Psychosocial - Unit 4

A nurse is reinforcing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates understanding? select all A - "We need to understand that she is responsible for her disorder." B - "Eliminating any codependent behavior will promote her recovery." C - "She should participate in an Al-Anon group to help her recover." D - "The primary goal of her treatment is abstinence." E - "She needs to discuss her feelings about substance use to help her recover."

B, D & E B - "Eliminating any codependent behavior will promote her recovery." D - "The primary goal of her treatment is abstinence." E - "She needs to discuss her feelings about substance use to help her recover." Rational A - Clients are not responsible for their disease but are responsible for their recover. B - Families should be aware of codependent behavior, such as enabling, that can promote substance use rather than recovery C - Al-Anon is a recovery for the family of a client, rather than the client who has a substance use disorder D - Abstinence is the primary treatment goal for a client who has a substance use disorder E - Clients must acknowledge their feelings about substance use as a part of a substance use recovery program

A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? Select all A - Bradycardia B - Fine tremors of both hands C - Hypotension D - Vomiting E - Restlessness

B, D & E B - Fine tremors of both hands D - Vomiting E - Restlessness Rational A - An expected finding of alcohol withdrawal is tachycardia rather than bradycardia B - Fine tremors of both hands is an expected finding of alcohol withdrawal C - An expected finding of alcohol withdrawal is hypertension rather than hypotension D - Restlessness is an expected finding of alcohol withdrawal

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? Select all A - Demonstrates extreme anxiety when placed in a social situation B - Has difficulty making even simple decisions C - Attempts to convince other clients to give him their belongings D - Becomes agitated if his personal area is not neat and orderly E - Blames others for his past and current problems

C & E C - Attempts to convince other clients to give him their belongings E - Blames others for his past and current problems Rational A - Anxiety in social situations is an expected finding of clients who have avoidant personalty disorder B - Indecisiveness, due to sensitivity to criticism, is an expected finding of clients who ave narcissistic personality disorder. C - Exploitation and manipulation of others is an expected finding of antisocial personality disorder D - Perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive-compulsive personality disorder E - Failure to accept personal responsibly is an expected finding of clients who have antisocial personality disorder

A nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A - "I can promote my client's sense of control by establishing a schedule." B - "I should encourage clients who have a schizoid personality disorder to increase socialization." C - "I should practice limit-setting to help prevent client manipulation." D - "I should implement assertiveness training with clients who have antisocial personality disorder."

C - "I should practice limit-setting to help prevent client manipulation. Rational A - Rather than establishing a schedule, the nurse should ask for the client's input and offer realistic choices to promote the client's sense of control B - The nurse should avoid trying to increase socialization for a client who has a schizoid personality disorder C - When caring for a client who has a personality disorder, limit-settings is appropriate to help prevent client manipulation D - The nurse should implement assertiveness training for clients who have dependent and histrionic personality disorder

A nurse is assisting in planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A - Orient the client frequently to time, place, and person B - Offer fluids and nourishing diet as tolerated C - Implement seizure precautions D - Encourage participation in group therapy sessions

C - Implement seizure precautions Rational A - Reorienting the client is an appropriate intervention, but it is not the priority B - Providing hydration and nourishment is an appropriate intervention, but it is not the priority C - The greatest risk to the client in injury. Implementing seizure precautions is the priority intervention D - Encouraging participation in therapy is an appropriate intervention, but it is not the priority

A nurse is assisting in planning a staff education program on substance use in older adults. Which of the following information should the nurse plan to include in the presentation? A - Older adults require higher doses of a substance to achieve a desired effect B - Older adults commonly use regression to cope with a substance use disorder C - Older adults are at an increased risk for substance use following retirement D - Older adults develop substance use to mask manifestations of dementia

C - Older adults are at an increased risk for substance use following retirement Rational A - Requiring higher doses of a substance to achieve a desired effect is a result of the length and severity of substance use rather than age B - Denial, rather than regression, is a defense mechanism commonly used by substance uses of all ages C - Retirement and other life changes stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use D - Substance use in the older adult can result in manifestations of dementia

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should anticipate prescriptions for which of the following medications to promote long-term abstinence from alcohol? Select all A - Lorazepam B - Diazepam C - Disulfiram D - Naltrexone E - Acamprosate

C, D & E C - Disulfiram D - Naltrexone E - Acamprosate Rational A - Lorazepam is prescribed for short-term use during withdrawal B - Diazepam is prescribed for short-term use during withdrawal C- Disulfiram promotes abstinence through aversion therapy D - Naltrexone promotes abstinence by suppressing the craving and pleasurable effects of alcohol E - Acamprosate decreases the unpleasant effects resulting from abstinence

The nurse is caring for a patient with suspected cocaine abuse. What would be appropriate for inclusion in the nursing care plan? Select all 1 - Assess for signs of impending seizures. 2 - Begin detoxification with a similar drug, as ordered. 3 -Use restraints only if he poses a threat to himself or others. 4 - Expect the duration of the drug's effects to be several hours. 5 - Keep the patient's environment as free of stimulation as possible.

1 ,3 & 5 1 - Assess for signs of impending seizures. 3 -Use restraints only if he poses a threat to himself or others. 5 - Keep the patient's environment as free of stimulation as possible. Rational Cocaine is a central nervous system stimulant; use of cocaine results in extreme agitation and puts the patient at high risk for seizures. Impaired judgment can result in injury to self or others, but the patient should not be restrained unless absolutely necessary because of the extreme agitation that can result from cocaine use. Cocaine detoxification is not accomplished by use of controlled amounts of a similar drug, as is the withdrawal protocol for other drugs (e.g., benzodiazepines).

A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is the nurse's best response? Select all 1 - "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." 2 - "You will likely experience euphoria from the medication." 3 - "You will likely become dependent on this medication and require other medications to control your pain." 4 - "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." 5 - "You will not become physically addicted, but you may develop a physiological addiction."

1 - "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." 4 - "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." Rational Tolerance is an increasing need for a substance or a lack of effect when a certain dose is given over time. Withdrawal is a syndrome of symptoms that result from stopping the use of a substance. Dependency and psychological addiction do not usually occur with patients that are in pain, because the pain receptors are not being artificially stimulated.

When the nurse is talking with a patient who is having active hallucinations, what is the priority action? 1 - Assess the content and themes of hallucinations 2 - Give an antipsychotic medication 3 - Take the patient to a secluded area 4 - Set boundaries and explain rationale

1 - Assess the content and themes of hallucinations Rational Assess the content and theme to determine if there is a danger or self or others. Based on your assessment, you may decide that medication or isolation is necessary. Setting boundaries does not alleviate the hallucinations; however, you should explain your actions if you medicate or isolate.

An older adult male patient on antipsychotic medications develops a flat affect with drooling and a shuffling gait. He has slowed movements, tremors, motor restlessness, apprehension, and irritability. The nurse would look for an order from the physician for which medication? 1 - Benztropine (Cogentin) 2 - Haloperidol (Haldol) 3 - Chlorpromazine (Thorazine) 4 - Perphenazine (Trilafon)

1 - Benztropine (Cogentin) Rational Patient is manifesting symptoms of Parkinsonism. Treatment is anticholinergic medications such as benztropine (Cogentin). Haloperidol (Haldol), chlorpromazine (Thorazine), and perphenazine (Trilafon) are conventional antipsychotic medications that may cause pseudo-parkinsonism.

A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. He insists that he is the real Santa Claus. Which of the following nursing interventions should the nurse implement when working with this patient? 1 - Consistently use the patient's name 2 - Point out to the patient why he cannot be Santa Claus 3 - Agree that he is Santa Clause so as not to upset him further 4 - Provide medication as needed (PRN)

1 - Consistently use the patient's name Rational The patient needs continuous reality-based orientation, so his name should be used in all interactions with the nurse and other staff. The nurse should not reinforce the delusion by agreeing with the patient. Logical arguments and PRN medication are not likely to change his thinking.

A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? Select all 1 - A motivational interview 2 - Observing for stress reaction 3 - Converting narcotic use from an illicit to a legally controlled drug 4 - Observing for delirium tremors 5 - Encouraging involvement in Narcotics Anonymous

1, 2 & 5 1 - A motivational interview 2 - Observing for stress reaction 5 - Encouraging involvement in Narcotics Anonymous Rational The motivational interview will help determine the patient's readiness to participate in therapies. Stress reaction is a withdrawal symptom that can occur when detoxification takes place too quickly. Support groups have been shown to be successful for drug addiction. Delirium tremens is usually associated with alcohol withdrawal.

When conducting a health history, the nurse identifies some of the following social risk factors as possible predictors of a diagnosis of schizophrenia. Select all 1 - Urban residence 2 - Recent immigration 3 - Impaired physical or mental health 4 - Older paternal age 5 - First-degree relative diagnosis with schizophrenia 6 - Ethnic and racial discrimination

1, 2, & 6 1 - Urban residence 2 - Recent immigration 6 - Ethnic and racial discrimination Rational Urban residence, recent immigration, and ethnic and racial discrimination are social conditions that have been implicated as risk factors for developing schizophrenia. Although the other factors are also considered to be risk factors, they are not classified as social predictors.

A patient's wife indirectly suggests that her husband has a substance abuse problem. Which initial assessment question(s) should the nurse ask the husband? Select all 1 - "What substances (alcohol, tobacco, or illicit substances) are you currently using?" 2 - "How often do you drink or use illicit substances?" 3 - "When did you last drink or use drugs of any kind?" 4 - "How do you feel about people who abuse substances?" 5 - "Why does your wife think you have a substance abuse problem?" 6 - "Is there a family history of alcoholism or substance abuse?"

1, 2, 3 & 6 1 - "What substances (alcohol, tobacco, or illicit substances) are you currently using?" 2 - "How often do you drink or use illicit substances?" 3 - "When did you last drink or use drugs of any kind?" 6 - "Is there a family history of alcoholism or substance abuse?" Rational Standard assessment questions include: what do you take, how often, and when. In addition, family history is important because of genetic and environmental influences and risk factors. (4) Eliciting feelings about others is not appropriate during the assessment or at any other time (focus is never about the substance abuse issues of others). (5) Asking the patient to explain the wife's perceptions should be postponed until a psychologist, psychiatrist, or a substance abuse counselor can have an in-depth discussion preferably with the entire family.

A patient is becoming progressively louder and more aggressive about getting a personal item (belt) that was taken from him for safety precautions. What interventions(s) should the nurse use? Select all 1 - Continuously assess for pacing, fidgeting, and increase in verbalizations 2 - Maintain a calm, self-assured attitude, even if frightened 3 - Listen and state, "I care and want to help." 4 - Move in close to the patient and reassure him 5 - Give the patient the belt and set strict limits on his behavior 6 - Stand to the side or sideways to prevent yourself as a small target 7 - Explain the hospital policy and offer him a copy

1, 2, 3, & 6 1 - Continuously assess for pacing, fidgeting, and increase in verbalizations 2 - Maintain a calm, self-assured attitude, even if frightened 3 - Listen and state, "I care and want to help." 6 - Stand to the side or sideways to prevent yourself as a small target Rational Watch the patient, be calm, listen, and protect yourself. Do not move toward patient; being too close can be perceived as a threat. Do not give him the belt. Objects are temporarily stored for the patient for safety purposes. Explaining the policy and offering a copy is too much information at this time.

The nurse is assessing a patient using the CAGE questionnaire. The nurse suspects possible alcoholism when the patient makes which of the following statements? Select all 1 - The patient states, "My wife keeps nagging me about my drinking." 2 - The patient states, "I am going to try to cut down on drinking. I have been partying too much." 3 - The patient states, "I go to meetings once or twice a week but continue to drink." 4 - The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." 5 - The patient says to the nurse, "I am ashamed of how much I have been drinking lately." 6 - The patient states, "I can quit whenever I want to."

1, 2, 4 & 5 1 - The patient states, "My wife keeps nagging me about my drinking." 2 - The patient states, "I am going to try to cut down on drinking. I have been partying too much." 4 - The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." 5 - The patient says to the nurse, "I am ashamed of how much I have been drinking lately." Rational The patient may need help admitting that there is a problem. The CAGE questionnaire is designed to objectively assist in assessing problems related to alcohol use. A patient who states that he is going to meetings of Alcoholics Anonymous (AA) is admitting he has a problem, even if he still drinks. A patient who feels he can quit whenever he wants to may be in denial of the problem.

The nurse is receiving report on a patient diagnosed with a thought disorder. The nurse should anticipate the patient to exhibit which symptoms or behaviors? Select all 1 - Apathy 2 - Anorexia 3 - Delusions 4 - Staff splitting 5 - Hallucinations 6 - Dramatic behavior

1, 3 & 5 1 - Apathy 3 - Delusions 5 - Hallucinations The patient with a thought disorder is likely to exhibit apathy, hallucinations, and delusions. Anorexia is associated with depression. Staff splitting and dramatic behavior are associated with personality disorders.

What are some primary prevention activities a nurse can perform related to substance abuse? Select all 1 - Education to prevent substance abuse 2 - Focusing on relapse prevention 3 - Identification of risk factors for abuse 4 - Medical detoxification 5 - Referral to a self-help group for stress relief and meditation

1, 3 & 5 1 - Education to prevent substance abuse 3 - Identification of risk factors for abuse 5 - Referral to a self-help group for stress relief and meditation Rational Primary prevention actions are those taken in order to prevent a problem from occurring. Primary prevention involves reducing stress to prevent addiction. Secondary prevention includes screening and early detection for prompt treatment. Referral to a support group might be considered secondary prevention if a patient has screened positive for substance abuse and has agreed to start attending a group. Tertiary prevention includes rehabilitative strategies.

A patient demonstrates negative symptoms of apathy, social isolation, and lack of motivation. To establish trust, what should the nurse do? Select all 1 - Offer self and be available 2 - Reorient to person, place, and time 3 - Keep all promises 4 - Invite the patient to join groups 5 - Leave the door open for future interactions 6 - Encourage independence in ADL's

1, 3, 4, & 5 1 - Offer self and be available 3 - Keep all promises 4 - Invite the patient to join groups 5 - Leave the door open for future interactions Rational Offering self, keeping promises, suggesting socialization, and planning future interactions are interpersonal ways to build trust. Reorienting to person, place, and time is useful when the patient is confused or has a cognitive disorder such as delirium. Encouraging independence in activities of daily living is a good general measure but not a first-line intervention for establishing trust.

The patient has anhedonia, flat affect, illusions, hallucinations, and delusions of persecution. The nurse knows which of this patient's symptoms are most likely to improve with antipsychotic medication? Select all 1 - Illusions 2 - Flat affect 3 - Anhedonia 4 - Hallucinations 5 - Delusions of grandeur

1, 4 & 5 1 - Illusions 4 - Hallucinations 5 - Delusions of grandeur Rational Antipsychotic medications are most effective for positive symptoms, including illusions, hallucinations, and delusions. They are less effective for negative symptoms (flat affect and anhedonia).

Which statement causes the nurse to document a schizophrenic patient's delusions of persecution? 1 - "Did you know that I own this hospital and pay all these people to work for me?" 2 - "My doctor talked to all the other patients, but not to me. He doesn't want me to get well." 3 - "The president's speech tonight is going to give me a coded message." 4 - "I am going to wait in front of the hospital this morning for my limousine to pick me up and take me to my private jet."

2 - "My doctor talked to all the other patients, but not to me. He doesn't want me to get well."

A self-confessed alcoholic asked, "Why is the purpose of the Antabuse that has been prescribed by my doctor?" What is the best explanation to give to the patient? 1 - "It blocks the craving for alcohol." 2 - "The medication causes unpleasant symptoms when you drink." 3 - "The medication keeps you from having seizures." 4 - "It controls symptoms of nausea, vomiting, pain, or cramps."

2 - "The medication causes unpleasant symptoms when you drink." Rational Disulfiram (Antabuse) can cause chest pain, nausea and vomiting, hypotension, weakness, blurred vision, and confusion if alcohol is consumed after taking the medication. (1) Antabuse does not block the craving for alcohol. Naltrexone (ReVia) can be used to block the craving for alcohol. (3, 4) Antabuse does not control nausea and vomiting, pain, cramps, or seizures.

A nurse is taking a history on an adult male who needs emergency surgery. He freely admits to using marijuana, alcohol, cocaine, and hallucinogens. What is the most important question that the nurse should ask this patient? 1 - "Does your wife know that you are using all these drugs?" 2 - "When was the last time you drank or took a substance?" 3 - "How frequently are you using these drugs and alcohol?" 4 - "Have you ever tired to control your substance use?"

2 - "When was the last time you drank or took a substance?" Rational The most important issue in this emergency situation is to determine the last use of substances so that the health care team is aware of drug-drug interactions or the possibility of withdrawal symptoms. (1) This is a not an appropriate question at this time. (3, 4) In addition, direct and nonjudgmental questioning is needed at this time. Other questions would also be included to develop short- and long-term interventions for this patient.

A patient is admitted to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing this patient's record, the nurse would expect to find which report? 1 - Below-average intelligence 2 - A history of cruelty to animals 3 - A history of consistent employment 4 - Expression of remorse for his actions

2 - A history of cruelty to animals Rational A history of cruelty to animals and people, truancy, fire setting, and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children; this becomes a diagnosis of antisocial personality disorder in adults. Patients with antisocial personality disorder generally do not hold consistent employment. Patients with antisocial personality disorder generally have a higher than average intelligence quotient (IQ). Patients with this diagnosis typically lack guilt or remorse for wrongdoing.

A patient with psychotic depression is receiving haloperidol. Which side effect is associated with this medication? 1 - Polyuria 2 - Akathisia 3 - Cataracts 4 - Diaphoresis

2 - Akathisia Rational Akathisia is pathologic restlessness and agitation; it is an extrapyramidal adverse effect of many of the older antipsychotic medications, such as haloperidol and chlorpromazine. Polyuria, cataracts, and diaphoresis are not associated with haloperidol use.

The wife of an alcoholic keeps making excuses to their children when he fails to do things with them that he promised he would do. What is the priority problem? 1 - Limited coping ability 2 - Altered family functioning 3 - Absence of compliance 4 - Decreased self-esteem

2 - Altered family functioning Rational The wife is trying to maintain the family because the father is unable to do so because of alcohol abuse. (1) It is likely that none of the family members are coping well; however, the scenario mostly discloses family dysfunction. (3) Nothing in the question has mentioned absence of compliance with a treatment plan. (4) The father or the mother may have a decreased sense of self-esteem in this situation but nothing in the question mentions this.

When you suspect an older adult is considering suicide, the most appropriate intervention is to: 1 - Discuss suspicions with a significant other 2 - Ask the patient directly about such plans 3 - Constantly watch the patient 4 - Refer the patient for mental health counseling

2 - Ask the patient directly about such plans Rationale: It is best to directly ask the older adult if he is considering suicide plans. If he acknowledges a suicide plan is in place, immediate crisis intervention is necessary to save his life.

A student nurse questions the nurse about frequency of administration of antipsychotics, such as risperidone (Risperdal). Which advantage is true of newer antipsychotics like risperidone (Risperdal)? 1 - Decreased photosensitivity 2 - Fewer serious side effects 3 - Less expensive 4 - Decreased incidence of headaches

2 - Fewer serious side effects

The patient confides in the nurse he would like help in controlling his drinking. The nurse should recommend which of the following types of therapy, shown to be most effective at helping patients quit drinking? 1 - Electroconvulsive therapy (ECT) 2 - Group support, such as Alcoholics Anonymous (A.A.) 3 - Drug therapy, especially aversive therapy with disulfiram 4 - Reduction of, but not elimination of, alcohol consumption

2 - Group support, such as Alcoholics Anonymous (A.A.) Rational Group support, such as AA, is one of the most effective treatments for alcoholism. ECT is not a treatment for alcoholism. Drugs may be used to manage acute withdrawal but are not consistently successful long-term therapy. Reducing alcohol consumption is not successful for most individuals with alcoholism.

A patient in the middle stage of Alzheimer's disease (AD) may exhibit which characteristic of behavior? 1 - Mild depression 2 - Hallucinations 3 - Weight loss 4 - Impaired mobility

2 - Hallucinations Rational Hallucinations may occur during the middle stage of AD. Mild depression may occur during the early stage of AD. Weight loss may occur during the late stage of AD. Impaired mobility may occur during the late stage of AD

A patient comes to the clinic with a history of alcohol abuse. The provider makes the medical diagnosis of Wernicke encephalopathy and orders large doses of vitamin B1. Which response indicates that the treatment is working? 1 - No seizure activity 2 - Less confusion and improvement of memory 3 - Decreased urge to drink alcohol 4 - No tremors, nausea, or vomiting

2 - Less confusion and improvement of memory Rational Patients with Wernicke encephalopathy are likely to show confusion, memory loss, and ataxia; it a reversible condition that responds to vitamin B1. (1, 4) Seizure activity, tremors, nausea, and vomiting are signs of alcohol withdrawal. (3) Naltrexone (ReVia) is an example of medication used to help block the craving for alcohol.

The usual standard for reporting elder abuse is one: 1 - Of 100% certainty 2 - Of reasonable belief that abuse has occurred or may occur 3 - That is beyond a shadow of a doubt 4 - With testimony of one or more eyewitnesses

2 - Of reasonable belief that abuse has occurred or may occur Rationale: The standard for reporting is usually a reasonable belief that an individual has been or is likely to be abused, neglected, or exploited.

A patient is readmitted for an acute psychotic episode. He appears to be having command hallucinations. What is the priority problem on his care plan? 1 - Altered sensory perception 2 - Potential for violence 3 - Anxiety 4 - Altered coping ability

2 - Potential for violence Rational The content of command hallucinations should be immediately assessed because patient may be getting a command to harm self or others. The other diagnoses are also relevant but less urgent.

The nurse has provided information about a safe shelter for a patient who is the victim of abuse. Which of the following is an additional intervention that the nurse must perform? 1 - Arrange for transportation to the shelter. 2 - Report the abuse to the appropriate legal authority. 3 - Offer paperwork for medical assistance. 4 - Provide food vouchers for the patient's children.

2 - Report the abuse to the appropriate legal authority. Rational All states have laws for mandatory reporting of suspected cases of abuse; it is not a violation of patient privacy to meet this requirement. Transportation, medical assistance, and emergency food are all helpful interventions, but there are no data indicating that such assistance is needed, and none of these interventions are mandatory.

Alcoholism is often overlooked in the elderly. Cues to alcoholism include: (Select all) 1 - Delirium 2 - Self-neglect 3 - frequent falls 4- Mental confusion

2 - Self-neglect 3 - frequent falls 4- Mental confusion Rational Self-neglect, frequent falls, and mental confusion are clues to alcoholism. Depression, not delirium, is a clue to alcoholism

The health care provider writes an order for continuous observation for a patient admitted for an acute adverse response to a hallucinogenic drug. Which characteristic of hallucinogenic drugs makes close observation necessary? 1 - Rapid physical dependence 2 - States of altered perception 3 - Severe respiratory depression 4 - Both stimulant and depressant effects

2 - States of altered perception Rational Hallucinogens produce altered perceptual states, making patient behavior unpredictable. Hallucinogenic drugs do not produce rapid physical dependence; they produce psychological dependence. Respiratory depression is an effect of narcotic use. Hallucinogens do not produce both stimulant and depressant effects.

A patient with a diagnosis of schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. Which would be an appropriate activity for this patient? 1 - Playing a game of solitaire 2 - Taking a walk with the nurse 3 - Working on a large-piece puzzle 4 - Watching a movie with other patients

2 - Taking a walk with the nurse Rational Actively involving the patient will minimize active hallucinations. Solitaire, puzzles, and movies provide ample opportunity for active hallucinations.

A postoperative patient who is a self-confessed drinker is given Librium for increased blood pressure, increased pulse, tremors, nausea and vomiting, and diaphoresis. Why did the provider prescribe this medication for the patient? 1 - To prevent postoperative clot formation 2 - To reduce the symptoms of alcohol withdrawal 3 - To control the blood pressure 4 - To relieve postoperative nausea and vomiting

2 - To reduce the symptoms of alcohol withdrawal Rational Chlordiazepoxide (Librium) is given to reduce the neurologic irritability associated with alcohol withdrawal. (1) Librium has nothing to do with clot formation. (3, 4) Librium should reduce the symptoms, including elevated blood pressure and nausea and vomiting as part of the overall symptom set associated withdrawal.

A patient with dementia wanders throughout the skilled nursing facility. A nursing intervention for wandering may include 1 - administering a sedative 2 - maintaining a regular activity program 3 - locking the patient's room form the outside 4 - keeping a staff member with the patient when wandering

2 - maintaining a regular activity program Rational A regular activity program is an appropriate nursing intervention for wandering. Sedatives should not be used. The patient should not be locked in his or her room. Keeping a staff member with the patient when wandering is not a realistic or appropriate intervention

The increased usage of "bath salts" is a societal problem because it: Select all 1 - is illegal in all states under federal law 2 - is the most addictive of all abused substances 3 - is easily obtained over the Internet and in many stores 4 - potentially causes violence, paranoia, and suicide 5 - causes lung cancer if smoked excessively

2, 3 & 4 2 - is the most addictive of all abused substances 3 - is easily obtained over the Internet and in many stores 4 - potentially causes violence, paranoia, and suicide Rational (2) These drugs are the most addictive of any recreational drug. (3) The drugs are easily obtained on the Internet and at head shops and other places. (4) "Bath salts" potentially cause the patient to become violent, paranoid, and/or suicidal. (1) "Bath salts" are not illegal as yet.

A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? Select all 1 - The patient states, "I don't think my body will recover from the drinking." 2 - The patient states, "I will watch the game at my friend's house instead of at the bar." 3 - The patient states, "I now realize that the drinking has affected my family life." 4 - The patient states, "I am glad that I did not drag others into my drinking." 5 - The patient states, "I have been attending one meeting a day."

2, 3 & 5 2 - The patient states, "I will watch the game at my friend's house instead of at the bar." 3 - The patient states, "I now realize that the drinking has affected my family life." 5 - The patient states, "I have been attending one meeting a day." Rational A patient who realizes that changing his environment will decrease temptation shows that he is motivated and willing to try to change. A patient who is able to see the effect the abuse is having on his life has a key component of motivation. A patient who is attending meetings of Alcoholics Anonymous (AA) is motivated toward recovery.

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. The nurse understands that because there are many kinds of potential abuse, she will need to assess for what type of factors? Select all 1 - High ratio of overweight residents 2 - Unexplained bruising of residents 3 - Altered cognitive function of residents 4 - Skin breakdown in residents resulting from poor hygiene 5 - Documentation of prescribed physical therapy sessions

2, 3, & 4 2 - Unexplained bruising of residents 3 - Altered cognitive function of residents 4 - Skin breakdown in residents resulting from poor hygiene Rational In addition to psychological signs such as depression, signs of elder abuse include bruising from physical abuse and skin breakdown from neglect of hygiene and nutrition; frailty and decreased cognitive function are also risk factors for abuse. Overweight residents and following prescribed treatments are not indicators of abuse or neglect.

Which symptoms is the nurse most likely to observe in a depressed, older adult? (Select all) 1 - Anger 2 - Poor memory 3 - Insomnia 4 - Loss of motivation 5 - Pacing

2, 3, and 4; 2 - Poor memory 3 - Insomnia 4 - Loss of motivation Rationale: A depressed older adult will often demonstrate memory problems, sleep problems, and lack of motivation. Anger is usually not demonstrated because it requires a great deal of emotion and energy.

While watching television, a 28-year-old male patient appears to be hallucinating. He is swearing loudly at the television and is becoming increasingly agitated. Which of the following nursing interventions would be appropriate in dealing with this patient? Select all 1 - In a firm voice, tell the patient to stop this behavior. 2 - Acknowledge the presence of the hallucinations. 3 - Instruct other team members to ignore the patient's behavior. 4 - Reassure the patient that he is not in any danger. 5 - Give simple commands in a calm voice

2, 4 & 5 2 - Acknowledge the presence of the hallucinations. 4 - Reassure the patient that he is not in any danger. 5 - Give simple commands in a calm voice Rational Using a calm voice and giving simple commands, the nurse should reassure the patient that he is not in any danger. It is not appropriate to tell the patient to stop the behavior, and ignoring the behavior will not reduce his agitation.

Which statement by a patient to the nurse indicates a positive step in the recovery from alcohol dependency? 1 - "I do think my job is at the root of my alcohol consumption." 2 - "I don't have any power over the effects alcohol has on me." 3 - "I don't ever want to use alcohol again." 4 - "To stay sober I will increase my exercise and eat healthy foods."

3 - "I don't ever want to use alcohol again." Rational Recognition of the need to not use alcohol is a positive step in the recovery from alcohol dependence. (1, 2) Blaming the stress of a job for alcohol consumption or stating, "I don't have any power over the effects alcohol has on me," is rationalization. (4) Increasing exercise and eating healthily is a good plan but does not in itself help the patient stay sober.

A nurse is caring for a patient with a personality disorder. Which statement by the nurse indicates a need for additional training and education on setting boundaries. 1 - "I can spend 20 minutes talking with you and then I have to pass mediations." 2 - "I understand that you are border, but you have to complete the task." 3 - "If you promise not to cause trouble, I'll give you the magazine." 4 - "When someone is speaking in group, it is polite to listen while they speak."

3 - "If you promise not to cause trouble, I'll give you the magazine." Rational If a privilege is granted and contingent on a future behavior, the patient and student are setting up for future manipulation and power struggles. The boundary and anticipated actions are very clear in this statement. In this statement, the feelings are acknowledged, but the expectations remain clear. Behavior and circumstances are clearly articulated.

The nurse discusses the effects of a patient's antipsychotic medication with him. Which patient statement indicates a need for further teaching? 1 - "The medication helps me to think more logically." 2 - "The medication makes my mouth dry." 3 - "The medication improves my mood." 4 - "The medication helps to stop the voices."

3 - "The medication improves my mood." Rational Antipsychotic medications do not function as mood elevators. They should help the patient to have less thought disorder and less distortion in sensory perception. A side effect is dryness to the mouth.

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for most interpersonal violence incidents that should be addressed? 1 - Poor working conditions 2 - Hypertension medications 3 - Alcohol use 4 - Poor self-esteem

3 - Alcohol use Rational The use or misuse of alcohol is a risk factor in partner violence, child abuse, youth abuse, and elder abuse. Poor working conditions add to stress but would not be a risk factor that most abuse incidents have in common. Hypertension medications do not increase the risk of abusive episodes. Poor self-esteem is not a common risk factor for most abusive episodes.

You recently admitted a patient with Alzheimer disease to your long-term care nursing unit. This patient appears restless and agitated. What should you do first? 1 - Obtain an order for restraints 2 - Medicate the patient with haloperidol 3 - Assist the patient in attending his scheduled music group therapy 4 - Obtain an order for duloxetine

3 - Assist the patient in attending his scheduled music group therapy Rationale: Behavioral therapies, such as art, music, and reminiscent therapy, must be used prior to using medication for anxiety and agitation. Antipsychotic medications, such as haloperidol (Haldol), have come under scrutiny in recent years and are being prescribed less frequently than in the past. Antidepressants, such as duloxetine (Cymbalta), may be appropriate, but only after other therapies have been tried.

A young man with suspected heroin intoxication is admitted to the unit. Which sign is consistent with opiate use? 1 - Rapid speech 2- Dilated pupils 3 - Constricted pupils 4 - Elevated blood pressure (BP)

3 - Constricted pupils Rational Opiate use causes constricted pupils; opiate overdose results in dilated pupils as a result of cerebral anoxia. However, there is no information given to indicate overdose. Opiate use results in slowed speech and decreased BP.

A 38-year-old patient has been admitted to the unit. The patient's medical history reveals that the patient, after a long history of amphetamine use, has abruptly discontinued the substance. Which of the following conditions is the patient at the greatest risk for developing? 1 - Tachycardia and euphoria 2 -Diaphoresis and tachypnea 3 - Depression and suicidal ideation 4 - Muscle cramping and abdominal pain

3 - Depression and suicidal ideation Rational Abrupt cessation of amphetamines produces profound depression and thoughts of suicide. Patients withdrawing from amphetamines must be closely observed for suicidal gestures. Tachycardia, euphoria, diaphoresis, tachypnea, muscle cramping, and abdominal pain are not associated with cessation of amphetamine use; rather, they are associated with opiate withdrawal. Amphetamine withdrawal causes bradycardia and depression.

A patient is in a early recovery process and is attempting to lead a drug-free life. Which intervention is the most appropriate to assist the patient? 1 - Remind the patient of the discomfort and pain that occurred during detoxification 2 - Tell the patient that there is no need to feel guilty or ashamed 3 - Help the patient to identify relationships that were part of the substance use pattern 4 - Advise the patient that stopping forever is the only choice for a drug-free life

3 - Help the patient to identify relationships that were part of the substance use pattern Rational Identifying relationships that were part of the substance use pattern will help the patient to avoid going back into the same circumstances. (1) The patient is already acutely aware of the physical experience of withdrawal. (2) Dealing with the guilt and shame are part of the recovery process. (4) The nurse should not give the patient absolution for past behaviors. Patient is likely to be intellectually aware of the need for a drug-free life; repeating this is not really helpful.

The nurse is caring for a patient addicted to morphine who is being treated for withdrawal symptoms. Which medication can the nurse anticipate will be prescribed to manage this condition? 1 - Disulfiram 2 - Lorazepam 3 - Methadone 4 - Naloxone hydrochloride

3 - Methadone Rational Methadone is used for opiate withdrawal and for long-term management of recovery from opiate addiction. Disulfiram is used as aversive therapy for alcoholism. Lorazepam is used for treatment of alcohol withdrawal. Naloxone hydrochloride is used to reverse narcotic and opiate overdose.

A 20-year-old male patient diagnosed with chronic schizophrenia is placed on an antipsychotic, 20 mg twice a day. At the evening medication time, he expresses that he is not feeling well. The nurse assesses the patient and finds the following symptoms: oral temperature 103° F (39.4° C), pulse 110 beats/min, and respirations 24 breaths/min. The patient is diaphoretic and appears rigid. This patient is most likely suffering from which of the following? 1 - Tardive dyskinesia 2 - Pneumonia 3 - Neuroleptic malignant syndrome 4 - Pseudoparkinsonism

3 - Neuroleptic malignant syndrome Rational The symptoms are consistent with neuroleptic malignant syndrome, which is an adverse reaction to antipsychotic medication. While the other conditions listed in answers A and D may also be side effects of antipsychotic medication, the symptoms presented are not indicative of these conditions. Pneumonia may present with these vital signs; however, the diaphoresis and muscular rigidity are not.

The nurse observes a withdrawn schizophrenic. The patient is sitting alone and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear. What should the nurse do first? 1 - Hug the patient's shoulders, refer to the patient by name, and ask if she's praying 2 - Document the patient's non-responsiveness and continued detached behavior 3 - Sit down in the chair next to the patient, touch her arm, and speak softly 4 - Touch the patient's shoulder and then join another group of patients

3 - Sit down in the chair next to the patient, touch her arm, and speak softly

Which nursing action may aggravate the behavior of a patient who has paranoid tendencies? 1 - Speaking in short, simple sentences 2 - Maintaining a structured environment 3 - Speaking in low tones to another patient in the area 4 - Providing written instructions regarding the patient's medication regimen

3 - Speaking in low tones to another patient in the area Rational Speaking so that this patient cannot hear may be interpreted negatively by the patient. Short and simple sentences, structured environments, and written instructions are appropriate for the patient with paranoia.

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient? 1 - The patient may be having an acute psychotic episode related to her mental illness. 2 - The patient may be abusing street drugs and needs a drug screening test. 3 - The patient may have been the victim of an acute assault. 4 - The patient may be a very demanding and particular person.

3 - The patient may have been the victim of an acute assault. Rational Refusing care from a caregiver of another gender, wanting easy escape access, and having poor eye contact all indicate that an assault may have occurred. Acute psychosis, use of street drugs, or being a demanding person does not elicit the signs of wanting to protect herself from others.

The nurse would consider a dual diagnosis for a patient who states: 1 - "I'm so very busy that I rarely get much sleep." 2 - "I find it difficult to get up in the morning and face the day." 3 - "I need a drink first thing in the morning to calm my down." 4 - "Alcohol helps me to function better on a daily basis

4 - "Alcohol helps me to function better on a daily basis Rational Many patients with mental illness use alcohol or other drugs to calm the symptoms of their illness or to calm the side effects of the medications for their mental illness. (1) Being busy and not getting enough sleep is a societal problem but doesn't indicate the need for a dual diagnosis. (2) Difficulty getting up in the morning to face the day can have many causes beside depression—lack of sleep for one. (3) Needing a drink first thing in the morning is a sign of alcoholism and doesn't necessarily indicate an additional mental illness.

A patient is suspicious and believes that he is surrounded by terrorist. He tells the nurse, "They put anthrax in the food and there is a bomb in the bathroom." What is the most therapeutic response? 1 - "Who do you think is doing all these things." 2 - "Let's go together and check the bathroom." 3 - "Tell me why you believe these things are happening." 4 - "I believe that the hospital is a safe place."

4 - "I believe that the hospital is a safe place." Rational Stating reality and emphasizing safety and security are the best response. The nurse should not validate or give credence to the delusion. The patient is not able to state why he believes what he does and asking only provides a forum to expand on delusional thoughts.

The nurse has asked a catatonic patient, "Where is your hat?" Which response should cause the nurse to document episodes of echolalia? 1 - The patient excitedly says, "Hat, cat, rat, fat, scat, splat!" 2 - The patient tearfully says, "I had a hat when my mother drove her yellow car." 3 - The patient repeatedly says, "Your hat your hat, your hat." 4 - "The patient places his hands on his head and says, "Where is your hat?"

4 - "The patient places his hands on his head and says, "Where is your hat?"

A patient has been admitted to the unit for a medically managed withdrawal from diazepam. During her third day on the unit, she angrily tells the nurse, "I know how it is. You're all writing lies about me in my chart. None of you care anything about me. You just want to get rid of me." Which response by the nurse is most therapeutic? 1 - "I'm not sure what you're referring to." 2 - "What do you think we're all saying about you?" 3 -"Nobody would write lies about you in your chart." 4 - "Would you like to talk to me some more about this?"

4 - "Would you like to talk to me some more about this?" Rational The most therapeutic response would attempt to get the patient to verbalize her concerns. The nurse should not play dumb, encourage the delusion, or ignore the patient's concerns.

The nurse is assessing a 4-year-old child in a health clinic. Which of the following situations would cause the nurse to explore for possible abuse? 1 - Being brought to the clinic from daycare 2 - Recent scrapes and bruises on both knees 3 - The caregiver reporting angry outbursts from the child while they were in a store 4 - Different explanations of the injury from the child's parents

4 - Different explanations of the injury from the child's parents Rational Inconsistent explanations from parents for how injuries occurred is a cause for further investigation. Being brought in from daycare, school, camp, or other public areas does not automatically indicate abuse. Scrapes on the knees are a common developmental injury for a 4 year old. Angry outbursts or tantrums in children in this age-group are still expected developmental behaviors.

A patient with schizophrenia is receiving clozapine 150 mg twice a day. The nurse knows to be vigilant for which sign of an adverse effect of this drug? 1 - Weight gain 2 - Photosensitivity 3 - Elevated blood pressure (BP) 4 - Extreme temperature elevations

4 - Extreme temperature elevations Rational Known as neuroleptic malignant syndrome, this is an adverse reaction to clozapine characterized by extreme elevations in body temperature. Elevations in BP are associated with interactions between foods containing tyramine and monoamine oxidase inhibitor. Weight gain and photosensitivity are common side effects of many antipsychotics and do not necessarily represent adverse effects.

The nurse is administering medication to a familiar patient, who has been on the unit for several weeks. When asked to state his name, the patient replies "I am Jesus Christ, the son of God." What is the best nursing action? 1 - Give the medication, because the nurse knows he in confused 2 - Document that the patient cannot state his name and hold the medication 3 - Hold the medication until the family can bring in a picture identification 4 - Have a second nurse verify his identity and document accordingly

4 - Have a second nurse verify his identity and document accordingly Rational Having another health care provider verify the patient's identification is the best option, so that the patient can continue to receive his medication. If nurse gives a medication without validating the patient's identity, there is possibility for medication error. Holding the medication is not in the best interests of the patient; however, it would be worthwhile for the staff to develop an alternative identification process for confused patients, and pictures could be used.

Medications that work by increasing acetylcholine in the cerebral cortex may produce: 1 - A calming effect and less hostility 2 - Greater ability to organize and carry out tasks 3 - Greater ability to concentrate and learn new things 4 - Improved memory, alertness, and social engagement

4 - Improved memory, alertness, and social engagement Rationale: It is thought that medications that result in increased acetylcholine at the synapse lead to improved memory and alertness as well as improved socialization. These medications help slow down the cognitive decline that occurs in Alzheimer disease.

The nurse explains that an alternative to disulfiram (Antabuse) is the drug naltrexone (ReVia). Which information should the nurse include in the teaching plan? 1 - Naltrexone (ReVia) causes severe headaches if alcohol is consumed while using the drug 2 - Naltrexone (ReVia) can cause a dependence on the medication itself if taken improperly 3 - Naltrexone (ReVia) release endorphin-like enzymes that mimic intoxication 4 - Naltrexone (ReVia) blocks craving and prevents relapse

4 - Naltrexone (ReVia) blocks craving and prevents relapse

What effects does the nurse desire to achieve by using clear, direct communication with patients with borderline personality disorders? 1 - Avoid generating an intense reaction from the patient 2 - Eliminate the possibility of manipulation 3 - Decrease the probability of the patient reaching emotionally 4 - Provide a role model for good communication

4 - Provide a role model for good communication

A patient with depression may be prescribed a(n) 1 - phenytoin (Dilantin) 2 - lorazepam (Ativan) 3 - quetiapine (Seroquel) 4 - amitriptyline hydrochloride (Elavil)

4 - amitriptyline hydrochloride (Elavil) Rational Tricyclic antidepressants, selective serotonin reuptake inhibitor (SSRIs), and monoamine oxidase inhibitors (MAOIs) are used to treat depression. Elavil is a tricyclic antidepressant. Dilantin is an anticonvulsant. Ativan is an anxiolytic. Seroquel is an antipsychotic

Alzheimer's disease may be suggested in it early stages by: 1 - magnetic resonance imaging (MRI) 2 - computed tomography (CT) 3 - positron emission tomography (PET) 4 - autopsy

4 - autopsy Rational Although there are many diagnostic tools to rule out some cognitive diseases, few can diagnose Alzheimer's disease. Positron emission tomography (PET) has shown reduced lobe activity early in the disease. MRI, CT, and autopsy would not be used early in the disease process. Autopsy is the only conclusive diagnostic tool for AD

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements should the nurse identify as characteristic for a client who has this disorder? A - "I'm scared that you're going to leave me." B - "I'll go to group therapy if you'll let me smoke." C - "I need to feel that everyone admires me." D - "I sometimes feel better if I cut myself."

A - "I'm scared that you're going to leave me." Rational A - Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected B - This statement indicated manipulation, which is expected form a client who has antisocial personality disorder C - This statement indicates a need for admiration, which is expected from a client who has narcissistic personality disorder D - This statement indicates a risk for self-injury, which is expected from a client who has borderline personality disorder

A nurse is reinforcing teaching with a client who has alcohol use disorder and new prescription for carbamazepine. Which of the following information should the nurse include? A - "This medication will help prevent seizures during alcohol withdrawal." B - "Taking this medication will decrease your cravings for alcohol." C - "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D - "Taking this medication will improve your ability to maintain abstinence from alcohol."

A - "This medication will help prevent seizures during alcohol withdrawal." Rational A - Carbamazepine is used during withdrawal to decrease the risk for seizures B - Carbamazepine is used to promote safe withdrawal rather than to decrease cravings for alcohol C - Clonidine or propranolol is used during withdrawal to depress the autonomic response and its effect on blood pressure D - Carbamazepine is used to promote safe withdrawal rather than abstinence

A nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the nurse identity as being effectively treated by first-generation antipsychotics? Select all A - Auditory hallucinations B - Withdrawal from social situations C - Delusions of grandeur D - Severe agitation E - Anhedonia

A, C & D A - Auditory hallucinations C - Delusions of grandeur D - Severe agitation Rational A - Positive symptoms of schizophrenia, such as auditory hallucinations, are effectively treated with first-generation antipsychotics B - First-generation antipsychotics have minimal effectiveness with negative symptoms of schizophrenia, such as social withdrawal C - Positive symptoms of schizophrenia, such as delusions of grandeur, are effectively treated with first-generation antipsychotics D - Positive symptoms of schizophrenia, are effectively treated with first-generation antipsychotics E - First-generation antipsychotics have minimal effectiveness with negative symptoms of schizophrenia, such as anhedonia.

A nurse is assisting with a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the nurse include? Select all A - Difficulty getting along with other members of a group B - Belief in the ability to become invisible during times of stress C - Display of defense mechanisms when routines are changed D - Claiming to be more important than other persons E - Difficulty understanding why it is inappropriate to have a personal relationship with staff

A, C & E A - Difficulty getting along with other members of a group C - Display of defense mechanisms when routines are changed E - Difficulty understanding why it is inappropriate to have a personal relationship with staff Rational A - Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types B - Clients who have schizotypal personality disorder can display magical thinking or delusions. However, this is not associated with all personality disorder types C - Maladaptive response to stress is a personality characteristic that can be seen with all personality disorder types D - Clients who have narcissistic personality disorder can display grandiose thinking. However, this is not associated with all personality disorder types E - Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personalty disorder types

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? Select all A - "When did you start hearing the voices?" B - "The voices are not real, or else we would both hear them." C - "It must be scary to hear voices." D - "Are the voices telling you to hurt yourself." E - "Why are the voices talking to only you."

A, C, & D A - "When did you start hearing the voices?" C - "It must be scary to hear voices." D - "Are the voices telling you to hurt yourself." Rational B - The nurse should not argue with the client's view of the situation E - The nurse should avoid asking a "why" questions, which is non-therapeutic and can promote a defensive client response

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her, "Kill your doctor." Which of the following actions should the nurse take first? A - Use therapeutic communication to discuss the hallucinations with the client B - Initiate one-on-one observation of the client C - Focus the client on reality D - Notify the provider of the client's statement

B - Initiate one-on-one observation of the client Rational A - The nurse should use therapeutic communication to discuss the client's hallucination. However, there is another action the nurse should take first B - A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one-on-one observation is the first action the nurse should take first C - The nurse should attempt to focus the client on reality. However, there is another action the nurse should take first D - The nurse should notify the provider of the client's hallucination. However, there is another action the nurse should take first.

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A - Regression B - Splitting C - Undoing D - Identification

B - Splitting Rational A - Regression refers to resorting to an earlier way of functioning, such as having a temper tantrum B - Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time. C - Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts, such as buying a gift for a spouse after having an extramarital affair D - In identification, the person imitates the behavior or someone admired or feared

A nurse is monitoring a client who is currently taking perphenazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPSs)? Select all A - Decreased level of consciousness B - Drooling C - Involuntary arm movement D - Urinary retention E - Continual pacing

B, C & E B - Drooling C - Involuntary arm movement E - Continual pacing Rational A - Decreased level of consciousness is an indication of neuroleptic malignant syndrome rather than an EPS B - Drooling is an indication of pseudoparkinsonism, which is an EPS C - Involuntary arm movements are an indication of tardive dyskinesia, which is an EPS D - Urinary retention is an anticholinergic effect rather than an EPS E - Continual pacing is an indication of akathisia, which is an EPS

A 50-year-old female patient is admitted to the psychiatric unit for an acute exacerbation of paranoid schizophrenia after she stopped taking her medications for several months. She tells the nurse that she believes her food is being poisoned, and she refuses to eat. What is the most appropriate intervention by the nurse? 1 - Provide canned food while expressing reasonable doubt. 2 - Agree with the patient's decision. 3 - Challenge the patient's delusion. 4 - Dismiss her fears and insecurities.

1 - Provide canned food while expressing reasonable doubt. Rational Highly suspicious patients may refuse to eat food from an individually prepared tray. While not reinforcing the patient's delusion by agreeing with it, providing canned food may be an acceptable alternative to ensure proper nutrition. Challenging the delusion may increase the patient's anxiety. Dismissing her fears and insecurities invalidates the patient's emotional state.

Which behavior is characteristic of a patient with schizoid personality disorder? 1 - Social detachment 2 - Attention-seeking behavior 3 - Excessive emotional outburst 4 - Violation of the rights of others

1 - Social detachment Rational Patients with schizoid personality disorder retreat and are generally described as withdrawn, reclusive, and "loners." Attention-seeking behaviors, excessive emotional outbursts, and the violation of the rights of others are not associated with schizoid personality disorders.

The nurse is assigned to care for patients who are admitted for detoxification. Which drug represents the potentially highest-risk situation during withdrawal? 1 - Heroin 2 - Cocaine 3 - Methadone 4 - Secobarbital

4 - Secobarbital Rational A patient withdrawing from barbiturates requires gradual detoxification to prevent convulsions, delirium, tachycardia, and death. Although withdrawal from heroin, cocaine, or methadone is extremely uncomfortable and exhausting for the patient, it is not life threatening.

A 31-year-old patient with a history of borderline personality disorder is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. Which nursing approach would be most therapeutic for this patient? 1 - Open and flexible 2 - Warm and nurturing 3 - Nonintrusive and passive 4 - Structured and consistent

4 - Structured and consistent Rational The nurse should be consistent and keep the environment structured when caring for a patient with borderline personality disorder. Open and flexible, warm and nurturing, and nonintrusive and passive do not provide boundaries for a patient with borderline personality disorder, and boundaries are crucial to the patient's management.

A patient admitted to the psychiatric unit states he is the "Son of God" and insists he "Will not be confined by mere mortals." Which is the most likely explanation for this behavior? 1 - Low self-esteem 2 - A stressful event 3 - A religious conversion 4 - Overwhelming anxiety

1 - Low self-esteem Rational Delusions of grandeur are associated with low self-esteem. Conversion is generally expressed as sensory and motor deficits. Stressful events, religious conversion, and overwhelming anxiety do not manifest as delusions of grandeur.

A patient reports to the nurse that he has been taking chlorpromazine (Thorazine) for 4 months. Which symptoms is the cause for greatest concern? 1 - Muscle rigidity 2 - Tongue protrusion 3 - Phtophobia 4 - Dry eyes

1 - Muscle rigidity Rational Muscle rigidity is a symptom of neuroleptic syndrome that is rare but potentially fatal. Tongue protrusion is a sign of tardive dyskinesia, which may not be reversible even if medication is discontinued. Photophobia and dry eyes are anticholinergic symptoms that will respond to trihexyphenidyl (Artane) or benztropine (Cogentin).

Which is a nursing goal when working with a patient with substance abuse? 1 - To provide safe detoxification for the patient 2 - To encourage the patient to eat a high-calorie diet 3 - To encourage enabling behaviors in the patient's family 4 - To ensure that the patient spends minimal amounts of time sleeping

1 - To provide safe detoxification for the patient Rational When caring for the patient who has substance abuse, it is important to provide a safe and protected environment. Patients who are experiencing withdrawal from a substance may face physiologic and psychological symptoms. These may be frightening and life threatening. Enabling behaviors worsen substance abuse. A high-calorie diet may not be helpful to a patient withdrawing from drugs. The patient should sleep as much as he or she needs.

An elderly patient has acute confusion after undergoing abdominal surgery. The patient most likely has 1 - delirium 2 - anxiety 3 - dementia 4 - depression

1 - delirium Rational Delirium is an acute confusional state that can occur suddenly as a result of an underlying biologic cause. Anxiety and depression are not acute confusional states. Dementia is characterized by a slow, insidious onset. Symptoms of dementia may mask depression and the reverse is also true.

What are some common behavioral symptoms related to substance abuse? Select all 1 - Loud 2 - Alert 3 - Paranoid 4 - Articulate 5 - No direct eye contact

1, 3, & 5 1 - Loud 3 - Paranoid 5 - No direct eye contact Rational Common behavioral symptoms related to substance abuse include being loud, being paranoid, and engaging in little or no direct eye contact. Patients with substance abuse tend to have a decreased level of consciousness (not alert) and have slurred speech (not articulate).

Which mental change is associated with aging? 1 - Confusion 2 - Gradual decline in cognitive skills 3 - Depression 4 - Inappropriate behavior

2 - Gradual decline in cognitive skills Rational Gradual decline in cognitive skills is related to age. Confusion, depression, and inappropriate behavior are not due to the normal aging process

During report, the nurse is told that a patient has Cluster B group type of personality disorder. Which type of behavior can the nurse anticipate? 1 - Paranoia 2 - Avoidance 3 - Antisocial behavior 4 - Obsessive-compulsive behavior

3 - Antisocial behavior

Approximately what percentage of the U.S. population is affected with schizophrenia? 1 - 1% 2 - 2% 3 - 3% 4 - 4%

1 - 1%

Which statement accurately explains the difference between an enabler and a dependent? 1 - A codependent covers up the substance abuser's behavior 2 - A codependent rationalizes the substance abuser's behavior 3 - An enabler uses the substance abuser's behavior to build up his or her own self-esteem 4 - An enabler is also a substance abuser.

1 - A codependent covers up the substance abuser's behavior

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? Select all A - Olanzapine B - Quetiapine C - Aripiprazole D - Clozapine E - Asenapine

A, C, D, E A - Olanzapine C - Aripiprazole D - Clozapine E - Asenapine Rational A - Olanzapine is available in an orally disintegrating table, which B- Quetiapine is available only in tablet sor extended-release tablets and will therefore not address the current concerns with medication administration C - Aripiprazole is available in an orally disintegrating tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases the risk for agitation associated with an injection D - Clozapine is available in an orally disintegrating tablet, which os appropriate for clients who have difficulty swallowing oral tablets. This route also decrease the risk for agitation associated with an injection E - Asenapine is available in a sublingual tablet, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decrease the risk for agitation associated with an injection

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A - "I am a superhero and am immortal." B - "I am no one, and everyone is me." C - "I feel monsters pinching me all over." D - "I know that you are stealing my thoughts."

B - "I am no one, and everyone is me." Rational A - This comment indicates the client is experiencing delusions of grandeur B - This comment indicates the client is experiencing a loss of identity or depersonalization C - This comment indicates the client is experiencing a tactile hallucination D - This comment indicates the client is experiencing though withdrawal

A nurse is reinforcing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding? A - "I will be able to stop taking this medication as soon as I feel better." B - "If I feel drowsy during the day, I will stop taking C - "I will be careful not to gain too much weight while taking this medication." D - "This medication is highly addictive and must be withdrawn slowly."

C - "I will be careful not to gain too much weight while taking this medication." Rational A - Antipsychotic medications are considered a long-term treatment for schizophrenia. Discontinuing the medication can result in an exacerbation of manifestations B - Drowsiness is a common adverse effect of antipsychotic medications. However, it is not appropriate to discontinue the medication C - Antipsychotic medications, such as iloperidone, have a high risk for significant weight gain D - Antipsychotic medications are not considered addictive, and it is not necessary to titrate iloperidone when discontinuing treatment.

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A - Chlordiazepoxide B - Bupropion C - Disulfiram D - Carbamazepine

C - Disulfiram Rational A - Chlordiazepoxide is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol B - Bupropion is indicated for nicotine withdrawal rather than to maintain abstinence from alcohol C - The nurse should expect to administer disulfiram to help the client maintain abstinence from alcohol D - Carbamazepine is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol.

Long-term recovery from alcohol abuse is most likely to occur when: 1 - The family is supportive and kind 2 - The patient uses disulfiram 3 - The patient undergoes detoxification with benzodiazepines 4- The patient admits to having a problem

4- The patient admits to having a problem Rationale: Admitting to an alcohol problem is the first step in treating alcoholism and provides the best chance for long-term recovery.

Medications taken early in Alzheimer's disease to improve memory and alertness work by: 1 - increasing dopamine in the frontal lobe 2 - decreasing dopamine in the frontal lobe 3 - increase acetylcholine in the cerebral cortex 4 - decreasing acetylcholine in the cerebral cortex

3 - increase acetylcholine in the cerebral cortex Rational Cholinesterase inhibitor drugs work by increasing acetylcholine in the cerebral cortex

A client who has schizophrenia suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A - Stop the interview at this point, and resume later when the client is better able to concentrate B - Ask the client, "Are you seeing something on the ceiling?" C - Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D - Continue the interview without comment on the client's behavior

B - Ask the client, "Are you seeing something on the ceiling?" Rational A - The nurse should address the client's current needs related to the possible hallucination rather than stop the interview B - The nurse should ask the client directly about the hallucination to identify client needs and determine if there is a potential risk fo injury C - The nurse should avoid agreeing with the client, which can promote psychotic thinking D - The nurse should address the client's current needs related to the possible hallucination rather than ignoring the change in behavior

A nurse is collecting data during admission from a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? Select all A - Auditory hallucination B - Lack of motivation C - Use of clang associations D - Delusion of persecution E - Constantly waving arms F - Flat affect

A, C, D & E A - Auditory hallucination C - Use of clang associations D - Delusion of persecution E - Constantly waving arms Rational B - Lack of motivation, or avolition, is an example of a negative symptom

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription of which of the following medications? A - Chlorpromazine B - Thiothixene C - Risperidone D - Haloperidol

C - Risperidone Rational A - First-generation antipsychotics, such as chlorpromazine, are used mainly to control positive symptoms of schizophrenia B - First-generation antipsychotics, such as thiothixene, are used mainly to control positive symptoms of schizophrenia C - Second-generation antipsychotics, such as risperidone, are effective in treating negative symptoms of schizophrenia, such as lack of grooming and flat affect. D - First-generations antipsychotics, such as haloperidol, are used mainly to control positive symptoms of schizophrenia