groups benefit your father by providing social interaction, sensory stimulation & reality orientation]

When questioned about bruises, a woman states "It was an accident. My husband just had a bad day at work. He's being so gentle now & even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering?

[The honeymoon phase]

A client diagnosed with major depressive disorder asks "What part of my brain controls my emotions?" which nursing response is appropriate?

[The limbic system is largely responsible for one's emotional state]

After am adolescent diagnosed w/attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10lbs in a 2 month period. What is the best explanation for this weight loss?

[The pharmacological action of Ritalin causes a decrease in appetite]

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. The staff nurse asks, "Why doesn't she leave him?" Which is the nursing supervisor's most appropriate response?

[These clients are paralyzed into inaction by a combination of physical threats a sense of powerlessness]

A client diagnosed recently w/Alzheimer's Disease is prescribed donepezil (Aricept). The client's spouse inquires, "How does this work? Will this cure him?" Which is the appropriate nursing response?

[This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop the progression of the disease]

A nursing instructor is teaching about the various categories of paraphilic disorders. Which categories are correctly matched w/expected behaviors? Select all that apply.

[Voyeuristic disorder: John is arrested for peering in a neighbor's bathroom window; Fetishistic disorder: Henry masturbates into his wife's silk panties; Frotteuristic disorder: Peter enjoys subway rush hour female contact that results in arousal]

Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in acceptance stage of grief?

[Yes, it was a difficult relationship, but I think I have learned from the experience]

An older client attending an adult day care program suddenly begins reporting dizziness, weakness & confusion. What should be the initial nursing intervention?

[advocate for a complete physical exam]

A rape victim tells the ED nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should:

[explain that washing would destroy evidence]

Severe & persistent mental illness is characterized as a:

[major chronic mental illness marked by significant functional impairments]